February 11, 2025 • 39 mins
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.
Connect with the Hearing Matters Podcast Team
Email: hearingmatterspodcast@gmail.com
Instagram: @hearing_matters_podcast
Twitter: @hearing_mattas
Facebook: Hearing Matters Podcast
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Blaise M. Delfino, M.S. - (00:19):
Thank you.
You to our partners.
Sycle, built for the entirehearing care practice.
Redux, the best dryer, handsdown.
CaptionCall by Sorenson, Lifeis Calling.
CareCredit, here today to helpmore people hear tomorrow.
Fader Plugs, the world's firstcustom adjustable earplug.
(00:41):
Welcome back to another episodeof the Hearing Matters podcast.
I'm founder and host BlaiseDelfino and, as a friendly
reminder, this podcast isseparate from my work at Starkey
.
Dr. Douglas L. Beck (00:56):
Good afternoon.
My name is Dr Douglas Beck, Iam an audiologist and today I am
honored to have my dear friend,Dr.
Michael Page.
Dr.
Page has served as a member ofthe Utah Cochlear Implant Team
and as president of UtahSpeech-Language Hearing
Association, member of thePrimary Children's Medical
Center Bioethics Committee andboard chair for the Division of
(01:16):
Occupational and ProfessionalLicensing.
Dr Page has held adjunctfaculty positions at Utah State
University, Brigham YoungUniversity, University,
University of Utah, SalusUniversity, Drexel University,
university of the Pacific, and,on and on, he served as chair
and committee member of the AAAEthical Practices Committee,
manager of audiology cochlearimplant program at Primary
(01:38):
Children's Hospital in Salt LakeCity and various management and
executive positions within theindustry.
He's a business consultant forhealthcare practices, education,
general business, specializingin aspects of ethical practice,
professional boundaries,industry relationships, contract
negotiations, employeerelations and improving
workplace culture.
That's a mouthful, dr Page.
(01:59):
How are you today?
Dr. Michael Page (02:01):
I'm well.
Thanks so much, and thanks forgetting us together.
This is a great occasion.
Dr. Douglas L. Beck (02:06):
It's always a joy.
Usually I see you with a drinkin hand and a cigar, but today's
a little different.
We've been trying to find timein our schedules, you and I, for
probably six or eight months toget this done, and I want to
make it an overview discussionof ethics and professionalism,
because you certainly have thatbackground and you give lectures
(02:27):
on this topic all the time andit's a rarity in audiology we
have probably eight or 10 peoplewho speak on ethics, but we
don't have that many and youcertainly have the history.
So tell me, how did you getinvolved with ethics?
Dr. Michael Page (02:39):
It's a great occasion actually, when you look
back at some of the history ofthat and what shaped that
portion of my professionalcareer.
I distinctly remember the day Iwas a pediatric audiologist
this would have been likely inthe late 1980s and I received a
memo that came to all hospitalpersonnel at the place where I
(03:00):
was working and said we arestarting a bioethics committee
for the hospital.
Any interested parties pleaseapply.
My eyes got big and I can'teven tell you why I was
interested because that wasn'tsomething that I had pursued at
that point.
But I did apply and wasaccepted on that committee.
That changed the trajectory ofmy understanding of ethics in
(03:25):
general.
Sitting around a big conferenceroom table with physicians,
nurses, billers, coders, parentseverybody was represented and a
file gets put in the middle andsay let's talk about this.
It was just incrediblyenlightening and that began this
journey of mine.
That's great.
Dr. Douglas L. Beck (03:45):
I think that's a great way to tiptoe
into it, because you know, we'reall professionals and ethical
dilemmas and ethical issues comeup almost daily and it's not
easy to navigate your waythrough.
So tell me what's thedefinition of ethics?
Let's start with ethics.
And is that the same as medicalethics, or do you see those as
two separate entities withethics?
Dr. Michael Page (04:05):
And is that the same as medical ethics or do
you see those as two separateentities?
Actually, I see all of ethicsas the same.
In fact, talking the right wayabout ethics, we're beyond
ethical codes and we get intoprinciples of ethics, which
really encompasses thedefinition of ethics.
Once we're in the principlemode, I should be able to take
universal principles of ethicsand apply them to Little Sus
principle mode.
I should be able to takeuniversal principles of ethics
(04:26):
and apply them to Little Susie'slemonade stand and Aunt
Martha's coffee shop, and Ishould be able to apply them
forever.
So definitions of ethics fallback on.
Some of the research that wasdone by Beauchamp and Childress
Started probably, if I remember,in the 1990s or so.
Dr. Douglas L. Beck (04:44):
Yeah, I remember that.
Dr. Michael Page (04:46):
Or principles, which are simply.
They are the respect forautonomy, non-maleficence,
beneficence and justice, and thedefinitions of those four
actually encapsulate what weshould understand about ethics
in general.
Give us the definitions, whatwe should understand about
ethics in general.
Give us the definitions.
(05:06):
Definitions the respect forautonomy is the ability for me,
as a clinician, to be able topractice autonomously.
That means that I have nooutside influences that would
represent my choices or myprofessional judgments.
It's also a respect forautonomy, for a patient's right
(05:28):
to choose.
Dr. Douglas L. Beck (05:29):
All right Now if we just examine that one
and we'll go through all four ifyou don't mind.
So on autonomy, if you're in anoffice and they say, okay, we
sell XYZ brand hearing aids andwe do our vestibular tests in
this protocol and we do earcleanings using these tools, or
(05:50):
whatever the example is, youknow, if I want to sell a
hearing aid that is of adifferent brand, whose ethics
are we violating?
Am I violating the ethics ofthe business or my own ethics,
or am I compromising the patient?
I mean, let's assume it's aspecial hearing aid, like a
cross, let's say, you know, it'snot the most typical, they're
(06:11):
also not rare.
And my company, the office Iwork for, sells brand X.
I don't care for that brand, Idon't get good results with it,
I always use brand Z.
So where does the ethicalautonomy come into this?
Dr. Michael Page (06:26):
Sure, keep in mind that out of these four
principles, nothing is everblack and white, of course,
never 100% or 0%, and we'realways going to be in the middle
somewhere.
I had a colleague of mine reachout and say it's impossible for
me to be 100% ethical all thetime.
It's almost the principle of Ithink it's called Zeno's rule of
(06:49):
paradox I think that's whatit's called where we use the
half.
We always get halfway to thedestination.
We get from point A to point B,and then we go halfway in
between, and we go halfway inbetween and we never really get
there, but we always get closer.
Dr. Douglas L. Beck (07:08):
That is so funny that you said that,
because I was having aconversation this morning with
Blaise Delfino, my partner and Iwas explaining infinity in not
pure mathematical terms, but Iwas talking about exactly the
same.
I said if you took a 10 footdistance between Dr Michael Page
and Dr Douglas Beck and yousaid, okay, we're going to
always half the distance everyday.
So the first day it's five feettwo and a half feet, one and a
quarter you would never getthere because there's always a
(07:30):
half to go and it's sointeresting to me that you use
that analogy today.
But you're always movingforward, you're always going in
the right direction, you'regoing towards that goal, but you
can never get there becausethere's always half of
whatever's left.
Dr. Michael Page (07:43):
So what's more important getting there or
getting on the journey togetting closer to getting there?
Absolutely, If we can't everget there, then some people
would say, well, if I can't getthere, I'm not going to even go
halfway.
Dr. Douglas L. Beck (07:57):
Well, this is very important because people
will see the world in black andwhite.
If that's all you got, that'sgreat.
But between black and whitethere's a bazillion different
shades of gray, and that's kindof where we live.
Dr. Michael Page (08:09):
Yeah, no doubt about that.
Back to your question about howis my autonomy?
One of the things that I thinkis really critical is to ask
ourselves what is the thief ofmy autonomy and what could
potentially take my autonomyaway as a practitioner, or what
(08:30):
things would take away theautonomy of a patient or a
candidate for a device that wemight dispense to prescribe.
And generally, if we look atthe business sense and the
business relationships we havewith members of industry, I will
contend that I think one of thegreatest thieves of my autonomy
as a practicing audiologist isany incentive or gift given to
(08:57):
me by someone, by a member ofindustry, who wants me to buy
their product.
Dr. Douglas L. Beck (09:02):
And this is a great dilemma because, as
business people, we'reclinicians and we're business
people particularly if we're inour own private practice.
