May 2, 2025 • 40 mins
What's the difference between following ethical codes and living ethical principles? In this thought-provoking conversation, Dr. Douglas Beck sits down with Dr. Michael Page, lead ethicist and author, to explore the complex ethical terrain healthcare professionals navigate daily.
Dr. Page draws a crucial distinction that transforms how we approach ethics: "If we live the principles of ethics, the codes of ethics just automatically fall underneath that." Rather than seeking the outer boundaries of permissible behavior, principled practitioners focus on making decisions that uphold trust and serve patients' best interests.
Through personal stories and practical examples, the conversation illuminates ethical gray areas we all face. When should you accept industry incentives? How do you maintain professional boundaries with patients? What happens when your role blurs between clinician and sales representative? These questions have no simple answers, but Dr. Page offers a thoughtful framework: consider whether actions are illegal, unethical according to codes, or simply immoral according to your principles.
The discussion delves into regulations like the Stark Law, Anti-Kickback Statute, and Physician Payment Sunshine Act, revealing how transparency shapes ethical practice. As healthcare becomes increasingly commercialized, understanding these guidelines becomes essential for maintaining professional integrity.
Perhaps most powerful is Dr. Page's assertion that "if we're not being honest with ourselves, there's no possibility of ethical practice with anyone else." This reminder that ethical practice begins within ourselves provides a compass for navigating the increasingly complex relationships between practitioners, patients, and industry partners.
Ready to deepen your understanding of professional ethics? Listen now to gain insights that will strengthen your practice and your relationships with those you serve.
Connect with the Hearing Matters Podcast Team
Email: hearingmatterspodcast@gmail.com
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Blaise Delfino (00:19):
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(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.
This is Dr Douglas Beck withthe Hearing Matters Podcast, and
I am here today with my friendand lead ethicist, Dr Michael
Page.
Michael, good to see you.
Dr. Michael Page (01:05):
Thank you, always nice to spend time with
you in these conversations.
Dr. Douglas L. Beck (01:09):
I appreciate that, and this is our
second one in 2025.
We did one a few months ago andit was so popular that I asked
you to come back and let's talka little bit about your new
chapter, which is in the book bya trainer and Taylor right,
taylor correct.
What's the title of the book?
I should know it, but I forgot.
Dr. Michael Page (01:27):
Here.
Let me show it to you becauseit's really quite the textbook
and I'm honored to be a part ofthat but Strategic Practice
Management.
It does focus primarily onaudiology, but there are a
number of healthcare professionsthat could benefit from it and
I think I've heard you refer toit as a great resource and I
(01:49):
call it a reference book.
It's not a book that I wouldread from cover to cover, but
great, great reference book.
Dr. Douglas L. Beck (01:55):
I won't mention that to Dr Traynor but
for those of you who don't knowDr Page, he is a frequent
national and internationalpresenter and consultant on
ethical practices and workplacetrust, healthcare management and
executive leadership, aaaNational Ethical Practice
Committee Chair, board Chair ofthe Utah Division of
Occupational and ProfessionalLicensing and Chair of the
(02:18):
Advisory Board for the UtahDivision for the Deaf and Hard
of Hearing, as well as being aguest professor and adjunct
faculty physician at theUniversity of Utah, utah State
University, brigham YoungUniversity, university of the
Pacific and Salus University.
So that's a quick update.
So what I'd like to do I wantto start with one of the quotes
from your chapter that I foundreally endearing.
(02:40):
So you talk about the risks wemay and may not see and you talk
about the study and practice ofethics is the complicated and
convoluted navigation of vitalrelationships for the protection
and goodwill of all.
And it kind of begs thequestion when we talk about
goodwill, whose judgment ofgoodwill are we talking about?
Dr. Michael Page (03:01):
Certainly so.
Much of this, doug, issubjective.
We always want things to beblack and white, plus or minus,
and so the subjective nature ofall of this is reflected in that
statement.
So who's goodwill, and can wecome back to any aspect of
(03:21):
ethics that would give us someblack and whiteness of these
ideas?
But let's talk about that interms of codes of ethics versus
principles of ethics.
Dr. Douglas L. Beck (03:32):
Yes, please .
Dr. Michael Page (03:33):
And codes of ethics.
You and I have been subject tothese codes of ethics for
decades.
Right, and basically that'swhat we study.
When we talk about ethics, wetalk about codes of ethics.
That's what we study when wetalk about ethics.
We talk about codes of ethics.
We go through a list of.
It's a checkbox Can I do thisor not do this?
They'll let me do this to thisextent, but not beyond that
amount.
All of those things become thecodes of ethics.
(03:57):
But if we take the higher road,which is the principles of
ethics, then we get into somewhat of more?
Even more subjectivity.
Dr. Douglas L. Beck (04:07):
but it's the subjective stuff that allows
us to really look within,because I think the most
important parts of ethics comefrom deep in our souls and you
know you point out in part ofyour discussion about the code
of ethics where for many of us,when you hear the code of ethics
you ask, okay, what's the limitto that right?
And we start to make sure thatwe're within the limit and
(04:30):
hopefully we don't exceed thelimit of ethical behavior.
But the principle of ethicswould say that you shouldn't be
looking for the outer marginright.
Dr. Michael Page (04:37):
Correct.
That's really correct.
In fact, I think if we live theprinciples of ethics, the codes
of ethics just automaticallyfall underneath that and we're
not thinking about do's anddon'ts anymore, we're just
thinking about what's morepowerful for us.
Dr. Douglas L. Beck (04:54):
I think that's a good way to look at it.
And then people talk aboutpersonal ethics versus
professional ethics versusmedical ethics.
Are those all the same, or doyou see them as different?
Dr. Michael Page (05:06):
Well, they have different aspects to them,
but certainly the principles ofethics could be applied to each
one of those, and in the chapterwe go through several sections
principles of or ethics of self,ethics with patients,
colleagues, industry, theprofession as a whole.
But I think the reason wewanted to start out with the
(05:27):
ethics of self is because ifwe're not being honest with
ourselves, there's nopossibility of ethical practice
with anyone else.
Dr. Douglas L. Beck (05:37):
And one of the things you said under the
test of ethics, which I reallyenjoyed.
While codes of ethics havecertainly transformed over time,
the best principles of ethicsdo not.
They remain the same.
Thank you.
Dr. Michael Page (05:49):
And that's I agree.
Those principles will neverchange.
But you and I both have seenthe evolution of codes of ethics
over the years.
Dr. Douglas L. Beck (05:57):
Yeah, because they apply to more
specific situations.
Right, and one of the majorones in healthcare in general,
whether it's audiology orpharmacy or orthopedics, you
know, has to do with ourinteractions with industry, you
know.
So you have people like you andI who are professionals, we are
licensed, we have degrees, wedo that stuff, but then you have
(06:17):
, you know, without industry inany of these areas, there's very
, very little profession left.
You know, in pharmaceuticals,for instance, you could be a
brilliant pharmacist, but if youdon't have access to the drugs,
it makes it rather difficult tosolve the problems of the
patient In our profession,without hearing aids, assistive
devices, over-the-counterproducts, things like that, we
can be the best audiologists inthe world, we could have a
(06:39):
brilliant diagnosis andtreatment plan, but without the
tools from industry, we can'tnecessarily facilitate those
answers.
Let's talk about some of theareas that we've all, I think,
been concerned with is theinteraction between professional
and industry ethics.
And now we're in 2025, and yousee an awful lot of new
(07:04):
companies coming on board inhearing healthcare, new
manufacturers and distributionnetworks.
Do you have any particularguidance for the interaction
between industry andprofessionals that are more
principled than, perhaps, rules?
Dr. Michael Page (07:21):
Sure, I'm going to call it a current
plague, it's a modern day plague, and that is how we are willing
and able to sacrifice theobjectivity that we need with
patients in order to satisfyeither a financial incentive or
some other type of incentivefrom industry.
Some of this, for me, issomething that I've watched over
(07:45):
years, and if I can share alittle story with you that
became symbolic of my own changein understanding this
particular principle, it wasprobably in the 1980s and I was
at Children's Hospital in SaltLake City.
I was in charge of all of thepurchasing of devices hearing
aids, assistive listeningdevices, supplies and all of
(08:11):
that and there was oneparticular vendor that began to
sort of incentivize us,particularly with cases of
batteries hearing aid batteriesand so they'd send a note and
say, hey, you know, buy 10 casesthis month and we'll give you a
$100 Amex gift card.
