Real Ear Measurement (R.E.M.)

@tenkan said:

it won’t be long before REM will be done exclusively by the next generation of receiver

How can the receiver tell what’s reaching the eardrum?

Sorry I should of added a bit more to that, but obviously though the HAs and software with xMEMS receiver for accuracy, so it’ll work just the same as the default probe microphone on say a MedRx etc, manufacturers are already trying Auto-REM with things like Target Match etc

Seems your last paragraph is another argument for inexperienced users to start with Costco. If another audiologist charges X additional for REM which Costco includes then Costco is effectively charging its price less X for the aid and the rest of the services. This analysis would further favor Costco because it offers free REM as many times as one needs.

The inexperienced patient often has little sense of whether Costco or an audiologist has done a thorough job or adjusted the aids well. Even for an experienced patient the return period can be too short other than at Costco.

Audiologists who reject REM seem to be hurting themselves by making Costco an even better value.

I thought that I would add my own two cents here.

I wonder if some people find REM beneficial and other’s don’t has more to do with the kind of hearing loss that you have? To me, that would be the only explanation why some people see no benefit?

Speaking for myself, I have had REM done twice and on both occasions, it has made a huge difference particularly in addressing audibility as in people not speaking loud enough.

Having said that, even with my new audio, that I am extremely pleased with, even after having REM done on my ears (which bumped up a lot of frequencies from her audiogram baseline settings), I had to go back for a second appointment and get her to further boost frequencies (in my left ear) because I still had a slight audibility problem such as I would walk into a coffee lounge where music was playing quietly in the background and I only realised that music was playing after sitting in the room for several minutes. Yet, my sister said, she noticed the music as she walked in, because the music was not so soft that you had to strain to hear it. That is a classic audibility issue. She has now corrected that.

So REM on it’s own, did not actually achieve a perfect fit. For me, it was a three stage process. Audiogram + REM + further adjustment. REM is not a magic wand. All it does is verify the fit in that it measures that your ears are actually receiving the amplification that your hearing aid is supposed to be delivering. This verification is necessary, because everyone’s ears are shaped differently and in most cases people are under fit. I have very small and beautiful ears, so REM made a huge difference, particularly with (but probably not limited to) to lower frequencies.

The problem with REM is that it only verifies the fit. If the fit (the audiogram) is not accurate or does not fully reflect how your ears hear (or don’t hear), then you still need to do more tweaking after REM. But that does not mean that REM is pointless nor does it negate the value of REM. It is simply one stage in the process. The single thing that makes the most difference is not REM, but the skill of the audiologist. Their skill is absolutely vital.

I now have reached a stage where I hear things that I never used to hear before (or at least not at a distance). I can hear oven beeping in the distance, I can hear laptop fans whirring and I hear so many other sounds in the world, that I was never really aware of before. REM helped towards that, but it was the skill of my audiologist that actually made it all possible.

I would never choose an Audio that does not do REM as standard, because even my audiologist (as good as she is), says REM is essential to cut out 95% of the guesswork. But I will concede that the skill of the audio is more important. I have actually had a better fit with a previous audio who did not provide REM over the audiologist before them, who did provide REM and still managed to do a crap job. But my current audio is definitely better than the previous audio.

I am surprised that there are still people who don’t believe in REM, especially when so many people have found it to be so beneficial. In my case it helped tremendously, even if I still have issues with soft input speech, which I think is more a limitation of my ears than hearing aid technology.

I would give another example. We can inflate the tires in the car by feeling, without taking measurements with a pressure gauge.

Nevertheless, most of us will agree that it is worth verifying the degree of inflation of the tires with (real) measurements.

@Roberto said:

I wonder if some people find REM beneficial and other’s don’t has more to do with the kind of hearing loss that you have? To me, that would be the only explanation why some people see no benefit?

There is also the skill of the HCP. If they don’t know how to use REM, or are actually bad, that could be another reason. People who insist on getting REM from a fitter that rarely does it, may find it lacking. It isn’t REM’s fault. Just like giving the wrong domes/molds, or picking equipment that doesn’t fit the loss, there are reasons.

