Mike Metz, PhD

by Mike Metz, PhD

A friend of mine spoke often on ethical and legal behavior. He repeatedly said that if Audiology wished to be considered a true healthcare profession, its practitioners would not base their ethical decisions on some examples found in medicine (and some other professions). He has a right to make such a statement since he is a physician as well as an ethicist.

I am neither a physician nor an ethicist, but comments and comparisons about the ethics of audiologists seem quite apparent.


Obligations of the Profession


Over all is a concept that can be argued but not denied: being a member of a professional group, regardless of belonging to a professional organization, obligates that professional to adhere to the ethical positions of the group. If one walks, talks, and acts like a duck (or physician, or audiologist) one is automatically (as well as professionally and legally) included in that group.

Arguments that deny professional or ethical responsibilities due to non-membership in a professional group are generally not valid. Arguments that condone behavior because some members of another professional group function outside the ethical boundaries of their profession are only examples of questionable behavior and not models for, or representative of, that profession.


Professional and Public Sectors


When adherence to ethical standards reaches a point that the public (or politicians) take issue with what is observed, not only is the public trust threatened, but also a common result may involve legislation or other legal actions to “patch” this breached issue. An example involves the establishment of licensing laws to assure the public that aspects of the professional group are under control.

Generally, it is not good for the profession when someone in the public sector interferes with a professional standard since this typically occurs when the profession does not meet public expectations. The public moves to investigate and modify the behavior, as public judgment of high standards is essential to continued trust in that profession.

Professions that function in the professional arena and might provide examples of past or potential public/political action include the pharmaceutical field and healthcare insurance providers. While these industries are not entirely “professional”, they do depend upon the public trust for financial, political, as well as professional status. When they find themselves under public and/or political (governmental) scrutiny, it quickly becomes apparent that occupying the narrow area between professional and business is difficult. Their “slip-ups” generally cause reduced profits or loss of public trust. Sometimes, both result.


Public Confusion


Fields in the professional, public work arena must take a professional stance. Despite advertising statements of “professionalism”, retail fields elect a stance that does not require the public trust. Retailers of all sorts may define their efforts as “professional” but do not meet the definitions in any other than a retail—profit motivated, caveat emptor—manner. Almost everyone seems to understand this position—salespersons and customers alike.

For years, there has been considerable public confusion involving the functional differences between audiologists and device salespeople. Many audiologists have prospered making decisions only on the make, model, and settings of hearing aids and thus have defined themselves in the greater public arena as hearing aid sellers. Audiologists must appear to these consumers as retailers and not healthcare providers, despite graduate training in other areas. Most audiology graduates dispense instruments, as fees for audiology services do not support clinical efforts. It’s difficult to dispute the public observation and resulting confusion.


Ourselves Redefined


Audiology will continue to be defined by the actions of our majority, not by our best intentions, any designator, or by any obscure code of behavior. In a recent letter in Audiology Today (Sep/Oct, 2016), James Jerger opined that a return to clinical, therapeutic roots involving activities other than device fitting might be the salvation of audiology. It’s difficult to argue with Dr. Jerger.

The PCAST and PSAP issues may be a force for the rebuilding of audiology. Not in the sense of devices, but in remapping the necessity of investigations into the hearing sense, the explanations of ear disease, and demonstrable benefits of the help to patients that audiology might be capable of delivering.

Our issues are in the process of being resolved on multiple levels and at least one thing is regrettably true. If our profession fails to act like a healthcare entity, the public and political impressions will inevitably lead to a definition of audiology that will largely be outside the healthcare arena. The re-establishing of the practice of audiology in all aspects, including the fitting of devices, could lead to a sustainable, beneficial, and profitable future. Good or bad, the coming ethical position of audiology will likely be different than in the past.


Mike Metz, PhD, has been a practicing audiologist for over 45 years, having taught in several university settings and, in partnership with Bob Sandlin, providing continuing education for audiology and dispensing in California for over 3 decades. Mike owned and operated a private practice in Southern California for over 30 years. He has been professionally active in such areas as electric response testing, hearing conservation, hearing aid dispensing, and legal/ethical issues. He continues to practice in a limited manner in Irvine, California.

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Barbara Weinstein PhD

by Barbara E. Weinstein, Ph.D.

Today’s post is an opinion piece contributed by Dr. Weinstein, who usually writes “Downstream Consequences” at Hearing Economics.

I recently completed an excellent piece in the New Yorker titled “The Heroism of Incremental Medicine,” by Atul Gawande a noted surgeon and author. It was inspirational and timely, leading me to conclude how audiologists should consider pivoting so the profession can continue to thrive and survive.


Why Pivot Now? 


We must pivot now because the increasing number of persons with hearing loss require our expertise.  A chronic condition, the effects of which develop over time, hearing loss management requires a partnership between the professional and the person with the condition. The recent findings of Kiely et al. (2016) underscore that hearing loss is long-lasting and persistent; a condition with which people must learn to live:

  • Adults 65 years of age and older will likely live more than half of their remaining years with at least mild hearing loss.
  • Adults over 75 years of age can expect to live more than half of their remaining life with moderate levels of hearing impairment.

