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 Speech Mapping
and Probe Microphone
Measurements
 Editor-in-Chief for Audiology
Brad A. Stach, PhD

Additional Books by These Authors

Modern Hearing Aids: Pre-Fitting Testing and Selection Considerations
Modern Hearing Aids: Verification, Outcome Measures, and Follow-Up
Essentials of Modern Hearing Aids: Selection, Fitting, and Verification
(coming fall 2017)
 Speech Mapping
and Probe Microphone
Measurements

H. Gustav Mueller, PhD

Todd A. Ricketts, PhD
Ruth Bentler, PhD
5521 Ruffin Road
San Diego, CA 92123

e-mail: [email protected]
Website: http://www.pluralpublishing.com

Copyright © 2017 by Plural Publishing, Inc.

Typeset in 10.5/13 Minion Pro by Flanagan’s Publishing Services, Inc.

Printed in the United States of America by McNaughton & Gunn, Inc.

All rights, including that of translation, reserved. No part of this publication may be
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gladly make the necessary arrangements at the first opportunity.

Library of Congress Cataloging-in-Publication Data:

Names: Mueller, H. Gustav, author. | Ricketts, Todd, author. | Bentler, Ruth
A., author.
Title: Speech mapping and probe microphone measurements / H. Gustav Mueller,
Todd A. Ricketts, Ruth Bentler.
Description: San Diego, CA : Plural Publishing, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2017009204| ISBN 9781944883942 (alk. paper) | ISBN
1944883940 (alk. paper) | ISBN 9781944883942 (e-ISBN) | ISBN 1944883940
(e-ISBN)
Subjects: | MESH: Hearing Aids | Correction of Hearing
Impairment--instrumentation | Audiometry, Speech--instrumentation
Classification: LCC RF290 | NLM WV 274 | DDC 617.8--dc23
LC record available at https://lccn.loc.gov/2017009204
 Contents

Preface vii

1 The Underlying Rationale 1

2 Developing a Gold Standard 37

3 Getting Started 65

4 The Essential Measurements 103

5 Verification and Assessment of Fittings and Features 151

6 Putting It All Together 197

7 Frequently Asked Questions 243

References 269
Appendices 279
Index 295

v
 Preface

Although the notion of measuring the equalization problems, not to mention a yelp
output of a hearing aid in the real ear had or two from the patient, but the resulting
been tossed around since the 1940s, it was information was worth the trouble. Word of
not until the late 1970s that a “dispenser this new testing technique traveled fast, and
friendly” system was available. In this case, a study of the clinical applications was soon
the term “dispenser friendly,” is used some- underway at Walter Reed Medical Center in
what loosely. The late 1970s equipment that Washington, D.C. In the fall of 1980, at the
we are referring to was first described in a ASHA convention in Detroit, Michigan, the
paper that was presented by Earl Harford, first paper on this topic at a national meet-
Ph.D. in September of 1979 at the Inter- ing was presented, authored by Walter Reed
national Ear Clinics’ Symposium in Min- audiologists Dan Schwartz, Brian Walden,
neapolis, Minnesota. At this meeting, Earl Gus Mueller, and Rauna Surr.
reported on his clinical experiences of test- In the early 1980s, the first computerized
ing hearing aids in the real ear using a min- probe tube microphone system, the Rastron-
iature (by 1979 standards) Knowles micro- ics CCI-10 (developed in Denmark by Steen
phone. The microphone was coupled to an Rasmussen), entered the U.S. market. This
interfacing impedance-matching system system had a silicone tube attached to the
(developed by David Preves, Ph.D., who at microphone (the transmission of sound
the time worked at Starkey Laboratories), through this tube was part of the calibration
which could be used with existing hearing process), which (thankfully) eliminated the
aid analyzer systems. Unlike today’s probe need to place the microphone itself in the
tube microphone systems, this early method ear canal. The Rastronics real-ear analyzer
of clinical real-ear measurement involved (in prototype form) was first demonstrated
putting the entire microphone (about 4 mm at the 1982 ASHA convention in Toronto,
by 5 mm by 2 mm) in the ear canal down Canada. At the time, there was a distribu-
by the eardrum of the patient. If you think tion link with Bernafon hearing aids, and
cerumen is a problem with probe micro- the demonstration was at the Bernafon
phone measurements today, you should booth. In October of 1983, the first clini-
have seen the condition of this microphone cal model, the CCI-10, was shown at the
after a day’s work! national hearing aid meeting in Denver. The
While this early instrumentation was product was bundled with Bernafon hear-
a bit cumbersome, we quickly learned the ing aid sales, deals were struck, and within a
advantages that probe microphone mea- few months, clinical probe microphone
sures provided in the fitting of hearing testing was occurring at offices across the
aids. We frequently ran into calibration and United States.

