Best Practices in Hearing Healthcare feat. Dr. Douglas L. Beck | Oticon

About the Hearing Matters Podcast

The Hearing Matters Podcast discusses hearing technology (more commonly known as hearing aids), best practices, and a growing national epidemic - Hearing Loss. The show is hosted by father and son - Blaise Delfino, M.S., HIS and Dr. Gregory Delfino, CCC-A. Blaise Delfino and Dr. Gregory Delfino treat patients with hearing loss at Audiology Services, located in Bethlehem, Nazareth, and East Stroudsburg, PA. 

What are Best Practices?

Dr. Beck explains that best practices are not set by individuals in the hearing healthcare profession. They are determined and codified by a group of national organizations. The International Hearing Society, the American Academy of Audiology, and the American Speech and Language Hearing Association assemble groups of experts, who come together and decide what practitioners need to do for their patients. They use outcomes-based research to make their determinations.

Best practices include, but are not limited to: air and bone conduction, word recognition, speech reception thresholds, otoacoustic missions, ipsi and contralateral reflexes, tympanometry, speech in noise testing, and communication and listening assessments.

Why are Best Practices Important?

Best practices follow the primary thought used by physicians: diagnose first, treat second. A physician will not prescribe antibiotics simply because a person has a cold. The cold could be caused by a virus, and antibiotics would not help. As with medical care, hearing healthcare is not one size fits all. Research has shown that people who go to practitioners who use best practices do much better than those who do not. Audiology Service strictly adheres to best practices, and only one percent of patients return because they are unhappy with their hearing instruments.

Real Ear Measurement

A procedure known as real ear verifies that the fitting the practitioner does is meeting the standards and is giving the patient the best possible hearing experience and meeting his/her goals. About 50 percent of hearing healthcare practitioners use real ear, but only about one in five use it on every patient. 

To do real ear the practitioner inserts an incredibly small microphone into the ear canal within five millimeters of the ear drum. A measurement is taken to determine how the patient’s ear canal responds to sound. The measurement is taken again with the hearing aid in the patient’s ear. The practitioner measures to determine if the hearing aid is producing the sound curve that is correct. If not, the patient may hear loud noises too loudly and soft noises not loud enough. The practitioner wants to get the most power for the quietest sounds and not increase the power when a sound is normally loud to the patient. If a hearing aid is not adjusted properly with real ear, the patient may suffer damage to his/her auditory system.

Discussions with the Patient

Dr. Beck explains that having a discussion with the patient is far better than giving him/her a questionnaire to fill out. It helps the patient feel secure with the practitioner’s expertise and gives the practitioner the chance to fully understand what the patient is experiencing and how best to fix the probl

Transcript

Blaise Delfino: 0:06

You're tuned into the Hearing Matters Podcast with Dr. Gregory Delfino, and Blaise Delfino of Audiology Services and Fader Plugs, the show that discusses hearing technology, best practices and a growing national epidemic hearing loss. On this episode, we are going to be discussing best practices. And we have Dr. Douglas Beck joining us again on this episode. Dr. Beck, what are best practices and how important is it for hearing healthcare providers to implement best practices while treating patients who present with hearing loss? One of my favorite questions, if you were to go up to 25 different hearing care providers, whether they be ENTs, audiologist or hearing aid dispensers, and you ask them that question, you're gonna 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 missions, we need to do Ipsy and contralateral reflexes, we need to do tympanic drums, 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. And the best reference I can give you for this for a quick read is if you go to hearing review, calm and just look up Michael Valenti, 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 hearing review.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 addition of hearing review in July or August of 2020. But you know, it covers that you're not just fitting ears, you're not just fitting pure tones, you know, 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 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 and 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 to pentagrams Well, because that tells us about the mobility of the eardrum. And we know that in the presence for example of acute otitis media, separative otitis media, disarticulated set of articles, 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 why 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 it 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 the license in that area of healthcare. Dr. Beck, do patients who receive best practice or high standard of care do better than patients who received subpar treatment? 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 what by 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, triple A's best practice reading ashes, 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? And is that wow, I do real ear! Yeah, I do real ear. So real ear, real ear is a great example. Because you know, 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 IRS seeks to do, it verifies that the fitting that you have supplied the patient with his meeting, a recognised standard, it could be something like national acoustic labs NAL2 and in NAL2, it could be DSL five, 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 3300 hertz. Oh my gosh, the total harmonic distortion, I think it's 7%. You can't make those guesses. There's no such thing. You can't even hear that when the hearing aid is malfunctioning sometimes, right? 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 Anssi 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 on 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 or validation is did you meet the patient's goals, you would discover that by doing listening and communication assessments such as the cosy, which is client oriented scale of intervention, ha ha hearing healthcare inventory for adults, HHIE, hearing healthcare inventory for the elderly, you could do the SSQ, which has speech and spatial sound qualities, you could do the IOI, international outcomes inventory, these are all Likert 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 Likert scale, like the cozy like the IOI, like any of these things, and have them fill it in at home and bring the very best thing you can do is work through whatever scale you're using with the patient. Because it gives you have the opportunity to have that conversation with patient, they realize you're interested in this. And if you're just looking at the outliers, it's very, very different because they're expecting us as professionals to listen to them to engage in conversation is the same with tinnitus patients. I never give them the thsi. 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 th II the tinnitus handicap inventory. And I think the patient and I both get a lot more out of that than if I just sit here fill this in. 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 our 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 has 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 a 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. And this is how the hearing is 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 positively influenced our patient fittings

