Tune in as we embark on a journey of discovery with esteemed guest, Dr. Douglas Beck. He enlightens us about the importance of individualized, comprehensive care, grounded on best practices set by globally recognized organizations like the International Hearing Society, the American Academy of Audiology, and the American Speech Language Hearing Association. Dr. Beck passionately underscores the pivotal role of these practices in enhancing patient outcomes.
We further delve into the intricacies of hearing aid fittings, specifically the indispensable role of the real ear measurement. If you're curious about how this process is conducted and why it matters, this episode is a treasure trove of information! We also dive into the significance of patient outcomes, with an emphasis on the twin pillars of verification and validation. Wrapping up, we reflect on the immense value of advocacy in hearing healthcare. Join us in this stimulating conversation and let’s Hear Life’s Story together!
Connect with the Hearing Matters Podcast Team
Email: hearingmatterspodcast@gmail.com
Instagram: @hearing_matters_podcast
Twitter: @hearing_mattas
Facebook: Hearing Matters Podcast
Tune in as we embark on a journey of discovery with esteemed guest, Dr. Douglas Beck. He enlightens us about the importance of individualized, comprehensive care, grounded on best practices set by globally recognized organizations like the International Hearing Society, the American Academy of Audiology, and the American Speech Language Hearing Association. Dr. Beck passionately underscores the pivotal role of these practices in enhancing patient outcomes.
We further delve into the intricacies of hearing aid fittings, specifically the indispensable role of the real ear measurement. If you're curious about how this process is conducted and why it matters, this episode is a treasure trove of information! We also dive into the significance of patient outcomes, with an emphasis on the twin pillars of verification and validation. Wrapping up, we reflect on the immense value of advocacy in hearing healthcare. Join us in this stimulating conversation and let’s Hear Life’s Story together!
Connect with the Hearing Matters Podcast Team
Email: hearingmatterspodcast@gmail.com
Instagram: @hearing_matters_podcast
Twitter: @hearing_mattas
Facebook: Hearing Matters Podcast
You're tuned in to the Hearing Matters podcast, the show that discusses hearing technology, best practices and a growing national epidemic: Hearing Loss. Before we kick this episode off, a special thank you to our partners: Weave, the all-in-one patient communication and engagement platform. Sycle, built for the entire hearing care practice. Redux - faster, drier, smarter, verified. Otoset - the modern ear cleaning system. Welcome back to another Hearing Matters podcast. On this episode, we are going to be discussing best practices, and we have Dr. Douglas Beck joining us on this episode. Dr Beck, what are best practices and how important is it for hearing health care providers to implement best practices while treating patients who present with hearing loss?
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:If you were to go up to 25 different hearing care providers whether they be ENTs, audiologists or hearing aid dispensers and you ask them that question, you're going to get 25 different answers. But here's the correct answer, and I mean this lovingly and with due respect: you and I don't get to set up what best practices are. That's not an individual decision. These are done and they are codified by the national organizations. So, the IHS, the International Hearing Society, the American Academy of Audiology, the American Speech Language Hearing Association. They assembled groups of experts over multiple years to discuss what should be done. How should you do it? What does it mean? And they're all audiologists, they may be dispensers, they may be ENTs, but whoever it is is a subject matter expert on the literature and the clinical practice. So they come together and there could be 10 of them, there could be 20 of them and they say, "What we need to do for our patients is we need to do air conduction, we need to do bone conduction, we need to do word recognition, we need to do speech reception thresholds, we need to do otoacoustic emissions, we need to do ipsi and contralateral reflexes, we need to do tympanograms, we need to do speech in noise, we need to do communication and listening assessments." Now, oddly enough, all three of those groups AAA, ASHA and IHS all say the exact same thing. The reference I can give you for this, for a quick read, is if you go to hearingreview. com and just look up Michael Valente. So Mike, very dear friend of mine, Mike just retired in I believe it was August of 20. And when Mike was retiring I did an interview with him for hearingreview. com to go over some of these things what are best practices, which ones are the most important, and things like that. So you'll find all of this in that edition of Hearing Review in July or August of 2020. But it covers that you're not just fitting ears, you're not just fitting pure tones. There's a person, there's a brain there, there's a whole family that's related to that individual, and so we have to dig deeper and we have to use outcomes-based research to determine what the best practices are. Now, if somebody says we should do speech in noise testing, that's great, that's an opinion and it's a very well-founded opinion. But that's based on the subject matter experts looking at the literature and the long-term outcomes for the individual patient and what they find is there's a couple of things that the results pivot on, and one of them is understanding the patient's speech in noise ability and facilitating an improved SNR signal to noise ratio. You'll have other outcomes-based decisions about why do we need to