Even though it is a work of fiction, Fredrik Backman, in his recent book Beartown (Artria Books, New York, NY, 2016), considers an interesting concept.

There are few words that are harder to explain than “loyalty.”  It’s always regarded as a positive characteristic, because a lot of people would say that many of the best things people do for each other occur because of loyalty. The only problem is that many of the very worse things we do to each other occur because of precisely the same thing.

It should come as no surprise that there are nuggets of wisdom in many places.  All one has to do is be open to their discovery.  This one got me thinking about loyalty in audiology, or in medicine for that matter, although I am not qualified to speak to the medical aspects.  You can do that for yourselves if you dare.

There would appear to be certain considerations in audiology that are related to the ideas of loyalty.  The first, and most likely the one that occurred to you, is the loyalty of your patients.  I know that many clinicians wish that patients remain loyal to the clinician or clinic, but I am not sure why they think they deserve that loyalty.  There are probably many rationales (read: excuses) that they could offer, but those might just fall under the “problem” category that Backman notes above.  Just because a patient is served by any clinic or clinician does not assure that they will promote, speak well of, or return to that clinician or clinic in the future, even though that’s what many may ask and expect, but often do little to deserve. 

When I was in clinical practice, several manufacturers hoping that they could assure my loyalty for purchases of their products approached me.  Many times I could have sold my continued business for their reduced prices.  I don’t think that I jeopardized my clinical standards when I considered these offers, but it may have undermined the concept of my loyalty if my patients had known what I was considering. After all, loyalty should run in at least two directions. 

I had some patients who stayed with me through the years and some who searched for services elsewhere.  I didn’t think to ask why they stayed or left. I probably should have.

I suspect that every patient who enters the office of any “medical services” supplier expects to receive timely, state-of-the-art, complete services, at a reasonable price.  Having received such treatment, one would seem to have a better chance of earning patient loyalty than if the patient received less.  As a patient, I think I would have little inclination for loyalty if I had received a cursory evaluation and pure tone test, followed by a sales pitch. Perhaps patients should make some demands from those to whom they will be loyal. When they don’t, the concept seems to lose some its value. Value is also lost if “loyalty” is defined by only one of the participants, as might be evident in a recent trade-journal advertisement for patient financing services. Could one ask for much loyalty on the part of the lending institution?

If I were a hearing-impaired person seeking help for my hearing problem, I would have done a little research into methods, devices, and services.  I would probably show up in an office with a pretty good idea of what’s what. So, I would expect to be evaluated in a manner that generated an understanding of my problems (data based), and offered various, validated methods of lessening my difficulties.  I would expect to be able to find or be informed of the “real information” needed to make a good decision. 

I would likely be skeptical of claims of a “big sales event”, a “study” needing a certain small number of participants, a brand-new technology that promises to fix my hearing problems in a way no other can, and claims of the wonderful successes of other users. 

I would grant my loyalty to any clinician who tested me thoroughly, explained the problems I experience with clearly presented data, and then outlined a process for helping me with my loss. I would hope that the addition of “extras” or options for any device or service would be justified in terms of cost and benefits.

All this delivered, then that clinician has a shot of obtaining my loyalty to that practice, my referrals of my friends, and my return in later years.

By way of disclaimers:

  1. There are clinics and clinicians who practice in this manner. They are quite successful.
  2. I can’t hear as well as I was once able. My audiologist practices in this manner. My loyalty to that practice has been earned.
  3. I am not an overly demanding patient.

The New York Times runs an occasional column called “Smarter Living”.  Some of the information you could come across there, should you read it, involves things like “forgiving yourself” by writing yourself a letter, or explaining why people who save or give themselves time are often more satisfied than people who just buy things in order to become “satisfied”.[1]

And, since I tend to relate most things to audiology, including the NY Times, these suggestions reminded me that my son has a philosophy that you might find as helpful as that advice from Tim Herrera.  I don’t know where my son came across this approach to things, but I am pretty sure it wasn’t from me.  It has to do with negative thinking.  It goes something like this: 

First, ask yourself if you can change what you don’t like or what it is that worries you. 

Second, if you can’t change it, decide if you should continue to worry about it. 

Finally, if you can change what bothers you, decide if it is worth changing. (This is probably a cost-benefit thing, and I hope that he might have learned a little bit of this from me.)

I wish I had come across this way of managing bothersome things a little earlier in my life. It could have helped in a couple of situations that caused me grief. It could have helped me deal with a few patients whom I remember with cringes (I couldn’t change them).  It definitely could have made my business life easier when it came to dealing with many issues that constituted a business day (I could have changed many of those issues). I would have minimized a lot of my stress.

For example, when considering the purchase of new equipment, isn’t it easier to justify the purchase when one forgets about the price and instead focuses on the expectation of return on the investment? 


If this equipment generates more information about the patient’s hearing loss, can be justified with clinical data?  If so, it’s of value to the patient. Are the odds good that it can pay for itself? Isn’t that enough?  Isn’t that what professionalism requires?


Gus Mueller had a recent AudiologyOnline course that talked about the necessity of doing real ear measures on every patient and every amplified ear.[2]  A additional issue worth considering here, beyond that of every one should do real ear measures, is that if you must do these tests—you cannot alter the “best practices” protocols and eliminate them—wouldn’t you be better off ceasing to worry, accepting the challenge, buying the best equipment possible, and getting on with it?  Figure out how to work it into your billing structure. An audiologist or clinic is allowed to charge for clinical services—and to bill third parties for these services. If the third party refuses or denies payment, and assuming that you operate the business in accordance with up-to date billing procedures, it’s OK to bill the patient. If there is value in this procedure, the front office task is to figure out how to bill and get paid.  The benefit to the patient will be obvious to you and the patient—read Gus’s paper if you don’t believe this.


In the long run, the increased, documentable, patient success should be sufficient to elicit things like, oh, say, patient referrals from impressed physicians, a better reputation in your clinical neighborhood, to say nothing of the potential good outcome reports to third party payers.  (This last may require a little nudging on your part.)  You will win when the patient wins first.


Consider another situation.  You don’t like the idea of PSAPs, DIY or OTC hearing instruments.  This is worrying you.  Your protests against these devices did not prevent the acceptance by the government, the patients, the industry, and so forth.

You are finally coming to the conclusion that there is little you, your colleagues, your associations, or your profession in general can do about this change. Maybe you should stop worrying at this point.  Or, you could keep battling, and….

Perhaps you can figure out what separates you from all the other businesses that sell amplifying devices.  Are you better trained?  Do you have more data?  Can you determine better, well-documented methods for treatment? Can you be more successful in your care?  Can you make these new things “positive”?

And, finally, you get to decide if this change is worth it.  I will thank my son on your behalf.



[1] Herrera, Tim, Smarter Living, New York Times Online, Nov. 27, 2017.

[2] Mueller, H.G., 20Q: Hearing Aid Verification – Can You Afford Not To? Accessed on line at AudiologyOnline.com, Nov. 20, 2017.