Well, who doesn't want that?
And so I was only going toorder eight, but now I ordered
(08:33):
10.
And in that shipment because Iwas in charge of receiving I
received that $100 Amex giftcard.
And I looked at that and Ithought, wow, it's a night out
on the town gift card.
And I looked at that and Ithought, wow, it's a night out
on the town, it's a night out onthe town and in the 80s a
hundred bucks went a long ways.
But I took that card and I justput it in my desk and then
(08:55):
every few weeks I was orderingmore and that stack of gift
cards got pretty substantial.
There was something in me thatjust kind of said that's not
yours, Even though I feltincentivized and I actually
bought more than we needed inorder to satisfy getting another
(09:20):
gift card.
And it was probably a couple ofyears later.
Thankfully, at that time, thesemaybe time, these maybe.
Thankfully, these didn't haveexpiration dates.
But I was working late onenight and cleaning out my desk
and stumbled on this stack ofgift cards.
The value of it was severalthousand dollars and I remember
just distinctly looking at thatand saying Mike, those are not
(09:43):
yours, yeah, Not yours.
And even though you could spendthose, no one would ever know.
That's right.
No one would know.
Patients wouldn't know,Supervisor wouldn't know.
The next morning when I came towork, I took that stack, walked
into my supervisor and I saidthese are gift cards that have
come as a result of ourpurchases to this company.
They're not mine.
(10:05):
I'm just going to give these toyou.
I have no idea what happened tothose.
Who knows what happened?
Dr. Douglas L. Beck (10:11):
Well, that's a really interesting
story and I think many of ushave been in that situation.
And what is the best answer?
Because, look, there arecompanies and I'm not going to
name names, of course who wouldsay if you buy this amount of
hearing aids, that amount ofbatteries, this amount of
whatever the product is, there'san incentive.
(10:33):
Now, yeah, you need eight, butif you buy 10, blah, blah, blah,
what should the audiologist orthe hearing aid dispenser or the
ENT who receives that offer,what should they do with that?
How should they?
Dr. Michael Page (10:45):
handle that?
That's a great question and Ithink in our thinking there are
three components that we shouldgo through answering that
question.
One is there any aspect of thisthat's illegal?
Is there any aspect of thisthat's forbidden in terms of
being unethical?
And then we're going to go tothe third one, and that is is
there any part of this that'simmoral?
(11:07):
And do we avoid immorality inour business relationships
simply because it's legal?
So is there something illegalabout that?
And there is some aspect ofillegality in it in terms of
what's allowed under the SafeHarbor Act, which was a law that
was given during the Reagan eraand it was in the hopes of
(11:28):
bringing down healthcare costsand it allowed hospitals and
healthcare entities to negotiatebetter pricing on goods and
services.
But it had to be in a contract.
So if I negotiate a 30%discount with XYZ Hearing Aid
Company, if it's in the contract, then we're legal.
We're legal If XYZ Companycalls and says on December 15th,
(11:53):
end of the year, if you buy 10more devices, we'll give you 35%
discount.
Well, if it's not in thecontract, then it can be illegal
.
So that's the first part wewant to go to.
Is it illegal?
But if we go to the unethical orthe ethical part of that of the
four principles of ethics.
Are we in violation of thatprinciple of ethics Because
(12:19):
there's nothing in AAA's code ofethics or ADA's or ASHA?
I don't believe that willforbid us from taking certain
discounts.
But they would say it wasunethical if it became illegal.
Yeah right, that's part of whatwe have to take into it.
And then really the moralitypart of it is what you alluded
(12:42):
to earlier, like whose morality,who's, yours or mine or
everybody else's?
And so we get less objectivewhen we get into the morality
part.
But the guidance, I think theguidance back to your question
first of all, is anything thatthey're proposing to us illegal?
If it is, that's a hard no,we're not doing that.
(13:04):
If it's not illegal, then is itunethical according to codes of
ethics?
And we may look at those codesand say, yeah, looks okay
according to the codes.
But then we take it to theprinciples of ethics and is
there a potential in thoseprinciples of ethics for this
arrangement that they're givingme to be devious or deleterious,
(13:28):
as they say?
And if that's possible, thenour morality has to kick in and
say the police aren't going tocome get me, the DOJ is not
going to come get me, myemployer is not going to come
get me, but this seems to bewrong, so I choose not to do it.
Dr. Douglas L. Beck (13:45):
Yeah, well, one of the things that I would
propose for people going throughsomething like that and I'm not
the ethicist it seems to me, ifyou're buying batteries, let's
use that as an example, and theygive you a $100 gift card I
might be really tempted to justsay, hey, listen, just give me a
$100 discount on the price ofthose batteries and we're fine.
Or maybe, if I'm going tocollect the gift cards for a
(14:08):
couple of months, maybe I can Iuse those for my next purchase
of batteries.
Right, so it may be coming,just because to me that would
seem like maybe that would solvethe problem and get rid of it
for you, because you're nottempted to use it for yourself.
You're still using it as the apriori purchasing agent at the
moment.
Dr. Michael Page (14:27):
I don't know.
I'll take that one step further, doug, and that is not only
please give me a hundred dollardiscount, but let's put that in
a contract so that we have thatsecure and that we're in line
with the Safe Harbor Act and Ibenefit from that and we're in
the legal part of that.
And then absolutely yes.
Dr. Douglas L. Beck (14:47):
And one of the other things that I learned
in the chapter, and I guess Iknew this, but I hadn't thought
about it until I read yourchapter.
So sometimes you have patientswho you know you have a strictly
professional relationship with.
Mrs Smith comes in once a year,gets her hearing test, for
whatever reason, and I reprogramher hearing aids to the most
current one and I do real earmeasures and all of that stuff.
(15:08):
And after four years you knowshe's thinking of me as a friend
, right, because she's coming in.
But she knows who I am, I knowwho she is and we always have
nice chit chat.
You know how are the kids,how's the family?
Blah, blah, blah.
And after a while she says ohlisten, I know that you're
(15:30):
really involved with onlinestuff and I'm looking to buy a
new phone.
What would you recommend?
Okay, so give us the upside andthe downside of answering that
as a friend or as a professional.
Dr. Michael Page (15:37):
Sure, I can take you to several examples of
real stories just like yoursthat have happened, and one that
is very analogous is whileworking in a department of rehab
years ago, there was a physicaltherapist who was an avid biker
and had been seeing thispediatric patient for months and
months.
And the family came in and saidah, we know you're an avid
(15:58):
biker and you've been such agreat part of our family and we
want to go buy bicycles for thefamily so we can go ride
together.
And he came to me at the timeand said should I do that?
And my question was well,what's the risk?
And he said well, I reallycan't think of any risk.
And I said well, you go to thebike store with them and you
(16:20):
help them select bikes that arewithin their budget.
And let's say they're out ridingwith the family and the front
wheel falls off of one of thebikes, causes a head injury in
one of the kids that may nothave been wearing their helmet
or whatever that is.
Or let's say they do the bikesand then they have another
friend who comes and says thosebikes are just worthless.
(16:42):
Who told you to buy those bikes?
And then they come back to youand say, wow, does that change
your professional relationship?
And I guess my quick answer tohim was is it in the scope of
your practice to make a bicyclerecommendation to a patient of
yours?
And the quick answer to that is, well, of course not, of course
(17:04):
not.
And what I offered to him inlieu of that is maybe give them
some resources to how, to youknow, select the appropriate
bikes or whatever else.
Be helpful, be friendly, bekind, but also be able to
establish the scope of yourpractice.
Dr. Douglas L. Beck (17:21):
Yeah, and I think that's one that is easy
to fall into a trap.
That is easy to fall intobecause you want to be a nice
guy, you want to help yourpatient, you want to give them
the benefit of knowledge thatmight be otherwise benign, but
you could be setting yourself upand your patient for failure.
So one of the things that justhappened in my life which is a
bit of an ethical dilemma for meI put a lot of stock in the
(17:41):
fact that there are very, verysubstantial correlations between
untreated hearing loss inat-risk patients over many years
and the potential for thathearing loss to exacerbate
cognitive decline.
Now, when I say these patientshave to be at risk, this is
pretty much what Achieve said.
This isn't something I created.
They said patients who wereolder were at higher risk.
(18:03):
Patients who have lesseducation higher risk.
Patients with multiplecomorbidities, cardiovascular
disease, diabetes, patients withmultiple comorbidities,
cardiovascular disease, diabetes, patients with greater degrees
of hearing loss.
