October 11, 2022 • 31 mins
This is the 3rd and final episode of the mini series dedicated to hearing aid fitting standards. In these podcasts we’ve been reflecting on the Audiology profession’s commitment to providing evidence-based clinical practises that lead to optimal patient outcomes.
Julia van Huyssteen is joined once again by Dr Gus Mueller, a US based consultant for WSAudiology and Founder of the American Academy of Audiology.
In this episode, we mostly talk about hearing aid verification including using a validated fitting formula, the application of AutoREMS and In-Situ Audiometry and we also discuss how much fine tuning is allowed after performing verification.
Read more about Gus: www.gusmueller.net
Sounding It Out has been produced by Annie Day. A Fresh Air Production for Signia.
See omnystudio.com/listener for privacy information.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Julia van Huyssteen (00:09):
Hello, and welcome back to Sounding It Out. I'm Julia
van Huyssteen, the Head of Audiology at Signia. This is
the final episode of a three- part mini series about
hearing aid fitting standards. If you missed the first two
episodes, you can download them for free from your usual
podcast provider. And remember to follow or subscribe so you
don't miss our further episodes. If you found these conversations
(00:31):
helpful, please tell colleagues, friends or family, so as many
people hear the wonderful advice you've heard. I'm pleased to
say I'm still joined by American audiology guru, Dr. Gus
Mueller. Thanks once again for your time.
Dr. Gus Mueller (00:46):
Hey, absolutely. And thanks for the invite. The only thing
I'm not liking about this is the word final. I
thought we could keep doing it all year long. But maybe it isn't
final, final. Who knows?
Julia van Huyssteen (00:57):
Who knows? And we can certainly do another series with
you visiting over to the UK.
Dr. Gus Mueller (01:02):
Sounds great.
Julia van Huyssteen (01:04):
And we are still joined by our live audience. Welcome
back to you all. Now, Dr. Mueller, before I ask
our first question, I'm just going to remind our audience
that the hearing aid fitting standards that you've helped put together
last year is divided into 15 standards. During the first deep-
dive, we focus on pre- fitting assessments and during this
second deep- dive, we will discuss some of the remaining
(01:24):
seven standards which focuses on the hearing aid fitting onwards,
mainly around verification. So we'll start with our first juicy
question for today's episode. And it is around standard 10,
which focuses on programming hearing aids using verification. Now, bearing
in mind that verification is not performed as standard across
all of our channels in the UK. Channels, meaning public
(01:45):
sector, key accounts and independents. I'd like for us to
revisit the importance of making verification a hearing aid fitting
standard. It is within this context that I think we
should focus on a few verification topics. The first is
using a validated prescriptive method, the second is using verified
(02:05):
ear canal output, and the third is optimizing the patient's
residual dynamic range. So let's start with the first one,
using a validated prescriptive method. I get this question often.
Do we use NAL, or do we use your proprietary
prescription formula? Isn't NAL a little bit dated? For example, NAL-
(02:26):
2 prescribes for 17 frequency channels, whereas some hearing aid
instruments have got up to 48 or even 64 channels. What
is your take on this part of the fitting standard
about validated prescription method?
Dr. Gus Mueller (02:39):
I guess to start at the beginning of how this validated,
first, that the key is validated, and second of all, prescriptive
method, like the NAL. People have come up to me at
times and said, " I don't believe in all that prescriptive
stuff. I have my own way of fitting hearing aids."
If you think about it, to get it right, you
really have to have good sound quality, you have to
(03:03):
have correct loudness restoration, you have to have good intelligibility,
you have to have hearing aid that the person's willing
to wear, and you have to fit all those things
together for every frequency and every input level. And how
are you going to come up with that yourself? So,
first of all, it's great that we have people like the
(03:26):
DSL people and the NAL, which has been around for over
40 years, who have really done all the work for
us. They did the heavy lifting. So I like to
just step back and use what they have put together
for us. As far as out of date, I don't
see that at all. Indeed, when we went to NL1,
(03:47):
that was when we started using wide dynamic range hearing
aids. And NAL- R only had target for one input
level. So NAL- R was out of date because we
needed targets for multiple input levels, which came to us in
NL1. 10 years down the road Harvey Dillon and his
crew did a lot of work with NL1 and said, "
(04:08):
Yes, there's some tweaking that needs to be done," although
it really wasn't major. Gain was reduced by about 3
dB I think in the mid- frequencies and some other
minor changes. So we have NL2, which has now been
with us, what, for 12, 13 years. The number of
channels in the hearing aid to me doesn't really matter
(04:29):
because, first of all, they're all overlapping. So when you
change one, you're really changing five or so. And we
certainly have enough key frequencies that getting a frequency in
between there really isn't going to change things. Audiograms are
pretty predictable and follow a pretty predictable pattern. That isn't
the issue. It's the issue of actually verifying that you
(04:52):
have the validated thing. Now you mentioned proprietary fittings. Well,
there's the word validated right there. I would encourage you
to go to every journal you can find that's peer-
reviewed, and find a manufacturer's algorithm that is published and
has been peer- reviewed. So I wouldn't even put that
in the category of validated, not my definition of validated.
Julia van Huyssteen (05:17):
And there's the issue as well when we talk about prescription
formulas, especially you mentioned manufacturers. Do they want their hearing
aids to sound nice? Is it about comfort? Or is
it about speech intelligibility in giving our patients access to
that speech that they need?
Dr. Gus Mueller (05:34):
Rumor has it, Julia, I actually work for a manufacturer out here. So
I got to be really careful here what I say. Manufacturers
have to sell hearing aids. They have to have a
product that patients are willing to wear on day one.
So you have to ask yourself what do patients like?
They like something that doesn't sound like a hearing aid. A
lot of times, if you let the patient program it,
(05:56):
they'll program back their own ear canal resonance that you
took away when you put an ear mold in the
ear. So, that's zero gain. And no loss, no gain.
But I understand if manufacturers know, and they do, that
the majority of people selling their product around the world,
and keep in mind also these proprietary methods are used
(06:16):
around the world. So if they know that around the
world, 90% of the people do not do verification anyway,
then I would say that they probably would come up
with a method that sounds pleasant. They would come up
with a method that doesn't have feedback, because audiologists like
to complain about products that have feedback, which means you're
(06:38):
going to roll off the highs, you're going to reduce
overall gain. And if I were doing a proprietary fitting,
that's what I would do. And that actually is what's
been done. The proprietary fittings across manufacturers are all pretty
similar. They have reduced gain, particularly for soft sounds. And
they all roll off gains compared to the NAL starting
(06:59):
at around 2K, by a sizable amount, by as much
as Mike Valente's study, who is indeed a peer- reviewed
study of a couple years ago. He found that in
the high frequencies, the product he was using rolled off
gain, on average, at 3K 15 dB and at 4K 20
dB. There's some important stuff going on out there that
(07:21):
I think our patients would like to hear.
