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Real Ear Measurement (R.E.M.)

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In reply to @x475aws

@x475aws said:

Given this experience, it’s strange to hear about a separate charge for REM, let alone a charge of hundreds of dollars.

Clinics which do usually have it built into their quoted price. If the audi does not have REM capability and you want it, they will refer you to a separate facility for REM and additional fitting.

In reply to @tenkan

Get a new audi, or buy your hearing aids from Costco.

@tenkan said:

I still don’t understand why clinic’s ask up to 1k to have it done,some offer as a “extra”

There are many things in life we probably will never understand.

Why charge $100 when 1 out of ten people will pay $1000. So do 10 ’s for $100 each or 1 for $1000. Same money, 9 hours of saved time. Of course, paying a $1000 is insane, but insanity is a hallmark of modern society.

I don’t think it would matter much, as in any clinic that decided to provide services then they’ve taken you in as a client, but what kind of “responsibility” would be involved I wonder? what’s the worst that can happen, you don’t like the results and want your money back or something else.

@tenkan said:

any clinic that decided to provide services then they’ve taken you in as a client

So if you need more adjustments (properly performed doesn’t guarantee that you won’t), either the selling provider or the REM provider will do it without additional charge? You can alternate visits between them? If programming adjustments don’t do the trick and you need a change in coupling, whether different domes or a set of molds, will you have to pay the REM provider again to do REM on the new coupling?

@x475aws said:

either the selling provider or the REM provider will do it without additional charge?

I’d think the provider would, free I don’t know, I guess whatever you sorted at the time, but certainly you could go back after REM to original clinic and ask for further adjustments, the problem is that once you start making major changes (including the acoustics then REM needs to be redone) but of course this would be a problem regardless which clinic did the REM! As for how clinic’s charge their respective clients for further adjustments we don’t know, they’ll probably want as much as they can get from anyone so “free” is a word most are deaf to.

In reply to @x475aws

@x475aws said:

So if you need more adjustments (properly performed REM doesn’t guarantee that you won’t), either the selling provider or the REM provider will do it without additional charge? You canalternate visits between them?

@x475aws In the cases I am familiar with the $800 gets you and 2 or 3 follow up visits and then back to your original audi

Edited

In reply to @wtolkien

@wtolkien said:

I’d be curious to know roughly what percentage of fittings were very different when comparing ‘first fit’ to ‘after REM’.

First fit being really close to target is rare enough than when we see it, we take a photo and send it to our colleagues and with a comment “Look at this great first fit!”

@wtolkien said:

Do you find that certain vendors are closer together than others?

Yes. Although they’ve all gotten better over the past decade.

@wtolkien said:

Are there differences between more open and more closed fittings?

Yes. First fit will be closest to target when the actual venting and volume in the ear canal are as close as possible to what the software is guessing it will be. Custom and closed typically wins at that, assuming a relatively average ear canal. We fit all babies/toddlers in with fully occluding earmolds (there’s just no room for venting most of the time) and the predicted age-matched have gotten pretty good, so they are often close.

@x475aws said:

Given this experience, it’s strange to hear about a separate charge for REM, let alone a charge of hundreds of dollars.

The basic hourly cost of keeping the lights on for a hearing clinic is generally hundreds of dollars these days. itself is relatively quick, but often if someone is coming in cold for it (you’ve never met them) from some clinician you don’t know or trust, you’re also re-testing, doing a mini eval, and some places are bundling in follow-up appointments to make sure it is all going okay. I absolutely see costs on it that raise my eyebrows, but if the clinician is spending a lot of time that will always drive the price up. I guess also if someone purchased the machine and only uses it 3 times a year prices might be high to justify the cost of the machine? But I wouldn’t want to see that person for REM.

@OcramSagev said:

If REM is not done, are in-situ measurements more accurate than using the audiogram + the average measure in the programming software?

Yes and no. In situ will take the acoustic coupling into account better than the can, assuming that the manufacturer is honest and the in situ works well. If you are doing it yourself rather than having someone doing it for you with an appropriate random ascending staircase method, you’re generally going to mark your thresholds a little bit better than they really are. You could boost them 5 and probably be closer.

I wonder why they have not made a mode that runs in situ automatically as a virtual tester. It could blank the screen and rely on keyboard input to acknowledge the tone like the button in a sound booth. I suppose they don’t want to encourage .

What would be the optimal method, a helper where one can’t see the key press triggering the tone, and then a hand signal or verbal acknowledgement.

I had an audiologist recently run a hearing test with a verbal confirmation instead of a button. It was an old booth. My talking sort of interfered with hearing. The result is close but perhaps less accurate.