So we're not talking aboutsomebody with a ski slope loss
at 6,000 hertz who's 27 yearsold.
We're talking about people withperhaps a severe or profound
loss.
We're talking about patients,lower socioeconomic groups, less
(18:24):
education, more comorbidities,all those things and I really
felt like people were trying toget me to say hearing loss
causes cognitive decline.
I wasn't about to say that andI've never said that.
What I've always said is, youknow, that untreated hearing
loss in at-risk patients as wejust defined at-risk tends to
exacerbate cognitive declineover many, many years.
(18:46):
And I felt like that was a bitof an ethical dilemma because I
didn't want to say that theevidence is clear one way or the
other.
But the preponderance ofevidence is that it's at-risk
people who we need to beconcerned about, not just
everybody with hearing loss, and, as a matter of fact, the vast
majority of people with hearingloss don't have cognitive
decline.
So it felt a little bit awkwardand a little bit off-putting
(19:08):
and I'm curious to get yourtakes on that as an ethicist and
as somebody who puts in a greatdeal of time thinking about
what I can and can't say, what Ishould and shouldn't say.
Dr. Michael Page (19:19):
Words matter, especially these days in
political arenas that we're in,that we're in the risk is anyone
taking even a snippet of whatyou say and putting it in a
different context can make itappear as if you said something
that you didn't intend.
And I think there's so muchcaution, especially in this
(19:43):
arena, and we see a lot offervor around this particular
idea as well, and there are anumber of individuals who want
to take these concepts, turnthem into hearing aid, sales
which is the use of the wordsell, as even another concept we
could talk about.
But it again comes back towhat's the potential risk that I
(20:04):
may not be able to see, and ittakes someone admitting that
there might be something thatthey cannot see.
And that's probably one of themost problematic parts of ethics
is that most of us and I'll saymyself as well, I'm not willing
to admit that I can't seeeverything.
(20:24):
Yeah, of course, and the mosteducated person will have to be
super vulnerable to say I maynot see everything.
In this context, in thissituation, I may not see
everything.
You don't hear that from thevoting at all.
Dr. Douglas L. Beck (20:42):
And you said something that to me is
very striking is that you haveto keep the original intent and
meaning within context.
You can't cherry pick your dataand you can't cherry pick a
sentence or a phrase.
You have to keep it withincontext to truly be ethical, I
think, and the essence of theword ethical is trust.
I mean, ethics is based ontrust and if people are cherry
(21:06):
picking and floating out ofcontext, as we see often in
politics and sometimes inscience, you know it becomes a
real trust issue immediately.
Dr. Michael Page (21:17):
Yeah, yeah, I have to agree with you.
And it all comes back to trustand there's some synonymous
ideas totally with ethics andtrust, for sure.
Dr. Douglas L. Beck (21:29):
Anonymous ideas, totally with ethics and
trust, for sure.
What do you think about thesituation now where you have
(21:52):
many manufacturers bringingproducts to market in the
over-the-counter space and someaudiologists and hearing aid
dispensers are in favor and theyvoice their opinions to the
consumers or the patients?
Some are antagonistic oragainst it.
Whether you're pro or con OTC,it's legal, it's FDA right, as
long as you're following the FDAguidelines.
Should audiologists anddispensers weigh in on this
stuff?
Or is it better, as we saidearlier, is that within your
scope of practice to comment onthis?
Dr. Michael Page (22:10):
So tell me about that, first of all, I
think the most importantacknowledgement is that
manufacturers and industrymembers are not health care
providers.
They're not.
Dr. Douglas L. Beck (22:22):
But there are situations where the sales
reps are audiologists.
Dr. Michael Page (22:26):
That's true, and you'll notice that neither
AAA nor ASHA I think none of thecodes of ethics address
audiologists functioning in asales role, Right, you don't
address that and that's aglaring misstep, if you will,
that we're not addressing that.
And I spent a number of yearsworking in industry with
(22:48):
cochlear implant companies andone of the first questions that
I asked when I was in thatclinical supportive role is, I
said is this a sales role or isthis a clinical support role?
And I'll never forget theanswer.
I want to hear it.
What was the answer?
They said we're still trying tofigure that out.
Well, that was in 2005.
(23:09):
That was in 2005.
And one of the difficulties isthat those roles that used to be
clinical support, surgicalsupport, they turned into sales
roles and those roles turnedinto commissions and
commission-based income andthose kinds of things.
But it's super important toremember that manufacturers, as
(23:31):
good-willed as they may appear,are not healthcare providers.
Dr. Douglas L. Beck (23:36):
And in that situation because I am an
audiologist, I'm licensed inaudiology and I worked for
manufacturers before and I workfor one currently it seems to me
that perhaps the smart thing todo is to disclose that if you
are the regional sales director,you're the account manager.
You know.
Make sure that's on your card,make sure that you introduce
(23:56):
yourself that way so peopleunderstand kind of what your
role is and who's who and what'swhat.
Does that help alleviate any ofthose problems?
Dr. Michael Page (24:05):
I don't know that it does.
I mean, anything that addstransparency is always good.
It's always good, but I thinkthe mistake that we see with
industry members that areaudiologists is that it's an
unspoken conflict with people.
So when I used to go in and dointegrity tests on cochlear
implants, I would introducemyself as a representative from
(24:28):
this company and I would say I'man audiologist and so you could
see in patients' eyes they werelike, oh well, yeah, I guess
that's good.
Yeah, I mean, but they couldsee the difference.
And then clinicians oftentimeswould struggle between Michael,
are you functioning as aclinical provider, are you an
(24:50):
audiologist, or are you hereactually to have a good
experience so that we'll buymore devices?
And they'd never say it likethat, but I would when I was
clinically active I would seeaudiologists coming in that kind
of a conflict role.
Dr. Douglas L. Beck (25:08):
I think it boils down to the wisdom of
Solomon, right, but I think it'simportant to highlight that it
could be a discrepancy rightbetween your roles that you have
to your license and your stateand the consumers and patients
you take care of versus youremployer.
And they're all important.
It's not like you know, likeone isn't important.
They all are.
Do you anticipate AAA or ASHAor IHS or anybody is going to
(25:31):
tackle this?
Dr. Michael Page (25:33):
I think at some point they're going to have
to, but I have not heardHeidner hair of any wind of
change in that way.
I think.
Audiologists it's one directivethat I was given by one implant
company was Michael, you're notfunctioning as an audiologist
when you go into that role,you're representing the
(25:54):
knowledge that you have.
But, for instance, I'm notlicensed in Kansas, in
Mississippi or any of the othercities or states.
I'm not licensed there, so Iwas not allowed to function in
the role of a clinical providerand you're not to touch a
patient without that audiologistbeing present and understanding
(26:17):
.
Again, you're advising thataudiologist but of course we had
to touch a patient if we'redoing integrity testing or
otherwise like that.
But it was a careful role.
Dr. Douglas L. Beck (26:29):
I'll tell you after spending the better
part of a decade in theoperating room and I'm happy to
share some of these stories.
But I won't give names ordetails.
But when there's a new drill,when there's a new surgical
instrument, when there's a newprotocol, sometimes you know
physicians will allowmanufacturers, reps, to come in
(26:51):
and show them how to use a toolin surgery, and you know they
also have classes.
You could learn it in atemporal bone lab or you could
learn it, you know, on a cadaverstudy or something like that.
But a lot of the ongoingmanufacturer's education occurs
in real time in the operatingroom and I, you know all these
(27:12):
same questions.
I mean for us it seemsrelatively minor.
Right, that you know we'retalking about hearing and
listening and cochlear implantsand hearing aids and very, very
important stuff, but not like akidney transplant or a CABG.
You know coronary artery bypasswith a graft, and I'm not
pointing fingers, but I'm sayingthat these things where you
have a very, very smartmanufacturer's rep who is
(27:34):
helping to educate and guide thesurgeon during surgery, that
could easily be the same sortand maybe by thinking about it
in those terms, it makes it moreclear that that's what the
issue is is that you have asalesperson telling the surgeon
how to set the drill, and maybethat's okay, maybe that's not
(27:57):
okay, but I think when we takeit at that level it becomes a
lot more serious than somebodysaying, okay, turn on implant
electrode number seven.
Dr. Michael Page (28:07):
This is so reminiscent and I've spent
probably that much time in theoperating room as well, in fact
functioning as an electrophysmonitor guy for spinal cord
fusion, spinal fusions andthings like that.