Julia van Huyssteen (07:23):
Absolutely. And if you think about the bulk of speech information
in 3 and 4K, that important mid to high frequency
information, you'd certainly struggle with understanding speech with 15 to 20 dB
less than you actually need with a prescription formula.
Dr. Gus Mueller (07:39):
Sure. SII calculation has become very popular in the last
few years. And partly because the probe mic equipment does
it for you. You'll look at a proprietary fit and
it's not uncommon at all that had you fitted to
NAL, you'd be getting an SII about 20% higher than you're
getting from a proprietary fit. Audibility is an amazing thing.
(08:01):
I think we owe it to our patients to give
them audibility.
Julia van Huyssteen (08:04):
Absolutely. And that actually leads really nicely into my next
question, or the second part of that question, and that's
around verified ear canal output. Now, I've seen click and
fit outputs differ as much as, again, 15 to 20 dB in
those really, really important speech information areas. Why do you
think we have such a high percentage of unverified fittings?
Dr. Gus Mueller (08:26):
Yeah. I've been talking about this for, well, we wrote
our first guidelines back in 1990. And in those guidelines,
very clearly it said that you would do probe microphone
verification. So we're not talking about anything new. It never
occurred to me that when probe mic equipment came out,
everybody I hung around with was just delighted and said, "
(08:48):
Finally, finally we can figure out how all these darn
hearing aids work." It never occurred to me that 95% of
people would not be using this. We had thought, well,
of course you'd use it. But it didn't work that
way. It didn't work that way. I think that manufacturers,
I think do focus groups. And in their focus groups,
(09:10):
one of the things they hear is, " I'm in a
rush." They're hearing this from the people who they bring in, "
I'm busy. I need something that works fast and easy."
And the manufacturer says, " Well, our proprietary fit is fast
and easy." And the people say, " Well, the manufacturer says
it's a good thing to do, then it has to
(09:30):
be okay." Which isn't really where, as audiologists, we should
be getting our guidance. No offense to manufacturers. But their
job is to build hearing aids; our job is to
fit hearing aids. I have never tried to build a hearing
aid in my life, and it would be a piece
of crap if I did. I stick to what I
do. Manufacturers, they do something else. They build very, very
(09:52):
good hearing aids. And that makes a great partnership if
we stay in our own lane, is the way I
see it.
Julia van Huyssteen (10:00):
So the final part of the question then is about
optimizing the patient's residual dynamic range. And most manufacturer software
will predict the MPO based on averages. We talked earlier
about ULLs and building that into our pre- assessments. And
I also know that you did some research last year
on what happens when you allow the manufacturer to pick
the MPO. Can you provide us a summary of the
(10:22):
findings of this research?
Dr. Gus Mueller (10:23):
Yeah. Well, there's two things. And this was a study done
with some people at the University of Iowa, Dr. Wu
and Dr. Stangl. We looked at the premier hearing aids,
the six main companies and we put the same audiogram
into all of them. First of all, we did measures
to see what we would get as the maximum output.
(10:47):
And with the exception of one company that did pretty
well, most of the companies, when programmed into their NAL,
the output was about 20/25 dB below what we would
predict as the person's LDL, based on the NAL prediction,
which is in the NAL software if you get the
(11:07):
original NAL software. So, that's problem number one. Problem number
two, then, we put in this audiogram that was a
typical audiogram going from 25 in the lows, down to
70 in the highs. What we would consider easy to
fit typical audiogram. We put that in, had picked the
manufacturer's NAL. And again, then went in to see where
(11:32):
the manufacturer set the output. Because you just go to the AGCo
kneepoints and you can see where the output is set.
And most manufacturers, somewhere in the fitting software, just has
that on a little tab that you can read the
numbers. What we found is... Well, first of all, we
said we wanted a NAL fit. So this should be pretty
easy, you would think. For that particular patient, what the
(11:54):
NAL said in a 2cc coupler, it should be 98 to 102,
low frequencies to high frequencies. 98 to 102. Well, that's pretty easy,
you would think to program. Right? We had some falling
10 to 15 dB below the NAL, and we had some 10
dB over the NAL. If we looked at the lowest
(12:15):
and the highest among manufacturers, the difference was 25 dB.
That means a given patient's MPO could be set different
by 25 dB just depending on what manufacturer you picked.
And the sad thing is, I'm afraid a lot of
people don't even know that. It's something that just doesn't
(12:36):
get a lot of attention, which goes back to podcast
number two that why not do LDLs and set the
MPO yourself? And then you don't have to rely on
somebody else to do it.
Julia van Huyssteen (12:48):
I think considering the evidence that you've just shared with
us, it actually makes that standard a standard.
Dr. Gus Mueller (12:53):
Yes.
Julia van Huyssteen (12:53):
It makes it essential. And that's why it's one of
the standards.
Dr. Gus Mueller (12:56):
That's why it's there.
Julia van Huyssteen (12:57):
Yes, absolutely.
Dr. Gus Mueller (12:57):
That's why it's there. Yeah.
Julia van Huyssteen (12:57):
So the next question is around another topic of interest
at the moment, and that is AutoREMs or AutoREM fitter or however the
manufacturers call it. So here we go. There's a curve
ball here. During COVID, a few hospital departments here in
the UK incorporated remote in- situ gram, so this was when you do
a hearing test with the hearing aids in situ, as
(13:19):
the second best option to doing REMs. In the remote
fitting pathways, this is kind of what they resorted to,
is in- situ gram. Now I know you've written a couple
of papers about REMs versus AutoREMs recently. Bringing then in-
situ gram into that conversation, how do you think it
compares to do something like that with the hearing test,
with the hearing aids in situ versus AutoREMs, versus your
(13:40):
manual REMs?
Dr. Gus Mueller (13:42):
Okay. Two different things. So let's take the in- situ
gram first, which Widex put that out many years ago
and wrote about it. And a few Widex customers picked
it up. It isn't commonly done, but that doesn't mean
it isn't good. If for some reason you cannot do
probe mic verification, you then could do this. And in
(14:06):
most cases, you would get a better fit than not
doing anything. It does account for the RECD, which is,
if the only difference, if the reason that the fits
aren't good was because of variance from person to person,
then in- situ fits would be okay. The problem is
(14:29):
that isn't the reason that fits are so bad. The
fits are so bad is that the manufacturers, NAL target,
is not the real NAL target. Well, your in- situ
gram isn't going to help you there at all because
you're still going to plug in those numbers, and you're
going to get a fit from the software that is
not really the NAL. But on the fitting screen, I
can assure you it's going to be a beautiful fit.
