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Audiology Issues 2015: The View from 50,000 feet

Audiology Issues 2015: The View from 50,000 feet

May 19, 2015 Editorials

Opinion Editorial by Douglas L. Beck AuD

Seth Godin (2015) is one of the most insightful and prolific writers on the planet. His marketing books, Web site, and blogs are referred to and praised internationally. Recently he noted that “imperfect substitutes” are often the go-to product, as they may be pretty much on target with regard to their value (in this case, I define value as what did you pay, versus what did you get).  He says if there are multiple brands of bottled water on the shelf, and one brand is significantly less than the others, it makes sense to buy the less expensive brand. These products are reasonable substitutes for each other. Books are not reasonable substitutes. For example, if you want to read the best-selling marketing (or audiology) book, you cannot just get the less expensive book on the same topic…it won’t have the same content. Same thing with a movie…you want see the one you want see. That is, the product you seek may not have an acceptable substitute, so if you want THAT one, you have to pay the asking price.

Seth offers an example in which he needed a photo for a project. Let’s suppose it was a photo of a car. He contacted the owner of the photo and asked to buy the rights, but the price was too high. Therefore, he used an open access car photo from Google Images, or another photo he had permission to use. That is, he preferred the first photo, as he needed a picture of a car, but he didn’t really need THAT photo for the specific project he  was working on.  He reports “The available substitute was imperfect but acceptable.” And then with keen insight he offers, “Your job then, isn’t to merely set your price low enough to keep people from seeking substitutes. It’s to create a product or service unique or connected or noteworthy enough that the other choices are ever more imperfect.” Wowsa!

Of note, the most common complaint of all patients (with and without hearing aids) relates specifically to speech-in-noise (SIN) issues. “Listening Is Where Hearing Meets Brain” (Beck and Flexer, 2011) explores these issues—that hearing thresholds do not (and cannot) represent the entirety of the auditory experience. Clearly,  hearing ability (the perception of sound)  is not the same as listening ability (attributing meaning to sound) and they argue that when a patient presents with a chief complaint of the inability to understand speech in quiet or noise, a thorough, detailed,  diagnostic battery (including an audibility index, a speech in noise test and more) is called for. Beck (2015) notes audiograms and audiometric pure-tones screenings are not sufficient to describe auditory status. Audiograms cannot document, estimate, reflect, or quantify speech-in-noise problems, neural or auditory processing difficulties, perceived auditory distortions (loudness, spectral, or timing and more), attentional difficulties, and more. That is, despite normal thresholds, MANY people have listening problems.

Bharadwaj et al (2015) reported “many listeners with normal hearing thresholds complain of communication difficulties…” and they reported statistically significant correlations were found regarding electrophysiological and behavioral measures of temporal coding fidelity and concluded  “hidden hearing deficits, likely originating at the level of the cochlear nerve, are part of “normal hearing.”

Fabry (2015) reports that from a consumer viewpoint, sound booth-based tests which do not include speech-in-noise test fail to satisfy the patient.  That is, the consumer may believe the hearing care professional didn’t understand the primary problem (speech-in-noise, SIN) as the professional didn’t replicate or test the specific, primary problem which motivated the patient to seek help! Fabry notes the literature clearly supports the use of SIN tests, yet (he reports) few clinicians perform SIN tests. Further, he suggest, we need to adapt our test protocols to include measures of memory, attention and cognition. He concludes by “thinking outside the text box and pure tones, we will be better prepared to address how hearing aids may help slow the aging process….”

To me, the earlier citations suggest it might be wise to package a product WITH an amazing service, in a phenomenal, personal and exemplary fashion, in which SERVICE (I'll define that as applying skill, talent and knowledge) is the overwhelming key feature. Further, when one removes service from the equation, the value of the product is grossly attenuated. Please note, I am not arguing in favor of “bundling.” In fact, I believe we need to un-bundle, as the market appears to be demanding it! (not in all sectors yet, but in many at this time, and certainly more will follow) and we should minimize the focus on the product, while maximizing our professional diagnostic skills, our counseling, our aural rehabilitation (AR) knowledge and delivery of AR services, the ability to verify and validate fittings, the ability to perform real-ear measures, the ability to perform pre-and-post fitting analysis of SIN (Beck and Nilsson, 2013) and perhaps we ought to speak to patient s in terms they understand.

That is, we can (and arguably should) measure and test in decibels, no argument, that’s fine (of course hearing aids are in SPL and hearing tests are in HL, so we might want to re-think, that, too). However, when speaking to patients, as they each really, really, really want to know their “percentage” of hearing loss, why not use a common standard speech intelligibility index (SII), or audibility/articulation index (AI) to tell them something meaningful to them, in terms they understand?

Specifically,  when you or I tell a patient (or each other!) a patient has a 45 dB hearing loss—that means precious little. The hearing loss might have been a three frequency average (250, 500, 1000 Hz respectively) of 35, 45 and 55 dB, or it might have been  45, 45 and 45 dB, or it could have been 55, 45, and 35 dB, and it could have been 25, 45, and 65 dB and on and on. Certainly you get my point. Why not convert their audiogram automatically (via software) or manually, onto an SII or AI chart and tell them the percentage of hearing loss in a way that makes sense to them (and to us!)?  Just sayin'.

Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology and the director of public relations with Oticon, Inc.

For More Information, References, and Recommendations

Beck DL, Flexer C. (2011) Listening is where hearing meets brain…in children and adults. Hear Rev 18(2):30–35

Beck DL, Nilsson M. (2013) Speech-In-Noise Testing: A Pragmatic Addendum to hearing Aid Fittings. Hear Rev May.

Bharadwaj HM, Masud S, Mehraei G, Verhulst S, Shinn-Cunningham BS. (2015) Individual Differences Reveal Correlates of Hidden Hearing Deficits. J Neuroscience 35(5): 2161-2172.

Fabry DA.(2015) Moving Beyond the Audiogram. Audiol Today 27(3):34-37.

Godin S. (May 13, 2015) Imperfect Substitutes.

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