A Real Ear Measurement Workflow For Better Hearing Aid Outcomes

Guessing is easy. Verifying is better, and in hearing aid fittings it can be the difference between “good enough” and genuinely clear speech. We sit down with Madison Levine, BC-HIS and Dr. Dave Fabry to unpack what real ear measurement actually looks like in a busy clinic, starting with a simple question: when should you run REM, at the first fitting or later? 

We share a first-fit workflow that’s built for speed: prep the room, connect devices ahead of time, set expectations the moment the patient sits down, and run verification before anything else steals the clock. Then we zoom out to the bigger “why” behind probe microphone measures, including how REM helps confirm audibility at the eardrum regardless of prescriptive targets, proprietary algorithms, or fitting software defaults. 

Dr. Fabry also lays out a practical verification protocol: multiple input levels, automated REM to match targets efficiently, and the often-missed safety-and-performance checks like MPO sweeps and LDL/UCL so comfort is protected without throwing away dynamic range. We end with the uncomfortable question: if the evidence is strong, why isn’t real ear measurement universal, and what can clinicians do to remove the time, cost, and confusion barriers? 

If you care about hearing aid verification, audiology best practices, and better patient outcomes, hit play, then subscribe, share with a colleague, and leave a review. What’s the biggest obstacle keeping REM consistent in your workflow?

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Transcript

Quick Intro And The Big Question

Blaise M. Delfino, M.S. - HIS 0:00

This is the Friday Audiogram. Let's go. Madison, walk us through your real ear measurement workflow. And the reason I really want you to dive into this, Madison, is because there are some hearing care professionals who will say you have to do it at the first fitting. There's some who will say do it at the second follow-up. So what is Levine Hearing's real ear measurement workflow? And what does that appointment look like for your patient?

Madison Levine, BC-HIS 0:30

It certainly is going to be clinic by clinic, right? So my way is not the only way, but we have found doing it on the first fit is very efficient. So when we're getting that equipment ready for the patient to walk out of the waiting room into our exam room, we have real years set up. We've got everything oriented in the room correctly. We've got the devices already connected to the computer. So when the patient enters the room, I try to make things a little funny when they're awkward. So I'll say, I know it's really weird. We're putting you in this position in this chair. Just take a seat. We're so excited to get you fit with your new hearing aids today. How are you feeling about it? So we put them right into position from the first moment. So we're not losing any time. It makes it very efficient. Once they're seated, we're explaining what to expect at this fitting appointment. And we go, okay, we're gonna run this test. And that's the very first thing that we do. And in doing that, it just makes it kind of takes the awkwardness and keeps it at the front of the appointment. And we get everything wrapped up in less than 10 minutes, and then we're able to get to more of the fun stuff.

Blaise M. Delfino, M.S. - HIS 1:39

I love that workflow of implementing Reel Ear on that first appointment because then at least you can toggle back and forth with the adaptation manager if need be, or tell here. But Dave, what have you found? And you are a major thought leader for lack of a better term, but you have seen the evolution of Reelier while it's the same in concept throughout the years. What have you found to be a real ear measurement appointment that works best for you? Is it still that first fitting, or do you kind of wait for a follow-up? Like what does your process look like?

Dr. Dave Fabry 2:18

Yes, in answer to your question, I do it at first fitting. I do it in follow-up. I don't wait for problems to occur for doing real ear measurements, because I believe that while real ear is not the end-all be-all, I want to be very clear on that. I think that if you don't do real ear, it's like practicing by astrology instead of by astronomy. It's still a mixture of art and science, but at least we can put the planet and the moons and get them in alignment. And by that I mean using real ear ensures audibility and ensures what I'm really looking for, independent of the fitting formula. And that's a different topic that we could go down rabbit holes as to whether proprietary or non-proprietary targets. When I was on Madison's side and a manufacturer said, Oh, well, our proprietary targets have been optimized for our technology, I would say, can I verify it? And they'd say, well, no. And I'd say, well, come back when it can. Well, now it can. And so within the Inventa system, the trumpet that I use as well, I mean have, because of its portability, because it incorporates speech testing, audiometry, and real ear measurements, it's ideal for my type. I'm licensed in Florida, California, Minnesota, and Rwanda. And so I'm very much likely to be on the go at some time doing either remote telehere or doing face-to-face audiometry and real ear measurements for the start and for uh after the fitting. My protocol is and my goal with real ear is very simple. Regardless of what formula I'm using, I'm trying to get a relatively smooth real ear-aided response. That prevents feedback in high-powered situations, improves sound quality for everyone across the board from mild to severe or to profound in degree, and really starts to set up as all hearing aids these days, almost all are nonlinear amplifiers. I use three input levels. I personally use 50 because my room where I do testing is pretty quiet. I mean, some people will bump it up 5 dB or so to get over the noise floor. My room is quiet, so I do 50, 65, and 80. And I use AutoREM. It's another tool that is incorporated within the Inventis system with the Starkey ProFit software to enable an automated solution that is faster than what I can do alone, if you will, on manually for those three levels, because it will not only do the three levels, but it will match to within a criterion amount of plus or minus 5 dB of the target, and then allow for manual adjustments before I go on. In addition, I always do an MPO sweep and I typically do LDL or UCL, whatever you want to call it, measurements to ensure that not only am I not exceeding the patient's measured discomfort thresholds, because that physical discomfort and acoustic discomfort are two things that will bring the hearing aids back fast for credit. And we don't want to see that. However, I won't say that it's almost as bad, but it is not a desirable contact to just set the MPO of the hearing aid at a level that leaves headroom for the patient, that is, residual auditory area above the maximum output of the hearing aid. If I'm leaving that on the table, I'm taking dynamic properties of sound away from the patient. So simply put, my strategy is to get a smooth, relayated response at three levels, ensure MPO never exceeds loudness discomfort level. I'm trying to provide as broad a frequency response as possible and trying to use as much of the patient's residual auditory area as possible to keep compression ratios as low as possible, which in my hands is how I achieve the best results from patients. I don't want to have compression ratios that are too high. So that's a little wonky, but I think it's important for people thinking about real ear. It's not, in my opinion, not simply saying, well, I use real ear measurements, and that's part of best practice, but understanding why you're using them is more important.

Compression Ratios And Patient Experience

Blaise M. Delfino, M.S. - HIS 6:14

Thank you for bringing that up, Dr. Fabry, because I think oftentimes we get so overwhelmed with the software and the technology of it. It's like, well, let's start at the basics with that compression ratio and what does that look and sound like, not only for us as hearing care professionals, what we're reading on real year, but also what the patient is subjectively experiencing. Madison, I want you to answer this next question first, and then Dave, I definitely want you to follow up. We know there's so much evidence in terms of real ear measurement and the importance of it and patient outcomes. Despite all that evidence, why isn't real ear measurement universally adopted?

Madison Levine, BC-HIS 6:56

My suspicion is that there's enough people who believe that data is a myth, but they don't really believe it. So I know that we might argue some people don't think there's enough time to do it, or maybe the investment in the equipment seems high. Those might be the case for some people. I still see on forums and out in the world plenty of people who are saying, ah, I don't really believe in it. So the data's in front of them, but there's mythology around it. Does that make sense?

Dr. Dave Fabry 7:30

I would add to that, and I think, yeah, time, money, I think confusion, because I think they get hamstrung by being told, well, you should use a proprietary formula or a non proprietary formula, or hooking up the equipment. The automated REM makes it simpler to get to that first space faster than you could do manually, as I said. But I think there is one other element with real that is a