(14:50):
And people believe it. They look at that cartoon and think
that that's what's going on in the real ear when
it isn't. And there's tons of data to show that
if you take various manufacturers and fit to their NAL,
you get roll off in the highs just like you
get with proprietary fits for the very same reasons that
you get that. So that's where a situ fit's not
(15:11):
going to help you at all, because you're still using
the wrong targets. Now AutoREM fit is really a different
thing and AutoREM fit is to increase efficiency. So for our
listeners who aren't familiar with this, I use the term
AutoREM fit because just about every manufacturer has their own
term for it, AutoFit and REM fit and so on. So I tried to
(15:35):
put together a term that no manufacturer was using and
Todd Ricketts and I wrote an article on this about
four years ago. The notion with this is that the
probe mic equipment and the fitting software talked to each
other and one of them is the boss and one
of them tells the other one what to do and
(15:55):
uses the measurements from the others to make corrections. And
once you do some initial setup and calibration, you can
pretty much sit back, watch the screen and watch the
fitting automatically do its best job of adjusting to target.
Every manufacturer has an article that's been published, most all
(16:15):
of them in Hearing Review about how good their AutoREM
procedure is. There are five different probe mic pieces of
equipment that are linked to different companies. Not all are
linked to all companies. So you'd sort of have to
check with your probe mic manufacturer and your hearing aid
(16:35):
manufacturer to make sure that they have a partnership going.
And so once that's been established, then what is the
advantage? Well, number one, it's going to be faster, particularly
if you're not experienced at programming hearing aids, it's going
to be faster. And for average speech, it probably will
(16:57):
be as good as what would be obtained by an
experienced clinician. We just did a study, John Pumford and
I, who's an audiologist with the equipment Verifit, and we
did a study actually with Signia hearing aids about that
and we found that fit to target on average was
within 2 dB for average. This is good. Okay?
Julia van Huyssteen (17:19):
That's very good.
Dr. Gus Mueller (17:20):
And if anybody out there doing fittings know that you
got to work pretty hard to get within 2 dB
across all the frequencies. So, that's good. And you can
do it bilaterally, which is good. So in the studies
they've actually looked at savings times, it's about three minutes
per ear. For an experienced fitter, that's about the time
(17:41):
that you would save. How important is that? Well, it could be.
That's six minutes for two ears. If your clinic is
so pressed that six minutes is that important, I might
look for a new job. But there are some clinics
that people are heavily pressured to get that fitting done
and that's one of the reasons that people have been
(18:02):
promoting AutoREM fit, particularly the companies that sell probe mic
equipment. Right? Well, how could this be bad or what's
the downside? There's a couple issues to consider. Issue number
one is some of the systems only fit to an
average input, which means that, and the biggest mistake you're
(18:22):
going to find there is that soft targets are off
by 5 to 10 dB. So if you think this
through, you've just gone through this whole AutoREM fit and
you got a good fit to average, now you run
a 55 dB curve and you see you're off by
8 dB. Well, you have to fix that. How do
you fix gain for soft? You have to turn up
(18:42):
overall gain. It's not a compression thing, right? Well, what
happens to 65 once you turn up overall gain? You
now just blew away that fit to target. You had 65
and you're fitting the whole hearing aid over again. So AutoREM
fit was absolutely no help in that case, unless you
don't care about soft and you're making a huge mistake.
There's been research that showed that if you have to get
(19:05):
one level right, the most important one to get right
is the input for soft sounds. And I'm talking either
a 50 or 55 dB SPL input. The second problem we have
is I said earlier that the manufacturers now, unfortunately, unless
something's been changed in the last six months or so,
most manufacturers now, if not all manufacturers now is not
(19:27):
the true NAL. Now, if the software is the boss
telling the probe mic system what to do, the hearing
aid will be AutoREM fit, but not really because it's
fit to the wrong targets. So you did a very
fancy AutoFit to the wrong targets. Now one probe mic
company in particular, Audioscan Verifit, which probably is not that
(19:51):
popular here, it's very popular in the US, Verifit won't
make an agreement with a company unless you use the
Verifit targets, which are the true NAL targets. The probe
mic system tells the software what to do, not the
other way around. Huge difference, huge difference. And that's the way it should be.
Julia van Huyssteen (20:12):
So it seems to me that AutoREMs have got great
potential for us in clinics, especially when you think you could save
some time. We've talked a lot about some of the
preassessment that happens before the fitting. We've talked about verification,
we've talked about ULLs, all of those things do take
time. So if in the future we can create even
(20:33):
just two or three minutes for another additional test, that
makes sense. However, we do need to do a little
bit more work with AutoREMs for that to be the
standard that we need it to be.
Dr. Gus Mueller (20:44):
Sure. What I would suggest for any clinician is just do
a crosscheck. Go ahead and do your AutoREM fit and
then once it's over, I mean you wouldn't do this
with every patient, but just when you first start doing it
and then simply do a crosscheck and say, " Okay, now
I'm going to fit the way I normally would fit
and if this system really works, I should be getting
a very close match to target using my approach the
(21:07):
way I fit hearing aids." That's a nice way to
check it out.
Julia van Huyssteen (21:10):
Absolutely. Give yourself the confidence that the auto that you're doing is actually
spot on. That's good advice for our listeners too. So
standard 11 then, which is our final question for today
is about individualization of the hearing aid gain and output
with minor deviations in gain and output where necessary. So
here we are treading on eggshells a little bit again.
(21:31):
Can you define or are you able to define what
minor deviations mean to our audience?
Dr. Gus Mueller (21:35):
Yeah, that's a excellent question on your part, because that was
the toughest two sentences to write in the entire standard.
Because it's sort of crazy, you say you have to
do this and you have to do this and you have to do this, but
just maybe you don't have to. Well, the notion was
that, a couple people strongly advocated it, the clinicians primarily
(22:00):
in our team and it's realistic. So let's start first,
what is a fit to target? So if you go
back to all the data that was collected by Harvey
Dillon's crew, they show average use gain for different hearing
losses. And they modeled NL2 somewhat after what was average
(22:25):
use gain for different inputs and so on. And it's
a range, of course it's a range. And what we
see in there that they looked at, I think plus
or minus three, plus or minus five, you're going to
get in around 60% of the people that that is right
for them. And so when we fit hearing aids today,
people talk about target, but target isn't like a dot
(22:46):
on the screen. Target is a 10 dB range, 5
dB above and 5 dB below. And if that's fine,
it's a target. It's like playing football or soccer or
whatever. You don't have to get it right in the
middle of the goal post. As long as you get
it in there, you're good enough. And that's the way
this is, it's a range. But yes, you would expect
just because of the size of the standard deviations, there
(23:09):
will be a patient whose maximum listening level, their preferred
listening level might be 7 dB below target. Well, are
you going to force them to be fit to target
or are you going to maybe start them out 70
dB below? Maybe put in some auto- acclimatization, maybe bring
them back in two weeks and see if you could
(23:31):
change their preferred listening level or maybe they spend the
rest of their life slightly below. So this is, I
think we did use the word minor in the actual
text. So this means that it's okay to tweak things
a little bit just because we need people wearing their
hearing aids. So you can't be so rigid that you
(23:52):
give them a fitting that they're not going to wear.
