Figure some MFGs, would be interested in data that helps them know which sophisticated feature is actually being utilized, and also what might their products need more training support to their vendors. I am too lazy to find the ideal words to express this, but sure you get my point. With all the great tech in the new units, what is the likelihood that a patient will have them tuned to their best performance for that patient? And as a follow up, is there a common failing? Is it across the board, or does failure increase as hearing needs increase? Are less common hearing curves more likely to receive ineffective programming? Is there a particular loss that is most problematic and in need of the most skilled programmer?
What percentage of failure is due to lack of time and attention vs lack of needed testing, and or lack of knowledge?
Relative to the Aurical , AutoREM REIG50 for + and ReSound NAL-NL2 was lower. Relative to the Aurical NAL-NL2, AutoREM REIG65 for Audiogram + was higher at 1,000 Hz and lower at 4,000 to 6,000 Hz and for ReSound NAL-NL2 it was lower...
Only one study, but in short, likely yes.
TLDR:
On 46 ears, 70-80% of audiologists seemed to just use the ‘first-fit’ software which meant for a range of frequencies the fitting was off by about ±5-8 decibels.
Aka, only 20% actually take the time to do a physical check of the format fit and tune it to your hearing.
Not sure if it varies with the type of hearing loss or any other variable! Also, this is US based, so not sure how this applies worldwide.
The manufacturers are datamining everything. So yes, they know if you’ve been first-fit. They know if your domes are different from what they recommended. They know how long you are wearing them and what programs you are in. I guess the question, then, is which if those measures can actually tell them whether the hearing aids have been “fit effectively”. Wear time might be a decent proxy? Higher wear time might suggest that they were well-tolerated and beneficial? But it’s all going to be inference on their part. They should probably just send out a likert scale through their app with a question “how well do your hearing aids work for you” and then they could corrolate that with settings and try to find patterns.
But they certainly do use the data to figure out things like “if all providers are changing our settings, why is that? Are our initial settings inappropriate?” and we do see changes.
I’m not sure how they would determine, from what they have access to, whether certain types of hearing loss were correlated with ineffective programming. What’s the outcome measure? Returns, maybe? Except that I don’t think they can currently match individual returns with the sorts of aggregate data they are collecting. Maybe they could look at the degree of variance in gain provision there is with different types of hearing loss. I’m 90% sure they aren’t doing that, but how fun would that be? I don’t think they currently have a way to use the data they collect to determine fitter skill and then divide fits by those done by good programmers and bad, based on whatever their measure of a “good programmer” would be. The data is all de-identified and aggregated pretty quickly because of privacy issues. (They could add an app question “how much do you like your clinician?”. . . but them some people like their clinician because they are skilled, and some like them because they are friendly and/or good looking.)
I think most failure is due to lack of communication/coaching, which could be seen as time and attention but not necessarily. One provider simply may be better at explaining things to a patient in a way that gets them motivated and on-board to accept appropriate gain. And there are patient factors too, so certain patients are going to do better with certain providers, although of course it is incumbent on the provider to be as good as possible for as wide a range of patient types as possible.
I had a patient come in today who had been fit by a colleague last year. They’d been consistently wearing their hearing aids but were disappointed in the degree of benefit they were receiving. Looking back at the notes, after the provider set the hearing aids appropriately the patient returned and insisted that the provider reduce the gain to the point that the hearing aids were doing very little (there was a little bit of back and forth with appointments in there before the provider capitulated). So the conversation we had today essentially went “I’m unhappy with these, I can’t hear what I want to hear”–”No kidding, you made us turn them down to the point that they aren’t doing much. Can we turn them up again and work on adaptation?” Was there a failure there? I’m not sure. The patient was wearing the hearing aids consistently, which was a success. They’d been wearing them inapproriately fit (at their request) and had experienced limitations and were now ready to turn them up. I think probably they should have been seen back sooner to work on it, but the patient was also very clearly unwilling to work on adaptation at that time AND they were getting frustrated with coming in so much. Patient seemed receptive to discussing what adaptation might look like today. Were they not receptive back then, or did they not understand the explanations given at the time? I’m not sure. How does that look from the manufacturer end? The manufacturers have no way to know precisely what the hearing aids were doing on the patient ear. They can see number of setting changes and that the hearing aids went up and then down. What do they take from that? They can’t know whether it was a tolerance issue or whether there was an error in the initial fit or what.
I don’t THINK they are typically looking at programming changes over time, although It hink that would be very interesting.