But I remember, specifically inthe implantable device arena,
being in the operating room,being in the surgical field, and
(28:30):
I could see what the surgeonwas doing.
And there were just a time ortwo these are highly skilled
people, but there were a time ortwo when I thought, hmm, I want
to tell you to do thatdifferently and you're tempted,
but who can't?
But what I would offer them ishave you considered XYZ and so
(28:55):
many people, audiologists, whoare in this role?
They become highly skilled.
And there were a time or two inthese operating rooms when it
was over and the surgeon wouldsay, wow, I'm so glad you were
there today.
That changed the course of ourcase and you feel grateful and
I'm thankful that changed it.
(29:15):
But is it in the scope of mypractice?
And those are the questions weask ourselves.
Dr. Douglas L. Beck (29:21):
Well, when I started in the operating room
was probably 1984, and it was amajor ordeal then and people
used to say, well, why is thataudiologist doing the
neurophysiologic monitoringduring skull base surgery?
And fortunately ASHA back thenhad a statement in their scope
of practice saying thatneurophysiologic monitoring was
(29:42):
a scope of practice.
But it was long before it wasin other scopes of practice and
it was always disconcerting andyeah, it's an issue.
All right, I want to move on.
Let's talk a little bit.
Can you tell me what the StarkLaw and the Anti-Kickback
Statute have to say about thesesorts of things?
What is the Stark Law?
What is the Anti-KickbackStatute?
Dr. Michael Page (30:01):
Sure, anti-kickback Statute is am I
receiving remuneration for?
Am I being incentivized?
Right, basically, am I beingincentivized and a lot of that.
The history of thatanti-kickback statute came from
even civil war time and othertimes in the country.
But anti-kickback statute wouldbe some of what we've talked
(30:24):
about already and that is, arecertain companies trying to
incentivize us into sales,purchasing or others of their
devices?
So technically, under the SafeHarbor Act, as long as it's in a
contract, it is not consideredkickback.
If it's not in a contract, itcould be considered a kickback
(30:50):
and that means that if I buycertain devices or a number of
devices, then I get something inreturn.
Dr. Douglas L. Beck (30:56):
So, michael , tell me a little bit then
about the Stark Law.
Dr. Michael Page (30:59):
How's that different from the other topics
we're discussing Sure Stark Lawcomes into the principle of
self-referral and that meansthat if I'm going to recommend a
treatment for you, if you're mypatient, will I send you to a
place that benefits me in theshort term or the long term as
(31:19):
well?
So, for instance, my wife's apediatric nurse practitioner and
if she in her practice were tosee kids that needed hearing
evaluations or treatment foraudiology-related issues, if she
were to send them exclusivelyto my practice, that could be
(31:39):
considered a violation of StarkLaw.
But Stark Law differs fromstate to state and federal and
statewide as well, so it may ormay not apply here.
But the idea is she would referkids to my practice.
I would make money based onthat, which would come home to
our home financial pool, andthen she would in turn benefit
(32:01):
from that as well.
Okay, but what about thesurgeons who own surgical
centers under differentcorporations?
Is that a violation or is thatlegal?
(32:21):
Where I provide that surgery, Iprefer to do it at this
surgical center, and here's why.
So there's.
I know that's been a legalbattle in a number of states.
Dr. Douglas L. Beck (32:32):
Well, and realtors with title companies
same sort of deal, right?
Sure, you know, just sold you ahouse, and blah, blah, blah.
And we're going to use thistitle company.
And they don't mention thatthey own a piece of that, you
know anyway.
Okay, so that's what the StarkLaw is self-referral.
Whether stuff is legal or not,we're not attorneys, we don't
know, but that's the one thatalways gets me right For
(32:53):
outpatient procedures.
Oh well, we're going torecommend ABC Surgical Center
and it's, you know, outpatient,and blah, blah, blah.
And then you look and you say,oh, it's the principle of that
that matters.
Dr. Michael Page (33:04):
And if you stay with the principle of Stark
Law, it even comes back to us.
For instance, if I were anaudiologist and I were on the
clinical advisory committee forXYZ Cochlear Implant Company and
I happened to do primarily thatdevice, the principle of Stark
(33:24):
Law would make us ask about thatdevice.
The principle of Stark Lawwould make us ask about that.
Now it may not be illegal, butI know a number of audiologists
who are on those advisorycommittees and the expectation
from that company is that theyget a greater referral number
because of that association.
Dr. Douglas L. Beck (33:43):
Yeah, tell me about the Physician Payment
Sunshine Act.
That seems to me that came inwith the Affordable Care Act and
it seems to be a very cleverwatchdog sort of a service.
Tell me what is the PhysicianPayment Sunshine Act and how
does that work.
Dr. Michael Page (33:57):
My only regret about the Physician Payment
Sunshine Act is that it doesn'tpertain to audiologists.
Generally it doesn't, butessentially it's a way for
watchdogs to keep track of therelationship between members of
industry and physicians notphysical therapists, not
optometrists, not audiologists.
But, for instance, I can go tothe physician I think it's
(34:21):
physicianpaymentgov, I think, oropenpaymentsgov.
I can go to that website andlook up any physician in the
country and see who has giventhem money, who took them to
dinner, who took them on acruise, who brought backpacks or
whatever else.
Dr. Douglas L. Beck (34:38):
Yeah, and that's the transparency you were
talking about earlier.
Dr. Michael Page (34:40):
Yes, and the obligation in open payments
comes to the industry member orthe industry company.
So if a member of Pfizer goesand visits a physician in the
area and takes them to lunch,the lunch costs $23.
They have to come back and logthat in, show a receipt, post
(35:03):
that online and so that shows upunder the physician receiving
that money and so it doesn'tapply to audiologists yet, but I
wish it would.
Dr. Douglas L. Beck (35:13):
Yeah, it makes good sense to me, because
then you're totally transparentand if you take somebody to
dinner, you take them to a showit's apparent for the entire
world to see and do with as theysee fit.
Dr. Michael Page (35:24):
One other piece about that which I think
is really critical and we oftenpass by on Physician Payment
Sunshine Act is you can go tothat site and look up any
company.
So I could look up any of theCI companies.
I could look up any of thepharmaceutical companies and
then they will rank order thephysicians that have received
(35:46):
money from them so you can seewho their biggest suitors are.
Dr. Douglas L. Beck (35:50):
And sometimes as a patient, you just
don't even care right, you likethe physician, you know the
physician's competent, you knowthe audiologist is great,
whatever, and so that's fine.
But at least the knowledge isavailable to you if you seek it.
So you know, for people whofind that interesting it would
be available.
Do you think that's going todescend from physicians down to
the rest of healthcarepractitioners sometime in the
(36:11):
near future?
Dr. Michael Page (36:12):
I'm surprised that it hasn't and honestly I
think if we really understoodthe value of that site, it
should attract legislators tomake a change that way.
But it would monumentallyexpand the scope of that, which
would be probably 10 times whatit's tracking with physicians,
(36:34):
because there are so many otherancillary healthcare
professionals.
Dr. Douglas L. Beck (36:39):
Let me change topics again.
The FTC the Federal TradeCommission considers an
advertisement's overall quotenet impression to determine
whether it misleads consumers.
The audiologists may be guiltyof deception if they
misrepresent their treatment,their services or their outcomes
.
The AAA Code of Ethics statesan audiologist may not guarantee
(37:01):
outcomes.
And then you had a specificcall-out that you were familiar
with.
Can you tell us about that?
Dr. Michael Page (37:08):
Well, I'm not sure which one you're referring
to, but maybe I'll tell you thestory, because that could be it.
I remember years ago being onthe Ethical Practices Committee
for AAA and someone took apicture of a billboard for a
hearing professional of somekind, an audiologist actually,
and the billboard said hearingresults guaranteed.
(37:30):
And that's really all it tookbecause they had to go and that
was kind of confessed to AAA.
There was a cease and desistorder and that really did come
back down to are we deceivingsomeone by guaranteeing results?
Dr. Douglas L. Beck (37:45):
Of course I mean surgeons can't guarantee
results, right, right, theydon't, nobody can.
Dr. Michael Page (37:51):
Surgeons will tell you right up front we're
going to make an incision inyour belly and you might die
from it.
Yeah, I mean, they're obligatedto say the risk, right.
Dr. Douglas L. Beck (38:00):
These are the risks and complications that
are correlated on rare occasionwith this procedure and you
have to sign it.
That are correlated on rareoccasion with this procedure and
you have to sign it.