I mean none of us want that. So that's why
that was put in there. It's sort of like there's
a little wiggle room. I wouldn't call it an eggshell,
but just wiggle room.
Julia van Huyssteen (24:06):
And I think, just listening from what you said there,
when we refer to this particular standard, I like the
fact that you said we manage expectations. So at the
end of the day we can tell our patients where
we want to end this up here. So for today,
because we want you to get used to your hearing
aids and we want you to have the hearing aids
on your ears, well, we'll bring you down a little
(24:26):
bit, but let's work together within the next weeks.
Dr. Gus Mueller (24:30):
Sure.
Julia van Huyssteen (24:30):
Months maybe, because this is ideally where we need to
end, because this is where you will get the most
benefit. And as you say, sometimes it might happen that
you never get there, but we'd rather have our patients wear their
hearing aids.
Dr. Gus Mueller (24:40):
And as you well know, the whole patient- centered thing
is becoming more and more required and more and more
implemented. You want the patient to be happy. The other
side of it, of course, is that I think we
all know that the patient isn't maybe really the best
judge of what's best for them. And this is then
(25:01):
when you run into problems and why there's an art
along with the science and the art is to manage
expectations, as you just said, and hopefully you end at
the right place. Again, providing audibility is just so keen
that you can't ignore that.
Julia van Huyssteen (25:20):
And I guess validation, whatever form you use to do
validation, whether that is your aided testing where you demonstrate
to your patients a difference that that 70 dB potentially
could make to hearing those words or identifying them. Or,
you mentioned the SII earlier on, maybe that's something that
you could work with your patients just to demonstrate.
Dr. Gus Mueller (25:41):
Sure.
Julia van Huyssteen (25:42):
That's the difference that we're talking about is that what's
more important to you, that comfort or hearing when you struggle.
Dr. Gus Mueller (25:49):
And remember, as we discussed way back in podcast number
one, that you already have these pre- fitting tests such
as the APHAB. Now the APHAB, we did it unaided
because we collected case history. Now we can do it
aided and see how were these people doing in quiet,
in background noise. And by the way, there's research evidence
(26:10):
to show comparing a NAL fitting to a proprietary fitting
that there's a significant more improvement on the APHAB. So
it isn't just what somebody in a university sat down
and thought maybe would work and let's stick these little
probes in the ears and measure it. There's data that
show that when you do it that way and people
(26:32):
go out in the real world, they will have more
benefit and satisfaction. And so, again, you can put all
that together as a package, why it all then becomes
the fitting sort of from A to Z.
Julia van Huyssteen (26:47):
We've come to the end of our conversation here and
I can see that we've got somebody in our audience
that would like a question. So over to you.
Michelle Booth (26:54):
Okay. So my name's Michelle Booth and I'm public account
manager for Signia, but previously an NHS audiologist. I did
find your comment regarding the use of the proprietary fitting
against NAL and DSL quite interesting because as an NHS
audiologist in practice, we would always use the NAL or the DSL and
(27:16):
use it with probe mic measurements and find it quite
strange that that perhaps doesn't happen as a routine. What
would you say about that?
Dr. Gus Mueller (27:27):
Good question. And just to clarify what I had said
before, the difference between using the NAL algorithm, meaning you
simply click on the button and assume you got lucky
versus using it and verifying with probe mic measures are
really two very different things. And good for you, because
it sounds like you're doing the right way. I can't
(27:49):
speak for how things happen in various countries. I can
only speak for what I know, which is what happens
in the US. And that is unfortunately probably no more
than 70, well, no more than 30% of audiologists actually
verify to either the NAL... Well, you can't really verify to
(28:11):
a proprietary fitting, because there are no targets on the
machine. I also know from data that has been collected
that in the US probably 70% of the audiologists use
proprietary fittings simply because somebody from their favorite manufacturer has
(28:32):
visited them and said, " This is what works the best.
Believe me, I know. Your patients will be happier." And
it's true, the patient actually might be happier because it
doesn't sound like a hearing aid. But the problem is
it usually is not a very good fitting. So this
is why I was sort of emphasizing the difference between
(28:52):
punching the button and hoping you get lucky versus actually
sitting down and making sure that that algorithm that you
want is really happening at the real ear. And the
fact that you and your colleagues are doing that would
put you in the top 30% in the US, maybe
the top 10%. I don't know. I can't resist adding
(29:12):
one more thing and that is the weird thing is we
have this Costco. Okay? It's in a warehouse for goodness
sakes. They buy 12% of all hearing aids sold in
the US. Costco does probe mic verification in a warehouse.
So if you can do it in a warehouse, I
would hope to heck you could do it in an office
(29:34):
or a clinic. Amen.
Julia van Huyssteen (29:38):
Great question.
Michelle Booth (29:38):
And I think that fits quite nicely with the sort of idea
around standards and guidelines, because our guidelines that we follow
in the NHS would suggest that probe mic measurement is done
on every patient. But because we don't have a standard,
then possibly those guidelines aren't followed in all clinics.
Dr. Gus Mueller (29:59):
Right. It's a slippery slope because if you really have
a standard, then the standard should have some teeth. And
what's the penalty for not following the standard? Usually none.
There is no penalty, which is too bad. I think
that's the reason that most national organizations call it guidelines
and not standard. Because if they call it a standard,
(30:20):
then what are you going to do to your member
who isn't following the standard? Do you kick that person
out of your organization? Probably not, because they'd get an
attorney and... Anyway, it's complicated, but let your heart be
your guide is what I say.
Michelle Booth (30:37):
Yeah. Thank you. That's an interesting insight.
Julia van Huyssteen (30:41):
Thank you very much. So, that actually wraps it up
nicely. So with that, I would like to thank you
so much for your insightful discussion with us today during
our third and final episode. Today we focused mostly on
verification, which clearly is an important focus within the standard.
Thank you so much for joining us for the first
series with Dr. Gus Mueller as our guest speaker. We
(31:02):
hope you have found this insightful and that you will reflect
on your own practice accordingly. If you have any thoughts
on the topics of these episodes, we'd love to hear
from you and you can look for the contact details
on the episode page. You'll find links to Signia's webpage
as well as links to more information on Dr. Gus
Mueller. And remember, if you found these conversations helpful, please
(31:22):
share them with your colleagues and with your friends, so
as many people as possible can hear Dr. Mueller's expertise.