In reply to @Elderly

It’s standard practice according to many of the professional societies.

Audiologists might be taking a risk if say someone couldn’t hear and got hit by a car. Lawyers find out wasn’t done and argue it’s below the standard of care.

One US-based article from a quick search: The Standard of Care - PMC Meeting the standard of care is legally required at the risk of medical malpractice. Providers may be assuming there will never be an injury and basis for malpractice and thus are less focused on the standard of care questions.

There’s also an issue of informed consent when not mentioning to patients. That’s a different issue. Informed consent with all options discussed is not great in medicine generally.

Fascinating thread

I appreciate the guidance provided by the pros who provide it here.

I also appreciate the contributions made by contributors that self program. They don’t use Real Ear Measurements at all.

My dispensing audiologist used . He also provided open domes for my hearing aids. They didn’t work

REM helped me recently. However I still have trouble hearing and understanding.

I’m completely dependent on my hearing aids. However, they could be so much better.

I’ve just retired. Cost is a real issue for me

Good luck. Setup is key.

DaveL

In reply to @Neville

@Neville

You provide so much help. And guidance.

2 questions.

What is In Situ?

Has NL3 provided better hearing for hearing aids used in noisy environments?

DaveL. Toronto

Paradise P90R hearing aids

(I’m now retired. I may need to use these hearing aids forever. )

In reply to @Elderly

@Elderly said:

My experience with REM has been mixed. I’ve had it done 6 times. A couple of times it made a small difference. The other 4 times I couldn’t hear any benefits.

In my case, most of the adjustments after REM were gain changes to some frequencies.

I hear so well with the Sphere i90s, I decided to skip the REM and save the $300 cost. After 2 fittings, I felt my aids were 95% as good as I thought they would get. Some female voices were still edgy or sharp, but it was mild and not a problem because the clarity was good.

After I switched to the P receivers, that problem went away, and I felt I was at 97%. The P-receivers made far more difference than any REM adjustments I’ve ever had.

REM is the “gold standard” but not all REM changes make a real hearing difference to the person having it done. So is it gold–sometimes, and sometimes not.

I really appreciate this post, because it lines up with some of what I’ve been trying to sort out myself.

Can I ask how the change to P receivers came about in your case? Was it suggested by Target software, by your audiologist, or was it something you personally wanted to try?

I ask because I have a recruitment/rollover issue, and I recently had a long discussion with my neuro- surgeon about my specific hearing loss. actually pushed me to ask him about recruitment/rollover in more detail, and I’m very glad it did. I want to be clear about that: without AI nudging me to ask the right questions, I never would have gotten as much useful background and explanation from the surgeon. That conversation helped me understand my hearing loss much better, which in turn helps me think about hearing-aid adjustments and even my headphone EQ hobby.

For anyone who wants the full recruitment/rollover background, it’s easy enough to look up. It’s too long to explain properly in one forum post.

On the issue, my surgeon’s office does not include REM as part of the /diagnosis process. Their audiogram is for determining hearing loss, not for programming hearing aids. Interestingly, the surgeon commented that my in-situ audiograms in Phonak Target are probably more accurate for me than the clinic audiograms, especially given the testing variables.

So for me, I’d be curious to have REM again, but mostly out of curiosity. I did have REM a few months ago, and in my case it was basically a rubber stamp of the settings I already had. I would always welcome any method that could more accurately program my hearing aids, but I personally would not pay separately for another REM test expecting a big return on investment.

I also think there can be a downside if the REM result is not reliable. Probe placement can be off, even with a good clinician, and other variables could potentially lead to adjustments that look correct on paper but do not actually work better for the person wearing the aids.

I know REM is widely called the “gold standard,” and I’m not dismissing it. But I also think your post makes an important point: “gold standard” does not always mean the user hears a meaningful improvement. If only a minority of practices are using it routinely, I get a little suspicious when the discussion turns into “good providers do REM, bad providers don’t.” That starts to sound a bit too neat to me.

That’s just my opinion, and I realize others may disagree. Hopefully I won’t get kicked off the forum for expressing it — I’m not trying to start a REM war. I just think real-world benefit matters, and in your case it sounds like the receiver change made a bigger difference than REM ever did.

A hearing aid users favorite topic.

Has anyone else seen this video from Dr. Cliff Olson1 ?

Set aside whatever opinion you have about Dr. Cliff or his content. He performed R.E.M. on a client but due to “patient perception” he had to turn down the gains to accommodate the client, leaving the fitting not meeting the prescriptive targets. Dr. Cliff admits the experience made him less dogmatic about meeting prescriptive targets.