Dr. Gregory Delfino: 9:24

It really provides both the patient and us with a roadmap 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. I think they appreciate that kind of care and concern,

Blaise Delfino: 10:06

Dr. 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? Yes. So real ear measures, every single peer reviewed journal in the history of the world has said that's the way to fit hearing it. There are no peer reviewed articles in the literature at all. That say it's okay not to, there are no national groups or 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 $1,000, 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 vise grip. Well, that's awesome. And that might work for you. But you're not taking the cylinder head off my car with a vise grip, you know, my car cost 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 it's I don't want to be snarky or mean. But if you can't afford a real IRS 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, is Dr. Delfino was saying this technology's 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 really our measures are, we take an incredibly small microphone, that's called a probe mic, and we put it within five 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 really 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 chance we go all the way, you know, lows to highs, that was my best period on sweet. So if we just do that we expect in a male ear canal, there should be a peak at about 2700 hertz. And what that means is that the human brain for males hears about 2700 hertz, about 10 or 1215 Db louder than it hears 250 or 1000. hertz. Same is true females at 3100 hertz on average. So we take these incredibly small mics, we can see what the unaided your canal resonances, and then we put the hearing aids and 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. Under fitting or incorrectly fitting, we might have too much lows, too much highs, too much mid range. 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 hearing aid should functionally do nothing. So the thing is that people with hearing aids are going to be allowed 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 real ear 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 Institutes of Health 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 As the sounds become too loud too quickly and too much exposure to sound, it's very important that we have professionals that are measuring real ear, because that assures us that we're within a safe bounds Dr. Beck when you conduct real ear measurement, and we're conducting real ear measurement on all of our patients and new hearing aid fittings, and also annual hearing aid fittings, if you will, when they patients come back for their annual hearing evaluation. Sometimes patients will prefer the software best fit versus the live speech mapping really, or measurement adjustments. We've only experienced this a couple of times, but we have experienced it, what is the cause of that?

Dr. Douglas L. Beck: 15:43

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 real ear 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 and 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. It'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 Redux Redux that that's a good thing to do.

Blaise Delfino: 17:26

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: 17:37

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 or 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 or 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 Delfino: 18:48

Dr. Delfino, how would you explain our counseling program here at Audiology Services?

Dr. Gregory Delfino: 18:55

It's patient base, we see each individual as just that they really are part of our family, we excised 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 into 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 Delfino: 19:46

Dr. Beck on behalf of the Hearing Matters Podcast, thank you so much for joining us these past couple of weeks, sharing your incredible knowledge and raising awareness of the importance of hearing health care and the impact hortence 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? Yeah, I want to thank you Blaise and Dr. Delfino for being patient advocates. I think when you approach it from that viewpoint, what's best for the patient? How do I make sure 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.

Dr. Gregory Delfino: 20:34

Thank you.

Blaise Delfino: 20:35

It's been a pleasure, Dr. Beck. You're tuned into the Hearing Matters Podcast with Dr. Gregory Delfino, and Blaise Delfino of Audiology Services and Fader Plugs. If you tuned in the past couple of weeks, 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, and he is the Vice President of Academic Sciences at Oticon. Until next time, hear life's story.