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Ethical Journeys in Audiology: Dr. Michael Page on Balancing Care and Professional Standards

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What if ethical practice isn't a destination but a continuous journey? Join us for a compelling discussion with Dr. Michael Page, an esteemed audiologist whose career has been profoundly shaped by his work in bioethics. Dr. Page offers invaluable insights into the universal application of ethical principles in audiology, sharing how his early experiences as a pediatric audiologist led to his involvement in a hospital bioethics committee. Listen as we uncover the foundational principles guiding ethical decision-making across diverse settings, transcending beyond specific fields like medical ethics.

Throughout the episode, we tackle the complexities of maintaining professional autonomy amidst business interests while ensuring uncompromised patient care. Drawing from Zeno's paradox, we explore the ongoing journey of ethical practice, emphasizing principles like autonomy, non-maleficence, beneficence, and justice. We address real-world challenges, including the ethical dilemmas that arise from industry relationships and the legal framework provided by the Safe Harbor Act. Our conversation illuminates the proactive responsibility audiologists have in discussing the long-term outcomes of untreated hearing loss and the importance of informed guidance over scare tactics.

From ensuring fairness and equity in professional relationships to balancing thorough patient care with business demands, this episode is a rich exploration of ethics in audiology. We highlight the role of organizations like the Audiology Practice Standards Organization in setting independent standards and the collaborative efforts of experts like John Coverstone. With ethical guidelines akin to those of the Rotary Club, we emphasize prioritizing the well-being of those we serve, underscoring the fundamental principle of doing the right thing for the right reasons. Tune in to gain a deeper understanding of the ethical landscape in audiology and beyond.

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Blaise M. Delfino, M.S. - HIS:

Thank you. You to our partners. Sycle, built for the entire hearing care practice. Redux, the best dryer, hands down. CaptionCall by Sorenson, Life is Calling. CareCredit, here today to help more people hear tomorrow. Fader Plugs, the world's first custom adjustable earplug. Welcome back to another episode of the Hearing Matters podcast. I'm founder and host Blaise Delfino and, as a friendly reminder, this podcast is separate from my work at Starkey.

Dr. Douglas L. Beck:

Good afternoon. My name is Dr Douglas Beck, I am an audiologist and today I am honored to have my dear friend, Dr. Michael Page. Dr. Page has served as a member of the Utah Cochlear Implant Team and as president of Utah Speech-Language Hearing Association, member of the Primary Children's Medical Center Bioethics Committee and board chair for the Division of Occupational and Professional Licensing. Dr Page has held adjunct faculty positions at Utah State University, Brigham Young University, University, University of Utah, Salus University, Drexel University, university of the Pacific, and, on and on, he served as chair and committee member of the AAA Ethical Practices Committee, manager of audiology cochlear implant program at Primary Children's Hospital in Salt Lake City and various management and executive positions within the industry. He's a business consultant for healthcare practices, education, general business, specializing in aspects of ethical practice, professional boundaries, industry relationships, contract negotiations, employee relations and improving workplace culture. That's a mouthful, dr Page. How are you today?

Dr. Michael Page:

I'm well. Thanks so much, and thanks for getting us together. This is a great occasion.

Dr. Douglas L. Beck:

It's always a joy. Usually I see you with a drink in hand and a cigar, but today's a little different. We've been trying to find time in our schedules, you and I, for probably six or eight months to get this done, and I want to make it an overview discussion of ethics and professionalism, because you certainly have that background and you give lectures on this topic all the time and it's a rarity in audiology we have probably eight or 10 people who speak on ethics, but we don't have that many and you certainly have the history. So tell me, how did you get involved with ethics?

