Understanding Audiology Best Practices with Dr. Cliff

This is a great opportunity for us to get together and talk a little bit with our listeners about the importance of audiology practices and best practices.

A full transcript is included below

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Welcome, Dr. Cliff from HearingUp. This is a great opportunity for us to get together and talk a little bit with our listeners about the importance of audiology practices and best practices of that.

Absolutely. Well, thank you for having me. I mean, as you know, I like to talk about best practices a lot because they are truly the difference maker between someone having an average level of success with hearing treatment and having outstanding results. Over the course of the past five years since I’ve really been talking about it, I think the exciting thing is that a lot of consumers have started to really take this knowledge that we’re putting out there and empowering themselves to make better educated decisions about their own hearing healthcare.

Oh yeah, absolutely. Listen, knowledge is power, and we preach that at Hearing Doctors every day. So, let’s talk a little bit more about in most industries, we have the gold standards. What does that mean to us? What does that mean to you? What does the consumer or our listeners need to know about that?

Yeah, I mean, I think when you talk about every profession out there that has any kind of research backing into what they do and when you think about professions like physicians who are surgeons, or you think about dentists, pretty much any profession that is kind of in that medical world, there’s research that goes into the things that they do and why they do them. And a lot of professions, not including audiology, but a lot of professions have basically the standard. So, what’s the bare minimum that you should be doing in order to be considering following your scope of practice. And the unfortunate thing is is that we don’t have even a basic standard of care. The fortunate thing is is that we have what have been identified to be considered best practices. So when you talk about gold standard of care, that is what best practices are. And inside the world of audiology, it’s basically a bunch of research proven procedures that we should be following to optimize the treatment outcomes for our patients. I mean, you wouldn’t want to go into a surgeon wherein one of their best practices is washing their hands before performing a surgery. And you go into them and they’re like “I don’t think I’m going to follow best practices today,” and “I’m going to eat lunch, eat a burrito for lunch, and then go in and perform surgery” without washing their hands. But I use that illustration to just kind of signify how ridiculous it is that we as a profession wouldn’t globally accept and follow best practices.

Yeah, no, that is so true especially in the hearing healthcare. We need to take command, and we need to be the ones talking about this, and I talk about this and educate our patients every day. So, you have developed this amazing checklist that I look forward to having when there is somebody that comes from your referral forum. And let’s talk about it. Let’s break it down. I want to educate our listeners as to what it means. So, let’s talk about the page one, consultation.

Yeah. When you look at when we develop these checklists, and just to be clear, I am not the one who determines what a best practice is. The AAA, the American Academy of Audiology developed a task force of audiologists, both clinical and research audiologists, to go in and look at the research and identify, okay, what are the things that we should be doing with every single one of our patients to result in the highest level outcome possible? And so they created their guidelines for adult audiologic management. And so what I did, and it’s no great feat on my part, but I just went through that guideline and it’s somewhat difficult to read if you don’t understand audiology. But I wanted to make it something that people could understand whether you have a degree in audiology or not. And so that’s kind of what led to me developing this checklist for the HearingUp network and to provide a little bit more context for that, The HearingUp Network, which you are a part of, is a group of hearing care professionals who are committed to following these best practices. So, if we start with page one, we are basically looking at the consultation checklist here. And so these are different tests that need to be performed, different considerations that need to be taken into account at the initial appointment that is had with a particular patient. And so it specifies things like getting a complete case history, looking inside the ear canals with autoscopy. I mean, to think that there are actually providers out there who are not at least looking inside of someone’s ear canal before administering testing or treatment is mind boggling. But the other thing that we need to look at is are we actually doing all of the proper testing in that consultation when we’re doing audiologic testing and are we administering it in the right way? One of the things that I’ll kind of zero in on is this idea of word recognition testing. So word recognition testing is when you’re presenting words to an individual and seeing how many of them they can repeat back accurately to you during the test. And if you do this where you’re actually speaking into a microphone like I am right now to you, and if you use that as the method of scoring, then that is not accurate. We need to be doing recorded speech testing with our patients. And if we’re not, we are technically not following best practices. And as you move through the list here, it’s one of those things where there are certain medical conditions that we have to take into account as well. Are there any red flags that this patient exhibits at that initial visit? Whether it’s a deformity of the ear, whether it’s a single sighted case of hearing loss, if there’s drainage coming out of their ears, if we identify during the testing that there is what we call an air bone gap, which is the difference between sound entering their entire pathway of their ear versus just entering their inner ear on its own. These are all things that would potentially lead to a medical referral to go to an ear, nose, and throat physician or to go to an otologist. So, during the consultation, I don’t think that people really understand or consumers really understand how much work really goes into this initial consultation. And this initial part of the checklist just helps the consumer comprehend the magnitude of what they should be expecting when they go and see their professional.