There are just like in pharmacy, just like in surgical supplies
, just like in any medicalsupply company, you get
discounts for quantity.
That's how business works.
You know supply and demand.
If you're buying more, you'reprobably getting a lesser price.
(09:24):
We have examples of that, ofcourse, with the VA, of course,
with big box, they pay quite abit less than regular
practitioners would pay for thesame product.
So how does it fit intoautonomy If I think I can see
and take care of 10 patientsthis month?
This is the typical hearing aidthat I use and it's very
programmable.
It fits all their needs nineout of 10 times.
(09:45):
So I want to stock up on that.
So I call my manufacturer and Isay 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 Idon't really want 12 to begin
with, but I want the betterprice because I know I can
probably sell nine or 10 thismonth and have a few going into
(10:05):
the next month.
What are the roadblocks there?
What are the impediments?
Dr. Michael Page (10:09):
There are several things that come to mind
.
One is the Safe Harbor Act.
Dr. Douglas L. Beck (10:13):
Yeah, tell me about that.
Dr. Michael Page (10:14):
It asks us whether or not there's something
legal or potentially illegalabout these discounted
arrangements we make withindustry.
Sure Harbor allows us tonegotiate contracts with
providers that give us a greaterdiscount.
Yes, that is considered legal,sure, and as long as these
discounts are in a writtencontract, yes, we are in a legal
(10:39):
realm.
Dr. Douglas L. Beck (10:40):
And so you are.
So, legally, you're on safeground because you're buying a
product at a known price, aknown quantity, from a known
supplier, so that and it has tohave a contract with it.
And it has to have a writtencontract.
All right, so that's the safeharbor In the safe harbor.
Why did that come into being?
What was the predisposingsituation that called for the
(11:01):
need for a safe harbor act?
Dr. Michael Page (11:03):
This was during the time when healthcare
costs were rising at monumentalrates and historically that was
alarming for that particular eraand administration politically.
So that was what prompted that.
Dr. Douglas L. Beck (11:18):
All right, and you know that goes back even
further.
I mean, I remember I'm oldenough to remember that before
we had Medicare and SocialSecurity, you know it was all
fee for service, right.
And those days things were very, very different.
Because when Medicare came inand I say this respectfully, I'm
not trying to make fun of themor anything but all of a sudden,
you know, people realized thatthey could charge a code and an
(11:40):
E&M code, a CPT, whatever it is,and never get paid for that.
So all of a sudden, in thattime period 20 years after
Medicare came in, because thatwas like mid-60s when that came
in people started charging moreand more and more and really
itemizing, because things thatyou would do in the office that
you would never think to chargefor, oh there's a code for that,
there's a code for that.
(12:01):
And things got really crazy outof hand.
I remember that quite clearly.
Dr. Michael Page (12:05):
So it's also interesting.
So if we bring this and circlethis back to autonomy, how is it
that if you negotiate thewholesale cost of hearing aids
to be less, the question then isare you more likely to fit a
particular hearing aid becauseyou know that your margin is
greater In a private practice?
(12:27):
That matters and that's areasonable way of thinking.
If I work for a hospital or alarge organization where I never
see wholesale costs I never amaware of what invoice is coming
across on that hearing aid I'mprobably less likely to be
influenced by which manufacturerI may choose, based on cost
(12:49):
alone.
Dr. Douglas L. Beck (12:50):
Yeah, that's a very interesting
situation.
And when you're employing theSafe Harbor Act and so you're
not under legal problems becauseyou purchased it in a legal
fashion, what about theselection of that product for
that patient?
Dr. Michael Page (13:05):
Sure Well, I was in a time frame where I was
managing a pediatric healthcarepractice in a hospital.
I was negotiating thosecontracts with the hearing aid
suppliers and I would neverdivulge the contract to the
audiologists that werepracticing.
I would never tell them that.
(13:26):
You know, we have a greaterdiscount over here.
We have a lesser discount overhere.
I always tried to counsel them.
Please do what's right and bestfor the patient.
Dr. Douglas L. Beck (13:36):
I like that plan If I have a staff of eight
or 10 audiologists and I have areasonable representation of
hearing aids and other productsassistive listening devices, you
know whatever.
So I have a reasonableassortment and I wouldn't tell
them the wholesale price becausethen it could influence what
they do.
I get that.
(13:56):
But now how do you apply thatif you're in a private practice
situation and it's the soleproprietorship and you're buying
it and you're the clinician?
Dr. Michael Page (14:04):
There are several categories of ethics,
but one of the categories thatapplies here is the ethics of
self.
That means what myself-awareness is.
How likely am I to beinfluenced by discounts, by
incentives, by gifts, by thosekinds of things?
And the government also saysthat discounts are gifts.
(14:26):
Now, they're legal gifts underSafe Harbor Act, but they're not
so legal gifts if that's justoffered as a weekend special.
And so I have to ask myself canI truly make the difference?
Can I make the difference in mychoice by selecting a hearing
aid that's going to cost me more?
I have less margin or do I gowith the hearing aid that's
(14:51):
going to cost me less?
Greater margin will be 90%correct of what this patient
needs, but in reality this otherhearing aid probably would be
better.
And again, this is sort of thatgray area.
Dr. Douglas L. Beck (15:06):
Yeah, we're back there again.
Dr. Michael Page (15:07):
We're back there again and we're always
going to be there.
But this is where we have toask ourselves how do we check in
on our own ethics?
Let's put autonomy to bed andlet's go to number two
Non-maleficence comes from, kindof stems from what people call
the Hippocratic Oath and do noharm.
It actually didn't come fromthe Hippocratic Oath, although
(15:31):
Hippocrates did say do no harm.
But even at his stage inhistory, millennia ago, one of
the first physicians was sayingI can't cause harm to my
patients.
First of all, I must cause noharm to my patients, and so
(15:51):
that's perpetuated overmillennia.
Now it's been interesting tosee that what people call the
Hippocratic Oath once taken uponphysicians upon graduation,
there are a number of medicalschools who are no longer
requiring the Hippocratic OathBecause, frankly, sometimes we
do cause pain, we might causeharm, but it's in the realm of a
(16:17):
greater perspective in terms ofwhat the net result is.
So non-maleficence.
And we have to ask ourselves asaudiologists how might I
potentially harm a patient?
Dr. Douglas L. Beck (16:29):
There are clinical ways that we can do
that accidentally taking earimpressions right, you know,
certainly vestibular tests andelectrococleography and ABR.
I mean you know we do a lot ofthings that can potentially
injure a patient.
Don't we have a burden toexplain that to the patient,
that there are risks anddownsides that could occur prior
(16:50):
to engaging in whateverclinical tests we're talking
about?
Dr. Michael Page (16:54):
And that would fall under informed consent,
and so we will always have weshould have a written informed
consent, but in addition to that, I think, any procedure that
would potentially cause someharm, 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 thisto happen.
(17:16):
It's almost like going in forsurgery and the surgeon says you
know, there's a chance youcould die on the table.
I'm just giving you theinformed consent Now.
The likelihood of thathappening is less than 1%.
Would you like to proceed?
And so we do that.
So non-maleficence.
But I'd like to explorenon-maleficence in a different
(17:36):
realm, and that is do ourpatients harm by not disclosing,
for instance, the relationshipswe might have with industry?
Do patients a disservice byselecting hearing aid A versus
hearing aid?
Dr. Douglas L. Beck (17:52):
B.
Yeah, I mean, that's a veryimportant consideration,
absolutely.
And it's a very hard thing toprove, of course, because you
know, even with the bestverification and validation to
prove, of course, because youknow, even with the best
verification and validation, youcan sometimes achieve the exact
same verification andvalidation outcomes and goals
with multiple products.
Dr. Michael Page (18:08):
Sure, and if we had equivalent outcomes on
two separate devices, onecheaper, one more expensive for
us, but let's say the patientpreferred one over the other?
If we did that, we have thatdilemma as well.
Dr. Douglas L. Beck (18:26):
Yeah, and I think more or less that if
you're always working for thepatient's best interest and if
the patient says clearly Iprefer this one, that's the
answer.
Dr. Michael Page (18:36):
Yeah, it is the answer.
I would say it's the answer formost of us.
Yeah, but I know for a factthat it's not the answer for
some.
Dr. Douglas L. Beck (18:43):
There are some people who would say that
you should not discuss long-termoutcomes for untreated hearing
loss for patients who haveperhaps diabetes, or patients
who have cognitive decline orpatients who have other medical
things going on.