Dr. Gus Mueller (31:28):
Great. Well, thank you. And remember, it doesn't necessarily have to be the
final, final.
Julia van Huyssteen (31:33):
I love that.
Dr. Gus Mueller (31:34):
All right.
Hello, and welcome back to Sounding It Out. I'm Julia
van Huyssteen, the Head of Audiology at Signia. This is
the final episode of a three- part mini series about
hearing aid fitting standards. If you missed the first two
episodes, you can download them for free from your usual
podcast provider. And remember to follow or subscribe so you
don't miss our further episodes. If you found these conversations
(00:31):
helpful, please tell colleagues, friends or family, so as many
people hear the wonderful advice you've heard. I'm pleased to
say I'm still joined by American audiology guru, Dr. Gus
Mueller. Thanks once again for your time.
Dr. Gus Mueller (00:46):
Hey, absolutely. And thanks for the invite. The only thing
I'm not liking about this is the word final. I
thought we could keep doing it all year long. But maybe it isn't
final, final. Who knows?
Julia van Huyssteen (00:57):
Who knows? And we can certainly do another series with
you visiting over to the UK.
Dr. Gus Mueller (01:02):
Sounds great.
Julia van Huyssteen (01:04):
And we are still joined by our live audience. Welcome
back to you all. Now, Dr. Mueller, before I ask
our first question, I'm just going to remind our audience
that the hearing aid fitting standards that you've helped put together
last year is divided into 15 standards. During the first deep-
dive, we focus on pre- fitting assessments and during this
second deep- dive, we will discuss some of the remaining
(01:24):
seven standards which focuses on the hearing aid fitting onwards,
mainly around verification. So we'll start with our first juicy
question for today's episode. And it is around standard 10,
which focuses on programming hearing aids using verification. Now, bearing
in mind that verification is not performed as standard across
all of our channels in the UK. Channels, meaning public
(01:45):
sector, key accounts and independents. I'd like for us to
revisit the importance of making verification a hearing aid fitting
standard. It is within this context that I think we
should focus on a few verification topics. The first is
using a validated prescriptive method, the second is using verified
(02:05):
ear canal output, and the third is optimizing the patient's
residual dynamic range. So let's start with the first one,
using a validated prescriptive method. I get this question often.
Do we use NAL, or do we use your proprietary
prescription formula? Isn't NAL a little bit dated? For example, NAL-
(02:26):
2 prescribes for 17 frequency channels, whereas some hearing aid
instruments have got up to 48 or even 64 channels. What
is your take on this part of the fitting standard
about validated prescription method?
Dr. Gus Mueller (02:39):
I guess to start at the beginning of how this validated,
first, that the key is validated, and second of all, prescriptive
method, like the NAL. People have come up to me at
times and said, " I don't believe in all that prescriptive
stuff. I have my own way of fitting hearing aids."
If you think about it, to get it right, you
really have to have good sound quality, you have to
(03:03):
have correct loudness restoration, you have to have good intelligibility,
you have to have hearing aid that the person's willing
to wear, and you have to fit all those things
together for every frequency and every input level. And how
are you going to come up with that yourself? So,
first of all, it's great that we have people like the
(03:26):
DSL people and the NAL, which has been around for over
40 years, who have really done all the work for
us. They did the heavy lifting. So I like to
just step back and use what they have put together
for us. As far as out of date, I don't
see that at all. Indeed, when we went to NL1,
(03:47):
that was when we started using wide dynamic range hearing
aids. And NAL- R only had target for one input
level. So NAL- R was out of date because we
needed targets for multiple input levels, which came to us in
NL1. 10 years down the road Harvey Dillon and his
crew did a lot of work with NL1 and said, "
(04:08):
Yes, there's some tweaking that needs to be done," although
it really wasn't major. Gain was reduced by about 3
dB I think in the mid- frequencies and some other
minor changes. So we have NL2, which has now been
with us, what, for 12, 13 years. The number of
channels in the hearing aid to me doesn't really matter
(04:29):
because, first of all, they're all overlapping. So when you
change one, you're really changing five or so. And we
certainly have enough key frequencies that getting a frequency in
between there really isn't going to change things. Audiograms are
pretty predictable and follow a pretty predictable pattern. That isn't
the issue. It's the issue of actually verifying that you
(04:52):
have the validated thing. Now you mentioned proprietary fittings. Well,
there's the word validated right there. I would encourage you
to go to every journal you can find that's peer-
reviewed, and find a manufacturer's algorithm that is published and
has been peer- reviewed. So I wouldn't even put that
in the category of validated, not my definition of validated.
Julia van Huyssteen (05:17):
And there's the issue as well when we talk about prescription
formulas, especially you mentioned manufacturers. Do they want their hearing
aids to sound nice? Is it about comfort? Or is
it about speech intelligibility in giving our patients access to
that speech that they need?
Dr. Gus Mueller (05:34):
Rumor has it, Julia, I actually work for a manufacturer out here. So
I got to be really careful here what I say. Manufacturers
have to sell hearing aids. They have to have a
product that patients are willing to wear on day one.
So you have to ask yourself what do patients like?
They like something that doesn't sound like a hearing aid. A
lot of times, if you let the patient program it,
(05:56):
they'll program back their own ear canal resonance that you
took away when you put an ear mold in the
ear. So, that's zero gain. And no loss, no gain.
But I understand if manufacturers know, and they do, that
the majority of people selling their product around the world,
and keep in mind also these proprietary methods are used
(06:16):
around the world. So if they know that around the
world, 90% of the people do not do verification anyway,
then I would say that they probably would come up
with a method that sounds pleasant. They would come up
with a method that doesn't have feedback, because audiologists like
to complain about products that have feedback, which means you're
(06:38):
going to roll off the highs, you're going to reduce
overall gain. And if I were doing a proprietary fitting,
that's what I would do. And that actually is what's
been done. The proprietary fittings across manufacturers are all pretty
similar. They have reduced gain, particularly for soft sounds. And
they all roll off gains compared to the NAL starting
(06:59):
at around 2K, by a sizable amount, by as much
as Mike Valente's study, who is indeed a peer- reviewed
study of a couple years ago. He found that in
the high frequencies, the product he was using rolled off
gain, on average, at 3K 15 dB and at 4K 20
dB. There's some important stuff going on out there that
(07:21):
I think our patients would like to hear.
Julia van Huyssteen (07:23):
Absolutely. And if you think about the bulk of speech information
in 3 and 4K, that important mid to high frequency
information, you'd certainly struggle with understanding speech with 15 to 20 dB
less than you actually need with a prescription formula.