Dr. Michael Page:

It's a great occasion actually, when you look back at some of the history of that and what shaped that portion of my professional career. I distinctly remember the day I was a pediatric audiologist this would have been likely in the late 1980s and I received a memo that came to all hospital personnel at the place where I was working and said we are starting a bioethics committee for the hospital. Any interested parties please apply. My eyes got big and I can't even tell you why I was interested because that wasn't something that I had pursued at that point. But I did apply and was accepted on that committee. That changed the trajectory of my understanding of ethics in general. Sitting around a big conference room table with physicians, nurses, billers, coders, parents everybody was represented and a file gets put in the middle and say let's talk about this. It was just incredibly enlightening and that began this journey of mine. That's great.

Dr. Douglas L. Beck:

I think that's a great way to tiptoe into it, because you know, we're all professionals and ethical dilemmas and ethical issues come up almost daily and it's not easy to navigate your way through. So tell me what's the definition of ethics? Let's start with ethics. And is that the same as medical ethics, or do you see those as two separate entities with ethics?

Dr. Michael Page:

And is that the same as medical ethics or do you see those as two separate entities? Actually, I see all of ethics as the same. In fact, talking the right way about ethics, we're beyond ethical codes and we get into principles of ethics, which really encompasses the definition of ethics. Once we're in the principle mode, I should be able to take universal principles of ethics and apply them to Little Sus principle mode. I should be able to take universal principles of ethics and apply them to Little Susie's lemonade stand and Aunt Martha's coffee shop, and I should be able to apply them forever. So definitions of ethics fall back on. Some of the research that was done by Beauchamp and Childress Started probably, if I remember, in the 1990s or so.

Dr. Douglas L. Beck:

Yeah, I remember that.

Dr. Michael Page:

Or principles, which are simply. They are the respect for autonomy, non-maleficence, beneficence and justice, and the definitions of those four actually encapsulate what we should understand about ethics in general. Give us the definitions, what we should understand about ethics in general. Give us the definitions. Definitions the respect for autonomy is the ability for me, as a clinician, to be able to practice autonomously. That means that I have no outside influences that would represent my choices or my professional judgments. It's also a respect for autonomy, for a patient's right to choose.

Dr. Douglas L. Beck:

All right Now if we just examine that one and we'll go through all four if you don't mind. So on autonomy, if you're in an office and they say, okay, we sell XYZ brand hearing aids and we do our vestibular tests in this protocol and we do ear cleanings using these tools, or whatever the example is, you know, if I want to sell a hearing aid that is of a different brand, whose ethics are we violating? Am I violating the ethics of the business or my own ethics, or am I compromising the patient? I mean, let's assume it's a special hearing aid, like a cross, let's say, you know, it's not the most typical, they're also not rare. And my company, the office I work for, sells brand X. I don't care for that brand, I don't get good results with it, I always use brand Z. So where does the ethical autonomy come into this?

Dr. Michael Page:

Sure, keep in mind that out of these four principles, nothing is ever black and white, of course, never 100% or 0%, and we're always going to be in the middle somewhere. I had a colleague of mine reach out and say it's impossible for me to be 100% ethical all the time. It's almost the principle of I think it's called Zeno's rule of paradox I think that's what it's called where we use the half. We always get halfway to the destination. We get from point A to point B, and then we go halfway in between, and we go halfway in between and we never really get there, but we always get closer.

Dr. Douglas L. Beck:

That is so funny that you said that, because I was having a conversation this morning with Blaise Delfino, my partner and I was explaining infinity in not pure mathematical terms, but I was talking about exactly the same. I said if you took a 10 foot distance between Dr Michael Page and Dr Douglas Beck and you said, okay, we're going to always half the distance every day. So the first day it's five feet two and a half feet, one and a quarter you would never get there because there's always a half to go and it's so interesting to me that you use that analogy today. But you're always moving forward, you're always going in the right direction, you're going towards that goal, but you can never get there because there's always half of whatever's left.

Dr. Michael Page:

So what's more important getting there or getting on the journey to getting closer to getting there? Absolutely, If we can't ever get there, then some people would say, well, if I can't get there, I'm not going to even go halfway.

Dr. Douglas L. Beck:

Well, this is very important because people will see the world in black and white. If that's all you got, that's great. But between black and white there's a bazillion different shades of gray, and that's kind of where we live.