vii
viii  Speech Mapping and Probe Microphone Measurements

We soon saw several other companies using the terminology that was rumored
introduce equipment to enter into the probe to be part of the standard, and was already
microphone market. One of the first to being tossed around by clinicians. The first
join Rastronics in the marketplace was complete summary of all these terms, how-
the product line Acoustimed from South ever, was in a 1992 book written by Gus
Africa, which operated using an Acorn Mueller, David Hawkins, and Jerry North-
Computer, and unlike other products that ern, titled Probe Microphone Measurements.
used swept tones, the Acoustimed used a Two hearing aid companies, Starkey and
click as in the input stimulus. The Bosch Siemens, bought thousands of these books,
company introduced a probe microphone and distributed them widely, free-of-charge
product with the perhaps the most intrigu- among audiologists. The word was finally
ing name—the “Invivo.” One product that out to the masses describing what probe
gained popularity quickly, and provided the microphone measurements were all about.
most competition for Rastronics was the So, 25 years have passed since that first
“IGO” (insertion gain optimizer) from Mad- book on probe microphone measurements​
sen. And finally, maybe the most over-engi- —it is now out of print, although some pris-
neered product of the day was the “Aurora,” tine collector’s copies can be found on eBay.
which was part of Nicolet’s Project Phoe- Interestingly, it was never revised, and no
nix, and was used to fit the digital hearing other book dedicated to probe microphone
aid from this project. The probe placement measurements has been published since—
device of the Aurora scared away most clini- until now! There are a few things that haven’t
cal audiologists, as it was a large metal appa- changed much in 25 years, but there are a
ratus, fitted to the head containing various lot more things that have. We have tried to
nobs to adjust the probe up or down, right include all of them in our current text.
or left, in or out. The preciseness probably The three of us are pretty confident, and
pleased a handful of researchers, but the we think we have the answers to most things
process was too cumbersome for clinical (at least regarding to hearing aids), but the
use, and the appearance was something one thing we can’t explain is why the verifi-
associated more with brain surgery than cation of hearing aid gain and output using
assessing the performance of a hearing aid. real-ear measures has not become routine
A bigger issue than the equipment itself practice—estimates for the U.S. place the
was developing standard terminology and adoption of this testing at no more than 20
procedures for all the new measures that to 25%. The equipment is readily available,
were now being conducted with hearing the procedures are easy to learn, and the
aids on the real ear. In 1986, Dave Preves time commitment is minimal. The penalty
was quoted in the Hearing Journal, as stat- (to the patient) if the audiologist does not
ing: “An Acoustical Society of America do the testing can be huge. For the audiolo-
study group will meet this month [May gist, failure to verify is bordering on mal-
1986] to begin discussing the standardiza- practice. Moreover, there isn’t an alterna-
tion of real-ear measurement terminology.” tive fitting method. We talk about all this in
It was a decade later before the first ANSI Chapter 1, hoping to get some of you who
standard on probe microphone measures, are on the fence to become believers.
S3.46-1997, was published. Like good wine, Fitting hearing aids using speech map-
standards take time to reach maturity. ping procedures indeed does require more
While waiting for the phantom standard time than simply asking the patient “So how
to emerge, audiologists published papers does that sound?” Clinicians often ask—is
 ix
Preface  