Dr. Gus Mueller (07:39):
Sure. SII calculation has become very popular in the last
few years. And partly because the probe mic equipment does
it for you. You'll look at a proprietary fit and
it's not uncommon at all that had you fitted to
NAL, you'd be getting an SII about 20% higher than you're
getting from a proprietary fit. Audibility is an amazing thing.
(08:01):
I think we owe it to our patients to give
them audibility.
Julia van Huyssteen (08:04):
Absolutely. And that actually leads really nicely into my next
question, or the second part of that question, and that's
around verified ear canal output. Now, I've seen click and
fit outputs differ as much as, again, 15 to 20 dB in
those really, really important speech information areas. Why do you
think we have such a high percentage of unverified fittings?
Dr. Gus Mueller (08:26):
Yeah. I've been talking about this for, well, we wrote
our first guidelines back in 1990. And in those guidelines,
very clearly it said that you would do probe microphone
verification. So we're not talking about anything new. It never
occurred to me that when probe mic equipment came out,
everybody I hung around with was just delighted and said, "
(08:48):
Finally, finally we can figure out how all these darn
hearing aids work." It never occurred to me that 95% of
people would not be using this. We had thought, well,
of course you'd use it. But it didn't work that
way. It didn't work that way. I think that manufacturers,
I think do focus groups. And in their focus groups,
(09:10):
one of the things they hear is, " I'm in a
rush." They're hearing this from the people who they bring in, "
I'm busy. I need something that works fast and easy."
And the manufacturer says, " Well, our proprietary fit is fast
and easy." And the people say, " Well, the manufacturer says
it's a good thing to do, then it has to
(09:30):
be okay." Which isn't really where, as audiologists, we should
be getting our guidance. No offense to manufacturers. But their
job is to build hearing aids; our job is to
fit hearing aids. I have never tried to build a hearing
aid in my life, and it would be a piece
of crap if I did. I stick to what I
do. Manufacturers, they do something else. They build very, very
(09:52):
good hearing aids. And that makes a great partnership if
we stay in our own lane, is the way I
see it.
Julia van Huyssteen (10:00):
So the final part of the question then is about
optimizing the patient's residual dynamic range. And most manufacturer software
will predict the MPO based on averages. We talked earlier
about ULLs and building that into our pre- assessments. And
I also know that you did some research last year
on what happens when you allow the manufacturer to pick
the MPO. Can you provide us a summary of the
(10:22):
findings of this research?
Dr. Gus Mueller (10:23):
Yeah. Well, there's two things. And this was a study done
with some people at the University of Iowa, Dr. Wu
and Dr. Stangl. We looked at the premier hearing aids,
the six main companies and we put the same audiogram
into all of them. First of all, we did measures
to see what we would get as the maximum output.
(10:47):
And with the exception of one company that did pretty
well, most of the companies, when programmed into their NAL,
the output was about 20/25 dB below what we would
predict as the person's LDL, based on the NAL prediction,
which is in the NAL software if you get the
(11:07):
original NAL software. So, that's problem number one. Problem number
two, then, we put in this audiogram that was a
typical audiogram going from 25 in the lows, down to
70 in the highs. What we would consider easy to
fit typical audiogram. We put that in, had picked the
manufacturer's NAL. And again, then went in to see where
(11:32):
the manufacturer set the output. Because you just go to the AGCo
kneepoints and you can see where the output is set.
And most manufacturers, somewhere in the fitting software, just has
that on a little tab that you can read the
numbers. What we found is... Well, first of all, we
said we wanted a NAL fit. So this should be pretty
easy, you would think. For that particular patient, what the
(11:54):
NAL said in a 2cc coupler, it should be 98 to 102,
low frequencies to high frequencies. 98 to 102. Well, that's pretty easy,
you would think to program. Right? We had some falling
10 to 15 dB below the NAL, and we had some 10
dB over the NAL. If we looked at the lowest
(12:15):
and the highest among manufacturers, the difference was 25 dB.
That means a given patient's MPO could be set different
by 25 dB just depending on what manufacturer you picked.
And the sad thing is, I'm afraid a lot of
people don't even know that. It's something that just doesn't
(12:36):
get a lot of attention, which goes back to podcast
number two that why not do LDLs and set the
MPO yourself? And then you don't have to rely on
somebody else to do it.
Julia van Huyssteen (12:48):
I think considering the evidence that you've just shared with
us, it actually makes that standard a standard.
Dr. Gus Mueller (12:53):
Yes.
Julia van Huyssteen (12:53):
It makes it essential. And that's why it's one of
the standards.
Dr. Gus Mueller (12:56):
That's why it's there.
Julia van Huyssteen (12:57):
Yes, absolutely.
Dr. Gus Mueller (12:57):
That's why it's there. Yeah.
Julia van Huyssteen (12:57):
So the next question is around another topic of interest
at the moment, and that is AutoREMs or AutoREM fitter or however the
manufacturers call it. So here we go. There's a curve
ball here. During COVID, a few hospital departments here in
the UK incorporated remote in- situ gram, so this was when you do
a hearing test with the hearing aids in situ, as
(13:19):
the second best option to doing REMs. In the remote
fitting pathways, this is kind of what they resorted to,
is in- situ gram. Now I know you've written a couple
of papers about REMs versus AutoREMs recently. Bringing then in-
situ gram into that conversation, how do you think it
compares to do something like that with the hearing test,
with the hearing aids in situ versus AutoREMs, versus your
(13:40):
manual REMs?
Dr. Gus Mueller (13:42):
Okay. Two different things. So let's take the in- situ
gram first, which Widex put that out many years ago
and wrote about it. And a few Widex customers picked
it up. It isn't commonly done, but that doesn't mean
it isn't good. If for some reason you cannot do
probe mic verification, you then could do this. And in
(14:06):
most cases, you would get a better fit than not
doing anything. It does account for the RECD, which is,
if the only difference, if the reason that the fits
aren't good was because of variance from person to person,
then in- situ fits would be okay. The problem is
(14:29):
that isn't the reason that fits are so bad. The
fits are so bad is that the manufacturers, NAL target,
is not the real NAL target. Well, your in- situ
gram isn't going to help you there at all because
you're still going to plug in those numbers, and you're
going to get a fit from the software that is
not really the NAL. But on the fitting screen, I
can assure you it's going to be a beautiful fit.