Yeah, and what I like about it also, Cliff, is the fact that we’re also educating the professionals. Make sure you’re not cutting corners, make sure you’re not forgetting. And for new professionals, we get to see students here at the offices, and it’s important for them to just follow that regimen and don’t forget, kind of follow the path of the ear, the outer, the middle of the inner ear. And it makes sense. And it makes sense to the actual patients that we’re servicing.

Yeah, I totally agree. And my thesis from when I started my YouTube channel, the Dr. Cliff AuD YouTube channel, is that hearing care professionals have not been very, I don’t know, able to be influenced. So, there have been professionals inside of audiology for decades who have been preaching to audiologists, “Would you please follow these best practices?” And they just won’t do it. So, the only way that I found to get around that is to go directly to the individual who has hearing loss, educate them on the things that they should demand from their hearing care professional, and then when they go to their professional, if they say, “Hey, you either need to do this stuff or I’m going to go find a different clinician,” that provider is going to start to do the things that that patient wants to do. So it all comes down to empowerment of the individual who has hearing loss themselves.

And you know, what an accountability, right? We like to hold each other accountable. So if I get somebody else’s audiogram, I know if they’re doing their job or not. And it’s important. It’s so easily digestible so that when the patients come in, it’s so easy. It’s in front of you. You’ve been educated, and the best patient is that educated patient. I love it. I think it’s great.

It is so easy to work with a patient who actually understands what you’re doing and why you’re doing it. And if they have a foundational understanding, that conversation is very easy for them. And so that’s why I encourage anyone who has hearing loss do some research on your own beforehand. Try to figure out what’s just marketing hype and what actual information is that’s out there that’s designed to help educate you rather than influencing you to purchase a certain product.

Yeah, absolutely. I like that. Okay, so let’s move on to maybe page two, Hearing Aid Evaluation and Treatment plan. Because at the end of the day, Cliff, this is a medical treatment, a medical device that we do it with. It’s just a vehicle, right?

Yeah. When you really think about hearing aids in and of themselves, they are just the thing that we need to use to utilize our skill set to our fullest potential. You’ve probably told patients this, I’ve told patients this, that you can have a million-dollar hearing aid. If that hearing aid is not set up the right way, it doesn’t matter. It’s going to act like a $5 hearing aid. So, if you really want to get the most out of the technology that you purchase, you really have to make sure that all of these steps are followed during the evaluation process and the recommendation process. And when a hearing aid is initially recommended to a patient based on their wants and needs that we identified during the consultation, that is only the beginning of all of this. Then we start going into the actual hearing aid fitting. And even before a patient would come in and get fit with hearing aids, there are a variety of different tests that need to be done on their hearing aids before that appointment even happens. So a lot of behind the scenes stuff. When we get a hearing aid into the clinic, we have to make sure that we do electroacoustic analysis. And that’s just a fancy way of saying is, is the hearing aids meeting the diagnostic specifications that the manufacturer has specified? And if they don’t, then those hearing aids have to go back to the manufacturer and have them send you back ones that actually function the right way. And there’s data out there that suggests that anywhere between 12 and 18% of hearing aids that are being fit on patients are not actually functioning the right way out of the box. So, even if you program them perfectly, it doesn’t matter. They’re not meeting their specifications, so you’re not getting the full amount of benefits. So when you think about the quality control, all of these things have to happen with a particular hearing aid before that hearing aid is even fit on a patient.

Right. Imagine how many times you’ve had a patient, they come in, something’s wrong, but it’s not because of your programming or the lack of the real ear that outcomes that you got, but it’s actually because the product was not even up to par to begin with.