all that work really worth it? The answer is FAQ chapter, which provides the answers
a resounding “yes.” Forgetting for a moment to just about every question that we could
the ethical and possible medical-legal rami- think of—most of which, are questions that
fications of fitting hearing aids and not pro- we have gotten at one of our workshops.
viding patients with appropriate audibility, Finally, because fitting hearing aids is not
considerable data show that as verification only just about real-ear verification, we
and validation measures increase, so do provide a final chapter on “putting it all
patient benefit and satisfaction. Research together.” Here we provide a brief outline
findings also show that in general, patients of other procedures that supplement probe
fitted to a validated prescriptive approach microphone measures before and after the
have improved speech understanding, real- fitting—the details of which you can find in
world outcomes, and a preference for the our other three books.
prescriptive gain and output. Moreover, For those of us who use probe micro-
large studies such as MarkeTrak VIII clearly phone measures routinely, it is difficult to
indicate that as audiologists add various imagine how hearing aids could be fitted
verification and validation components of without this testing. Certainly, using either
Best Practice to their fitting protocol, satis- the REAR or the REIG is essential for veri-
faction increases accordingly, patient loyalty fication of prescriptive targets and deter-
increases significantly, and follow-up visits mining appropriate audibility of the ampli-
for hearing aid adjustments are reduced. fied signals—there is no alternative choice.
The primary use of speech mapping and Along with being critical verification mea-
probe microphone measures is to verify sures, these procedures are also helpful in
gain and output on the day of the fitting. assessing and adjusting several hearing aid
To state the obvious, if something is veri- features, and in troubleshooting post-fitting
fied, there must be a reference standard. We problems. Moreover, conducting these mea-
believe an excellent starting point is the use sures can be fascinating and educational,
of a validated prescriptive fitting approach. and sharing the results with the patient is a
Today, we have two, well-researched meth- very effective counseling procedure. Clearly,
ods, the NAL-NL2 and the DSL v5.0. We the routine use of probe microphone assess-
provide you with a review of both of these ment and making reasoned decisions based
well-established and validated methods. on the findings is one of the most important
The core of this book is dedicated to components in the overall fitting of hear-
the nuts and bolts of conducting the probe ing aids. Without this information, we are
microphone measures. This could be speech forced to make choices based on guesses,
mapping for determining a match to target, hunches, or clinical intuition, instead of
or it could be an RESR85 measure to assure data. This is certainly not something we
that the MPO is okay, or it could be the use want to do if we are truly interested in pro-
of special speech signals for programming viding evidence-based services.
frequency lowering. For each test and pro-
cedure, we provide background informa-
tion, a clinical step-by-step protocol, and The authors wish to acknowledge
case examples, all geared toward the day- the generous support of Otometrics
to-day fitting of hearing aids. Just in case during the writing and production
we forgot to mention something in these of this book.
core chapters, we also included a special
1 The Underlying Rationale

Wrong does not cease to be wrong because the majority share in it.
—Leo Tolstoy

Every university professor who teaches we are having on audibility when we make
hearing aid classes knows the story. Five changes from a validated method, and the
years after her graduation, you run into potential impact of those changes. Perhaps it’s
one of your prized AuD students at a con- obvious, but we’ll say it anyway, the only way
ference. She was, of course, trained to follow you know if you are fitting to a specific fitting
Best Practice Documents and always con- method, is to observe SPL in the ear canal.
duct probe microphone verification back at We all know of cases in which a patient
the university. But now she says, “I probably was fitted without real-ear verification, and
shouldn’t tell you this, but I never do probe several patient-driven adjustments had to
microphone verification anymore. No one be made, and the patient ended up with
else at my clinic is doing it, so I don’t either.” little or no gain. For instance, we recall one
The Tolstoy quote above says it best. case of a hearing aid wearer—who inter-
We want all of our hearing aid patients estingly also happened to be an audiolo-
to be happy, right, and leave our offices with gist—using new instruments he had fitted
a smile on their face? Although it is nice to to himself through careful listening. After
see them smile, this verification approach volunteering to be a demonstration patient
doesn’t quite follow evidence-based practice. at one of our probe microphone workshops,
It has been shown time and time again that a he and the rest of the audience discovered
validated prescriptive fitting method should that he had simply programmed his hearing
be used as a starting point for verification. aids to match his unaided open-ear canal
As we discuss later, when we have verifica- resonance—the hearing aids had no real-ear
tion of a validated prescriptive method, we gain above 1500 Hz.
have a good understanding of the trade-offs Although behavioral measures can be
between audibility, speech understanding, helpful, they are complementary and not
sound quality, comfort, and other factors a substitute for the objective assessment
involved in the fitting of the typical patient. of hearing aid output in the ear canal. It is
This may not be the end point for all pa- important to understand that a prescriptive
tients, and gain adjustments may be nec- fitting is ultimately based on the desired
essary. However, if we start with ear canal amplified signal level in the ear canal, not
sound pressure level (SPL) reference infor- a 2cc-coupler measure (at least not without
mation relative to the individual patient’s correcting for differences between the ear
dynamic range, we then know what effect and the coupler), a KEMAR measure, or a