(14:50):
And people believe it. They look at that cartoon and think
that that's what's going on in the real ear when
it isn't. And there's tons of data to show that
if you take various manufacturers and fit to their NAL,
you get roll off in the highs just like you
get with proprietary fits for the very same reasons that
you get that. So that's where a situ fit's not
(15:11):
going to help you at all, because you're still using
the wrong targets. Now AutoREM fit is really a different
thing and AutoREM fit is to increase efficiency. So for our
listeners who aren't familiar with this, I use the term
AutoREM fit because just about every manufacturer has their own
term for it, AutoFit and REM fit and so on. So I tried to
(15:35):
put together a term that no manufacturer was using and
Todd Ricketts and I wrote an article on this about
four years ago. The notion with this is that the
probe mic equipment and the fitting software talked to each
other and one of them is the boss and one
of them tells the other one what to do and
(15:55):
uses the measurements from the others to make corrections. And
once you do some initial setup and calibration, you can
pretty much sit back, watch the screen and watch the
fitting automatically do its best job of adjusting to target.
Every manufacturer has an article that's been published, most all
(16:15):
of them in Hearing Review about how good their AutoREM
procedure is. There are five different probe mic pieces of
equipment that are linked to different companies. Not all are
linked to all companies. So you'd sort of have to
check with your probe mic manufacturer and your hearing aid
(16:35):
manufacturer to make sure that they have a partnership going.
And so once that's been established, then what is the
advantage? Well, number one, it's going to be faster, particularly
if you're not experienced at programming hearing aids, it's going
to be faster. And for average speech, it probably will
(16:57):
be as good as what would be obtained by an
experienced clinician. We just did a study, John Pumford and
I, who's an audiologist with the equipment Verifit, and we
did a study actually with Signia hearing aids about that
and we found that fit to target on average was
within 2 dB for average. This is good. Okay?
Julia van Huyssteen (17:19):
That's very good.
Dr. Gus Mueller (17:20):
And if anybody out there doing fittings know that you
got to work pretty hard to get within 2 dB
across all the frequencies. So, that's good. And you can
do it bilaterally, which is good. So in the studies
they've actually looked at savings times, it's about three minutes
per ear. For an experienced fitter, that's about the time
(17:41):
that you would save. How important is that? Well, it could be.
That's six minutes for two ears. If your clinic is
so pressed that six minutes is that important, I might
look for a new job. But there are some clinics
that people are heavily pressured to get that fitting done
and that's one of the reasons that people have been
(18:02):
promoting AutoREM fit, particularly the companies that sell probe mic
equipment. Right? Well, how could this be bad or what's
the downside? There's a couple issues to consider. Issue number
one is some of the systems only fit to an
average input, which means that, and the biggest mistake you're
(18:22):
going to find there is that soft targets are off
by 5 to 10 dB. So if you think this
through, you've just gone through this whole AutoREM fit and
you got a good fit to average, now you run
a 55 dB curve and you see you're off by
8 dB. Well, you have to fix that. How do
you fix gain for soft? You have to turn up
(18:42):
overall gain. It's not a compression thing, right? Well, what
happens to 65 once you turn up overall gain? You
now just blew away that fit to target. You had 65
and you're fitting the whole hearing aid over again. So AutoREM
fit was absolutely no help in that case, unless you
don't care about soft and you're making a huge mistake.
There's been research that showed that if you have to get
(19:05):
one level right, the most important one to get right
is the input for soft sounds. And I'm talking either
a 50 or 55 dB SPL input. The second problem we have
is I said earlier that the manufacturers now, unfortunately, unless
something's been changed in the last six months or so,
most manufacturers now, if not all manufacturers now is not
(19:27):
the true NAL. Now, if the software is the boss
telling the probe mic system what to do, the hearing
aid will be AutoREM fit, but not really because it's
fit to the wrong targets. So you did a very
fancy AutoFit to the wrong targets. Now one probe mic
company in particular, Audioscan Verifit, which probably is not that
(19:51):
popular here, it's very popular in the US, Verifit won't
make an agreement with a company unless you use the
Verifit targets, which are the true NAL targets. The probe
mic system tells the software what to do, not the
other way around. Huge difference, huge difference. And that's the way it should be.
Julia van Huyssteen (20:12):
So it seems to me that AutoREMs have got great
potential for us in clinics, especially when you think you could save
some time. We've talked a lot about some of the
preassessment that happens before the fitting. We've talked about verification,
we've talked about ULLs, all of those things do take
time. So if in the future we can create even
(20:33):
just two or three minutes for another additional test, that
makes sense. However, we do need to do a little
bit more work with AutoREMs for that to be the
standard that we need it to be.
Dr. Gus Mueller (20:44):
Sure. What I would suggest for any clinician is just do
a crosscheck. Go ahead and do your AutoREM fit and
then once it's over, I mean you wouldn't do this
with every patient, but just when you first start doing it
and then simply do a crosscheck and say, " Okay, now
I'm going to fit the way I normally would fit
and if this system really works, I should be getting
a very close match to target using my approach the
(21:07):
way I fit hearing aids." That's a nice way to
check it out.
Julia van Huyssteen (21:10):
Absolutely. Give yourself the confidence that the auto that you're doing is actually
spot on. That's good advice for our listeners too. So
standard 11 then, which is our final question for today
is about individualization of the hearing aid gain and output
with minor deviations in gain and output where necessary. So
here we are treading on eggshells a little bit again.
(21:31):
Can you define or are you able to define what
minor deviations mean to our audience?
Dr. Gus Mueller (21:35):
Yeah, that's a excellent question on your part, because that was
the toughest two sentences to write in the entire standard.
Because it's sort of crazy, you say you have to
do this and you have to do this and you have to do this, but
just maybe you don't have to. Well, the notion was
that, a couple people strongly advocated it, the clinicians primarily
(22:00):
in our team and it's realistic. So let's start first,
what is a fit to target? So if you go
back to all the data that was collected by Harvey
Dillon's crew, they show average use gain for different hearing
losses. And they modeled NL2 somewhat after what was average
(22:25):
use gain for different inputs and so on. And it's
a range, of course it's a range. And what we
see in there that they looked at, I think plus
or minus three, plus or minus five, you're going to
get in around 60% of the people that that is right
for them. And so when we fit hearing aids today,
people talk about target, but target isn't like a dot
(22:46):
on the screen. Target is a 10 dB range, 5
dB above and 5 dB below. And if that's fine,
it's a target. It's like playing football or soccer or
whatever. You don't have to get it right in the
middle of the goal post. As long as you get
it in there, you're good enough. And that's the way
this is, it's a range. But yes, you would expect
just because of the size of the standard deviations, there
(23:09):
will be a patient whose maximum listening level, their preferred
listening level might be 7 dB below target. Well, are
you going to force them to be fit to target
or are you going to maybe start them out 70
dB below? Maybe put in some auto- acclimatization, maybe bring
them back in two weeks and see if you could
(23:31):
change their preferred listening level or maybe they spend the
rest of their life slightly below. So this is, I
think we did use the word minor in the actual
text. So this means that it's okay to tweak things
a little bit just because we need people wearing their
hearing aids. So you can't be so rigid that you
(23:52):
give them a fitting that they're not going to wear.