@Neville, thanks for the detailed answer, I always find it very interesting to read about how things look from the perspective of the professionals!
I’m wondering though if the manufacturers really care about all the data they can collect. After all, the hearing aid wearers are not their direct customers.
In the best case for the manufacturer (and worst case for the consumer), the HA manufacturer owns the entire value chain all the way down to the hearing aid clinic. To grow the business the manufacturer needs to open more clinics, or get more people into existing clinics (marketing!). Improving the product so that HA wearers like them more might lead to increased revenue through word of mouth, but that’s only a second order effect if it exists at all.
I’m guessing that with independent clinics word of mouth is more important, so they might be more inclined to recommend HAs based on features and performance.
But audiologists working independently also have to run a business, so I assume they care just as much about a streamlined fitting process (good fitting software), reliable HAs, good RMA handling, a responsive manufacturer rep, etc.
Perversely, adding end customer features might actually be detrimental for the HA manufacturer because it puts an extra burden on clinics. For example, here in this forum the question came up why Phonak does not have an Apple watch app. Phonak also hasn’t delivered or . Given that these features take up the clinic’s time for setup, explaining and troubleshooting with with the end customer, this might actually steer independent Audiologists away form a certain brand.
But audiologists working independently also have to run a business, so I assume they care just as much about a streamlined fitting process (good fitting software), reliable HAs, good RMA handling, a responsive manufacturer rep, etc.
I work at an independent clinic where we have accounts with all manufacturers. “Best in class” hearing aid for the release cycle is a big factor for us for what we fit for sure, and our perception of what that is gets driven by the information the manufacturer gives us as well as our own investigation and use of the product and customer feedback (it’s one of the things that keeps me knocking about here, actually). The degree to which a clinician’s opinion of a product comes down to them wholeheartedly swallowing whatever the manufacturer tells them versus doing their own skeptical digging is very individual from clinician to clinician and is probably one of those intangible factors that helps to make a better clinician and is difficult for a patient to know. I would say some of this is education, curiosity, work ethic, some is personal principles and personality. I have a very high level of skepticism which makes some of my wider colleagues very annoyed with me, but others do find it valuable. However, you are correct that probably the bigger influences on what a clinic fits are: 1) the level of support and grace they get from the manufacturers (especially in an era where differences between device performance can be razor thin), which itself is a funny sort of feedback loop because the more of a product you sell the more support and grace you get. By “grace” what I mean is special exceptions mostly. Say, for example, that my patient gets skin cancer 1.5 years in to owning their hearing aids and has half their ear removed and now needs to switch from a custom to a or vice versa. Manufacturer A might tell them to purchase new, Manufacturer B might make a switch with a charge, Manufacturer C might burn the L&D replacement and do the switch for free, and the whole thing might be more or less easy. This also plays into factor 2) Minimal headaches. Headaches for a clinician look like multiple custom remakes, regular receiver failures, shoddy bluetooth stability, hard-to-use accessories, reps who are hard to get a hold of, long waits for phone support, any little thing that makes their regular day-to-day more challenging or pisses their patients off.
Software is PROBABLY a factor as well. I think a lot of the people on this forum lean to being a bit techy, a bit comfortable with computers, and would probably share my perspective that most hearing aid fitting software is largely the same. This is not the case for everyone though, and there are definitely clinicians who aren’t “computer people” and unless they have been trained within a certain ecosystem they find it difficult to just click around and find things. For them, software ease-of-use absolutely factors in. Where this is a direct hit on manufacturers is that if you give a clinician too much control in the software and they are kind of. . . uhh. . . I was going to say dim, but actually many of these people are fabulous at counselling and interpersonal issues and amazing diagnosticians and just have a weird thing about computers. . . but they can really mess the hearing aids up. Whereas the clinicians who are at ease with that sort of software and control will really prefer to have more options within the software that they can leverage. But for the former, the blame doesn’t get laid at the feet of the clinician, the hearing aid just sounds bad to the patient. So the manufacturers are often trying to walk a line between making their software powerful enough for the clinicians who want that and simple enough for the clinicians who struggle with it.
I think we always need to keep in mind, though, that manufacturers aren’t a monolith. I’m sure that there are people there making some cold and cynical decisions in order to keep the business profitable for their share holders, but most of the people working within the company really do view themselves as being a cog in a machine that is ultimately trying to make devices that will improve the lives of people with hearing loss. The researchers and engineers are trying to make things that are cool and new and useful, and they are absolutely the sorts of people who like graphs and data.