1
2  Speech Mapping and Probe Microphone Measurements

computer simulation in the fitting software. a speedometer, and you have it—it’s your
Therefore, probe microphone measures of probe microphone equipment.
hearing aid performance (or individual real- Mueller and Picou (2010) identified
ear corrections to the coupler these provide) a similar disconnect in their survey find-
are needed for verification of our chosen ings. From their sample, 79% of audiolo-
prescriptive method. gists reported using a validated prescriptive
The importance of these procedures fitting approach, and yet only 59% of this
has been emphasized and recommended group routinely used probe microphone ver-
in every hearing aid-fitting guideline pub- ification. Another peculiar finding from this
lished in the past 20 years. As an example, survey was, that of the respondents who said
the following excerpt is taken from the 2006 they used prescriptive methods routinely
fitting guidelines of the American Academy and also reported conducting probe micro-
of Audiology (AAA) (p. 25): phone testing routinely, only 37% said that
their primary reason for using probe micro-
The objective of this segment of the fit- phone testing was to verify these targets.
ting process is to ensure that the fitting
and verification procedure is viewed as
a process rather than an event, which Real Ear Versus Probe
culminates in the optimal fitting for the
Microphone Versus
patient. Verification procedures also
serve as a benchmark against which
Speech Mapping
future hearing aid changes can be com-
pared. Specific goals and rationales There are a few different terms that refer
underlie all hearing aid fittings. Verifi- to the act of putting a tube in the ear canal
cation procedures should be based on and measuring the output from the hear-
validated hearing aid fitting rationales. ing aid in the real ear. An early term that
was used for this was in situ measurement,
As mentioned earlier, you are using a meaning “in position”—a reasonable term,
validated method only when that method’s as indeed the hearing aid is measured in
prescribed gain and/or output are referenced the use position. In early marketing efforts
to what is required in the ear canal. We men- of probe microphone equipment, however,
tion this again as this concept doesn’t seem it was important to make the distinction
to be obvious to all clinicians. For example, that the testing was conducted on the real
Mueller (2005b) reported that in a survey of ear and not in a 2cc coupler. In situ did not
audiologists fitting hearing aids, 78% stated have much meaning to most audiologists,
that they routinely were using a validated so it made more sense to refer to the testing
prescriptive fitting approach (i.e., either the as real-ear measurements (REM). The term
NAL or the DSL). Interestingly, however, of REM (pronounced rhem) is sometimes used
this 78%, only 44% reported routinely using today by manufacturers and audiologists.
probe microphone measures. Question of Whereas testing during the first 20 years
the day: How do the remaining 56% know of probe microphone assessment mostly
what method they are using, or if they are involved swept pure tones and composite
using any method at all? This is like saying noise as the input signal, in the past decade,
that you drove exactly 60 mph all the way speech shaped signals, or real-speech inputs,
to work, only to admit that the speedometer have become routine. The use of these signals
in your car never moves off zero! You need in combination with plotting the patient’s
 1. The Underlying Rationale   3