Dr. Michael Page:

Yeah, no doubt about that. Back to your question about how is my autonomy? One of the things that I think is really critical is to ask ourselves what is the thief of my autonomy and what could potentially take my autonomy away as a practitioner, or what things would take away the autonomy of a patient or a candidate for a device that we might dispense to prescribe. And generally, if we look at the business sense and the business relationships we have with members of industry, I will contend that I think one of the greatest thieves of my autonomy as a practicing audiologist is any incentive or gift given to me by someone, by a member of industry, who wants me to buy their product.

Dr. Douglas L. Beck:

And this is a great dilemma because, as business people, we're clinicians and we're business people particularly if we're in our own private practice. There are just like in pharmacy, just like in surgical supplies, just like in any medical supply company, you get discounts for quantity. That's how business works. You know supply and demand. If you're buying more, you're probably getting a lesser price. We have examples of that, of course, with the VA, of course, with big box, they pay quite a bit less than regular practitioners would pay for the same product. So how does it fit into autonomy If I think I can see and take care of 10 patients this month?

Dr. Douglas L. Beck:

This is the typical hearing aid that I use and it's very programmable. It fits all their needs nine out of 10 times. So I want to stock up on that. So I call my manufacturer and I say listen, I'm going to get 10 of those this month. And they say in response okay, well, if you get 12, we can give you a better price. Now that's a dilemma, because I don't really want 12 to begin with, but I want the better price because I know I can probably sell nine or 10 this month and have a few going into the next month. What are the roadblocks there? What are the impediments?

Dr. Michael Page:

There are several things that come to mind. One is the Safe Harbor Act.

Dr. Douglas L. Beck:

Yeah, tell me about that.

Dr. Michael Page:

It asks us whether or not there's something legal or potentially illegal about these discounted arrangements we make with industry. Sure Harbor allows us to negotiate contracts with providers that give us a greater discount. Yes, that is considered legal, sure, and as long as these discounts are in a written contract, yes, we are in a legal realm.

Dr. Douglas L. Beck:

And so you are. So, legally, you're on safe ground because you're buying a product at a known price, a known quantity, from a known supplier, so that and it has to have a contract with it. And it has to have a written contract. All right, so that's the safe harbor In the safe harbor. Why did that come into being? What was the predisposing situation that called for the need for a safe harbor act?

Dr. Michael Page:

This was during the time when healthcare costs were rising at monumental rates and historically that was alarming for that particular era and administration politically. So that was what prompted that.

Dr. Douglas L. Beck:

All right, and you know that goes back even further. I mean, I remember I'm old enough to remember that before we had Medicare and Social Security, you know it was all fee for service, right. And those days things were very, very different. Because when Medicare came in and I say this respectfully, I'm not trying to make fun of them or anything but all of a sudden, you know, people realized that they could charge a code and an E&M code, a CPT, whatever it is, and never get paid for that. So all of a sudden, in that time period 20 years after Medicare came in, because that was like mid-60s when that came in people started charging more and more and more and really itemizing, because things that you would do in the office that you would never think to charge for, oh there's a code for that, there's a code for that. And things got really crazy out of hand. I remember that quite clearly.

Dr. Michael Page:

So it's also interesting. So if we bring this and circle this back to autonomy, how is it that if you negotiate the wholesale cost of hearing aids to be less, the question then is are you more likely to fit a particular hearing aid because you know that your margin is greater In a private practice? That matters and that's a reasonable way of thinking. If I work for a hospital or a large organization where I never see wholesale costs I never am aware of what invoice is coming across on that hearing aid I'm probably less likely to be influenced by which manufacturer I may choose, based on cost alone.

Dr. Douglas L. Beck:

Yeah, that's a very interesting situation. And when you're employing the Safe Harbor Act and so you're not under legal problems because you purchased it in a legal fashion, what about the selection of that product for that patient?