Per putting annoying features into hearing aids, Bluetooth has been a mixed blessing for hearing care clinicians. On the one hand, streaming audio is very powerful for users with hearing loss. On the other hand, we never expected that our job was to teach people how to use their phone. Clinicians are still annoyed, to various degrees, about this. Do you know how many people I have to teach how to just CLOSE THEIR APPS? It’s very annoying. I didn’t get my degree so that I could show people how to recover their Apple ID password and download an app. There is a revolving door of patients coming in asking us to reconnect their devices to their Bluetooth because they have no interest in learning how to do it themselves.
Well said. Bluetooth has taken over the entirety of the hearing aid for a large portion of users. And some users that struggle with getting past the lock screen will demand to have a perfect understanding. It introduces so much frustration to the user and, for some, provides very little benefit. For others, it’s a lifeline to the outside world and their only method to communicate with their family. Getting them to accept that the experience can be less than optimal can feel impossible.
I also constantly find myself in a position where someone comes in wanting a specific highly regarded device that is nearly impossible to prescriptively fit to their needs without some major trade offs, but they saw something online which they have become devoted to entirely. I remember when online information was supposed to be treated with skepticism. Now if you make a blog and write a couple of opinion articles with some specifications thrown in, it feels that it is regarded as the final word.
And I remember one particular release of a particular hearing aid that I was able to demonstrate with real ear measurements that nearly nothing that I changed inside the fitting software would impact the output of the device. I think they were trying to fix the issue that you mentioned about some providers having difficulty managing the software side of things. I’ve seen too many clear examples of that as well. But to be fair, even the software changes over time and sometimes the most important change isn’t even mentioned or documented. And that’s assuming that there is time to read the changes or documents since every moment of my time is taken months ahead of time. So unless I spend my free time learning about some of these things, or having to actually experiment/give it the ol’ college try, it’s easier to stick to the things already known.
Oh and then good luck trying to learn how to be better at things. A mixture of vague answers, (potentially unintended) arrogance, impatience, or they might be embarrassed to admit that they don’t know either. People spent years telling me what a waste real ear measurements were and how users can’t tolerate , which I have found to be nearly completely untrue and largely based off of flaws in the way that they perform real ear measurements or apply the prescriptive targets or in the way that they prepare & counsel the user.
I also constantly find myself in a position where someone comes in wanting a specific highly regarded device that is nearly impossible to prescriptively fit to their needs without some major trade offs, but they saw something online which they have become devoted to entirely.
I haven’t run into this too much yet. Certainly there is the old chestnut of patients with HF loss who want a that shouldn’t have a CIC, but lately when someone comes in and says “I want the Zeal” and I say “Yes, it’s very cool right? Unfortunately it’s not appropriate for your hearing loss and here’s why.” They’ve generally been taking me at my word. Although I had a colleague who reported that everything they said, the patient checked against ChatGPS’s suggestion and that was WILD.
Oh and then good luck trying to learn how to be better at things. A mixture of vague answers, (potentially unintended) arrogance, impatience, or they might be embarrassed to admit that they don’t know either.
Oh, I think you’re probably past this now but if there’s anything I can do to help let me know. I’ve been privileged that this has not been my experience. I went directly from a school where I was essentially taught how to do by its original developers into a private practice whose clinicians had been taught by the same people and had never not done it plus had years of experience working with pediatrics where it is highly emphasized in a georgraphical area with high-level training and oversight for pediatric care. And then on top of that, because of my original time in the academia I was already just used to contacting and badgering high level people until I understood things and had a pre-existing network of people who could explain things to me if I needed help. I have seen over time how many young clinicians exit school and find themselves with either no support to advance their learning or actual push-back from clinicians who just want to do things the way they have always done them.
People spent years telling me what a waste real ear measurements were and how users can’t tolerate NAL-NL2, which I have found to be nearly completely untrue and largely based off of flaws in the way that they perform real ear measurements or apply the prescriptive targets or in the way that they prepare & counsel the user.
Absolutely. And the “go-slow” fitting procedure is so widely adopted and ingrained whereas the majority (not all, but the majority) of my patients can tolerate 100% target gain from day one.
(A farily well-known influencer in our field told me that the big reason he did go-slow for everyone was that extra appointments in the beginning to do this made patients feel like they were getting more value. Which is probably true, but feels pretty inefficient. I wonder whether making the initial phase of getting a hearing aid feel extra busy and difficult supports later patient retention–probably. But for a lot of users you could replace the slow gain increases with some other service.)
