At the last convention of the Hearing Loss Association of America (HLAA), a woman gave me an article she thought might be of interest to me, since it related to topics I frequently write about in the HLAA magazine. The article, which appeared in the May/June 2008 issue of Escapees, describes how its author went about purchasing hearing aids.

He began the process in the usual way, by first visiting a "shop that dispenses them" where he was given hearing tests. After the tests, came the "sales talk" by the "salesman," who proceeded to try to convince him to "buy the most expensive devices" that he thought he might sell. Objecting to what felt like an "unconscionable" markup, the author sought to find a less expensive way to purchase the hearing aids he felt he needed.

He went online and found a location that sold the same hearing aids he had tried at the hearing aid shop, but at greatly reduced prices. Since the Internet vendor required an audiogram (the shop personnel would not give him the one they had done), he visited a local ENT office where he received a medical examination and an audiogram (covered by Medicare). He then contacted an Internet site that sent him a kit for taking ear impressions at home. He sent the completed impressions and the audiogram to the Internet hearing aid vendor. A few weeks later, he received two new Siemens Cielo hearing aids, which came with a 2-year warranty. He declares that the aids fit comfortably and that, according to his wife, his hearing has been "vastly improved." The total cost was about $1,600, compared to (he says) a retail price of $6,800. Clearly, he saved a lot of money.

A Growing Trend

It looks to me like this kind of event is happening more and more often, with the popularity of Internet purchases of all kinds. At least one Internet hearing aid site will even arrange a hearing test via one's home computer.¹Presently, the accuracy of such a test is questionable as is the quality of home-taken ear impressions,²but both these areas are bound to improve in the future. With the popularity of open canal fittings, ear impressions will be less and less necessary.

And it's not just Internet sites that promise big bargains when it comes to hearing aid purchases. Every day, it seems, I see advertisements in the paper or on TV that proclaim major price reductions for ­hearing aids. The other day I received a direct mail sales letter that promised excellent hearing aids for $299; according to the letter, the company has over "450,000 satisfied customers." Clearly, price competition is now a major basis for hearing aid sales (when "invisibility" is not being touted!).

The aids extolled in the Internet and newspaper ads include all product levels, from entry-level digital aids to the latest "premium" models. It is apparent that these appeals must be effective in attracting customers, or we wouldn't be seeing so many of them. Consumers that respond are simply doing what comes naturally; if the same or a similar product can be obtained at a significant discount, they're going to go for the less expensive one. I see one discount healthcare catalog that is advertising four "listening aids," ranging in price from $9.95 to $39.95! And as much as we would hate to admit it, all of these aids can likely provide "some" help in a few situations. but then again so would a speaking tube or a cupped palm!

Inherent Dangers

The flaws in these courses of action are apparent to audiologists. The goal is not just getting "some" help, but getting the maximum amount of realistic help possible in every situation. Audiologists point out that the proper fitting and follow-up of a hearing aid takes time and expertise, which it does, and that they must be recompensed for their skills and the time they devote to the hearing aid fitting process. Furthermore, people who require a hearing aid frequently have many questions relating to their hearing loss, as well as communication needs that can best be helped by some other hearing assistive technology (personal FM systems, special telephones, television listening devices, etc.).

While it is possible, audiologists would assert, to purchase hearing aids at reduced prices, this benefit relates only to the product itself and not to the totality of fitting and rehabilitation services that they offer. But this assumes that audiologists do indeed utilize their unique training and expertise for the benefit of their hearing-impaired clients. When this does indeed occur, the resulting benefits for a client should justify the additional cost, given the importance of hearing for one's quality of life. Unfortunately, this ideal management scenario appears to be questionable for far too many hearing aid users, who are not getting the quality of hearing aid fitting and follow-up services they need and for which they are paying good money.

Let us first consider the fitting of a hearing aid. From what I can see, the actual fitting procedures provided by audiologists are essentially the same as those that the author of the article received. The audiogram that he sent to the Internet vendor was probably used to program the hearing aids, just as would occur when an audiologist sends a client's audiogram to a hearing aid manufacturer. According to Lindley (2006), about 70 percent of hearing aids are fit using this "first-fit" option.³This fitting procedure would be fine if 1) loudness discomfort levels could be validly predicted from threshold measures (which is questionable) and 2) different hearing aids fit in this manner produced the same results.