do tympanograms. Well, because that tells us about the mobility of the eardrum and we know that in the presence, for example, of acute otitis media, subtertive otitis media, disarticulated set of ossicles, that the eardrum is not going to move in a normal fashion. So, we do that because it's important for our patients to make sure that they have normal mobility in their eardrum, and so all of these things derive over time based on the expertise of the subject matter experts. Looking at the peer reviewed literature, to say, a, b and C lead to X, y and Z, and if you skip C, then you're not going to get Y. You have to take care of it on the front end in order to know what you're doing. So, this is something we mentioned weeks ago and it's a primary thought in physicians' minds: diagnosis first, treatment second. For a physician to just give you antibiotics because you have a cold, that's ludicrous, because the vast majority of people with colds have viral infections and antibiotics only take care of bacterial infections and it depends exactly what the infection is and exactly what the antibiotic is. But the point is that you can't just have one size fits all healthcare. It doesn't work. There are individuals involved and the very best approach is to go to a professional who does best practices, because then you're going to get comprehensive care and if you have an underlying issue whether it's speech, language, whether it's hearing, whether it's audition, whether it's medical, whether it's surgical it's very likely to be discovered because that's why that person has a license in that area of healthcare.
Blaise M. Delfino, M.S. - HIS:Dr. Beck, do patients who receive best practice or high standard of care do better than patients who receive subpar treatment?
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:Absolutely. There's no doubt at all, and that's the essence of best practice models. That's why the American Academy of Audiology, that's why the American Speech Language Hearing Association, that's why the International Hearing Society create best practices. I can tell you I was the lead author for the IHS best practice model and that involved at least 10 or 12 of us over about an 18 to 24 month period of time reading AAA's best practice, reading ASHA's best practice, coming up with some newer stuff as well and it's all based on outcomes, because the patients who do best had the best diagnostics and they had the best treatment. So, this is a really important issue. Now, there are some people who will tell you they do best practices and you ask them what are those best practices?
Blaise M. Delfino, M.S. - HIS:I do real ear. It's in the closet.
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:It's in the closet, so real ear is a great example because that is a verification method. So when you talk about patient outcomes, there's two clean areas. One is verification, one is validation. Verification is what real ear seeks to do. It verifies that the fitting that you have supplied the patient with is meeting a recognized standard. It could be something like National Acoustic Labs NL2, NAL-NL2, it could be DSL5, it's whatever is appropriate for that professional. But you see, it's very important to verify that, because you can't listen to a hearing aid and say, oh, that has a dip at 3,300 Hertz. Oh my gosh, the total harmonic distortion. I think it's 7%. You can't make those guesses.
Dr. Gregory Delfino, CCC-A:There's no such thing.
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:You can't even hear the when the hearing aid is malfunctioning. Sometimes the patient wearing it will not do well, but we can't do a listening check and hear all the flaws of a hearing aid based on an ANSI, spec American National Standards Institute. So it's very important. The only way to verify hearing aid fitting is indeed real ear, which, as you said earlier, 50% of hearing care professionals own them, but only about one out of five uses them all the time. Some professionals will say well, I use it when I need to. And my answer to that, not to be snooty is how do you know when you need it? Because you can't hear the deficit, neither can the patient, but it's not feeding the patient's brain appropriately. So that's verification is real ear. Validation is did you meet the patient's goals? You would discover that by doing listening and communication assessments, such as the COSI, which is client oriented scale of intervention, HHI-A - hearing health care inventory for adults, HHI-E - hearing health care inventory for the elderly. You could do the SSQ, which is speech and spatial sound qualities. You could do the IOI international outcomes inventory. These are all likard scales, they're very simple and takes, you know, five or 10 minutes to administer. One of the things that I really urge clinicians not to do: Don't give the patient a likard scale like the COSI, like the IOI, like any of these things, and have them fill it in at home and bring it. The very best thing you can do is work through whatever scale you're using with the patient, because it gives you the opportunity to have that conversation with the patient. They realize you're interested in this and if you're just looking at the outliers, that's very, very different, because they're expecting us as professionals to listen to them, to engage in conversation. It's the same with tinnitus patients. I never give them the THI. I read all 25 questions to them because I want to have an intelligent conversation with my patient about their tinnitus so they understand that I know what I'm talking about and I'm listening to them so that I know that they know what they're talking about. We just talked about 25 separate issues on the THI, the tinnitus handicap inventory and I think the patient and I both get a lot more out of that than if I just hear Phil listen.