Clinical Concept: You Don’t Fit Hearing Aids by PROBE

We often overhear at audiology validated rationale is the way ​— which

meetings, perhaps around a cocktail needs to be verified.
table, one audiologist asking another, To reiterate this point in another
“So do you fit your aids by probe?” way, we use a weekend construction
There seems to be a common belief project as an analogy to the fitting of
that probe microphone measures are a hearing aid. Let’s say you are going
a way to fit hearing aids. They are not. to build a doghouse. You start with a
They are simply a way to verify your general design (type of roof, door size,
way of fitting hearing aids. We know of etc.—just as you start with selection of a
large clinics where the audiologists are validated fitting rationale). You then go
required by their supervisor to do probe online and find a blueprint for building
microphone measures. What audiolo- the doghouse that fits your design (exact
gists may do is push the magic button dimensions for all the pieces that will
that provides a fit to the manufacturer’s need to be assembled—just as you obtain
default fitting, then conduct probe desired gain and output values for your
microphone testing for inputs of 55, fitting method). Now, while cutting the
65, and 75 dB SPL, and put the results pieces for this doghouse you might use a
in the patient’s chart. Not one hearing tape measure to verify that all the pieces
aid adjustment involved! Did they fit fit your blueprint. (Remember the adage,
by probe? Some might say they do. Are “Measure twice, cut once.”) Would you tell
they fitting by a validated rationale? your woodworking colleagues that a tape
Not likely, as we describe in detail measure is a way to build a doghouse?
later in this chapter. Again, the act of Not likely. But could you build a sturdy
conducting probe microphone testing and nice-looking doghouse without
is not a way of fitting hearing aids — the using a tape measure? Probably not!

dynamic range in SPL has prompted audiolo- the patient’s residual range of hearing, they
gists to refer to the testing as speech map- are conducting speech mapping. That is,
ping. This term was first used in the early if it’s not plotted for different input levels,
1990s when Bill Cole and his colleagues it’s not really a “map” of the ear canal out-
introduced this feature, trademarked as put. Of course, you can’t do REM or speech
Speechmap™ on the Audioscan coupler/ mapping without a probe microphone, so
probe microphone unit from his company, that too is a reasonable term, particularly
Etymonic Design Incorporated. This equip- because many probe microphone measure-
ment did not produce a shaped speech sig- ments to not involve using a speech signal.
nal all at once, but rather a series of tone Which term is correct? Or better, which
pips/bursts whose levels reflected the fre- term will cause the least confusion? We
quency-specific long-term average speech believe there is a clear choice, and that
spectrum (LTASS) levels. Most audiologists choice is probe microphone measures, for
today use a speech-shaped/shaped-speech several reasons. First, consider the proce-
input signal, and if different input levels dures for conducting aided sound-field
are used and they are plotted relative to testing and functional gain. The last time
4  Speech Mapping and Probe Microphone Measurements

we checked, these are real-ear measures of Hawkins et al., 1991), probe microphone
hearing aid performance. There are govern- assessment has been mentioned as either
ment forms that very specifically require the preferred method or one of the preferred
the “real-ear measure of hearing aid perfor- methods for verification. Over the years,
mance” with the patient wearing one versus published guidelines from the Independent
two hearing aids. They are referring to aided Hearing Aid Fitting Forum (IHAFF), the
sound-field testing. If you believe that the ASHA, and the AAA have recommended
term real ear relates only to probe micro- the use of probe microphone verification.
phone measures, this request would be quite The statement on this topic from the 2006
puzzling, as there is no probe microphone AAA document is unambiguous: “Pre-
measure that would assess the summation scribed gain (output) from a validated pre-
effects of two instruments. scriptive method should be verified using
On a recent audiology Listserv we saw a probe microphone approach that is refer-
this posting: “I’m going to buy some real- enced to ear canal SPL.”
ear equipment, but I can’t decide if I should In case you think this is only a United
purchase probe microphone or speech map- States recommendation, this International
ping?” This posting highlights our second Society of Audiology (2005) excerpt from
point. Probe microphone testing nearly their document “Good Practice Guidance
always is speech mapping; speech map- for Adult Hearing Aid Fittings and Services”
ping nearly always is a component of the states the fitting tolerances that are accept-
probe microphone assessment of a hear- able internationally.
ing aid. They are not two different things.
Therefore, it is much simpler to call the Where a fitting rationale contains an
entire process probe microphone measures, acoustical target, each hearing aid fit-
as, although it is likely that this will include ting should be verified by real-ear
speech mapping, it is also very possible that measurement using an input stimulus
some of the testing will not be speech map- appropriate for the hearing aid under
ping; for example, a swept-tone MPO mea- test prior to any fine-tuning. Tolerances
sure, the measure of the occlusion effect, to the prescription rationale of ±5 dB
and so forth. at frequencies of 250 Hz, 500 Hz, 1000
So, with all that said, in this book we Hz, and 2000 Hz and of ±8 dB at 3000
use the term probe microphone measures to and 4000 Hz should be achieved in all
describe all types of real-ear testing of hear- cases. In addition, the slope in each
ing aid performance. octave should be within ±5 dB/octave
of the target. Where it is not desirable
or possible to achieve a prescriptive tar-
get (e.g., because of feedback issues) or
Compliance with Best
where the measurement is not techni-
Practice Guidelines cally feasible, the clinical record should
contain an explicit statement to this
The use of probe microphone measures for effect. (p. 5)
hearing aid verification has always been
assumed when Best Practice guidelines We know, however, that what is sup-
were written. Going back to the recommen- ported by research evidence, recommended
dations of the 1990 Vanderbilt Report II (see by opinion leaders, and published in Best
 1. The Underlying Rationale   5