You're aware of that and youprobably have to have a
co-signature of somebody whosaid yeah, I saw him sign.
Dr. Michael Page (38:11):
So deception also comes back to what you
mentioned earlier and that wasthe cognitive decline relative
to hearing loss.
I mean that could be seen as aform of deception if that
research has been taken out ofcontext or used for other
purposes other than its originalintention.
Dr. Douglas L. Beck (38:30):
Yeah, All right.
Well, michael, once again,totally fascinating.
I always enjoy catching up withyou and I want to urge people
to get the book and, inparticular, I read the chapter
that you wrote on this.
We just did the greatest senseof that chapter.
There's so much goodinformation in there and I think
the practitioners will find itto be very useful.
Michael, you're a joy to speakwith.
Thank you so much for your time.
Dr. Michael Page (38:50):
Always enjoyable.
Thank you so much, doug, mypleasure.
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(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.
This is Dr Douglas Beck withthe Hearing Matters Podcast, and
I am here today with my friendand lead ethicist, Dr Michael
Page.
Michael, good to see you.
Dr. Michael Page (01:05):
Thank you, always nice to spend time with
you in these conversations.
Dr. Douglas L. Beck (01:09):
I appreciate that, and this is our
second one in 2025.
We did one a few months ago andit was so popular that I asked
you to come back and let's talka little bit about your new
chapter, which is in the book bya trainer and Taylor right,
taylor correct.
What's the title of the book?
I should know it, but I forgot.
Dr. Michael Page (01:27):
Here.
Let me show it to you becauseit's really quite the textbook
and I'm honored to be a part ofthat but Strategic Practice
Management.
It does focus primarily onaudiology, but there are a
number of healthcare professionsthat could benefit from it and
I think I've heard you refer toit as a great resource and I
(01:49):
call it a reference book.
It's not a book that I wouldread from cover to cover, but
great, great reference book.
Dr. Douglas L. Beck (01:55):
I won't mention that to Dr Traynor but
for those of you who don't knowDr Page, he is a frequent
national and internationalpresenter and consultant on
ethical practices and workplacetrust, healthcare management and
executive leadership, aaaNational Ethical Practice
Committee Chair, board Chair ofthe Utah Division of
Occupational and ProfessionalLicensing and Chair of the
(02:18):
Advisory Board for the UtahDivision for the Deaf and Hard
of Hearing, as well as being aguest professor and adjunct
faculty physician at theUniversity of Utah, utah State
University, brigham YoungUniversity, university of the
Pacific and Salus University.
So that's a quick update.
So what I'd like to do I wantto start with one of the quotes
from your chapter that I foundreally endearing.
(02:40):
So you talk about the risks wemay and may not see and you talk
about the study and practice ofethics is the complicated and
convoluted navigation of vitalrelationships for the protection
and goodwill of all.
And it kind of begs thequestion when we talk about
goodwill, whose judgment ofgoodwill are we talking about?
Dr. Michael Page (03:01):
Certainly so.
Much of this, doug, issubjective.
We always want things to beblack and white, plus or minus,
and so the subjective nature ofall of this is reflected in that
statement.
So who's goodwill, and can wecome back to any aspect of
(03:21):
ethics that would give us someblack and whiteness of these
ideas?
But let's talk about that interms of codes of ethics versus
principles of ethics.
Dr. Douglas L. Beck (03:32):
Yes, please .
Dr. Michael Page (03:33):
And codes of ethics.
You and I have been subject tothese codes of ethics for
decades.
Right, and basically that'swhat we study.
When we talk about ethics, wetalk about codes of ethics.
That's what we study when wetalk about ethics.
We talk about codes of ethics.
We go through a list of.
It's a checkbox Can I do thisor not do this?
They'll let me do this to thisextent, but not beyond that
amount.
All of those things become thecodes of ethics.
(03:57):
But if we take the higher road,which is the principles of
ethics, then we get into somewhat of more?
Even more subjectivity.
Dr. Douglas L. Beck (04:07):
but it's the subjective stuff that allows
us to really look within,because I think the most
important parts of ethics comefrom deep in our souls and you
know you point out in part ofyour discussion about the code
of ethics where for many of us,when you hear the code of ethics
you ask, okay, what's the limitto that right?
And we start to make sure thatwe're within the limit and
(04:30):
hopefully we don't exceed thelimit of ethical behavior.
But the principle of ethicswould say that you shouldn't be
looking for the outer marginright.
Dr. Michael Page (04:37):
Correct.
That's really correct.
In fact, I think if we live theprinciples of ethics, the codes
of ethics just automaticallyfall underneath that and we're
not thinking about do's anddon'ts anymore, we're just
thinking about what's morepowerful for us.
Dr. Douglas L. Beck (04:54):
I think that's a good way to look at it.
And then people talk aboutpersonal ethics versus
professional ethics versusmedical ethics.
Are those all the same, or doyou see them as different?
Dr. Michael Page (05:06):
Well, they have different aspects to them,
but certainly the principles ofethics could be applied to each
one of those, and in the chapterwe go through several sections
principles of or ethics of self,ethics with patients,
colleagues, industry, theprofession as a whole.
But I think the reason wewanted to start out with the
(05:27):
ethics of self is because ifwe're not being honest with
ourselves, there's nopossibility of ethical practice
with anyone else.
Dr. Douglas L. Beck (05:37):
And one of the things you said under the
test of ethics, which I reallyenjoyed.
While codes of ethics havecertainly transformed over time,
the best principles of ethicsdo not.
They remain the same.
Thank you.
Dr. Michael Page (05:49):
And that's I agree.
Those principles will neverchange.
But you and I both have seenthe evolution of codes of ethics
over the years.
Dr. Douglas L. Beck (05:57):
Yeah, because they apply to more
specific situations.
Right, and one of the majorones in healthcare in general,
whether it's audiology orpharmacy or orthopedics, you
know, has to do with ourinteractions with industry, you
know.
So you have people like you andI who are professionals, we are
licensed, we have degrees, wedo that stuff, but then you have
(06:17):
, you know, without industry inany of these areas, there's very
, very little profession left.
You know, in pharmaceuticals,for instance, you could be a
brilliant pharmacist, but if youdon't have access to the drugs,
it makes it rather difficult tosolve the problems of the
patient In our profession,without hearing aids, assistive
devices, over-the-counterproducts, things like that, we
can be the best audiologists inthe world, we could have a
(06:39):
brilliant diagnosis andtreatment plan, but without the
tools from industry, we can'tnecessarily facilitate those
answers.
Let's talk about some of theareas that we've all, I think,
been concerned with is theinteraction between professional
and industry ethics.
And now we're in 2025, and yousee an awful lot of new
(07:04):
companies coming on board inhearing healthcare, new
manufacturers and distributionnetworks.
Do you have any particularguidance for the interaction
between industry andprofessionals that are more
principled than, perhaps, rules?
Dr. Michael Page (07:21):
Sure, I'm going to call it a current
plague, it's a modern day plague, and that is how we are willing
and able to sacrifice theobjectivity that we need with
patients in order to satisfyeither a financial incentive or
some other type of incentivefrom industry.
Some of this, for me, issomething that I've watched over
(07:45):
years, and if I can share alittle story with you that
became symbolic of my own changein understanding this
particular principle, it wasprobably in the 1980s and I was
at Children's Hospital in SaltLake City.
I was in charge of all of thepurchasing of devices hearing
aids, assistive listeningdevices, supplies and all of
(08:11):
that and there was oneparticular vendor that began to
sort of incentivize us,particularly with cases of
batteries hearing aid batteriesand so they'd send a note and
say, hey, you know, buy 10 casesthis month and we'll give you a
$100 Amex gift card.
Well, who doesn't want that?
And so I was only going toorder eight, but now I ordered
(08:33):
10.
And in that shipment because Iwas in charge of receiving I
received that $100 Amex giftcard.
And I looked at that and Ithought, wow, it's a night out
on the town gift card.
And I looked at that and Ithought, wow, it's a night out
on the town, it's a night out onthe town and in the 80s a
hundred bucks went a long ways.
But I took that card and I justput it in my desk and then
(08:55):
every few weeks I was orderingmore and that stack of gift
cards got pretty substantial.
There was something in me thatjust kind of said that's not
yours, Even though I feltincentivized and I actually
bought more than we needed inorder to satisfy getting another
(09:20):
gift card.
And it was probably a couple ofyears later.
Thankfully, at that time, thesemaybe time, these maybe.
Thankfully, these didn't haveexpiration dates.