Blaise M. Delfino, M.S. - HIS:Let's take a quick break. Running a private practice is challenging, and it's especially difficult if you're using a management software system that's out of date or it doesn't really fit your needs. As a former private practice owner, I personally found Sycle to be such an incredible tool that is easy to use and is really in the best interest of my patients. Sycle provides you with Industry specific workflows and features for a smooth running front office, and if you've been listening to the hearing matters podcast, you will know that I believe that the front office staff is really the most important position in a hearing care clinic. Learn more at Syclecom. That's s y c l e dot com. Enjoy the rest of the episode. Absolutely. And, dr Beck, to echo everything that you just said. So when we work with patients and of course, we implement best practices Not to brag, boast or to impress you rather impress upon you or return rate is less than 1%. I've been doing this full time for four years and our return rate is less than 1%. Our patients are very happy. We implement best practice. My father's been doing this for a long time, as have you, and when we talk about doing what is right by the patient, really that's best practice and verification and validation, the importance of the abbreviated profile of hearing aid benefit and what we do here. We work and administer that with the patient because you and I had a correspondence and you had recommended that and it works incredibly well. Well, now there's software that patients can see. This is where I was before hearing aids. This is where I am exactly and this is how the hearing aids have improved my life. Dr Delfino, with regard to the discussion of real ear measurement, how important is it and what have you seen with regard to patient outcomes, even here in our own clinic, how it's just possibly influenced our patient fittings it?
Dr. Gregory Delfino, CCC-A:really provides both the patient and us with a road map to how well they're doing initially and then how well they are doing when they leave our office. It's such an incredibly objective way to determine whether or not they are appropriately amplified or not. That technology has been around for many, many years. I remember doing it for infants, trying to set them up with instruments appropriately, using real ear measure. It is a tool that's been well established. It has such a great impact just even on patient interaction. They get to see where they were, the changes that are made and while this is all happening in there, it's interactive. They're seeing and hearing how well the instruments are functioning for them and I think they appreciate that kind of care and concern. Dr.
Blaise M. Delfino, M.S. - HIS:Beck, for our listeners tuned in right now who maybe aren't aware of what real ear measurement is. Maybe we have a few audiology students tuned in. What is real ear measurement and why is it essential when fitting patients with hearing aids and should everyone who fits hearing aids be doing and conducting real ear measurement?