Dr. Michael Page:

Sure Well, I was in a time frame where I was managing a pediatric healthcare practice in a hospital. I was negotiating those contracts with the hearing aid suppliers and I would never divulge the contract to the audiologists that were practicing. I would never tell them that. You know, we have a greater discount over here. We have a lesser discount over here. I always tried to counsel them. Please do what's right and best for the patient.

Dr. Douglas L. Beck:

I like that plan If I have a staff of eight or 10 audiologists and I have a reasonable representation of hearing aids and other products assistive listening devices, you know whatever. So I have a reasonable assortment and I wouldn't tell them the wholesale price because then it could influence what they do. I get that. But now how do you apply that if you're in a private practice situation and it's the sole proprietorship and you're buying it and you're the clinician?

Dr. Michael Page:

There are several categories of ethics, but one of the categories that applies here is the ethics of self. That means what my self-awareness is. How likely am I to be influenced by discounts, by incentives, by gifts, by those kinds of things? And the government also says that discounts are gifts. Now, they're legal gifts under Safe Harbor Act, but they're not so legal gifts if that's just offered as a weekend special. And so I have to ask myself can I truly make the difference? Can I make the difference in my choice by selecting a hearing aid that's going to cost me more? I have less margin or do I go with the hearing aid that's going to cost me less? Greater margin will be 90% correct of what this patient needs, but in reality this other hearing aid probably would be better. And again, this is sort of that gray area.

Dr. Douglas L. Beck:

Yeah, we're back there again.

Dr. Michael Page:

We're back there again and we're always going to be there. But this is where we have to ask ourselves how do we check in on our own ethics?

Dr. Michael Page:

Let's put autonomy to bed and let's go to number two Non-maleficence comes from, kind of stems from what people call the Hippocratic Oath and do no harm. It actually didn't come from the Hippocratic Oath, although Hippocrates did say do no harm. But even at his stage in history, millennia ago, one of the first physicians was saying I can't cause harm to my patients. First of all, I must cause no harm to my patients, and so that's perpetuated over millennia. Now it's been interesting to see that what people call the Hippocratic Oath once taken upon physicians upon graduation, there are a number of medical schools who are no longer requiring the Hippocratic Oath Because, frankly, sometimes we do cause pain, we might cause harm, but it's in the realm of a greater perspective in terms of what the net result is. So non-maleficence. And we have to ask ourselves as audiologists how might I potentially harm a patient?

Dr. Douglas L. Beck:

There are clinical ways that we can do that accidentally taking ear impressions right, you know, certainly vestibular tests and electrococleography and ABR. I mean you know we do a lot of things that can potentially injure a patient. Don't we have a burden to explain that to the patient, that there are risks and downsides that could occur prior to engaging in whatever clinical tests we're talking about?

Dr. Michael Page:

And that would fall under informed consent, and so we will always have we should have a written informed consent, but in addition to that, I think, any procedure that would potentially cause some harm, we have, I think, a moral obligation more than anything, to inform a patient. I'm about to do this. There is a potential for this to happen. It's almost like going in for surgery and the surgeon says you know, there's a chance you could die on the table. I'm just giving you the informed consent Now. The likelihood of that happening is less than 1%. Would you like to proceed? And so we do that. So non-maleficence. But I'd like to explore non-maleficence in a different realm, and that is do our patients harm by not disclosing, for instance, the relationships we might have with industry? Do patients a disservice by selecting hearing aid A versus hearing aid?

Dr. Douglas L. Beck:

B. Yeah, I mean, that's a very important consideration, absolutely. And it's a very hard thing to prove, of course, because you know, even with the best verification and validation to prove, of course, because you know, even with the best verification and validation, you can sometimes achieve the exact same verification and validation outcomes and goals with multiple products.

Dr. Michael Page:

Sure, and if we had equivalent outcomes on two separate devices, one cheaper, one more expensive for us, but let's say the patient preferred one over the other? If we did that, we have that dilemma as well.

Dr. Douglas L. Beck:

Yeah, and I think more or less that if you're always working for the patient's best interest and if the patient says clearly I prefer this one, that's the answer.