But I was working late onenight and cleaning out my desk
and stumbled on this stack ofgift cards.
The value of it was severalthousand dollars and I remember
just distinctly looking at thatand saying Mike, those are not
(09:43):
yours, yeah, Not yours.
And even though you could spendthose, no one would ever know.
That's right.
No one would know.
Patients wouldn't know,Supervisor wouldn't know.
The next morning when I came towork, I took that stack, walked
into my supervisor and I saidthese are gift cards that have
come as a result of ourpurchases to this company.
They're not mine.
(10:05):
I'm just going to give these toyou.
I have no idea what happened tothose.
Who knows what happened?
Dr. Douglas L. Beck (10:11):
Well, that's a really interesting
story and I think many of ushave been in that situation.
And what is the best answer?
Because, look, there arecompanies and I'm not going to
name names, of course who wouldsay if you buy this amount of
hearing aids, that amount ofbatteries, this amount of
whatever the product is, there'san incentive.
(10:33):
Now, yeah, you need eight, butif you buy 10, blah, blah, blah,
what should the audiologist orthe hearing aid dispenser or the
ENT who receives that offer,what should they do with that?
How should they?
Dr. Michael Page (10:45):
handle that?
That's a great question and Ithink in our thinking there are
three components that we shouldgo through answering that
question.
One is there any aspect of thisthat's illegal?
Is there any aspect of thisthat's forbidden in terms of
being unethical?
And then we're going to go tothe third one, and that is is
there any part of this that'simmoral?
(11:07):
And do we avoid immorality inour business relationships
simply because it's legal?
So is there something illegalabout that?
And there is some aspect ofillegality in it in terms of
what's allowed under the SafeHarbor Act, which was a law that
was given during the Reagan eraand it was in the hopes of
(11:28):
bringing down healthcare costsand it allowed hospitals and
healthcare entities to negotiatebetter pricing on goods and
services.
But it had to be in a contract.
So if I negotiate a 30%discount with XYZ Hearing Aid
Company, if it's in the contract, then we're legal.
We're legal If XYZ Companycalls and says on December 15th,
(11:53):
end of the year, if you buy 10more devices, we'll give you 35%
discount.
Well, if it's not in thecontract, then it can be illegal
.
So that's the first part wewant to go to.
Is it illegal?
But if we go to the unethical orthe ethical part of that of the
four principles of ethics.
Are we in violation of thatprinciple of ethics Because
(12:19):
there's nothing in AAA's code ofethics or ADA's or ASHA?
I don't believe that willforbid us from taking certain
discounts.
But they would say it wasunethical if it became illegal.
Yeah right, that's part of whatwe have to take into it.
And then really the moralitypart of it is what you alluded
(12:42):
to earlier, like whose morality,who's, yours or mine or
everybody else's?
And so we get less objectivewhen we get into the morality
part.
But the guidance, I think theguidance back to your question
first of all, is anything thatthey're proposing to us illegal?
If it is, that's a hard no,we're not doing that.
(13:04):
If it's not illegal, then is itunethical according to codes of
ethics?
And we may look at those codesand say, yeah, looks okay
according to the codes.
But then we take it to theprinciples of ethics and is
there a potential in thoseprinciples of ethics for this
arrangement that they're givingme to be devious or deleterious,
(13:28):
as they say?
And if that's possible, thenour morality has to kick in and
say the police aren't going tocome get me, the DOJ is not
going to come get me, myemployer is not going to come
get me, but this seems to bewrong, so I choose not to do it.
Dr. Douglas L. Beck (13:45):
Yeah, well, one of the things that I would
propose for people going throughsomething like that and I'm not
the ethicist it seems to me, ifyou're buying batteries, let's
use that as an example, and theygive you a $100 gift card I
might be really tempted to justsay, hey, listen, just give me a
$100 discount on the price ofthose batteries and we're fine.
Or maybe, if I'm going tocollect the gift cards for a
(14:08):
couple of months, maybe I can Iuse those for my next purchase
of batteries.
Right, so it may be coming,just because to me that would
seem like maybe that would solvethe problem and get rid of it
for you, because you're nottempted to use it for yourself.
You're still using it as the apriori purchasing agent at the
moment.
Dr. Michael Page (14:27):
I don't know.
I'll take that one step further, doug, and that is not only
please give me a hundred dollardiscount, but let's put that in
a contract so that we have thatsecure and that we're in line
with the Safe Harbor Act and Ibenefit from that and we're in
the legal part of that.
And then absolutely yes.
Dr. Douglas L. Beck (14:47):
And one of the other things that I learned
in the chapter, and I guess Iknew this, but I hadn't thought
about it until I read yourchapter.
So sometimes you have patientswho you know you have a strictly
professional relationship with.
Mrs Smith comes in once a year,gets her hearing test, for
whatever reason, and I reprogramher hearing aids to the most
current one and I do real earmeasures and all of that stuff.
(15:08):
And after four years you knowshe's thinking of me as a friend
, right, because she's coming in.
But she knows who I am, I knowwho she is and we always have
nice chit chat.
You know how are the kids,how's the family?
Blah, blah, blah.
And after a while she says ohlisten, I know that you're
(15:30):
really involved with onlinestuff and I'm looking to buy a
new phone.
What would you recommend?
Okay, so give us the upside andthe downside of answering that
as a friend or as a professional.
Dr. Michael Page (15:37):
Sure, I can take you to several examples of
real stories just like yoursthat have happened, and one that
is very analogous is whileworking in a department of rehab
years ago, there was a physicaltherapist who was an avid biker
and had been seeing thispediatric patient for months and
months.
And the family came in and saidah, we know you're an avid
(15:58):
biker and you've been such agreat part of our family and we
want to go buy bicycles for thefamily so we can go ride
together.
And he came to me at the timeand said should I do that?
And my question was well,what's the risk?
And he said well, I reallycan't think of any risk.
And I said well, you go to thebike store with them and you
(16:20):
help them select bikes that arewithin their budget.
And let's say they're out ridingwith the family and the front
wheel falls off of one of thebikes, causes a head injury in
one of the kids that may nothave been wearing their helmet
or whatever that is.
Or let's say they do the bikesand then they have another
friend who comes and says thosebikes are just worthless.
(16:42):
Who told you to buy those bikes?
And then they come back to youand say, wow, does that change
your professional relationship?
And I guess my quick answer tohim was is it in the scope of
your practice to make a bicyclerecommendation to a patient of
yours?
And the quick answer to that is, well, of course not, of course
(17:04):
not.
And what I offered to him inlieu of that is maybe give them
some resources to how, to youknow, select the appropriate
bikes or whatever else.
Be helpful, be friendly, bekind, but also be able to
establish the scope of yourpractice.
Dr. Douglas L. Beck (17:21):
Yeah, and I think that's one that is easy
to fall into a trap.
That is easy to fall intobecause you want to be a nice
guy, you want to help yourpatient, you want to give them
the benefit of knowledge thatmight be otherwise benign, but
you could be setting yourself upand your patient for failure.
So one of the things that justhappened in my life which is a
bit of an ethical dilemma for meI put a lot of stock in the
(17:41):
fact that there are very, verysubstantial correlations between
untreated hearing loss inat-risk patients over many years
and the potential for thathearing loss to exacerbate
cognitive decline.
Now, when I say these patientshave to be at risk, this is
pretty much what Achieve said.
This isn't something I created.
They said patients who wereolder were at higher risk.
(18:03):
Patients who have lesseducation higher risk.
Patients with multiplecomorbidities, cardiovascular
disease, diabetes, patients withmultiple comorbidities,
cardiovascular disease, diabetes, patients with greater degrees
of hearing loss.
So we're not talking aboutsomebody with a ski slope loss
at 6,000 hertz who's 27 yearsold.
We're talking about people withperhaps a severe or profound
loss.
We're talking about patients,lower socioeconomic groups, less
(18:24):
education, more comorbidities,all those things and I really
felt like people were trying toget me to say hearing loss
causes cognitive decline.
I wasn't about to say that andI've never said that.
What I've always said is, youknow, that untreated hearing
loss in at-risk patients as wejust defined at-risk tends to
exacerbate cognitive declineover many, many years.
(18:46):
And I felt like that was a bitof an ethical dilemma because I
didn't want to say that theevidence is clear one way or the
other.
But the preponderance ofevidence is that it's at-risk
people who we need to beconcerned about, not just
everybody with hearing loss, and, as a matter of fact, the vast
majority of people with hearingloss don't have cognitive
decline.