You should just stay in yourlane and I would argue, of
course, that it's all in my lanewhen I talk to a patient who
(19:08):
has diabetes about the need tohave comprehensive audiometric
evaluation, not a hearingscreening.
When I have a patient whodoesn't do well on speech and
noise and I do a cognitivescreening and they don't do well
, there, it seems it would bemaleficent to not discuss with
the patient the potentialcorrelations between untreated
hearing loss in at-risk patients.
I agree with thatwholeheartedly.
Dr. Michael Page (19:29):
We have that obligation.
Dr. Douglas L. Beck (19:31):
But there are people who are writing in
our professional journals andI'm not going to mention any
names who are saying, oh, youshouldn't discuss that with the
patient, and I think it's ourresponsibility.
I mean the same way that Iwould with a patient with
auditory neuropathy or a patientwho needs a cochlear implant.
I don't think anybody shouldscare a patient into action ever
(19:51):
, but I do think, since we aredoctors and we have knowledge
and we see these same thingsevery day and we read journals
and we write journals, you know,we know that people who are at
higher risk for certain thingsit'll impact their hearing.
I think we're in this veryinteresting age where we have so
(20:12):
much knowledge aboutcorrelations between cardiac
disease and hearing health care,between diabetes and hearing
health care, between cognition,mild cognitive impairment,
alzheimer's, other forms ofdementia.
We know a lot about patientswho have hearing loss,
particularly the at-risk group,which would be older patients,
(20:36):
which would be patients who arein lower socioeconomic groups,
and patients who are multiplepharmacy patients.
Right, they're on five or moremeds and I would say that in my
view, it would be unethical totalk to the patient about these
things.
Being untreated couldsubstantially make their hearing
and listening ability.
Worse, there are people in ourprofession who take the opposite
(20:56):
view.
They say well, you shouldn'ttalk to them about that because
it's a scare tactic.
I'm not trying to scare theminto anything, it's not a scare
tactic.
And I wonder what's the pointof having knowledge and
education and reading journalsif you're not using that for the
patient's benefit, to helpenlighten them as to the way
their life may unfold?
Would we?
Dr. Michael Page (21:15):
fault a primary care practitioner for
not talking about relateddisorders that were outside of
their specialties.
And that's what they do everyday, 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 wesee potential or hints for other
(21:37):
related disorders, I think wehave the absolute ethical
obligation to discuss those.
Dr. Douglas L. Beck (21:43):
Frankly, I've seen patients who have tick
day of the room.
I've seen patients who haveBell's palsy.
I've done invasiveelectro-neuronography studies on
these patients.
You know we do so much morethan just air, bone and speech.
And I think you know you neverpractice beyond your area of
expertise.
You always practice within yourlicense.
But when you, you know it's theold.
When you see something, saysomething.
(22:05):
Now, when I have a patient withBell's palsy, I don't treat them
, I measure their Bell's palsyto help determine how long and
how successful a recovery mightbe or whether surgery is
indicated.
And I can talk to the patientabout that.
I am not a technician, I'm adoctor.
You're a doctor and I thinkthat we are scared to practice
(22:27):
to the top of our license.
And I like your analogy that aprimary care doctor.
They send patients toorthopedic people all the time,
to cardiovascular people, allthe time to neurosurgeons,
because that's not their area.
But they will say Mr Smith, I'ma little concerned about that
limp, it hasn't gotten better.
Let's get you an MRI, let's getyou over to orthopedics, let
them take a look at that.
Dr. Michael Page (22:47):
That totally makes sense to me.
Dr. Douglas L. Beck (22:49):
And you wonder, you know, in audiology,
though people would say, oh,that's a scare tactic, you're
telling them this, that theyshould treat their hearing loss
because you want to sell hearingaids.
Well, I don't know, that's thatgray area.
I don't want to sell hearingaids to anybody who won't
benefit from them, but I do wantto sell hearing aids to people
who would benefit from them, andI think that we're in that gray
(23:10):
area again.
Dr. Michael Page (23:11):
Well, that comes back to, maybe, the
definition of how we.
Do we sell or do we dispense?
When I go to the orthopedicspecialist, do I expect him or
her to sell me a new shoulder?
They never talk in terms ofselling a shoulder or selling a
hip replacement.
They don't.
It is all about we'redispensing a medical or surgical
(23:31):
device that will treat thedisorder that you have.
Dr. Douglas L. Beck (23:35):
And do they ever say do you want the low
one, the mid one or the high one?
Do you want the premium, youwant the premium hip, or do you
want the cheap hip?
Dr. Michael Page (23:43):
Right, they don't.
They don't.
I think we've missed the boaton that so many times.
That it alarms me and I'll tellyou where I think that comes
from is the tighterrelationships that we've had
with members of industry, andparticularly where industry has
come in to purchase privatepractices.
(24:04):
Yeah, that creates arelationship that we're not
quite used to.
That's almost as if Pfizerwould come in and buy out
physicians, own physicians, andrequire their prescription of
only Pfizer drugs.
Would we tolerate that?
Dr. Douglas L. Beck (24:21):
I don't think so, not for a minute, I
don't think so, and we have astrange relation with industry
in our profession.
So that's number two, and Iappreciate the conversation on
that.
Tell me about number three,number three is beneficence and
beneficence.
Dr. Michael Page (24:38):
these are simple principles, but
beneficence is the proactive actof doing good.
Dr. Douglas L. Beck (24:45):
Yeah, and it's not just in your personal
manner, of course.
I would assume that when wetalk about beneficence, we're
talking about doing bestpractices.
We're talking about doingthings that our colleagues would
all agree are necessary and areimportant and should be done in
order to determine a diagnosisfirst and a treatment second.
But I think we get caught up inthis because many people won't
(25:07):
do a complete diagnosis.
You know they'll see mild tomoderate 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 scopeof practice and best practice
guidelines AAA, asha and IHSthey all say the same thing,
right, airbone and speechreflexes, timps, otoacoustic
emissions.
(25:27):
You might do a screening forspeech and noise.
You might do a test for speechand noise.
You should do listening andcommunication assessments.
I don't know anybody who doesthat.
Dr. Michael Page (25:35):
I think you're right.
It's uncommon.
Dr. Douglas L. Beck (25:37):
And so you know, when we talk about, are we
doing the very best for thepatient?
Well, you know, when you haveAAA and ASHA and ITS and you
have these very, very smartpeople all sitting down and
deciding what's in the patient'sbest interest, based on
outcomes, based on bestpractices, we know what we
should do, but so many times wejust take these shortcuts and to
a large degree it's because wecan't get paid to do the other
stuff.
So then how do you mix that in?
(25:59):
Because now I know I should bedoing an OIE, I know I should be
doing high-frequency audiometry.
I mean, holy moly, it's easy todo.
Most audiometers can't do itunless they're more recently
made, let's say the last 10 or15 years.
But we know how importanthigh-frequency audiometry is,
it's critically important, andyet it's probably not done in
(26:20):
90% of clinics.
So how do we dot that I orcross that T?
I mean?
Dr. Michael Page (26:27):
how do we make that right?
It's fascinating, and these aresome dilemmas that I found
myself in, even managing aclinic, because I would have the
finance people coming down andevaluating 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, andthe bottom line was always
(26:51):
you're not generating enoughrevenue to justify your
existence.
So they're saying what can youcut out?
What will you cut out tojustify your existence?
And so then we argue just froman ethical standpoint.
And all of that happens withmost people who are in larger
institutions.
They're audiologists that arereally given the charge by
(27:16):
whoever owns that practice,whether it's a private person or
an industry.
They're given the charge tospend as little time as possible
to get the amount of work andinformation done to fit a
particular device.
Those are the instructions,whether spoken or not.
Dr. Douglas L. Beck (27:36):
I was reading.
Yesterday or the day before,there was a company that works
for one of the major insurers Iwon't tell you their name and
this company is hired as acontractor 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
(27:58):
pre-authorized.
And this company, their wholegoal.
What they do is they look atthat code and they say nope.
And to me it's the same thing.
Your doctor calls in aprescription to a pharmacy
Walgreens, cvs, rite Aid,whomever and then the pharmacy
calls and says oh, that's not onyour formula, you can't have
that, so we can give you this.
Aren't they practicing medicinewithout a license?
Dr. Michael Page (28:19):
Yes, I've always felt that way.