Dr. Michael Page:

Yeah, it is the answer. I would say it's the answer for most of us. Yeah, but I know for a fact that it's not the answer for some.

Dr. Douglas L. Beck:

There are some people who would say that you should not discuss long-term outcomes for untreated hearing loss for patients who have perhaps diabetes, or patients who have cognitive decline or patients who have other medical things going on. You should just stay in your lane and I would argue, of course, that it's all in my lane when I talk to a patient who has diabetes about the need to have comprehensive audiometric evaluation, not a hearing screening. When I have a patient who doesn't do well on speech and noise and I do a cognitive screening and they don't do well, there, it seems it would be maleficent to not discuss with the patient the potential correlations between untreated hearing loss in at-risk patients. I agree with that wholeheartedly.

Dr. Michael Page:

We have that obligation.

Dr. Douglas L. Beck:

But there are people who are writing in our professional journals and I'm not going to mention any names who are saying, oh, you shouldn't discuss that with the patient, and I think it's our responsibility. I mean the same way that I would with a patient with auditory neuropathy or a patient who needs a cochlear implant. I don't think anybody should scare a patient into action ever, but I do think, since we are doctors and we have knowledge and we see these same things every day and we read journals and we write journals, you know, we know that people who are at higher risk for certain things it'll impact their hearing. I think we're in this very interesting age where we have so much knowledge about correlations between cardiac disease and hearing health care, between diabetes and hearing health care, between cognition, mild cognitive impairment, alzheimer's, other forms of dementia. We know a lot about patients who have hearing loss, particularly the at-risk group, which would be older patients, which would be patients who are in lower socioeconomic groups, and patients who are multiple pharmacy patients.

Dr. Douglas L. Beck:

Right, they're on five or more meds and I would say that in my view, it would be unethical to talk to the patient about these things. Being untreated could substantially make their hearing and listening ability. Worse, there are people in our profession who take the opposite view. They say well, you shouldn't talk to them about that because it's a scare tactic. I'm not trying to scare them into anything, it's not a scare tactic. And I wonder what's the point of having knowledge and education and reading journals if you're not using that for the patient's benefit, to help enlighten them as to the way their life may unfold? Would we?

Dr. Michael Page:

fault a primary care practitioner for not talking about related disorders that were outside of their specialties. And that's what they do every day, of course, and that's what we should do every day. We are specialists in some way, but we're not the specialist of everything. When we see risks and when we see potential or hints for other related disorders, I think we have the absolute ethical obligation to discuss those.

Dr. Douglas L. Beck:

Frankly, I've seen patients who have tick day of the room. I've seen patients who have Bell's palsy. I've done invasive electro-neuronography studies on these patients. You know we do so much more than just air, bone and speech. And I think you know you never practice beyond your area of expertise. You always practice within your license. But when you, you know it's the old. When you see something, say something.

Dr. Douglas L. Beck:

Now, when I have a patient with Bell's palsy, I don't treat them, I measure their Bell's palsy to help determine how long and how successful a recovery might be or whether surgery is indicated. And I can talk to the patient about that. I am not a technician, I'm a doctor. You're a doctor and I think that we are scared to practice to the top of our license. And I like your analogy that a primary care doctor. They send patients to orthopedic people all the time, to cardiovascular people, all the time to neurosurgeons, because that's not their area. But they will say Mr Smith, I'm a little concerned about that limp, it hasn't gotten better. Let's get you an MRI, let's get you over to orthopedics, let them take a look at that.

Dr. Michael Page:

That totally makes sense to me.

Dr. Douglas L. Beck:

And you wonder, you know, in audiology, though people would say, oh, that's a scare tactic, you're telling them this, that they should treat their hearing loss because you want to sell hearing aids. Well, I don't know, that's that gray area. I don't want to sell hearing aids to anybody who won't benefit from them, but I do want to sell hearing aids to people who would benefit from them, and I think that we're in that gray area again.