So it felt a little bit awkwardand a little bit off-putting
(19:08):
and I'm curious to get yourtakes on that as an ethicist and
as somebody who puts in a greatdeal of time thinking about
what I can and can't say, what Ishould and shouldn't say.
Dr. Michael Page (19:19):
Words matter, especially these days in
political arenas that we're in,that we're in the risk is anyone
taking even a snippet of whatyou say and putting it in a
different context can make itappear as if you said something
that you didn't intend.
And I think there's so muchcaution, especially in this
(19:43):
arena, and we see a lot offervor around this particular
idea as well, and there are anumber of individuals who want
to take these concepts, turnthem into hearing aid, sales
which is the use of the wordsell, as even another concept we
could talk about.
But it again comes back towhat's the potential risk that I
(20:04):
may not be able to see, and ittakes someone admitting that
there might be something thatthey cannot see.
And that's probably one of themost problematic parts of ethics
is that most of us and I'll saymyself as well, I'm not willing
to admit that I can't seeeverything.
(20:24):
Yeah, of course, and the mosteducated person will have to be
super vulnerable to say I maynot see everything.
In this context, in thissituation, I may not see
everything.
You don't hear that from thevoting at all.
Dr. Douglas L. Beck (20:42):
And you said something that to me is
very striking is that you haveto keep the original intent and
meaning within context.
You can't cherry pick your dataand you can't cherry pick a
sentence or a phrase.
You have to keep it withincontext to truly be ethical, I
think, and the essence of theword ethical is trust.
I mean, ethics is based ontrust and if people are cherry
(21:06):
picking and floating out ofcontext, as we see often in
politics and sometimes inscience, you know it becomes a
real trust issue immediately.
Dr. Michael Page (21:17):
Yeah, yeah, I have to agree with you.
And it all comes back to trustand there's some synonymous
ideas totally with ethics andtrust, for sure.
Dr. Douglas L. Beck (21:29):
Anonymous ideas, totally with ethics and
trust, for sure.
What do you think about thesituation now where you have
(21:52):
many manufacturers bringingproducts to market in the
over-the-counter space and someaudiologists and hearing aid
dispensers are in favor and theyvoice their opinions to the
consumers or the patients?
Some are antagonistic oragainst it.
Whether you're pro or con OTC,it's legal, it's FDA right, as
long as you're following the FDAguidelines.
Should audiologists anddispensers weigh in on this
stuff?
Or is it better, as we saidearlier, is that within your
scope of practice to comment onthis?
Dr. Michael Page (22:10):
So tell me about that, first of all, I
think the most importantacknowledgement is that
manufacturers and industrymembers are not health care
providers.
They're not.
Dr. Douglas L. Beck (22:22):
But there are situations where the sales
reps are audiologists.
Dr. Michael Page (22:26):
That's true, and you'll notice that neither
AAA nor ASHA I think none of thecodes of ethics address
audiologists functioning in asales role, Right, you don't
address that and that's aglaring misstep, if you will,
that we're not addressing that.
And I spent a number of yearsworking in industry with
(22:48):
cochlear implant companies andone of the first questions that
I asked when I was in thatclinical supportive role is, I
said is this a sales role or isthis a clinical support role?
And I'll never forget theanswer.
I want to hear it.
What was the answer?
They said we're still trying tofigure that out.
Well, that was in 2005.
(23:09):
That was in 2005.
And one of the difficulties isthat those roles that used to be
clinical support, surgicalsupport, they turned into sales
roles and those roles turnedinto commissions and
commission-based income andthose kinds of things.
But it's super important toremember that manufacturers, as
(23:31):
good-willed as they may appear,are not healthcare providers.
Dr. Douglas L. Beck (23:36):
And in that situation because I am an
audiologist, I'm licensed inaudiology and I worked for
manufacturers before and I workfor one currently it seems to me
that perhaps the smart thing todo is to disclose that if you
are the regional sales director,you're the account manager.
You know.
Make sure that's on your card,make sure that you introduce
(23:56):
yourself that way so peopleunderstand kind of what your
role is and who's who and what'swhat.
Does that help alleviate any ofthose problems?
Dr. Michael Page (24:05):
I don't know that it does.
I mean, anything that addstransparency is always good.
It's always good, but I thinkthe mistake that we see with
industry members that areaudiologists is that it's an
unspoken conflict with people.
So when I used to go in and dointegrity tests on cochlear
implants, I would introducemyself as a representative from
(24:28):
this company and I would say I'man audiologist and so you could
see in patients' eyes they werelike, oh well, yeah, I guess
that's good.
Yeah, I mean, but they couldsee the difference.
And then clinicians oftentimeswould struggle between Michael,
are you functioning as aclinical provider, are you an
(24:50):
audiologist, or are you hereactually to have a good
experience so that we'll buymore devices?
And they'd never say it likethat, but I would when I was
clinically active I would seeaudiologists coming in that kind
of a conflict role.
Dr. Douglas L. Beck (25:08):
I think it boils down to the wisdom of
Solomon, right, but I think it'simportant to highlight that it
could be a discrepancy rightbetween your roles that you have
to your license and your stateand the consumers and patients
you take care of versus youremployer.
And they're all important.
It's not like you know, likeone isn't important.
They all are.
Do you anticipate AAA or ASHAor IHS or anybody is going to
(25:31):
tackle this?
Dr. Michael Page (25:33):
I think at some point they're going to have
to, but I have not heardHeidner hair of any wind of
change in that way.
I think.
Audiologists it's one directivethat I was given by one implant
company was Michael, you're notfunctioning as an audiologist
when you go into that role,you're representing the
(25:54):
knowledge that you have.
But, for instance, I'm notlicensed in Kansas, in
Mississippi or any of the othercities or states.
I'm not licensed there, so Iwas not allowed to function in
the role of a clinical providerand you're not to touch a
patient without that audiologistbeing present and understanding
(26:17):
.
Again, you're advising thataudiologist but of course we had
to touch a patient if we'redoing integrity testing or
otherwise like that.
But it was a careful role.
Dr. Douglas L. Beck (26:29):
I'll tell you after spending the better
part of a decade in theoperating room and I'm happy to
share some of these stories.
But I won't give names ordetails.
But when there's a new drill,when there's a new surgical
instrument, when there's a newprotocol, sometimes you know
physicians will allowmanufacturers, reps, to come in
(26:51):
and show them how to use a toolin surgery, and you know they
also have classes.
You could learn it in atemporal bone lab or you could
learn it, you know, on a cadaverstudy or something like that.
But a lot of the ongoingmanufacturer's education occurs
in real time in the operatingroom and I, you know all these
(27:12):
same questions.
I mean for us it seemsrelatively minor.
Right, that you know we'retalking about hearing and
listening and cochlear implantsand hearing aids and very, very
important stuff, but not like akidney transplant or a CABG.
You know coronary artery bypasswith a graft, and I'm not
pointing fingers, but I'm sayingthat these things where you
have a very, very smartmanufacturer's rep who is
(27:34):
helping to educate and guide thesurgeon during surgery, that
could easily be the same sortand maybe by thinking about it
in those terms, it makes it moreclear that that's what the
issue is is that you have asalesperson telling the surgeon
how to set the drill, and maybethat's okay, maybe that's not
(27:57):
okay, but I think when we takeit at that level it becomes a
lot more serious than somebodysaying, okay, turn on implant
electrode number seven.
Dr. Michael Page (28:07):
This is so reminiscent and I've spent
probably that much time in theoperating room as well, in fact
functioning as an electrophysmonitor guy for spinal cord
fusion, spinal fusions andthings like that.
But I remember, specifically inthe implantable device arena,
being in the operating room,being in the surgical field, and
(28:30):
I could see what the surgeonwas doing.
And there were just a time ortwo these are highly skilled
people, but there were a time ortwo when I thought, hmm, I want
to tell you to do thatdifferently and you're tempted,
but who can't?
But what I would offer them ishave you considered XYZ and so
(28:55):
many people, audiologists, whoare in this role?
They become highly skilled.
And there were a time or two inthese operating rooms when it
was over and the surgeon wouldsay, wow, I'm so glad you were
there today.
That changed the course of ourcase and you feel grateful and
I'm thankful that changed it.
(29:15):
But is it in the scope of mypractice?
And those are the questions weask ourselves.
Dr. Douglas L. Beck (29:21):
Well, when I started in the operating room
was probably 1984, and it was amajor ordeal then and people
used to say, well, why is thataudiologist doing the
neurophysiologic monitoringduring skull base surgery?