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:Yes, so real ear measures. Every single peer review journal in the history of the world has said that's the way to fit hearing aids. There are no peer reviewed articles in the literature at all that say it's okay not to. There are no national groups of professionals that say it's okay not to. So that should be a bit of a warning, a bit of a heads up that this is a really important part of fitting hearing aids. Now sometimes professionals have said well, I can't afford a real ear machine. You know they could be expensive. They could run a couple of thousand dollars, maybe a little bit more. But then the question is can you afford to really be doing this? Because you have to have the tools of your profession. If you're a car mechanic and you don't have a set of ratchet wrenches and you just say, well, I have a vice grip, well that's awesome and that might work for you, but you're not taking the cylinder head off my car with a vice grip. You know my car costs whatever it costs and I don't want it stripped out, right, and it's the same. If you're a plumber, if you don't have one of those snake things, how are you going to clear a blockage? Well, those snakes, man, they're like so expensive I don't have one of those. Well then, can you really afford to be a plumber? So I don't want to be snarky or mean, but if you can't afford a real ear system, then the question becomes can you afford to do this job properly? Because if you're not doing it properly, then perhaps it's better left to somebody who is doing it properly. As Dr Dolfino was saying, this technology has been around for almost 40 years now. Everybody who's looked at this seriously has endorsed it as something that we must do. So for the novice who's not sure what real ear measures are, we take an incredibly small microphone it's called a probe mic and we put it within 5 millimeters of your eardrum and then we take an unaided measure sometimes to see just how does your ear canal respond to sound, because everybody's is different. You don't understand this information without real ear. That is, the average ear canal resonance for a male is about 2700 hertz and for females it's about 3100 hertz. So what that means is we expect to see. If we just do a pure tone sweep we go All the way, you know, lows to highs that was my best beer tone sweep. But so if we just do that, we expect in a male ear canal there should be a peak at about 2,700 Hertz, and what that means is that the human brain for males here's about 2,700 Hertz, about 10 or 12, 15 dB louder than it hears 250 or 8,000 Hertz. Same is true of females at 3,100 Hertz on average. So we take these incredibly small mics and we can see what the unaided ear canal resonance is, and then we put the hearing aids in set how they're supposed to be and we turn them on and we measure and we see are we getting the curve we expected at that microphone? Because if we're not, we could be overfitting, underfitting or incorrectly fitting. We might have too much lows, too much highs, too much midrange. So all of those things can be adjusted in modern hearing aids that are professionally fit. We can. It's a total mixing board. We can change all the sounds, we can change the relative weighting, we can change how much gain there is, we can change the maximum output, and most folks getting fit for hearing aids don't understand this. But it's such an important concept. When you have a professionally fit hearing aid, there's something called MPO, which is maximum power output, and when you think about it it's almost counterintuitive. What we try to do with hearing aids is add the most power for the quietest sounds and then when sounds are pretty normally loud for the patient, we don't really need to amplify those at all. And the most important thing is that when a loud sound comes in, the hearing aid should functionally do nothing. So the thing is that people with hearing aids are going to be on loud environments, but the hearing aid should not be amplifying loud environments and that's the basics of compression. So compression, particularly wide dynamic range compression, the purpose of that is to amplify the softest sounds so that they're audible, comfortable and fine, but loud sounds shouldn't be amplified at all. This is the beautiful thing with Reallier is you can introduce a soft sound to that hearing aid a medium and a loud and you should see three different responses. And if you're doing it properly, then you can rest assured you're not causing damage to that auditory system, you're not causing acoustic trauma, you're not causing hearing loss in that patient due to overexposure of sound. You know I used to be an expert witness in all sorts of audiologic matters when I was in private practice and I remember doing a search of the peer reviewed literature in PubMed, which is the National Institute of Health's repository of peer reviewed articles, and one of the questions was does a properly fitted hearing aid cause hearing loss? And the last time I looked this up was probably 17 years ago, but the answer was no. A properly fitted hearing aid has never caused hearing loss. Improperly fitted hearing aids may cause hearing loss because the sounds become too loud too quickly and then too much exposure to sound. It's very important that we have professionals that are measuring Reallier, because that assures us that we're within a safe balance.
Blaise M. Delfino, M.S. - HIS:Dr Beck, when you conduct Reallier measurement and we're conducting Reallier measurement on all of our patients and new hearing aid fittings and also annual hearing aid fittings, if you will, when the patients come back for their annual hearing evaluation, sometimes patients will prefer the software best fit versus the live speech mapping Reallier measurement adjustments Yep, We've only experienced this a couple of times, but we have experienced it. What is the cause of that?