Dr. Michael Page:

Well, that comes back to, maybe, the definition of how we. Do we sell or do we dispense? When I go to the orthopedic specialist, do I expect him or her to sell me a new shoulder? They never talk in terms of selling a shoulder or selling a hip replacement. They don't. It is all about we're dispensing a medical or surgical device that will treat the disorder that you have.

Dr. Douglas L. Beck:

And do they ever say do you want the low one, the mid one or the high one? Do you want the premium, you want the premium hip, or do you want the cheap hip?

Dr. Michael Page:

Right, they don't. They don't. I think we've missed the boat on that so many times. That it alarms me and I'll tell you where I think that comes from is the tighter relationships that we've had with members of industry, and particularly where industry has come in to purchase private practices. Yeah, that creates a relationship that we're not quite used to. That's almost as if Pfizer would come in and buy out physicians, own physicians, and require their prescription of only Pfizer drugs. Would we tolerate that?

Dr. Douglas L. Beck:

I don't think so, not for a minute, I don't think so, and we have a strange relation with industry in our profession. So that's number two, and I appreciate the conversation on that. Tell me about number three, number three is beneficence and beneficence.

Dr. Michael Page:

these are simple principles, but beneficence is the proactive act of doing good.

Dr. Douglas L. Beck:

Yeah, and it's not just in your personal manner, of course. I would assume that when we talk about beneficence, we're talking about doing best practices. We're talking about doing things that our colleagues would all agree are necessary and are important and should be done in order to determine a diagnosis first and a treatment second. But I think we get caught up in this because many people won't do a complete diagnosis. You know they'll see mild to moderate high frequency sensory neural loss. That's interesting. Where did that come from? You know? And that means digging deeper. You know, if you look at scope of practice and best practice guidelines AAA, asha and IHS they all say the same thing, right, airbone and speech reflexes, timps, otoacoustic emissions. You might do a screening for speech and noise. You might do a test for speech and noise. You should do listening and communication assessments. I don't know anybody who does that.

Dr. Michael Page:

I think you're right. It's uncommon.

Dr. Douglas L. Beck:

And so you know, when we talk about, are we doing the very best for the patient? Well, you know, when you have AAA and ASHA and ITS and you have these very, very smart people all sitting down and deciding what's in the patient's best interest, based on outcomes, based on best practices, we know what we should do, but so many times we just take these shortcuts and to a large degree it's because we can't get paid to do the other stuff. So then how do you mix that in? Because now I know I should be doing an OIE, I know I should be doing high-frequency audiometry. I mean, holy moly, it's easy to do. Most audiometers can't do it unless they're more recently made, let's say the last 10 or 15 years. But we know how important high-frequency audiometry is, it's critically important, and yet it's probably not done in 90% of clinics. So how do we dot that I or cross that T? I mean?

Dr. Michael Page:

how do we make that right? It's fascinating, and these are some dilemmas that I found myself in, even managing a clinic, because I would have the finance people coming down and evaluating all of what we did, the amount of time we spent. We would create relative value, units, our views around which procedure that we conducted, and the bottom line was always you're not generating enough revenue to justify your existence. So they're saying what can you cut out? What will you cut out to justify your existence? And so then we argue just from an ethical standpoint. And all of that happens with most people who are in larger institutions. They're audiologists that are really given the charge by whoever owns that practice, whether it's a private person or an industry. They're given the charge to spend as little time as possible to get the amount of work and information done to fit a particular device. Those are the instructions, whether spoken or not.

Dr. Douglas L. Beck:

I was reading. Yesterday or the day before, there was a company that works for one of the major insurers I won't tell you their name and this company is hired as a contractor to deny claims. That's their job. So your doctor orders a test, your audiologist orders a test, your chiropractor, your whoever, and you want to get it pre-authorized. And this company, their whole goal. What they do is they look at that code and they say nope. And to me it's the same thing. Your doctor calls in a prescription to a pharmacy Walgreens, cvs, rite Aid, whomever and then the pharmacy calls and says oh, that's not on your formula, you can't have that, so we can give you this. Aren't they practicing medicine without a license?