And fortunately ASHA back thenhad a statement in their scope
of practice saying thatneurophysiologic monitoring was
(29:42):
a scope of practice.
But it was long before it wasin other scopes of practice and
it was always disconcerting andyeah, it's an issue.
All right, I want to move on.
Let's talk a little bit.
Can you tell me what the StarkLaw and the Anti-Kickback
Statute have to say about thesesorts of things?
What is the Stark Law?
What is the Anti-KickbackStatute?
Dr. Michael Page (30:01):
Sure, anti-kickback Statute is am I
receiving remuneration for?
Am I being incentivized?
Right, basically, am I beingincentivized and a lot of that.
The history of thatanti-kickback statute came from
even civil war time and othertimes in the country.
But anti-kickback statute wouldbe some of what we've talked
(30:24):
about already and that is, arecertain companies trying to
incentivize us into sales,purchasing or others of their
devices?
So technically, under the SafeHarbor Act, as long as it's in a
contract, it is not consideredkickback.
If it's not in a contract, itcould be considered a kickback
(30:50):
and that means that if I buycertain devices or a number of
devices, then I get something inreturn.
Dr. Douglas L. Beck (30:56):
So, michael , tell me a little bit then
about the Stark Law.
Dr. Michael Page (30:59):
How's that different from the other topics
we're discussing Sure Stark Lawcomes into the principle of
self-referral and that meansthat if I'm going to recommend a
treatment for you, if you're mypatient, will I send you to a
place that benefits me in theshort term or the long term as
(31:19):
well?
So, for instance, my wife's apediatric nurse practitioner and
if she in her practice were tosee kids that needed hearing
evaluations or treatment foraudiology-related issues, if she
were to send them exclusivelyto my practice, that could be
(31:39):
considered a violation of StarkLaw.
But Stark Law differs fromstate to state and federal and
statewide as well, so it may ormay not apply here.
But the idea is she would referkids to my practice.
I would make money based onthat, which would come home to
our home financial pool, andthen she would in turn benefit
(32:01):
from that as well.
Okay, but what about thesurgeons who own surgical
centers under differentcorporations?
Is that a violation or is thatlegal?
(32:21):
Where I provide that surgery, Iprefer to do it at this
surgical center, and here's why.
So there's.
I know that's been a legalbattle in a number of states.
Dr. Douglas L. Beck (32:32):
Well, and realtors with title companies
same sort of deal, right?
Sure, you know, just sold you ahouse, and blah, blah, blah.
And we're going to use thistitle company.
And they don't mention thatthey own a piece of that, you
know anyway.
Okay, so that's what the StarkLaw is self-referral.
Whether stuff is legal or not,we're not attorneys, we don't
know, but that's the one thatalways gets me right For
(32:53):
outpatient procedures.
Oh well, we're going torecommend ABC Surgical Center
and it's, you know, outpatient,and blah, blah, blah.
And then you look and you say,oh, it's the principle of that
that matters.
Dr. Michael Page (33:04):
And if you stay with the principle of Stark
Law, it even comes back to us.
For instance, if I were anaudiologist and I were on the
clinical advisory committee forXYZ Cochlear Implant Company and
I happened to do primarily thatdevice, the principle of Stark
(33:24):
Law would make us ask about thatdevice.
The principle of Stark Lawwould make us ask about that.
Now it may not be illegal, butI know a number of audiologists
who are on those advisorycommittees and the expectation
from that company is that theyget a greater referral number
because of that association.
Dr. Douglas L. Beck (33:43):
Yeah, tell me about the Physician Payment
Sunshine Act.
That seems to me that came inwith the Affordable Care Act and
it seems to be a very cleverwatchdog sort of a service.
Tell me what is the PhysicianPayment Sunshine Act and how
does that work.
Dr. Michael Page (33:57):
My only regret about the Physician Payment
Sunshine Act is that it doesn'tpertain to audiologists.
Generally it doesn't, butessentially it's a way for
watchdogs to keep track of therelationship between members of
industry and physicians notphysical therapists, not
optometrists, not audiologists.
But, for instance, I can go tothe physician I think it's
(34:21):
physicianpaymentgov, I think, oropenpaymentsgov.
I can go to that website andlook up any physician in the
country and see who has giventhem money, who took them to
dinner, who took them on acruise, who brought backpacks or
whatever else.
Dr. Douglas L. Beck (34:38):
Yeah, and that's the transparency you were
talking about earlier.
Dr. Michael Page (34:40):
Yes, and the obligation in open payments
comes to the industry member orthe industry company.
So if a member of Pfizer goesand visits a physician in the
area and takes them to lunch,the lunch costs $23.
They have to come back and logthat in, show a receipt, post
(35:03):
that online and so that shows upunder the physician receiving
that money and so it doesn'tapply to audiologists yet, but I
wish it would.
Dr. Douglas L. Beck (35:13):
Yeah, it makes good sense to me, because
then you're totally transparentand if you take somebody to
dinner, you take them to a showit's apparent for the entire
world to see and do with as theysee fit.
Dr. Michael Page (35:24):
One other piece about that which I think
is really critical and we oftenpass by on Physician Payment
Sunshine Act is you can go tothat site and look up any
company.
So I could look up any of theCI companies.
I could look up any of thepharmaceutical companies and
then they will rank order thephysicians that have received
(35:46):
money from them so you can seewho their biggest suitors are.
Dr. Douglas L. Beck (35:50):
And sometimes as a patient, you just
don't even care right, you likethe physician, you know the
physician's competent, you knowthe audiologist is great,
whatever, and so that's fine.
But at least the knowledge isavailable to you if you seek it.
So you know, for people whofind that interesting it would
be available.
Do you think that's going todescend from physicians down to
the rest of healthcarepractitioners sometime in the
(36:11):
near future?
Dr. Michael Page (36:12):
I'm surprised that it hasn't and honestly I
think if we really understoodthe value of that site, it
should attract legislators tomake a change that way.
But it would monumentallyexpand the scope of that, which
would be probably 10 times whatit's tracking with physicians,
(36:34):
because there are so many otherancillary healthcare
professionals.
Dr. Douglas L. Beck (36:39):
Let me change topics again.
The FTC the Federal TradeCommission considers an
advertisement's overall quotenet impression to determine
whether it misleads consumers.
The audiologists may be guiltyof deception if they
misrepresent their treatment,their services or their outcomes
.
The AAA Code of Ethics statesan audiologist may not guarantee
(37:01):
outcomes.
And then you had a specificcall-out that you were familiar
with.
Can you tell us about that?
Dr. Michael Page (37:08):
Well, I'm not sure which one you're referring
to, but maybe I'll tell you thestory, because that could be it.
I remember years ago being onthe Ethical Practices Committee
for AAA and someone took apicture of a billboard for a
hearing professional of somekind, an audiologist actually,
and the billboard said hearingresults guaranteed.
(37:30):
And that's really all it tookbecause they had to go and that
was kind of confessed to AAA.
There was a cease and desistorder and that really did come
back down to are we deceivingsomeone by guaranteeing results?
Dr. Douglas L. Beck (37:45):
Of course I mean surgeons can't guarantee
results, right, right, theydon't, nobody can.
Dr. Michael Page (37:51):
Surgeons will tell you right up front we're
going to make an incision inyour belly and you might die
from it.
Yeah, I mean, they're obligatedto say the risk, right.
Dr. Douglas L. Beck (38:00):
These are the risks and complications that
are correlated on rare occasionwith this procedure and you
have to sign it.
That are correlated on rareoccasion with this procedure and
you have to sign it.
You're aware of that and youprobably have to have a
co-signature of somebody whosaid yeah, I saw him sign.
Dr. Michael Page (38:11):
So deception also comes back to what you
mentioned earlier and that wasthe cognitive decline relative
to hearing loss.
I mean that could be seen as aform of deception if that
research has been taken out ofcontext or used for other
purposes other than its originalintention.
Dr. Douglas L. Beck (38:30):
Yeah, All right.
Well, michael, once again,totally fascinating.
I always enjoy catching up withyou and I want to urge people
to get the book and, inparticular, I read the chapter
that you wrote on this.
We just did the greatest senseof that chapter.
There's so much goodinformation in there and I think
the practitioners will find itto be very useful.
Michael, you're a joy to speakwith.
Thank you so much for your time.
Dr. Michael Page (38:50):
Always enjoyable.
Thank you so much, doug, mypleasure.
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