WH

Another reason might be that many hearing aids don’t require any adjustment, therefore no improvement.

I surprised to hear that it is a large extra fee to have REM done at some practices. After all, Costco includes REM and their prices are lower than any other place other than the VA.

How do VA ‘costs’ compare with Costco? The VA patients may not be paying but VA uses audiologists and may have more overhead or be more thorough. The VA does not need to make a profit. Costco cost/expenses may be lower than the VA.

That’s a good question, but not relevant to why some practices charge a lot extra for something that Costco includes in their much lower pricing. I only mentioned the VA to exclude them from that discussion.

You probably haven’t missed out on anything. It’s just another tool that helps with the guesswork that “audiologist” do. The current hearing tests haven’t changed since 1951. They have no tools to tell them what is actually happening inside your inner ear where the problems are. REM just measures if your ear canal is affecting the amplification range of the hearing aid profile. They can tell that from other means such as Widex SensoGram which doesn’t require any additional equipment, But knowing how the hearing aid is performing in your ear canal is only a small piece of the puzzle.

The bigger issue is that

1. The hearing test from the 1950s only measures and few widely spaced frequency points and the unmeasured gaps are approximated (guesses). So, REM confirms a prescription based essentially on inaccurate guesses. Meaning it’s just another guessing tool.
2. The hearing test is somewhat subjective and even if you can hear a frequency at a certain level, it doesn’t mean when you amplify that frequency to the prescribed level that it will benefit you BECAUSE the damaged portion of your ear may present that sound as distorted and chaotic noise.
   In my opinion, REM is just another guessing tool and much more useful information will be gained by simply listening to your description of what you actually hear. REM is more of a marketing tool to provide clinics with something they can point to gain your business.

3. Most Hearing aid makers pay no attention to frequencies above 8khz or below 150hz so no matter what prescription the audiologist comes up with, music and many other things will not sound very good. (Some Widex models go up to 10khz).

The sad news is that audiologist aren’t miracle workers and have very few actual solutions available for your problem. Thus, the universal answer “your brain has to adapt to your new hearing aids”, in other words, get used to not hearing well because we can’t really fix that.

So, what actual benefit does REM provide? It’s only confirming that a prescription matches based on a test from the 1950s that has widely spaced frequency markers and gaps that are estimations. It doesn’t tell you what’s actually happening with the patient’s hearing mechanisms. It’s only measuring the performance of the hearing aid programming which is based essentially on guesswork and estimations . Won’t far more valuable information be gained from simply discussing with the patient what they are hearing with the current hearing aid settings? Yes, I know , you will say that feedback from patients is very subjective, but this whole process is very subjective because doctors cannot actually measure what’s happening the tiny sensory hair cells inside the inner ear (the cochlea) or to the auditory nerve.

Does research support some reason that hearing tests covering more frequencies in the 250-8k range would not provide benefits? With digital aids curves could be better smoothed which might clean up the signal enough to benefit some.

Even without altering the pure tone frequencies, in situ could offer broader testing and then try to better for the prescriptive targets with less interpolation.

@bhughes_99 said:

widely spaced frequency markers and gaps that are estimations.

If we take just one line, if you do the half octave points, you’re getting a ‘measure’ every 4 notes on a piano, approximately 10-12 points on each side that pretty accurately describes a hearing loss. Even 6 or 7 points will give you a statistically representative level and trend. Once you’ve established this, you can realistically provide a gain profile and a prescriptive target.

Just because the norm was established in the 1950’s (as part of NASA ‘s anthropological measures), doesn’t mean it’s inherently wrong. Also when you’re building a testing system you have to consider that there’s a human being (possibly aged or tired) sitting on both sides of the box, the test mechanism must allow for this. Further refinement ‘IS’ possible, it’s just that there’s no absolutely defined standards for this, and the widely touted WRS has similar repeatability to throwing three darts at the same time from the same hand.