Dr. Douglas L. Beck (28:22):
And again, I think we're back in the gray
zone once again.
So what are the guidelines formaking sure you're doing the
best for the patient?
Dr. Michael Page (28:29):
Practice Standards Organization that's
relatively new.
Apso has been around for acouple of years now the
Audiology Practice StandardsOrganization.
John Coverstone is the currentexecutive director, but there
(28:59):
have been many, many very astutevoices on that in that
organization to help us developthose standards.
Dr. Douglas L. Beck (29:03):
And you were mentioning to me earlier
that those standards have beenused in courts of law as
practice guidelines.
What we should actually bedoing.
Dr. Michael Page (29:10):
Now the interesting part of that and one
of the reasons I've been a fanof APSO, is because of their
independent.
That means sometimes ourprofessional organizations get a
bit hijacked by people who havea financial interest in the
organization or in the peoplewithin that organization yeah,
oh sure and where APSO will actwithout that outside influence
(29:34):
of other individuals.
So they've maintained thatindependence, which I like.
Dr. Douglas L. Beck (29:38):
Yeah, and I want to give a shout out to
John Coverstone too.
I was on the adult hearing aidcommittee for APSO and it was
quite a good process.
I can't tell you how many timeswe've met, but I want to guess
between eight and 12 and two orthree hour meetings and you have
six or 10 experiencedaudiologists discussing what
should we do and why should wedo it, and it's a very
(29:59):
democratic process and I thinkmy hat's off to them.
I think they do a great job.
Dr. Michael Page (30:04):
John and many others.
I think John's been a veryleveling force and a very
persistent thread in that andlots of gratitude for anyone who
has participated that,especially those subject matter
experts like yourself and others.
Dr. Douglas L. Beck (30:18):
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 fourhere.
Dr. Michael Page (30:28):
Part four of the principles of ethics that
were originally described byBeauchamp and Childress is
justice, and justice has a lotto do with, essentially, it's me
getting what I came for and yougiving what you're there and
licensed to give.
Justice has a lot to do withfairness, with equity and my
(30:49):
relationship with my physician,etc.
We see justice playing a role,though, in ethics in unfortunate
ways where audiologists mightget caught in a legal realm
where they've been convicted ofa crime or criminal activity or
violation of codes of ethics orthose kinds of things, and
unfortunately there are someprolific presentations of those
(31:13):
things.
And we study those, not tobring fault against anyone, but
we study them in the context ofhow could that potentially
happen to me?
Dr. Douglas L. Beck (31:26):
Yeah, we've all seen those situations you
know, written up in the papersand online, where you know
there's liars, thieves andcheaters and you know they're
charging for products thatweren't delivered and they're
charging CPT codes for processesthat were never performed and,
yeah, that's terrificallyunfortunate.
Dr. Michael Page (31:43):
I think it's a sad reflection on those people
in particular, but it does makeconsumers and patients wonder
about the rest of us it suredoes, and that's why, when these
go to the newspapers, they willput the word audiologist in the
headline.
I remember years ago when anaudiologist was convicted of
(32:03):
murder and that was the headlinein the newspaper Audiologist
commits murder.
Well, why would we sayaudiologist?
Why would?
Because we're held to thatstandard and we are, in the
community's eyes, somebody thatshould have respect and
credibility, so it behooves usto respect that as well.
Dr. Douglas L. Beck (32:25):
Yeah, and all of this, I think, would be
wrapped up in the word humility.
You know so, mike, when youhave that feeling deep in your
chest that something is wronghere, I mean it seems to me you
would reach out to a trustedcolleague and say I'm not going
to give you names, not going togive 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, quitehonestly, since I did that, but
(32:49):
I've seen situations thatreally made me think this isn't
right and I turned to trustedcolleagues and they were more
experienced than I and that wasuseful and I think we got the
right results.
Is there a pathway when you knowsomething is wrong?
There used to be somethingcalled the Green Book by AAA.
I don't think I've seen anupdate on that in 20 years.
Maybe it has been.
(33:09):
If it has been, I don't knowabout it.
What readings, what books, whatpublications and how would you
suggest for an audiologist orhearing aid dispenser who finds
that weird situation?
How do you recommend peopleproceed?
Dr. Michael Page (33:24):
There's all kinds of directions.
We could go with that, butfirst of all, let me mention
that I think codes of ethics areessential for us, and yet their
limitation is that they are I'mgoing to call them merely a
checklist of do's and don'ts,and we should do those things or
not do those things accordingto the codes of ethics.
Dr. Douglas L. Beck (33:44):
And you can extrapolate from the do's and
don'ts.
I mean, you don't have to writeevery single situation.
Dr. Michael Page (33:48):
Sure, and so if we look at those do's and
don'ts, one thing I think hasalways been missing from codes
of ethics is why what we see arethings 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.
(34:08):
Once we understand the reasonwhy we do things, and so one of
the references should always be,I think, first of all, legality
.
When we see something thatwe're concerned about, that's a
dilemma for us that we witness.
First question for me is is itlegal or is it illegal?
And if it is illegal, show mechapter and verse, show me the
(34:31):
statute behind that.
If it's not illegal, then I'dgo to the next one Is it
unethical?
If it is unethical, then let'sgo 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 codeof ethics, I'm going to ask just
(34:52):
a moral question, and that iswow, what would my mom say, or
what would the rabbi say, orwhat would the pastor or priest
say?
Those tend to be our moralguides, but overall, I've always
tried to help us get beyond thecodes of ethics and get into
the principles of ethics.
(35:13):
So if we're still not quitethere with legal, ethical and
moral, then let's go to the fourprinciples which we just
discussed.
Is somebody's autonomy beingbroken?
Is someone being maleficent?
Is someone not being orexercising beneficence?
Or again, is this an aspect ofjustice or fairness or equity
(35:36):
that we should address?
Dr. Douglas L. Beck (35:37):
And I think that's great, Dan.
That decision tree makes goodsense.
Is there a particular book or aparticular article that you're
aware of that would serve as agood guideline for people who
want to learn more about this?
Dr. Michael Page (35:49):
Well, let me toot my own horn for just a
minute.
Bob Traynor and Glazer's bookis coming out in the spring of
this year, which is on practicemanagement.
Bob Traynor asked me if I wouldwrite the chapter on ethics for
that, which is a littledifferent approach.
He had mentioned that he wasvery much moved by some of my
approaches to ethics and that Iwas one of the first guys that
(36:12):
told him why why we have to havethese ethics.
And so he said would you writethe chapter for my textbook
coming up, which I did.
It's been submitted, but Iapproached that a little
different way as well, and Ithink that I'm hoping that will
become a great resource.
Dr. Douglas L. Beck (36:29):
That's fantastic.
I'm glad you mentioned that.
Well, listen, I want to thankyou, Mike.
I know we could talk aboutthese things for hours and hours
and hours, but I appreciate theencapsulation and the update
and I'm really glad to hear thatyou wrote that chapter.
I think you're the perfectperson for it.
Bob Traynor, Bob Glazer havebeen friends of mine forever and
I'm really glad you're involvedwith them.
I think they do a great jobwriting books and I think they
(36:51):
do a great job lecturing, so I'msure you're going to fit in
just fine and that book will bea bestseller.
So, Mike, I want to thank you.
It's a joy to spend time withyou, even without cigars or
bourbon, you know, but we'll dothat again, and I really
appreciate your knowledge onthis.
This is an area where I thinkall professionals need to be
aware of, and certainly becognizant of, the ramifications
(37:14):
of doing things right and doingthings wrong, and I think that
it's what your mom always toldyou right Wash your hands flush,
take care of other people.
And I think also, when youthink about I don't know if
you've ever seen the Rotary Club, they have guidelines that go
very much the same as theseethical guidelines my dad used
(37:34):
to be a big wheel at Rotary andthey had all these decision
points which were, you know isit fair for everybody involved?
Is it ethical, Is it moral,Does it make sense?
Are you doing it to helpsomebody?
Are you doing it to hurtsomebody?
You know all of those decisionpoints and I think they all get
you to the right thing, which is, you know, do the right thing
for the right reason and alwaystake care of your patient first.
Dr. Michael Page (37:52):
Thank you, that's a great way to wrap up.
Thanks so much for today.
My pleasure, mike.
Dr. Douglas L. Beck (37:57):
Talk to you soon.
Thank you.
You to our partners.
Sycle, built for the entirehearing care practice.
Redux, the best dryer, handsdown.