That’s right. And it’s crummy that it’s a very simple test that we need to do. And oftentimes I have an assistant do it for me, and then I go and I evaluate the outcome of that test. And if I say, “No, that one did not meet specifications, it needs to go back,” then we basically start over from scratch because I refuse to fit a patient with a hearing aid that is not functioning the right way at their initial fitting appointment. And then once we get past that, we start going into the hearing aid fitting. And so there’s a couple of different aspects about this. First and foremost, I think everyone thinks of me as the person who’s like you do verification measures and you’re stickler for that and that’s the only thing that you care about. And I tell people that the thing I care more about than the verification of a hearing aid is if that hearing aid has been physically fit to the point where it can do the things that we need it to do acoustically, but it also has to be comfortable. If you’re walking around out there with a hearing aid that you find to be uncomfortable inside of your ear, that is the first deal breaker of a hearing aid because you have to be able to wear it all day. It has to stay put inside of your ear all day. So, if you’re having it migrate out of your ears, that is a no go. That is a hard stop. And you say we have to fix the physical fit before we can fix the acoustic fit. And then once we get done with that, we have to make sure that there’s no feedback or whistling going to occur with that particular hearing aid. And there’s a variety of different testing that we can do with that. Typically running a feedback manager inside of the programming software can solve that issue. And then we get down to probably the cornerstone that everyone thinks about when we talk about best practices and that is real ear measurements. This is a form of verification. So when we’re programming hearing aids, we have to make sure that we are verifying that they’re capable of meeting your hearing loss prescription. Because if we do not meet your prescription, then the hearing aid, that million-dollar hearing aid, is not going to provide you any benefit anyway.

Right. It’s not all about the value and meeting learning their goals and just meeting their needs, right? Yes, it starts with the audiogram and everybody thinks it’s all about the audiogram and it’s really not. It’s the art and the science where they all come together and it’s really our job to be the best, be the experts at that.

Yeah, and I’m glad you bring that up because art and science is exactly what it is. You can follow the science to a T, but if you don’t have the art form of understanding what’s actually going on, when a patient has a certain type of response to a certain type of sound and you can’t manipulate that, then what are you really doing here? You could teach a grade schooler to follow, and nothing against grade schoolers, I think there’s a lot of smart grade schoolers out there, but you could teach them to actually follow a protocol and a checklist. But if you don’t have the other side, which is the expertise of what you’re doing, then you’re going to fall flat on your face as well.

All the time. And it’s just being cognizant that you’re dealing with the human. So, between all this great technology and great software and equipment and instrumentation that we have, I think it’s really important that us audiologists that we listen to the patient and we understand and put ourselves in those shoes to try to meet their goals and maybe even saying we’re going to start a little slower. But our ultimate goal is going to be X, Y, and Z and just giving them that opportunity to learn where you’re going to, where you’re starting, where you’re coming from, where you’re going to.

Absolutely. And I like to call that person centered care. And I think that person centered care is an important aspect of or an important component to include with best practice care. And that’s making sure that you understand the wants, needs, and values of your patients and you’re including them in the decision making process of the treatment
as well as how you administer the treatment, making sure that they understand why you’re making certain decisions with them and for them.

Yeah. And at the end of the day, to have the most optimal outcomes, you have to have them be knowledgeable enough. I’m not asking them to become an audiologist with me, but I’m asking them to understand a little bit where we’re coming from so that I can then have them be like you’re saying, a full participant so that the journey never ends with the real ear. And I’ll see you in two weeks, and I’ll see you in six months, and then I’m going to see you again for your annual evaluation. It’s a journey and we’re going to stay on that journey. And you talked about verification, but I also like to talk about validation.


Let’s talk a little bit on that because I think to me that’s just another important component for their success, long term.

Yeah, for sure. So when we talk about the differences between verification and validation, so verification is more of an objective measure that you would do with someone and then validation is okay, is the treatment that I am objectively treating you with, is that creating a subjective improvement in your performance? So are you actually perceiving the benefit in normal daily situations that you actually wanted to correct with this particular hearing treatment? And there are a variety of validated outcome measures that can be used for that. The client oriented scale of improvement. The abbreviated profile of hearing aid benefit, the International Outcome Inventory for Hearing Aid. So, there’s a lot of different scales that can be used to actually see and measure has there been a subjective improvement with this hearing treatment? I tell people all the time if a provider is saying a) “How does that sound?” Or, if they’re saying, “How do you think you’re dealing with hearing treatment?” Those are so broad in general, they actually have no utility whatsoever. So you actually have to use a validated outcome measure and that’s considered best practice to do it. I mean, this could uncover things that are not actually being improved upon through treatment that your provider could go and be like, “Huh, I didn’t realize that you were not getting as much benefit on the telephone that you wanted to based on this outcome measure. So, let’s go in and adjust your program settings to help you with the phone more.” It’s very important that you do validation along with verification and doing one or the other is not acceptable. You have to do both if you’re following best practices.