We must pivot now because the new models of hearing aid delivery, which include self-contained, self-fitting hearing aid (SFHA) and over the counter (OTC) hearing aids, remove audiology from the hearing health care equation. Proponents of self-fitting hearing aids and OTC hearing aids argue that accessibility, and affordability of hearing health care will be realized with these innovations.

In reality, the potential benefits of internet based delivery of hearing aids namely, lower cost, convenience or physical accessibility, may not outweigh the value added from working with a trusted and experienced hearing health care professional who will maximize skills essential to self management of hearing loss and its ramifications (Chandra & Searchfield, 2016).


How to Pivot – Shift the Focus 


We must reach people with hearing loss earlier, perhaps at the juncture between the preclinical and clinical phase, when symptoms first begin to appear and before the progression and onset of the devastating consequences of untreated hearing loss.  By adopting an incremental approach to hearing loss, we could help persons with mild or moderate hearing loss benefit from earlier uptake of a tailored situation specific hearing health care intervention/solution when cognitive resources and functional abilities are optimal (Kiely et al, 2016).  

Consider the principles underlying incremental medicine as described by Gawande, namely that the relationships and trust that are built through the provision of incremental care or the commitment to seeing people over time, makes all of the difference in the lives of persons with chronic conditions.  Incrementalists, according to Gawande, produce value by improving the lives of the people they treat over extended periods of time; great value is placed on care that takes time to pay off. At the heart of incremental medicine are the four kinds of information, listed in Table 1, which matter to health and well-being of persons with hearing loss.


Table 1. Four Factors that Matter When it Comes to Hearing Health and Well-Being (Modified from Gawande, 2017)

  • The state of one’s internal systems (audiologic test results)
  • The state of one’s living conditions (housing, community, economic, environmental circumstances-public health approach)
  • The state of the care one receives (what the hearing health care professional has done, treatments provided)
  • The state of one’s behavior and that of family members (e.g. stress levels, adherence to treatments)


Focus on our Long Game 


Familiarity and trust built over time, incrementalists argue, influence willingness to seek out medical attention when there is a change in one’s health that is impacting quality of life. Gawande points out that to make a difference, health professionals must understand what is normal for their patients and identify barriers to change for individuals (i.e. what is getting in the way of taking the steps that will reduce stress and improve quality of life)?

Figure 1.  Technology adoption cycle. (Wikipedia)

According to the diffusion of innovations theory as described by Rogers (2003), long term relations with our patients will help us learn about and influence their propensity to adopt a specific innovation which will be driven by social influences as much as our expertise.  In fact, the technology adoption cycle (Fig 1), a sociological model that describes acceptance of a new product, holds that the decision to adopt an innovation takes place over time in five stages which conform to the normal bell shaped curve.

We should be present at the first stage to help influence the rate of adoption of a targeted intervention and we must recognize that a powerful influence on the decision to adopt is peer pressure and how widespread or accepted actions are by others (Rogers, 1962). Once eyeglasses became a fashion statement, an entire industry blossomed.


Let’s Do This!


So how can we reach the 80% (i.e. persons with mild to moderate hearing loss) so that we are the professional to whom persons with hearing loss can turn when the need arises?  To begin,

  • We must accept that along with other health professionals we are poorly prepared to deal with hearing loss as the chronic condition it is. We must be viewed as the main source of care for people with hearing loss be it children, adolescents, adults or older adults. It is the relationship and familiarity with what we do as professionals which can turn the tide. 
  • We must work hard to erase the stigma of an audiologist as being a hearing aid sales person, much like someone who sells cars.  We should work to become the go-to professional to help persons self manage hearing loss when environmental and social barriers preclude participation in daily activities, impact job performance, enjoyment of concerts, etc.

Let’s begin to customize our care to match patients needs and behaviors.

Let’s lower the entry cost, guarantee performance in challenging situations.

Let’s inspire persons with milder hearing loss to turn to hearing care experts to expose them to the latest innovations, as knowledge is power and we should be the go to resource.

Let’s take a vow to focus on a person’s hearing health over time, customize our care to match the needs and behaviors of the persons with whom we work.


Pivot To the 80%


There are many explanations for failed diffusion, but I would argue that in hearing health care, low adoption rates of hearing health care interventions are attributable to our failure to be incrementalists, to bring people in to our offices early, to start small and slowly. We have little to lose– and the 80% have much to gain–if we pivot now.




Chandra, N. & Searchfield, G. (2016). Perceptions Toward Internet-Based Delivery of  Hearing Aids among Older Hearing-Impaired AdultsJournal of the American Academy of Audiology. 27:441-457.

Gawande, A. (2017). The Heroism of Incremental Care. The New Yorker. Jan. 23. Accessed online 30 January 2017 at http://www.newyorker.com/magazine/2017/01/23/theheroism-of-incremental-care.html.

Kiely, K., Mitchell, P., Gopinath, B., et al., (2016). Estimating the Years Lived With and Without Age-Related Sensory Impairment. J Gerontol A Biol Sci Med Sci. 71: 637–642.

Rogers, E. (2003). Diffusion of Innovations, Fifth Edition. New York: Free Press.

Rogers, E. (1962). Diffusion of Innovations, Glencoe:  Free Press.


Barbara E. Weinstein, Ph.D. earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly.  Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.

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