Practice Documents, does not always find graduates (either masters level or
its way into routine clinical audiology use. AuDs) and for experienced audiologists
The best example of this might be the per- who had obtained their AuD through
sistent use of live-voice speech recognition distance learning.
testing, despite the abundance of literature
showing the many shortcomings of this The results of these surveys are surpris-
practice (see Hornsby & Mueller, 2013; ingly similar, showing, in general, routine
Mueller, Ricketts, & Bentler, 2014). But use of probe microphone verification of
what about probe microphone measures? about 35% to 40%. This takes us to the most
The clinically friendly equipment for this recent and extensive survey on the topic by
testing has been available for more than 30 Mueller and Picou (2010). This online sur-
years. Are these measures a routine part of vey used data only from U.S. practitioners
the hearing aid fitting protocol for all or who dispense hearing aids, and included a
most audiologists? This topic has generated total of 420 respondents, of which 309 were
a number of surveys, so we do have a pretty audiologists (74%) and 111 (26%) were HISs.
good idea of compliance. In the following One of the questions related to the routine
four surveys, the audiologists respond- use of the equipment on the day of the fit-
ing were actively engaged in the fitting of ting. The results are shown in Figure 1–1.
hearing aids, and routine use was defined as If we first look at the left portion of Fig-
using probe microphone measures with at ure 1–1, we see use rates that are quite simi-
least 50% of adult patients: lar to what has been found in other surveys:
about 45% for audiologists, 36% for HISs,
n In 1995, Mueller and Strouse with an overall use rate of 41%. These data
reported that the routine use of probe are for the total sample, which includes
microphone measures was 54% for individuals who do not have the equipment.
audiologists (n = 134) and 18% for The data on the right portion of the chart
hearing instrument specialists (HISs; are only for those respondents who stated
n = 108), with an overall average use that they have the equipment available. As
rate of 39%. we would predict, this increases the use of
n In 1999, Mueller again examined use this testing (more so for HISs), but not by
rates for both audiologists and HISs, nearly the amount that would be expected.
but this time limited the survey to Consider that for both groups, about 45%
those who owned or had access to the of the audiologists and HISs who have the
equipment. When the two professional equipment don’t use it routinely. These
groups were combined, 42% reported data are nearly as low as surveys regarding
routine use. use rates for people who own treadmills!
n In 2003, a Mueller survey of primarily Of course, people completing this survey
audiologists (n = 558 audiologists, 49 knew what the correct answer was. Using
HISs) showed an overall routine use the findings from some lie detector ques-
rate of 37%. tions embedded in the survey, Mueller and
n A few years later, Mueller (2005b) Picou (2010) concluded that the actual use
again examined the popularity of these rate is not even as high as their results indi-
measures, this time among audiologists cated—as many as 25% of respondents said
only. The overall use rate was 34%. It that they were doing probe microphone
was slightly higher (~40%) for recent measures that don’t even exist.
6  Speech Mapping and Probe Microphone Measurements

Figure 1–1. Survey results comparing “routine use of probe

microphone measures” indicating across all respondents, about
41% use, and across practitioners who have the equipment,
about 55% use. Adapted from Mueller and Picou, 2010.