Dr. Michael Page:

Yes, I've always felt that way.

Dr. Douglas L. Beck:

And again, I think we're back in the gray zone once again. So what are the guidelines for making sure you're doing the best for the patient?

Dr. Michael Page:

Practice Standards Organization that's relatively new. Apso has been around for a couple of years now the Audiology Practice Standards Organization. John Coverstone is the current executive director, but there have been many, many very astute voices on that in that organization to help us develop those standards.

Dr. Douglas L. Beck:

And you were mentioning to me earlier that those standards have been used in courts of law as practice guidelines. What we should actually be doing.

Dr. Michael Page:

Now the interesting part of that and one of the reasons I've been a fan of APSO, is because of their independent. That means sometimes our professional organizations get a bit hijacked by people who have a financial interest in the organization or in the people within that organization yeah, oh sure and where APSO will act without that outside influence of other individuals. So they've maintained that independence, which I like.

Dr. Douglas L. Beck:

Yeah, and I want to give a shout out to John Coverstone too. I was on the adult hearing aid committee for APSO and it was quite a good process. I can't tell you how many times we've met, but I want to guess between eight and 12 and two or three hour meetings and you have six or 10 experienced audiologists discussing what should we do and why should we do it, and it's a very democratic process and I think my hat's off to them. I think they do a great job.

Dr. Michael Page:

John and many others. I think John's been a very leveling force and a very persistent thread in that and lots of gratitude for anyone who has participated that, especially those subject matter experts like yourself and others.

Dr. Douglas L. Beck:

So yeah, it's a great group and anybody really interested, I'm sure. If you just Google APSO, they're always looking for volunteers. So let's move on to part four here.

Dr. Michael Page:

Part four of the principles of ethics that were originally described by Beauchamp and Childress is justice, and justice has a lot to do with, essentially, it's me getting what I came for and you giving what you're there and licensed to give. Justice has a lot to do with fairness, with equity and my relationship with my physician, etc. We see justice playing a role, though, in ethics in unfortunate ways where audiologists might get caught in a legal realm where they've been convicted of a crime or criminal activity or violation of codes of ethics or those kinds of things, and unfortunately there are some prolific presentations of those things. And we study those, not to bring fault against anyone, but we study them in the context of how could that potentially happen to me?

Dr. Douglas L. Beck:

Yeah, we've all seen those situations you know, written up in the papers and online, where you know there's liars, thieves and cheaters and you know they're charging for products that weren't delivered and they're charging CPT codes for processes that were never performed and, yeah, that's terrifically unfortunate.

Dr. Michael Page:

I think it's a sad reflection on those people in particular, but it does make consumers and patients wonder about the rest of us it sure does, and that's why, when these go to the newspapers, they will put the word audiologist in the headline.

Dr. Michael Page:

I remember years ago when an audiologist was convicted of murder and that was the headline in the newspaper Audiologist commits murder. Well, why would we say audiologist? Why would? Because we're held to that standard and we are, in the community's eyes, somebody that should have respect and credibility, so it behooves us to respect that as well.

Dr. Douglas L. Beck:

Yeah, and all of this, I think, would be wrapped up in the word humility. You know so, mike, when you have that feeling deep in your chest that something is wrong here, I mean it seems to me you would reach out to a trusted colleague and say I'm not going to give you names, not going to give you a chart, numbers, no identification. Here's what's going on. What do you recommend? And I've done that. I mean it's been decades, quite honestly, since I did that, but I've seen situations that really made me think this isn't right and I turned to trusted colleagues and they were more experienced than I and that was useful and I think we got the right results.

Dr. Douglas L. Beck:

Is there a pathway when you know something is wrong? There used to be something called the Green Book by AAA. I don't think I've seen an update on that in 20 years. Maybe it has been. If it has been, I don't know about it. What readings, what books, what publications and how would you suggest for an audiologist or hearing aid dispenser who finds that weird situation? How do you recommend people proceed?