CaptionCall by Sorenson, Lifeis Calling.
CareCredit, here today to helpmore people hear tomorrow.
Fader Plugs, the world's firstcustom adjustable earplug.
(00:41):
Welcome back to another episodeof the Hearing Matters podcast.
I'm founder and host BlaiseDelfino and, as a friendly
reminder, this podcast isseparate from my work at Starkey
.
Dr. Douglas L. Beck (00:56):
Good afternoon.
My name is Dr Douglas Beck, Iam an audiologist and today I am
honored to have my dear friend,Dr.
Michael Page.
Dr.
Page has served as a member ofthe Utah Cochlear Implant Team
and as president of UtahSpeech-Language Hearing
Association, member of thePrimary Children's Medical
Center Bioethics Committee andboard chair for the Division of
(01:16):
Occupational and ProfessionalLicensing.
Dr Page has held adjunctfaculty positions at Utah State
University, Brigham YoungUniversity, University,
University of Utah, SalusUniversity, Drexel University,
university of the Pacific, and,on and on, he served as chair
and committee member of the AAAEthical Practices Committee,
manager of audiology cochlearimplant program at Primary
(01:38):
Children's Hospital in Salt LakeCity and various management and
executive positions within theindustry.
He's a business consultant forhealthcare practices, education,
general business, specializingin aspects of ethical practice,
professional boundaries,industry relationships, contract
negotiations, employeerelations and improving
workplace culture.
That's a mouthful, dr Page.
(01:59):
How are you today?
Dr. Michael Page (02:01):
I'm well.
Thanks so much, and thanks forgetting us together.
This is a great occasion.
Dr. Douglas L. Beck (02:06):
It's always a joy.
Usually I see you with a drinkin hand and a cigar, but today's
a little different.
We've been trying to find timein our schedules, you and I, for
probably six or eight months toget this done, and I want to
make it an overview discussionof ethics and professionalism,
because you certainly have thatbackground and you give lectures
(02:27):
on this topic all the time andit's a rarity in audiology we
have probably eight or 10 peoplewho speak on ethics, but we
don't have that many and youcertainly have the history.
So tell me, how did you getinvolved with ethics?
Dr. Michael Page (02:39):
It's a great occasion actually, when you look
back at some of the history ofthat and what shaped that
portion of my professionalcareer.
I distinctly remember the day Iwas a pediatric audiologist
this would have been likely inthe late 1980s and I received a
memo that came to all hospitalpersonnel at the place where I
(03:00):
was working and said we arestarting a bioethics committee
for the hospital.
Any interested parties pleaseapply.
My eyes got big and I can'teven tell you why I was
interested because that wasn'tsomething that I had pursued at
that point.
But I did apply and wasaccepted on that committee.
That changed the trajectory ofmy understanding of ethics in
(03:25):
general.
Sitting around a big conferenceroom table with physicians,
nurses, billers, coders, parentseverybody was represented and a
file gets put in the middle andsay let's talk about this.
It was just incrediblyenlightening and that began this
journey of mine.
That's great.
Dr. Douglas L. Beck (03:45):
I think that's a great way to tiptoe
into it, because you know, we'reall professionals and ethical
dilemmas and ethical issues comeup almost daily and it's not
easy to navigate your waythrough.
So tell me what's thedefinition of ethics?
Let's start with ethics.
And is that the same as medicalethics, or do you see those as
two separate entities withethics?
Dr. Michael Page (04:05):
And is that the same as medical ethics or do
you see those as two separateentities?
Actually, I see all of ethicsas the same.
In fact, talking the right wayabout ethics, we're beyond
ethical codes and we get intoprinciples of ethics, which
really encompasses thedefinition of ethics.
Once we're in the principlemode, I should be able to take
universal principles of ethicsand apply them to Little Sus
principle mode.
I should be able to takeuniversal principles of ethics
(04:26):
and apply them to Little Susie'slemonade stand and Aunt
Martha's coffee shop, and Ishould be able to apply them
forever.
So definitions of ethics fallback on.
Some of the research that wasdone by Beauchamp and Childress
Started probably, if I remember,in the 1990s or so.
Dr. Douglas L. Beck (04:44):
Yeah, I remember that.
Dr. Michael Page (04:46):
Or principles, which are simply.
They are the respect forautonomy, non-maleficence,
beneficence and justice, and thedefinitions of those four
actually encapsulate what weshould understand about ethics
in general.
Give us the definitions, whatwe should understand about
ethics in general.
Give us the definitions.
(05:06):
Definitions the respect forautonomy is the ability for me,
as a clinician, to be able topractice autonomously.
That means that I have nooutside influences that would
represent my choices or myprofessional judgments.
It's also a respect forautonomy, for a patient's right
(05:28):
to choose.
Dr. Douglas L. Beck (05:29):
All right Now if we just examine that one
and we'll go through all four ifyou don't mind.
So on autonomy, if you're in anoffice and they say, okay, we
sell XYZ brand hearing aids andwe do our vestibular tests in
this protocol and we do earcleanings using these tools, or
(05:50):
whatever the example is, youknow, if I want to sell a
hearing aid that is of adifferent brand, whose ethics
are we violating?
Am I violating the ethics ofthe business or my own ethics,
or am I compromising the patient?
I mean, let's assume it's aspecial hearing aid, like a
cross, let's say, you know, it'snot the most typical, they're
(06:11):
also not rare.
And my company, the office Iwork for, sells brand X.
I don't care for that brand, Idon't get good results with it,
I always use brand Z.
So where does the ethicalautonomy come into this?
Dr. Michael Page (06:26):
Sure, keep in mind that out of these four
principles, nothing is everblack and white, of course,
never 100% or 0%, and we'realways going to be in the middle
somewhere.
I had a colleague of mine reachout and say it's impossible for
me to be 100% ethical all thetime.
It's almost the principle of Ithink it's called Zeno's rule of
(06:49):
paradox I think that's whatit's called where we use the
half.
We always get halfway to thedestination.
We get from point A to point B,and then we go halfway in
between, and we go halfway inbetween and we never really get
there, but we always get closer.
Dr. Douglas L. Beck (07:08):
That is so funny that you said that,
because I was having aconversation this morning with
Blaise Delfino, my partner and Iwas explaining infinity in not
pure mathematical terms, but Iwas talking about exactly the
same.
I said if you took a 10 footdistance between Dr Michael Page
and Dr Douglas Beck and yousaid, okay, we're going to
always half the distance everyday.
So the first day it's five feettwo and a half feet, one and a
quarter you would never getthere because there's always a
(07:30):
half to go and it's sointeresting to me that you use
that analogy today.
But you're always movingforward, you're always going in
the right direction, you'regoing towards that goal, but you
can never get there becausethere's always half of
whatever's left.
Dr. Michael Page (07:43):
So what's more important getting there or
getting on the journey togetting closer to getting there?
Absolutely, If we can't everget there, then some people
would say, well, if I can't getthere, I'm not going to even go
halfway.
Dr. Douglas L. Beck (07:57):
Well, this is very important because people
will see the world in black andwhite.
If that's all you got, that'sgreat.
But between black and whitethere's a bazillion different
shades of gray, and that's kindof where we live.
Dr. Michael Page (08:09):
Yeah, no doubt about that.
Back to your question about howis my autonomy?
One of the things that I thinkis really critical is to ask
ourselves what is the thief ofmy autonomy and what could
potentially take my autonomyaway as a practitioner, or what
(08:30):
things would take away theautonomy of a patient or a
candidate for a device that wemight dispense to prescribe.
And generally, if we look atthe business sense and the
business relationships we havewith members of industry, I will
contend that I think one of thegreatest thieves of my autonomy
as a practicing audiologist isany incentive or gift given to
(08:57):
me by someone, by a member ofindustry, who wants me to buy
their product.
Dr. Douglas L. Beck (09:02):
And this is a great dilemma because, as
business people, we'reclinicians and we're business
people particularly if we're inour own private practice.
There are just like in pharmacy, just like in surgical supplies
, just like in any medicalsupply company, you get
discounts for quantity.
That's how business works.
You know supply and demand.
If you're buying more, you'reprobably getting a lesser price.
(09:24):
We have examples of that, ofcourse, with the VA, of course,
with big box, they pay quite abit less than regular
practitioners would pay for thesame product.
So how does it fit intoautonomy If I think I can see
and take care of 10 patientsthis month?