Oh, absolutely. And I think it’s important also to bring up to our listeners that we do it every six months or whenever you get to see them. If you have a protocol, if you do it, you come in four times a year, twice a year, whatever that may be. I think it’s important that both of them are followed every time because maybe they started doing something new and different. So you need to rearrange the programming or address that need because maybe they’re more outgoing. Maybe things are not as well as you thought you would. Because as providers, we always want to do a fantastic job and we always think that we’re doing a fantastic job. But the reality is that I don’t want to hear all the good. I want to hear the good, the bad, and the ugly so that I can then expand on their outcomes and making sure that we’re always doing a good job for them because the research and those inventories have shown me that I need to just keep probing at it.

Yeah, for sure. And I think a lot of us who are committed to following best practices are the same. We know that we can never be perfect in anything that we do, but it’s about striving for perfection. And the closest that you can get to perfection is making sure that you’re doing everything that you need to do in the best way you can possibly think to do it. And the best practices are just that foundation. Like I mentioned, if you don’t care if your patient has a good outcome, then you are ultimately not going to get a good outcome with a patient. And I think that it takes both the compassion to desire that for your patient as well as making sure you’re doing everything humanly possible to make sure that you don’t make any mistakes in that process.

And it’s okay to make a mistake and it’s okay to talk about it and just say, “You know what, I didn’t do this, but I’m committed to doing this,” or, “Maybe I haven’t been doing best practices,” or, “I haven’t been implementing,” I should say, “best practices.” And I think it’s important that we can just get back onto the horse, so to speak, and just say, “I’m committed to doing it because I’m committed to our patients and their families and their total outcomes.” Because as you know, having a hearing loss doesn’t just affect the individual, it really affects the whole family. So, let’s talk a little bit about following best practice should be the standard level of care. In reality, a lot of providers are not doing it. So, let’s talk about why do you think that is?

I have this conversation a lot and I’ve thought about it a lot. So, there’s a couple of different components. Number one is the time component. So, it takes a lot of time to follow best practices. When I tell people that over the course of a fitting sequence, I’m spending four and a quarter hours with a patient to make sure that we’re following comprehensive best practices. And that does not include the time that we spend doing diagnostic testing and things like that outside of those actual appointments. And then over the course of the rest of the first year, we’re seeing them for four additional hours of time to make sure that we educate them properly and follow best practices along the time frame. So the initial resistance, I would say, is time. I mean, a lot of clinics are not going to be willing to spend eight and a quarter hours, not even including the consultation with a patient during that window. And if you do, you have to charge more money for it because otherwise you’re not going to be keeping your doors open. Number two is the lack of understanding of what the best practices are, so not even knowing how to administer them as an audiologist. When you think about a lot of audiology programs, they teach you what best practices are and you end up going to the real world and going to clinic rotations and they’re not following best practices. So you don’t really know the real world implementation of how to do it as an audiologist. So, you’re going to do the things that you’re taught, and if you are not taught how to do best practices inside of a clinic, you’re not going to do it. There’s also this potential that you as an audiologist would go get and seek employment and you go to a clinic that does not have the equipment to follow best practices, even if you had the time to do it. And that’s a question of can you convince your owner to purchase the equipment that’s required to follow best practices like real ear measurement equipment or test box equipment and things of that nature? And then it really comes down to if providers choose to not make it mandatory to work for a clinic that has the ability to follow best practices. Essentially, what’s happening here is that they’re making a decision to support their own family and pay off their own student debt at the expense of their patients that they are signing up to be essentially the caretaker for when it comes to their hearing treatment. So, there’s a lot of reasons or excuses not to follow best practices, but if you end up as a provider taking a position or starting a clinic and you are not following best practices, you are basically saying that you are more important than the patients that you serve and I find that to be an ethical and moral dilemma.

Yeah, it’s so true. And so we talk a lot about being unbundled versus bundling, right? To me, I call it chair time. The chair time that the patients take if I do my job correctly, I’m going to save up in the long run, my chair time so that I can then better serve other people and other patients. So, if I do it right on the front, then the back end will end up having, in my opinion, we’ll have more referrals either from friends and family or even their physicians. And so how great is that? So cutting corridors over here, you’re going to gain it over there.

And that’s proven by research. Individuals who’ve had best practices followed verification, validation, all of the above. They end up coming in like initially. There’s more work that has to go into it. So, there’s more time that’s spent on the front end, just like you talked about. But long term, they are much happier and they require less follow up because there’s less issues that they’re having of trying to figure out, why am I not hearing good in this situation? Why am I still not hearing good in that situation? All of those situations can be solved early on in treatment. And then it’s just a maintenance that you need to keep them going through to identify, okay, has their hearing loss changed? Has their prescription changed? Do I need to make adjustments? Do we have to do care and maintenance and things like that? And there’s actually data out there that proves that following best practices will save the clinician time over the course of time because you have happier patients and that they are more willing to refer in friends and family to get treatment as well.