I mean none of us want that. So that's why
that was put in there. It's sort of like there's
a little wiggle room. I wouldn't call it an eggshell,
but just wiggle room.
Julia van Huyssteen (24:06):
And I think, just listening from what you said there,
when we refer to this particular standard, I like the
fact that you said we manage expectations. So at the
end of the day we can tell our patients where
we want to end this up here. So for today,
because we want you to get used to your hearing
aids and we want you to have the hearing aids
on your ears, well, we'll bring you down a little
(24:26):
bit, but let's work together within the next weeks.
Dr. Gus Mueller (24:30):
Sure.
Julia van Huyssteen (24:30):
Months maybe, because this is ideally where we need to
end, because this is where you will get the most
benefit. And as you say, sometimes it might happen that
you never get there, but we'd rather have our patients wear their
hearing aids.
Dr. Gus Mueller (24:40):
And as you well know, the whole patient- centered thing
is becoming more and more required and more and more
implemented. You want the patient to be happy. The other
side of it, of course, is that I think we
all know that the patient isn't maybe really the best
judge of what's best for them. And this is then
(25:01):
when you run into problems and why there's an art
along with the science and the art is to manage
expectations, as you just said, and hopefully you end at
the right place. Again, providing audibility is just so keen
that you can't ignore that.
Julia van Huyssteen (25:20):
And I guess validation, whatever form you use to do
validation, whether that is your aided testing where you demonstrate
to your patients a difference that that 70 dB potentially
could make to hearing those words or identifying them. Or,
you mentioned the SII earlier on, maybe that's something that
you could work with your patients just to demonstrate.
Dr. Gus Mueller (25:41):
Sure.
Julia van Huyssteen (25:42):
That's the difference that we're talking about is that what's
more important to you, that comfort or hearing when you struggle.
Dr. Gus Mueller (25:49):
And remember, as we discussed way back in podcast number
one, that you already have these pre- fitting tests such
as the APHAB. Now the APHAB, we did it unaided
because we collected case history. Now we can do it
aided and see how were these people doing in quiet,
in background noise. And by the way, there's research evidence
(26:10):
to show comparing a NAL fitting to a proprietary fitting
that there's a significant more improvement on the APHAB. So
it isn't just what somebody in a university sat down
and thought maybe would work and let's stick these little
probes in the ears and measure it. There's data that
show that when you do it that way and people
(26:32):
go out in the real world, they will have more
benefit and satisfaction. And so, again, you can put all
that together as a package, why it all then becomes
the fitting sort of from A to Z.
Julia van Huyssteen (26:47):
We've come to the end of our conversation here and
I can see that we've got somebody in our audience
that would like a question. So over to you.
Michelle Booth (26:54):
Okay. So my name's Michelle Booth and I'm public account
manager for Signia, but previously an NHS audiologist. I did
find your comment regarding the use of the proprietary fitting
against NAL and DSL quite interesting because as an NHS
audiologist in practice, we would always use the NAL or the DSL and
(27:16):
use it with probe mic measurements and find it quite
strange that that perhaps doesn't happen as a routine. What
would you say about that?
Dr. Gus Mueller (27:27):
Good question. And just to clarify what I had said
before, the difference between using the NAL algorithm, meaning you
simply click on the button and assume you got lucky
versus using it and verifying with probe mic measures are
really two very different things. And good for you, because
it sounds like you're doing the right way. I can't
(27:49):
speak for how things happen in various countries. I can
only speak for what I know, which is what happens
in the US. And that is unfortunately probably no more
than 70, well, no more than 30% of audiologists actually
verify to either the NAL... Well, you can't really verify to
(28:11):
a proprietary fitting, because there are no targets on the
machine. I also know from data that has been collected
that in the US probably 70% of the audiologists use
proprietary fittings simply because somebody from their favorite manufacturer has
(28:32):
visited them and said, " This is what works the best.
Believe me, I know. Your patients will be happier." And
it's true, the patient actually might be happier because it
doesn't sound like a hearing aid. But the problem is
it usually is not a very good fitting. So this
is why I was sort of emphasizing the difference between
(28:52):
punching the button and hoping you get lucky versus actually
sitting down and making sure that that algorithm that you
want is really happening at the real ear. And the
fact that you and your colleagues are doing that would
put you in the top 30% in the US, maybe
the top 10%. I don't know. I can't resist adding
(29:12):
one more thing and that is the weird thing is we
have this Costco. Okay? It's in a warehouse for goodness
sakes. They buy 12% of all hearing aids sold in
the US. Costco does probe mic verification in a warehouse.
So if you can do it in a warehouse, I
would hope to heck you could do it in an office
(29:34):
or a clinic. Amen.
Julia van Huyssteen (29:38):
Great question.
Michelle Booth (29:38):
And I think that fits quite nicely with the sort of idea
around standards and guidelines, because our guidelines that we follow
in the NHS would suggest that probe mic measurement is done
on every patient. But because we don't have a standard,
then possibly those guidelines aren't followed in all clinics.
Dr. Gus Mueller (29:59):
Right. It's a slippery slope because if you really have
a standard, then the standard should have some teeth. And
what's the penalty for not following the standard? Usually none.
There is no penalty, which is too bad. I think
that's the reason that most national organizations call it guidelines
and not standard. Because if they call it a standard,
(30:20):
then what are you going to do to your member
who isn't following the standard? Do you kick that person
out of your organization? Probably not, because they'd get an
attorney and... Anyway, it's complicated, but let your heart be
your guide is what I say.
Michelle Booth (30:37):
Yeah. Thank you. That's an interesting insight.
Julia van Huyssteen (30:41):
Thank you very much. So, that actually wraps it up
nicely. So with that, I would like to thank you
so much for your insightful discussion with us today during
our third and final episode. Today we focused mostly on
verification, which clearly is an important focus within the standard.
Thank you so much for joining us for the first
series with Dr. Gus Mueller as our guest speaker. We
(31:02):
hope you have found this insightful and that you will reflect
on your own practice accordingly. If you have any thoughts
on the topics of these episodes, we'd love to hear
from you and you can look for the contact details
on the episode page. You'll find links to Signia's webpage
as well as links to more information on Dr. Gus
Mueller. And remember, if you found these conversations helpful, please
(31:22):
share them with your colleagues and with your friends, so
as many people as possible can hear Dr. Mueller's expertise.
Dr. Gus Mueller (31:28):
Great. Well, thank you. And remember, it doesn't necessarily have to be the
final, final.
Julia van Huyssteen (31:33):
I love that.
Dr. Gus Mueller (31:34):
All right.
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