This is the typical hearing aidthat I use and it's very
programmable.
It fits all their needs nineout of 10 times.
(09:45):
So I want to stock up on that.
So I call my manufacturer and Isay 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 Idon't really want 12 to begin
with, but I want the betterprice because I know I can
probably sell nine or 10 thismonth and have a few going into
(10:05):
the next month.
What are the roadblocks there?
What are the impediments?
Dr. Michael Page (10:09):
There are several things that come to mind
.
One is the Safe Harbor Act.
Dr. Douglas L. Beck (10:13):
Yeah, tell me about that.
Dr. Michael Page (10:14):
It asks us whether or not there's something
legal or potentially illegalabout these discounted
arrangements we make withindustry.
Sure Harbor allows us tonegotiate contracts with
providers that give us a greaterdiscount.
Yes, that is considered legal,sure, and as long as these
discounts are in a writtencontract, yes, we are in a legal
(10:39):
realm.
Dr. Douglas L. Beck (10:40):
And so you are.
So, legally, you're on safeground because you're buying a
product at a known price, aknown quantity, from a known
supplier, so that and it has tohave a contract with it.
And it has to have a writtencontract.
All right, so that's the safeharbor In the safe harbor.
Why did that come into being?
What was the predisposingsituation that called for the
(11:01):
need for a safe harbor act?
Dr. Michael Page (11:03):
This was during the time when healthcare
costs were rising at monumentalrates and historically that was
alarming for that particular eraand administration politically.
So that was what prompted that.
Dr. Douglas L. Beck (11:18):
All right, and you know that goes back even
further.
I mean, I remember I'm oldenough to remember that before
we had Medicare and SocialSecurity, you know it was all
fee for service, right.
And those days things were very, very different.
Because when Medicare came inand I say this respectfully, I'm
not trying to make fun of themor anything but all of a sudden,
you know, people realized thatthey could charge a code and an
(11:40):
E&M code, a CPT, whatever it is,and never get paid for that.
So all of a sudden, in thattime period 20 years after
Medicare came in, because thatwas like mid-60s when that came
in people started charging moreand more and more and really
itemizing, because things thatyou would do in the office that
you would never think to chargefor, oh there's a code for that,
there's a code for that.
(12:01):
And things got really crazy outof hand.
I remember that quite clearly.
Dr. Michael Page (12:05):
So it's also interesting.
So if we bring this and circlethis back to autonomy, how is it
that if you negotiate thewholesale cost of hearing aids
to be less, the question then isare you more likely to fit a
particular hearing aid becauseyou know that your margin is
greater In a private practice?
(12:27):
That matters and that's areasonable way of thinking.
If I work for a hospital or alarge organization where I never
see wholesale costs I never amaware of what invoice is coming
across on that hearing aid I'mprobably less likely to be
influenced by which manufacturerI may choose, based on cost
(12:49):
alone.
Dr. Douglas L. Beck (12:50):
Yeah, that's a very interesting
situation.
And when you're employing theSafe Harbor Act and so you're
not under legal problems becauseyou purchased it in a legal
fashion, what about theselection of that product for
that patient?
Dr. Michael Page (13:05):
Sure Well, I was in a time frame where I was
managing a pediatric healthcarepractice in a hospital.
I was negotiating thosecontracts with the hearing aid
suppliers and I would neverdivulge the contract to the
audiologists that werepracticing.
I would never tell them that.
(13:26):
You know, we have a greaterdiscount over here.
We have a lesser discount overhere.
I always tried to counsel them.
Please do what's right and bestfor the patient.
Dr. Douglas L. Beck (13:36):
I like that plan If I have a staff of eight
or 10 audiologists and I have areasonable representation of
hearing aids and other productsassistive listening devices, you
know whatever.
So I have a reasonableassortment and I wouldn't tell
them the wholesale price becausethen it could influence what
they do.
I get that.
(13:56):
But now how do you apply thatif you're in a private practice
situation and it's the soleproprietorship and you're buying
it and you're the clinician?
Dr. Michael Page (14:04):
There are several categories of ethics,
but one of the categories thatapplies here is the ethics of
self.
That means what myself-awareness is.
How likely am I to beinfluenced by discounts, by
incentives, by gifts, by thosekinds of things?
And the government also saysthat discounts are gifts.
(14:26):
Now, they're legal gifts underSafe Harbor Act, but they're not
so legal gifts if that's justoffered as a weekend special.
And so I have to ask myself canI truly make the difference?
Can I make the difference in mychoice by selecting a hearing
aid that's going to cost me more?
I have less margin or do I gowith the hearing aid that's
(14:51):
going to cost me less?
Greater margin will be 90%correct of what this patient
needs, but in reality this otherhearing aid probably would be
better.
And again, this is sort of thatgray area.
Dr. Douglas L. Beck (15:06):
Yeah, we're back there again.
Dr. Michael Page (15:07):
We're back there again and we're always
going to be there.
But this is where we have toask ourselves how do we check in
on our own ethics?
Let's put autonomy to bed andlet's go to number two
Non-maleficence comes from, kindof stems from what people call
the Hippocratic Oath and do noharm.
It actually didn't come fromthe Hippocratic Oath, although
(15:31):
Hippocrates did say do no harm.
But even at his stage inhistory, millennia ago, one of
the first physicians was sayingI can't cause harm to my
patients.
First of all, I must cause noharm to my patients, and so
(15:51):
that's perpetuated overmillennia.
Now it's been interesting tosee that what people call the
Hippocratic Oath once taken uponphysicians upon graduation,
there are a number of medicalschools who are no longer
requiring the Hippocratic OathBecause, frankly, sometimes we
do cause pain, we might causeharm, but it's in the realm of a
(16:17):
greater perspective in terms ofwhat the net result is.
So non-maleficence.
And we have to ask ourselves asaudiologists how might I
potentially harm a patient?
Dr. Douglas L. Beck (16:29):
There are clinical ways that we can do
that accidentally taking earimpressions right, you know,
certainly vestibular tests andelectrococleography and ABR.
I mean you know we do a lot ofthings that can potentially
injure a patient.
Don't we have a burden toexplain that to the patient,
that there are risks anddownsides that could occur prior
(16:50):
to engaging in whateverclinical tests we're talking
about?
Dr. Michael Page (16:54):
And that would fall under informed consent,
and so we will always have weshould have a written informed
consent, but in addition to that, I think, any procedure that
would potentially cause someharm, 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 thisto happen.
(17:16):
It's almost like going in forsurgery and the surgeon says you
know, there's a chance youcould die on the table.
I'm just giving you theinformed consent Now.
The likelihood of thathappening is less than 1%.
Would you like to proceed?
And so we do that.
So non-maleficence.
But I'd like to explorenon-maleficence in a different
(17:36):
realm, and that is do ourpatients harm by not disclosing,
for instance, the relationshipswe might have with industry?
Do patients a disservice byselecting hearing aid A versus
hearing aid?
Dr. Douglas L. Beck (17:52):
B.
Yeah, I mean, that's a veryimportant consideration,
absolutely.
And it's a very hard thing toprove, of course, because you
know, even with the bestverification and validation to
prove, of course, because youknow, even with the best
verification and validation, youcan sometimes achieve the exact
same verification andvalidation outcomes and goals
with multiple products.
Dr. Michael Page (18:08):
Sure, and if we had equivalent outcomes on
two separate devices, onecheaper, one more expensive for
us, but let's say the patientpreferred one over the other?
If we did that, we have thatdilemma as well.
Dr. Douglas L. Beck (18:26):
Yeah, and I think more or less that if
you're always working for thepatient's best interest and if
the patient says clearly Iprefer this one, that's the
answer.
Dr. Michael Page (18:36):
Yeah, it is the answer.
I would say it's the answer formost of us.
Yeah, but I know for a factthat it's not the answer for
some.
Dr. Douglas L. Beck (18:43):
There are some people who would say that
you should not discuss long-termoutcomes for untreated hearing
loss for patients who haveperhaps diabetes, or patients
who have cognitive decline orpatients who have other medical
things going on.
You should just stay in yourlane and I would argue, of
course, that it's all in my lanewhen I talk to a patient who
(19:08):
has diabetes about the need tohave comprehensive audiometric
evaluation, not a hearingscreening.
When I have a patient whodoesn't do well on speech and
noise and I do a cognitivescreening and they don't do well
, there, it seems it would bemaleficent to not discuss with
the patient the potentialcorrelations between untreated
hearing loss in at-risk patients.