Yeah, it’s so true. We proved it. We follow it, we talk about it, we preach it. We have many students comment on, “Oh, that’s really great that you do follow,” so we have to teach our new students, our new professionals out there, that this is the level of care that they should be implementing down the road.

And they want it. Students coming out of graduate school want it. I talk with a ton of students. I give a ton of talks with Student Academy of Audiology chapters across the country. And every single one of those students has the intention of leaving school and working for a clinic that is going to be doing things in the right way. And when I say the right way, there is a right way, it’s by following best practices. And they are crushed when they go to clinics and they’re like, “Wait a second, we’re not going to do verification? How do I know if this patient is even getting the amount of sound that they need?” and they’re forced to trade their soul for a paycheck. And it’s horrible that they have to make that decision, but until we make it ubiquitous across clinics across the country, they are going to be put in these awkward positions because the students want to do it. It just happens to be a group of providers that have control over these clinics that are not allowing best practices to occur.

Yeah, and that’s a shame, but what do you think we should do? Well, to put it out there.

Yeah. So here’s the thing. Like I said earlier, I do not believe that I can convince professionals to follow best practices. People who are much smarter than me, who are much more influential than me inside of this profession that we happen to be a part of have not been successful at increasing the adoption rates of best practices inside of clinics. If you take a look at two of some of our more prominent individuals that are out there. So Dr. Doug Beck, if you take a look at Dr. Mike Valente, recently retired Dr. Mike Valente, I think it’s anywhere between like five and 30% of hearing care professionals actually follow best practices, which means the vast majority do not. And I think that the higher end of that spectrum, that 30% is overly inflated as well, if you ask my perception because we’re not talking comprehensive, we’re just talking real or measurements as a bare minimum for that. And so my belief is is that you have to demand it as a consumer. If you do not demand it as a consumer, the providers are not going to provide it in most cases.

Yeah, absolutely. And now with the OTC coming, I think that this is an opportunity for the consumer to really be educated about. Okay, now that I’ve got this OTC product, now what? Who’s going to verify? Who’s going to validate it? I’d like to invite everybody who gets it. Come on into our offices. Let’s do it. Because just like, because you get a car doesn’t mean, an expensive car, doesn’t mean that it’s just going to drive itself, maybe a Tesla, but it’s about the driver, right? I need to put you in control to be able to understand what it is that you’re driving because at the end of the day, it’s just a tool, whether it’s just for a mild hearing loss, a moderate or severe more traditional medical grade that you would want for yourself. So I need to teach, and I’m so glad that you’re doing this because I think it’s so important. It’s about education and it’s about making sure that you’re empowering the consumer to understand, what do I have and when is I good for me to move up to the next level?

So I’ve tested probably more over-the-counter hearing aids than anyone since I started my YouTube channel. And what I can tell you is that while they’re capable of amplifying sound and some of them doing it better than others, they are nowhere even in the stratosphere of what you can do with a prescriptive level device. Now, I’m not saying this to try to just right off the bat get people to skip over that step and just go get a prescriptive level hearing aid. I just want to make sure people understand that over-the-counter hearing aids are not identical almost in any way to a prescriptive level device and my ability to adjust them. So, over the past three years, I’ve had hundreds of patients come into my clinic with these direct to consumer devices that are now considered over the counter. And never have I ever had one of them that I could customize and adjust to match their hearing loss prescription, which means that they were leaving benefit on the table whether they liked it or not. And the only way for them to optimize their treatment outcome was to go with a prescriptive level device that essentially removes restrictions for me to customize it for them. And when you think about how difficult it can be to treat certain types of hearing loss with a prescriptive level device, to think that you’re going to try to solve that even at a mild to moderate level perceptually for patients, that’s going to be a very tall order. And I’ll finish by saying this about OTC. All of these DTC products, direct to consumer products that have been sold over the past couple of years, there is data out there that shows that two thirds of the individuals who think that direct to consumer or over-the-counter hearing aids are right for them turns out that they’re not right for them. So this turns into an educational thing like you’re talking about yourself, which is if you think they’re right for you, go test them out. But do not be shocked if they don’t work because there is a 66.6% chance that you try an OTC product and it’s not going to work for you and you’re going to have to go with the prescriptive route.

That is so true. Very true. So thank you, Dr. Cliff, for spending some time with us, really educating our listeners, and I look forward to doing this again.

Well, thank you. I appreciate it. And keep up the good work.

Thank you. Thank you.

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