Dr. Michael Page:

There's all kinds of directions. We could go with that, but first of all, let me mention that I think codes of ethics are essential for us, and yet their limitation is that they are I'm going to call them merely a checklist of do's and don'ts, and we should do those things or not do those things according to the codes of ethics.

Dr. Douglas L. Beck:

And you can extrapolate from the do's and don'ts. I mean, you don't have to write every single situation.

Dr. Michael Page:

Sure, and so if we look at those do's and don'ts, one thing I think has always been missing from codes of ethics is why what we see are things like thou shalt not, or those things. But what I'd like to see is, because of the principle of X, y, z, thou shalt not do this. Once we understand the reason why we do things, and so one of the references should always be, I think, first of all, legality. When we see something that we're concerned about, that's a dilemma for us that we witness. First question for me is is it legal or is it illegal? And if it is illegal, show me chapter and verse, show me the statute behind that. If it's not illegal, then I'd go to the next one Is it unethical?

Dr. Michael Page:

If it is unethical, then let's go to the code of ethics to which that pertains and find, identify that specific code, so that we understand that. If it's not found in the code of ethics, I'm going to ask just a moral question, and that is wow, what would my mom say, or what would the rabbi say, or what would the pastor or priest say? Those tend to be our moral guides, but overall, I've always tried to help us get beyond the codes of ethics and get into the principles of ethics. So if we're still not quite there with legal, ethical and moral, then let's go to the four principles which we just discussed. Is somebody's autonomy being broken? Is someone being maleficent? Is someone not being or exercising beneficence? Or again, is this an aspect of justice or fairness or equity that we should address?

Dr. Douglas L. Beck:

And I think that's great, Dan. That decision tree makes good sense. Is there a particular book or a particular article that you're aware of that would serve as a good guideline for people who want to learn more about this?

Dr. Michael Page:

Well, let me toot my own horn for just a minute. Bob Traynor and Glazer's book is coming out in the spring of this year, which is on practice management. Bob Traynor asked me if I would write the chapter on ethics for that, which is a little different approach. He had mentioned that he was very much moved by some of my approaches to ethics and that I was one of the first guys that told him why why we have to have these ethics. And so he said would you write the chapter for my textbook coming up, which I did. It's been submitted, but I approached that a little different way as well, and I think that I'm hoping that will become a great resource.

Dr. Douglas L. Beck:

That's fantastic. I'm glad you mentioned that. Well, listen, I want to thank you, Mike. I know we could talk about these things for hours and hours and hours, but I appreciate the encapsulation and the update and I'm really glad to hear that you wrote that chapter. I think you're the perfect person for it. Bob Traynor, Bob Glazer have been friends of mine forever and I'm really glad you're involved with them. I think they do a great job writing books and I think they do a great job lecturing, so I'm sure you're going to fit in just fine and that book will be a bestseller. So, Mike, I want to thank you. It's a joy to spend time with you, even without cigars or bourbon, you know, but we'll do that again, and I really appreciate your knowledge on this.

Dr. Douglas L. Beck:

This is an area where I think all professionals need to be aware of, and certainly be cognizant of, the ramifications of doing things right and doing things wrong, and I think that it's what your mom always told you right Wash your hands flush, take care of other people. And I think also, when you think about I don't know if you've ever seen the Rotary Club, they have guidelines that go very much the same as these ethical guidelines my dad used to be a big wheel at Rotary and they had all these decision points which were, you know is it fair for everybody involved? Is it ethical, Is it moral, Does it make sense? Are you doing it to help somebody? Are you doing it to hurt somebody? You know all of those decision points and I think they all get you to the right thing, which is, you know, do the right thing for the right reason and always take care of your patient first.

Dr. Michael Page:

Thank you, that's a great way to wrap up. Thanks so much for today. My pleasure, mike.

Dr. Douglas L. Beck:

Talk to you soon.

People on this episode

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Blaise M. Delfino, M.S. - HIS

Host
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Dr. Douglas Beck

Co-host
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Dr. Michael Page

Guest