I agree with thatwholeheartedly.
Dr. Michael Page (19:29):
We have that obligation.
Dr. Douglas L. Beck (19:31):
But there are people who are writing in
our professional journals andI'm not going to mention any
names who are saying, oh, youshouldn't discuss that with the
patient, and I think it's ourresponsibility.
I mean the same way that Iwould with a patient with
auditory neuropathy or a patientwho needs a cochlear implant.
I don't think anybody shouldscare a patient into action ever
(19:51):
, but I do think, since we aredoctors and we have knowledge
and we see these same thingsevery day and we read journals
and we write journals, you know,we know that people who are at
higher risk for certain thingsit'll impact their hearing.
I think we're in this veryinteresting age where we have so
(20:12):
much knowledge aboutcorrelations between cardiac
disease and hearing health care,between diabetes and hearing
health care, between cognition,mild cognitive impairment,
alzheimer's, other forms ofdementia.
We know a lot about patientswho have hearing loss,
particularly the at-risk group,which would be older patients,
(20:36):
which would be patients who arein lower socioeconomic groups,
and patients who are multiplepharmacy patients.
Right, they're on five or moremeds and I would say that in my
view, it would be unethical totalk to the patient about these
things.
Being untreated couldsubstantially make their hearing
and listening ability.
Worse, there are people in ourprofession who take the opposite
(20:56):
view.
They say well, you shouldn'ttalk to them about that because
it's a scare tactic.
I'm not trying to scare theminto anything, it's not a scare
tactic.
And I wonder what's the pointof having knowledge and
education and reading journalsif you're not using that for the
patient's benefit, to helpenlighten them as to the way
their life may unfold?
Would we?
Dr. Michael Page (21:15):
fault a primary care practitioner for
not talking about relateddisorders that were outside of
their specialties.
And that's what they do everyday, 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 wesee potential or hints for other
(21:37):
related disorders, I think wehave the absolute ethical
obligation to discuss those.
Dr. Douglas L. Beck (21:43):
Frankly, I've seen patients who have tick
day of the room.
I've seen patients who haveBell's palsy.
I've done invasiveelectro-neuronography studies on
these patients.
You know we do so much morethan just air, bone and speech.
And I think you know you neverpractice beyond your area of
expertise.
You always practice within yourlicense.
But when you, you know it's theold.
When you see something, saysomething.
(22:05):
Now, when I have a patient withBell's palsy, I don't treat them
, I measure their Bell's palsyto help determine how long and
how successful a recovery mightbe or whether surgery is
indicated.
And I can talk to the patientabout that.
I am not a technician, I'm adoctor.
You're a doctor and I thinkthat we are scared to practice
(22:27):
to the top of our license.
And I like your analogy that aprimary care doctor.
They send patients toorthopedic people all the time,
to cardiovascular people, allthe time to neurosurgeons,
because that's not their area.
But they will say Mr Smith, I'ma little concerned about that
limp, it hasn't gotten better.
Let's get you an MRI, let's getyou over to orthopedics, let
them take a look at that.
Dr. Michael Page (22:47):
That totally makes sense to me.
Dr. Douglas L. Beck (22:49):
And you wonder, you know, in audiology,
though people would say, oh,that's a scare tactic, you're
telling them this, that theyshould treat their hearing loss
because you want to sell hearingaids.
Well, I don't know, that's thatgray area.
I don't want to sell hearingaids to anybody who won't
benefit from them, but I do wantto sell hearing aids to people
who would benefit from them, andI think that we're in that gray
(23:10):
area again.
Dr. Michael Page (23:11):
Well, that comes back to, maybe, the
definition of how we.
Do we sell or do we dispense?
When I go to the orthopedicspecialist, do I expect him or
her to sell me a new shoulder?
They never talk in terms ofselling a shoulder or selling a
hip replacement.
They don't.
It is all about we'redispensing a medical or surgical
(23:31):
device that will treat thedisorder that you have.
Dr. Douglas L. Beck (23:35):
And do they ever say do you want the low
one, the mid one or the high one?
Do you want the premium, youwant the premium hip, or do you
want the cheap hip?
Dr. Michael Page (23:43):
Right, they don't.
They don't.
I think we've missed the boaton that so many times.
That it alarms me and I'll tellyou where I think that comes
from is the tighterrelationships that we've had
with members of industry, andparticularly where industry has
come in to purchase privatepractices.
(24:04):
Yeah, that creates arelationship that we're not
quite used to.
That's almost as if Pfizerwould come in and buy out
physicians, own physicians, andrequire their prescription of
only Pfizer drugs.
Would we tolerate that?
Dr. Douglas L. Beck (24:21):
I don't think so, not for a minute, I
don't think so, and we have astrange relation with industry
in our profession.
So that's number two, and Iappreciate the conversation on
that.
Tell me about number three,number three is beneficence and
beneficence.
Dr. Michael Page (24:38):
these are simple principles, but
beneficence is the proactive actof doing good.
Dr. Douglas L. Beck (24:45):
Yeah, and it's not just in your personal
manner, of course.
I would assume that when wetalk about beneficence, we're
talking about doing bestpractices.
We're talking about doingthings that our colleagues would
all agree are necessary and areimportant and should be done in
order to determine a diagnosisfirst and a treatment second.
But I think we get caught up inthis because many people won't
(25:07):
do a complete diagnosis.
You know they'll see mild tomoderate 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 scopeof practice and best practice
guidelines AAA, asha and IHSthey all say the same thing,
right, airbone and speechreflexes, timps, otoacoustic
emissions.
(25:27):
You might do a screening forspeech and noise.
You might do a test for speechand noise.
You should do listening andcommunication assessments.
I don't know anybody who doesthat.
Dr. Michael Page (25:35):
I think you're right.
It's uncommon.
Dr. Douglas L. Beck (25:37):
And so you know, when we talk about, are we
doing the very best for thepatient?
Well, you know, when you haveAAA and ASHA and ITS and you
have these very, very smartpeople all sitting down and
deciding what's in the patient'sbest interest, based on
outcomes, based on bestpractices, we know what we
should do, but so many times wejust take these shortcuts and to
a large degree it's because wecan't get paid to do the other
stuff.
So then how do you mix that in?
(25:59):
Because now I know I should bedoing an OIE, I know I should be
doing high-frequency audiometry.
I mean, holy moly, it's easy todo.
Most audiometers can't do itunless they're more recently
made, let's say the last 10 or15 years.
But we know how importanthigh-frequency audiometry is,
it's critically important, andyet it's probably not done in
(26:20):
90% of clinics.
So how do we dot that I orcross that T?
I mean?
Dr. Michael Page (26:27):
how do we make that right?
It's fascinating, and these aresome dilemmas that I found
myself in, even managing aclinic, because I would have the
finance people coming down andevaluating 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, andthe bottom line was always
(26:51):
you're not generating enoughrevenue to justify your
existence.
So they're saying what can youcut out?
What will you cut out tojustify your existence?
And so then we argue just froman ethical standpoint.
And all of that happens withmost people who are in larger
institutions.
They're audiologists that arereally given the charge by
(27:16):
whoever owns that practice,whether it's a private person or
an industry.
They're given the charge tospend as little time as possible
to get the amount of work andinformation done to fit a
particular device.
Those are the instructions,whether spoken or not.
Dr. Douglas L. Beck (27:36):
I was reading.
Yesterday or the day before,there was a company that works
for one of the major insurers Iwon't tell you their name and
this company is hired as acontractor 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
(27:58):
pre-authorized.
And this company, their wholegoal.
What they do is they look atthat code and they say nope.
And to me it's the same thing.
Your doctor calls in aprescription to a pharmacy
Walgreens, cvs, rite Aid,whomever and then the pharmacy
calls and says oh, that's not onyour formula, you can't have
that, so we can give you this.
Aren't they practicing medicinewithout a license?
Dr. Michael Page (28:19):
Yes, I've always felt that way.
Dr. Douglas L. Beck (28:22):
And again, I think we're back in the gray
zone once again.
So what are the guidelines formaking sure you're doing the
best for the patient?
Dr. Michael Page (28:29):
Practice Standards Organization that's
relatively new.
Apso has been around for acouple of years now the
Audiology Practice StandardsOrganization.
John Coverstone is the currentexecutive director, but there
(28:59):
have been many, many very astutevoices on that in that
organization to help us developthose standards.