One finding we find interesting is that equipment, and a contemporary fitting

in 1995, probe microphone use for audiolo- protocol.
gists, versus hearing instrument specialists n More and more, the fitting is driven
(HISs), was 54 to 18%. Today, or at least in by consumers, as they become better
the 2010 survey, the use rate is essentially educated regarding the right and
the same between these two groups, due wrong way to fit a hearing aid. In July
to a considerable uptake by the HISs. Why 2009, Consumer Reports reported that
is this? Although we have little data on the in their sample, about two-thirds of
topic, we do have some opinions formed hearing aids sold were fitted incorrectly.
from discussions with individuals from The article concluded: “The provider
both groups, as well as manufacturer’s sales should do several tests to verify
reps, who probably know the straight scoop that they (hearing aids) are working
the best. Here are our thoughts: optimally. Of that battery of tests, one
stands out as a must-have: the real-ear
n There are fewer “mom and pop” HISs test.”
today than there were 20 years ago. n Finally, in recent years the hearing
Currently, HISs are younger and more aid distribution system has changed,
tech savvy. with many chains and big-box stores
n Many HISs in private practice are no dispensing hearing aids. These are
longer with a franchise company, but common employment sites for HISs,
are now selling the same hearing aids as and many, if not most of these stores,
the audiology practice down the street. make an effort to follow Best Practice
This places a greater emphasis on the guidelines; sadly, perhaps more so than
quality of the fitting, using the right some audiology practices. Individuals
 1. The Underlying Rationale   7

working at these sites are strongly Most of us think of unethical practice

encouraged to follow the established related to the fitting of hearing aids as things
Best Practice protocols. such as free trips to Hawaii or giving kick-
backs to referral sources. But the Code of
Much of the MarkeTrak VIII report Ethics for professional organizations also
focused on verification, including the includes items related to how we perform
administration of tests such as probe micro- clinical audiology. For example, Principle 2
phone measurements (e.g., Kochkin et al., of the AAA Code of Ethics states, “Mem-
2010; Kochkin, 2011). The approach taken bers shall maintain high standards of pro-
by MarkeTrak VIII was different from that fessional competence in rendering services.”
used in the other surveys we have reported. Principle 4 states, “Members shall provide
Rather than asking audiologists and HISs only services and products that are in the
if they conducted the testing, individuals best interest of those served.” Principle of
purchasing hearing aids were queried if Ethics II from the ASHA Code of Ethics
they had received testing using a probe tube states that “Individuals shall honor their
inserted in the ear. Survey findings reported responsibility to achieve and maintain the
that 42% of the respondents stated that they highest level of professional competence.”
received this testing, and there was not a Consider this example: If you don’t use
significant difference in the frequency if the probe microphone measures, how would
patient had been fitted by an audiologist or you know if you had even made soft sounds
an HIS—findings which more or less agree audible—one of the most basic components
with the Mueller and Picou (2010) survey. of the hearing aid fitting? If you actually sold
a pair of hearing aids and didn’t make soft
sounds audible (simply because the neces-
Possible Ethics Violation? sary software adjustments were not made),
would this be a “high standard of profes-
Ever since it became obvious that audiolo- sional competence?” Would it be “providing
gists were not adopting the use of probe services that are in the best interests of those
microphone measures at the rate that served?” Not really.
everyone expected, many of us have pub- Palmer (2009) concludes her article with
licly commented that not doing probe the following.
microphone assessment when hearing aids
are fitted is clearly poor clinical practice. In I hope we can continue to discuss the
a 2009 article in Audiology Today titled, reasons that hearing aid acceptance is
“It’s a Matter of Ethics,” Catherine Palmer not higher in the hearing-impaired pop-
took it to a different level. She questioned ulation. The fact that a doctoral profes-
if not doing probe microphone testing is a sion is arguing about whether or not to
violation of the code of ethics of our major individually verify the gain and output
audiology professional organizations. She of a hearing aid in a patient’s ear that
specifically stated, “If we talk about ethical takes less than 5 minutes might just be
practice, then we have to be comfortable a good place to start. If you are wonder-
saying that there are hearing health care ing if providing this level of verification
providers (audiologists) who are not prac- will establish you as an expert and set
ticing ethically” (p. 32). you apart from other providers, keep
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