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:So one of the things that my students hear all the time is everything depends on everything and you know individual brains like specific sounds. However, brains over time adapt to other sounds. The sounds that you liked when you were 16 years of age the way you used to set your stereo, may not be the same way you set it when you're 65 years of age. And patients adapt. When they have hearing aid fittings they tend to get used to a sound. They tend to think of that as the natural sound. They tend to like that. When they take their hearing aids out, they feel very disabled because all of a sudden their brain is getting much less information and it's not comfortable. It's like right now I'm wearing contact lenses so I can see pretty clearly up, close and far away. When I take my contacts off, I have really bad visual problems, you know. So I might put on glasses one day if I'm doing a lot of reading. They're just more comfortable than contacts all day. So it's situational and it depends on what I'm doing and what's more comfortable in that environment. One of the discussions we have with Rear Lear is did you hit target or not? Well, the reason that we have targets is because we've looked at hundreds and hundreds of patients over years and years and years and we know that certain hearing losses tend to like this type of fitting. That's the target, but that's not every single patient every single time. It just gets you in the ballpark. But the important thing is that you have quantified exactly how much sound that hearing aid is putting out. So patient comes back the next year and they may like a little bit different sound. Well, that could be. Maybe they've developed some hearing loss, some listening problems, maybe some cognitive decline, maybe some dementia. Maybe the hearing aid has a little bit of wax in it, maybe the hearing aid has some microphone moisture that's impacting how that hearing aid works. So then you reprogram it to their current needs. But of course you would clean the hearing aid first and check where you're going to do all that.
Blaise M. Delfino, M.S. - HIS:Redux it right.
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:Yeah, of course, redux it. That's a good thing to do.
Blaise M. Delfino, M.S. - HIS:Dr Beck, how can we as an industry continue to stress the importance of best practice to ensure that hearing aid users do not wear their hearing technology in the drawer?
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:This is a huge problem. I hate to put a number to it, but probably 10 to 30% of people who get hearing aids. They do keep them in the drawer, they're not wearing them and I think that's an issue that has a lot to do with counseling. When you do listening and communication assessments and you're fitting patients based on patient-centered care, based on best practices, it's much more likely that you're going to discover their deficits, their disabilities, their needs and so you can fit them appropriately. If all you have is pure tones, that doesn't necessarily fit the same bill and you're not going to get the same buy-in from the patients because you haven't dug as deep into their problems. So again we get back to diagnosis first, treatment second. I suspect the majority of people whose hearing aids are right now in the drawer didn't have a full audiometric evaluation, probably didn't have a speech and noise test, probably didn't have a listening and communication assessment, so they can't be expected to know how beneficial those hearing aids are. They're just wearing hearing aids when they think they need things louder and that's okay. We get that. That makes good sense. Hearing aids make things louder, but that's not the primary goal of a hearing aid fitting the primary goal of a hearing aid fitting is to make it easier to listen, to understand speech and noise.
Blaise M. Delfino, M.S. - HIS:Thank you, Dr Delfino, how would you explain our counseling program here at Audiology Services?
Dr. Gregory Delfino, CCC-A:It's patient-based. We see each individual as just that. They really are part of our family. We excise from them as much information as we possibly can with regard to what their listening situations are like, what their lifestyle is like, what their expectations are, and for some people that comes very fluidly. They're anxious and want to talk to us about what's going on in their lives and others. It's more a question and answer, drawing it from them, but obtaining as much information as we can about what their expectations are, what they've had in the past, really has a huge impact on their success here. We bring them through the process very slowly. Time is important, but not of the essence, and so every individual is given the amount of care, concern that they need, so that when they leave here, they know, first, that we care and, second, that what they're getting is best for their needs. So I think that's really what has made us successful.
Blaise M. Delfino, M.S. - HIS:Dr Beck, on behalf of the Hearing Matters podcast. Thank you so much for joining us, sharing your incredible knowledge and raising awareness of the importance of hearing healthcare and the importance of visiting an audiologist or a licensed hearing healthcare professional. Before we sign off, do you have any last words that you would like to share with our listeners?
Dr. Douglas L. Beck, AuD, F-AAA, CCC-A:Yeah, I want to thank you, blaise, and Dr Colfino, for being patient advocates. I think when you approach it from that viewpoint, what's best for the patient? How do I make sure that the patient understands what I'm going to do? How do I understand what the patient needs? When you're approaching it from that patient-centered care viewpoint, you're very, very likely to have a successful outcome and I think that's why you guys are thriving and I wish you continued success and I thank you for allowing me to blabber on for these last four or five weeks.
Blaise M. Delfino, M.S. - HIS:Thank you, Doug. Well, it's been a pleasure. Dr Beck, You're tuned in to the Hearing Matters podcast. We've had the pleasure of hosting our guest, Dr Douglas Beck. He is one of the most prolific authors in the field of audiology. Until next time, hear life story.