Dr. Douglas L. Beck (29:03):
And you were mentioning to me earlier
that those standards have beenused in courts of law as
practice guidelines.
What we should actually bedoing.
Dr. Michael Page (29:10):
Now the interesting part of that and one
of the reasons I've been a fanof APSO, is because of their
independent.
That means sometimes ourprofessional organizations get a
bit hijacked by people who havea financial interest in the
organization or in the peoplewithin that organization yeah,
oh sure and where APSO will actwithout that outside influence
(29:34):
of other individuals.
So they've maintained thatindependence, which I like.
Dr. Douglas L. Beck (29:38):
Yeah, and I want to give a shout out to
John Coverstone too.
I was on the adult hearing aidcommittee for APSO and it was
quite a good process.
I can't tell you how many timeswe've met, but I want to guess
between eight and 12 and two orthree hour meetings and you have
six or 10 experiencedaudiologists discussing what
should we do and why should wedo it, and it's a very
(29:59):
democratic process and I thinkmy hat's off to them.
I think they do a great job.
Dr. Michael Page (30:04):
John and many others.
I think John's been a veryleveling force and a very
persistent thread in that andlots of gratitude for anyone who
has participated that,especially those subject matter
experts like yourself and others.
Dr. Douglas L. Beck (30:18):
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 fourhere.
Dr. Michael Page (30:28):
Part four of the principles of ethics that
were originally described byBeauchamp and Childress is
justice, and justice has a lotto do with, essentially, it's me
getting what I came for and yougiving what you're there and
licensed to give.
Justice has a lot to do withfairness, with equity and my
(30:49):
relationship with my physician,etc.
We see justice playing a role,though, in ethics in unfortunate
ways where audiologists mightget caught in a legal realm
where they've been convicted ofa crime or criminal activity or
violation of codes of ethics orthose kinds of things, and
unfortunately there are someprolific presentations of those
(31:13):
things.
And we study those, not tobring fault against anyone, but
we study them in the context ofhow could that potentially
happen to me?
Dr. Douglas L. Beck (31:26):
Yeah, we've all seen those situations you
know, written up in the papersand online, where you know
there's liars, thieves andcheaters and you know they're
charging for products thatweren't delivered and they're
charging CPT codes for processesthat were never performed and,
yeah, that's terrificallyunfortunate.
Dr. Michael Page (31:43):
I think it's a sad reflection on those people
in particular, but it does makeconsumers and patients wonder
about the rest of us it suredoes, and that's why, when these
go to the newspapers, they willput the word audiologist in the
headline.
I remember years ago when anaudiologist was convicted of
(32:03):
murder and that was the headlinein the newspaper Audiologist
commits murder.
Well, why would we sayaudiologist?
Why would?
Because we're held to thatstandard and we are, in the
community's eyes, somebody thatshould have respect and
credibility, so it behooves usto respect that as well.
Dr. Douglas L. Beck (32:25):
Yeah, and all of this, I think, would be
wrapped up in the word humility.
You know so, mike, when youhave that feeling deep in your
chest that something is wronghere, I mean it seems to me you
would reach out to a trustedcolleague and say I'm not going
to give you names, not going togive 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, quitehonestly, since I did that, but
(32:49):
I've seen situations thatreally made me think this isn't
right and I turned to trustedcolleagues and they were more
experienced than I and that wasuseful and I think we got the
right results.
Is there a pathway when you knowsomething is wrong?
There used to be somethingcalled the Green Book by AAA.
I don't think I've seen anupdate on that in 20 years.
Maybe it has been.
(33:09):
If it has been, I don't knowabout it.
What readings, what books, whatpublications and how would you
suggest for an audiologist orhearing aid dispenser who finds
that weird situation?
How do you recommend peopleproceed?
Dr. Michael Page (33:24):
There's all kinds of directions.
We could go with that, butfirst of all, let me mention
that I think codes of ethics areessential for us, and yet their
limitation is that they are I'mgoing to call them merely a
checklist of do's and don'ts,and we should do those things or
not do those things accordingto the codes of ethics.
Dr. Douglas L. Beck (33:44):
And you can extrapolate from the do's and
don'ts.
I mean, you don't have to writeevery single situation.
Dr. Michael Page (33:48):
Sure, and so if we look at those do's and
don'ts, one thing I think hasalways been missing from codes
of ethics is why what we see arethings 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.
(34:08):
Once we understand the reasonwhy we do things, and so one of
the references should always be,I think, first of all, legality
.
When we see something thatwe're concerned about, that's a
dilemma for us that we witness.
First question for me is is itlegal or is it illegal?
And if it is illegal, show mechapter and verse, show me the
(34:31):
statute behind that.
If it's not illegal, then I'dgo to the next one Is it
unethical?
If it is unethical, then let'sgo 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 codeof ethics, I'm going to ask just
(34:52):
a moral question, and that iswow, what would my mom say, or
what would the rabbi say, orwhat would the pastor or priest
say?
Those tend to be our moralguides, but overall, I've always
tried to help us get beyond thecodes of ethics and get into
the principles of ethics.
(35:13):
So if we're still not quitethere with legal, ethical and
moral, then let's go to the fourprinciples which we just
discussed.
Is somebody's autonomy beingbroken?
Is someone being maleficent?
Is someone not being orexercising beneficence?
Or again, is this an aspect ofjustice or fairness or equity
(35:36):
that we should address?
Dr. Douglas L. Beck (35:37):
And I think that's great, Dan.
That decision tree makes goodsense.
Is there a particular book or aparticular article that you're
aware of that would serve as agood guideline for people who
want to learn more about this?
Dr. Michael Page (35:49):
Well, let me toot my own horn for just a
minute.
Bob Traynor and Glazer's bookis coming out in the spring of
this year, which is on practicemanagement.
Bob Traynor asked me if I wouldwrite the chapter on ethics for
that, which is a littledifferent approach.
He had mentioned that he wasvery much moved by some of my
approaches to ethics and that Iwas one of the first guys that
(36:12):
told him why why we have to havethese ethics.
And so he said would you writethe chapter for my textbook
coming up, which I did.
It's been submitted, but Iapproached that a little
different way as well, and Ithink that I'm hoping that will
become a great resource.
Dr. Douglas L. Beck (36:29):
That's fantastic.
I'm glad you mentioned that.
Well, listen, I want to thankyou, Mike.
I know we could talk aboutthese things for hours and hours
and hours, but I appreciate theencapsulation and the update
and I'm really glad to hear thatyou wrote that chapter.
I think you're the perfectperson for it.
Bob Traynor, Bob Glazer havebeen friends of mine forever and
I'm really glad you're involvedwith them.
I think they do a great jobwriting books and I think they
(36:51):
do a great job lecturing, so I'msure you're going to fit in
just fine and that book will bea bestseller.
So, Mike, I want to thank you.
It's a joy to spend time withyou, even without cigars or
bourbon, you know, but we'll dothat again, and I really
appreciate your knowledge onthis.
This is an area where I thinkall professionals need to be
aware of, and certainly becognizant of, the ramifications
(37:14):
of doing things right and doingthings wrong, and I think that
it's what your mom always toldyou right Wash your hands flush,
take care of other people.
And I think also, when youthink about I don't know if
you've ever seen the Rotary Club, they have guidelines that go
very much the same as theseethical guidelines my dad used
(37:34):
to be a big wheel at Rotary andthey had all these decision
points which were, you know isit fair for everybody involved?
Is it ethical, Is it moral,Does it make sense?
Are you doing it to helpsomebody?
Are you doing it to hurtsomebody?
You know all of those decisionpoints and I think they all get
you to the right thing, which is, you know, do the right thing
for the right reason and alwaystake care of your patient first.
Dr. Michael Page (37:52):
Thank you, that's a great way to wrap up.
Thanks so much for today.
My pleasure, mike.
Dr. Douglas L. Beck (37:57):
Talk to you soon.
Popular Podcasts
Bookmarked by Reese's Book Club
Welcome to Bookmarked by Reese’s Book Club — the podcast where great stories, bold women, and irresistible conversations collide! Hosted by award-winning journalist Danielle Robay, each week new episodes balance thoughtful literary insight with the fervor of buzzy book trends, pop culture and more. Bookmarked brings together celebrities, tastemakers, influencers and authors from Reese's Book Club and beyond to share stories that transcend the page. Pull up a chair. You’re not just listening — you’re part of the conversation.
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com