However, as Mueller and Bentler (2008) reported, there were output variations of as much as 15 dB when they input the same hearing loss using six different manufacturers' hearing aids.⁴Getting the output right, as Mueller and Bentler have pointed out-for the third time in 14 years!-is not taking place. This is not a trivial consideration, as the authors, two of the most eminent audiologists in the country, remind us. They recommend conducting frequency-specific loudness discomfort threshold measures, a practice also recommended by our professional organizations (both ASLHA and AAA).

Adopt Best Practices

There is much more that can be said about the current state of hearing aid fittings conducted by audiologists, such as the necessity to conduct real-ear measures (a practice routinely followed by only about 20 to 30 percent of audiologists), speech-in-noise tests (also relatively rarely done) and the routine administration of pre- and post-fitting self-assessment scales. One need only examine the guidelines recommended by the American Academy of Audiology⁵to note the discrepancy between a "best practice" approach and what commonly takes place in hearing aid dispensing practices.

It seems to me that our failure to practice a "best practices" approach leads the public to the same perception of the audiological profession that is apparently held by the author of the article. From his perspective, audiologists appear to be primarily salesmen who do what any salesman does: explain the product, extol its virtues and try to sell the one that offers the greatest profit. Aural rehabilitation is dismissed as "hand-holding" by the author of the article. This is our public image and the reason why, I think, the future viability of the profession is endangered. If we're just about selling some product, it makes sense for a consumer to look for the best price. But if what we're "selling" is ourselves and our expertise in dealing with the full gamut of the effects of a hearing loss, then the competency and conscientiousness of the audiologist becomes the most significant factor.

The way to begin is to provide every new hearing aid user with the best services that we can offer, by adhering as closely as we can to the guidelines promulgated by the AAA. There's a lot there and not everybody will require every procedure, but the possible need for each one should be explicitly evaluated for every client. This course of action would demonstrate to the public that the price they pay to see an audiologist includes much more than the cost of the hearing device itself. It would begin the process of changing our public image from that of a salesman to that of a true professional. In short, the way to ensure the future of audiology is to practice what we preach, what our best and most knowledgeable practitioners have been recommending for years: to simply do what we have been trained to do and should have been doing all along.

Acknowledgement: This article is supported in part by grant # H133EO80006 from the U.S. Department of Education, NIDRR, to Gallaudet University. The opinions expressed herein are those of the author and do not necessarily reflect those of the Department of Education.

References

1. Kimball, SH. (2008). Inquiry into online hearing test raises doubts about the validity. Hear J, 18(3): 38-46.

2. Kimball, SH. (2008). Making earmold impressions at home: How well can consumers do it? Hear J, 61(4): 26-31.

3. Lindley, G. (2006). Current hearing aid fitting protocols: Results from an online survey. Audiol Today, 18 (3): 19-22.

4. Mueller, GH and Bentler, RA. (2008). How loud is allowed? It's a three-peat. Hear J: 61(4), 10-15.

5. American Academy of Audiology Task Force. (2006). Guidelines for the Audiological Management of Adult Hearing Impairment. Audiol Today; 18(5): 32-36.

This article is part of an original series under the direction of Jess Dancer, EdD.

Mark Ross, PhD, dates his ­emergence into audiology to the time he attended the Army Aural Rehabilitation program as a patient in early l952. After his discharge, he ­attended Brooklyn College, receiving a BA in l957, an MA in l958 and then a PhD from Stanford University in l962.

The rubella epidemic of l964-65 found him teaching at the University of Connecticut and working as a clinical audiologist at Newington Children's Hospital. He left the University for 3 years to direct the Willie Ross School for the Deaf (no relation) in Massachusetts. Since his "retirement" from the University, Dr. Ross has worked as director of research and training at the League for the Hard of Hearing in New York, served as board member and vice-president of Self-Help for Hard of Hearing People (SHHH, now known as the Hearing Loss Association of America, HLAA) as well as the International Federation of the Hard of Hearing, editing its journal for 6 years.

Dr. Ross has published extensively in the hearing field. He writes regular articles for Hearing Loss Magazine, published by HLAA, and is currently associated with the Rehabilitation ­Engineering Research Center at Gallaudet University.

Among his professional honors are American Speech-Language-Hearing Association (ASHA) fellowship, Honors of the Connecticut Speech-Language-Hearing Association, Distinguished Alumnus of Brooklyn College, the Frank Kleffner Career Award from the ASHA Foundation, the Award of Honor from the Academy of Rehabilitative Audiology, the Frederick S. Berg Educational Audiology Award, the Oticon Lifetime Achievement Award, the Career Award in Hearing from the American Academy of Audiology, the Rocky Stone award from SHHH, the Lifetime Career Achievement award from the American Auditory Society and the Lifetime Career Award from HLAA.