Consider the opposite client experience. Would it be possible that a client who has been fitted with R.E.M. continues to struggle because the client requires gain that exceeds prescriptive targets?

I had R.E.M. performed years ago when I was still wearing Marvel 70s. I found the experience less than satisfactory and I had the hearing aids factory reset and reprogrammed using non-R.E.M.

R.E.M. may guarantee the output of the hearing aid, but R.E.M. has no idea how the client is responding to the hearing aid output.

If R.E.M. is the gold standard then why isn’t it a mandated industry standard? If performing R.E.M. guaranteed a perfect fitting, why would we need volume control on our hearing aids? This 2021 publication from Audiology.org1 states only 30% of hearing care professionals use R.E.M. That’s hardly gold standard.

I think craft capability of the audiologist and listening to the client is more important than the technology of R.E.M.

In summary, in my opinion R.E.M. is over rated and I personally would never seek another R.E.M. fitting.

To your point - I am struggling with the whole idea. But my situation is that my audi can’t seem to find the correct dome to help my right ear which constantly moves around and I have to adjust all day long. I can sometimes hear fine - I think - but most of the day is spent adjusting that right ear only and it goes from feeling clogged overall, to very tinny and metallic when I am speaking. I recently - like the person who started this thread - stumbled upon and live and I am hoping that a session will help in some way. I have worn my for almost 5 months and have been very frustrated since my left ear hardly needs to be adjusted. Of course the right ear has the more severe hearing loss.

First, I will say that my audi NEVER even mentioned REM. When I did find out about it, I was in tears because I felt ‘betrayed’ in a way. I will note here that the NIH is where I found a lot on the subject besides Dr. Cliff, and they as well say it is recommended. So to say it is gold standard does say to me it’s something that should have at least been offered. I called some other audis in my area and found the fees to be from 300-500. Then on my next audi appointment, I asked my audi about REM and she said she had used it many times before in her 20 years of experience, but didn’t think it was really necessary in her office now (she works in an office) to recommend that they purchase this equipment. Also let me say that in her office, she never spends more than 15 minutes with me to try and find solutions. Does she listen to me? Yes. But do I think she really HEARS ME? Maybe not. She did, however, recommend another office in this ENT group that DOES use REM if I wanted to try it, and she gave me their number. I did call, and their charge was the least expensive, but when I spoke with the person on the phone I felt her really LISTENING TO ME. She asked me questions about my hearing and wanted to know what I expected from the test and she seemed much more attentive and understanding and sympathetic. So I scheduled the appointment because I thought maybe it’s more about the person who is the audiologist than the equipment. I still feel on the fence about having to pay a lot more for this (my hearing appointments right now with my current audi are included in the HA cost for the first year) but at the same time, I really feel like I have to at least try this. I am concerned that I might find it didn’t help and then have to seek yet another audiologist, but at this point it seems the only option for me. There’s no guarantee and I am disappointed overall that in this day and age we can’t find the best hearing care without having to jump through so many hoops.

So to all in this thread: I hear what you are saying, and I understand the frustration. I am sorry we are not alone, but I am grateful we have a place to try and find more answers. Please cross your fingers that this will finally help my issue. :slightly_smiling_face: I wish the same for all of you.

@AltoGal said:

I have worn my HAs for almost 5 months and have been very frustrated since my left ear hardly needs to be adjusted. Of course the right ear has the more severe hearing loss.

Sharing your would help us help you with that dome/mold issue. A dome might not be the correct acoustics for that right ear??

These threads sure bring out the excuses.

The pros are correct about REM.

In reply to @AltoGal

@AltoGal, it sounds like there are two issues which are somewhat connected:

  1. The dome in your right ear doesn’t stay in place. Different positioning leads to changing acoustics.
  2. You never had done, so you don’t know if you get the amplification you need. Shame on your audi. Seriously.

I’m inclined to say that fixing issue #1 is almost as important as doing REM.

Without the receiver being consistently in the same place in your ear, you won’t have consistency in what you hear. You might do REM with a certain receiver placement, but after it moves, what you hear is no longer the same.

You may want to consider custom molds.

If you want to stay with domes, here is what I learned. I had similar issues on one side:

  • Wire length can make a huge difference. A longer wire will allow to you push the receiver into your ear deeper, where you might get better retention. Deeper placement usually requires a smaller dome. Deeper placement also helps against the ‘clogged’ feeling.
  • Try domes from different manufacturers - they are largely interchangeable, but they have different stiffness and slightly different sizes. Tiny difference can matter a lot.

Unfortunately, if you throw REM into the mix, you’d have to redo REM after each dome change.
If you have to pay each time you do REM, then you may want to fix issue #1 first.

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