You start with a cage containing four monkeys, and inside the cage you hang a banana on a string, and then you place a set of stairs under the banana.

Before long, a monkey will go to the stairs and climb toward the banana. You then spray ALL the monkeys with cold water.  After a while, another monkey makes an attempt. As soon as he touches the stairs, you spray ALL the monkeys with cold water. 

Pretty soon, when another monkey tries to climb the stairs, the other monkeys will try to prevent it. 

Now, put away the cold water. Remove one monkey from the cage and replace it with a new monkey. The new monkey sees the banana and attempts to climb the stairs. ALL of the other monkeys beat on him.  After another attempt and attack, he seems to know that if he tries to climb the stairs he will be assaulted. 

Next, remove another of the original four monkeys, replacing it with a new monkey. The newcomer goes to the stairs and is attacked. The previous newcomer takes part in the punishment – with enthusiasm – because he is now part of the “team.” 

Then, replace a third original monkey with a new monkey, followed by the fourth. Every time the newest monkey takes to the stairs, he is attacked. 

Now, the monkeys that are beating him up have no idea why they were not permitted to climb the stairs. 

Neither do they know why they are participating in the beating of the newest monkey. Having replaced all of the original monkeys, none of the remaining monkeys will have ever been sprayed with cold water. 

Nevertheless, not one of the monkeys will try to climb the stairway for the Banana. 

Why, you ask? Because in their minds, that is the way it has always been! (see at Disgruntled Millennial on Facebook)

 

I’ll bet you’re wondering, “What the heck does this story have to do with Audiology?” 

Since I have some space left and you may still be reading, let’s start with why significant innovation is almost always disruptive.  I dislike the term “herd mentality”, but it seems appropriate in light of many examples.  People act like they do in many situations because others act that way too.  Whenever a new approach pops up, they get agitated because “that’s not the way to do it”, or “that’s not how I was trained”.  They react accordingly.

This barrier to abrupt change happens often in politics—recent events and observations support that conclusion.  It certainly happens in medicine and healthcare.  In support, I recommend Elisabeth Rosenthal’s book An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, Penguin Press, New York, 2017.  And it surely is also happening in audiology, as evidenced by the thoughts and opinions of many regarding the FTC and over-the-counter hearing devices.

For years, the hearing aid industry has attempted to get more people aware of and interested in hearing aids.  They (we) reach fewer than 25% of hearing impaired people who would likely benefit from hearings aids.  For years, we couldn’t get better “penetration”, to use a peculiar concept that would seem to imply that our industry is “dull”.  And, for those many years, we did not change our approaches all that much.

Now, along come the Feds and their data-driven ideas, testimony from “outside” organizations, regulations, and maybe even laws, which they propose would allow for more people to get device help for their impaired hearing.  And, many audiologists and dispensers don’t like that.

What’s the matter?  Can’t audiology and dispensers justify their position in health care?  Are we afraid of what might happen?  After all, we put ourselves in this position.  Don’t audiologists have anything to offer in this proposed new scenario?  Or will we respond by shouting “it’s not like it always has been”?

Dr. Rosenthal’s mission, stated in her epilogue, should be echoed in the goals of every health care provider, including audiologists: “…to advocate for a return to a system of affordable, evidence-based, patient-centered care.” 

I hope that you will consider reading Rosenthal’s book.  I hope you will take some lessons from it.  I think these might top the list:

  1. Understand who has “skin in the game”.
  2. Be prepared to change.
  3. Follow the data/facts.
  4. Realize that all of us might have been “sprayed”.

feature image from monkey worlds

It would have been unrealistic for most audiologists to have attended or listened to the entire FTC hearing on April 18th involving over-the-counter and self-fit hearing devices.  Without attendance, many might be left with incomplete summaries or biased opinions.  You should spend some time watching the day’s activities. 

If you can’t watch, here are some biased thoughts on what I observed. (The four-part discussions are available at ftc.gov. Scroll to 2017 workshops and hearing aids.)

 

A Push for Information

 

The first part of the meeting—Now Hear This: Competition, Innovation, and Consumer Protection Issues in Hearing Health Care—aside from the audiological explanation of acquired hearing loss—essentially involved a 5-member panel discussing the questions posed by two members of the FTC committee assigned to hold this public hearing.  Subsequent panels met to discuss additional aspects of amplifying devices.  All were interesting but not particularly informing.

A number of cogent issues were brought up, but the one that seemed always in the background and of most concern was that of “making the public empowered”, giving people transparency, access, and (implicitly) letting hearing impaired people get information and make their own decisions. 

And, I think that’s a problem.

 

More Information Doesn’t Equal Sufficient Information

 

Let’s suppose that a person has a persistent pain in their abdomen plus a little trouble hearing.  They look on the web and find several causes of both these ailments.  Much of their meanderings through the websites—both generic and otherwise—would lead them to conclude that the problems with their ears and their tummies are caused by “nerve” loss in the ear and indigestion in the gut.  From all this information, it would seem that many might think about trying “hearing aids” and buying some antacid—both from the same drug store.  Are these consumers empowered?

Part of the problem in healthcare today is that a Google search is no substitute for a healthcare degree.  “Sufficient information” involves more data than can be easily obtained through discussion in a chat room.  Empowering patients means that patients have sufficient correct information to arrive at an appropriate decision about their care.  And, how does an impatient, “get ‘er done”-type consumer know when s/he has sufficient information?

Using the GI example, some good tests—available through a physician and a lab—will provide the necessary data for the patient to make an informed decision.  Same for hearing loss—some good tests are necessary.  NOT tests done for the purpose of selling a hearing aid, but rather tests done to determine the nature, cause, clinical degree, and true impact of the hearing loss.  These clinical tests are billable (and reimbursable) by almost all clinical providers (emphasis on clinical).

 

Enlightening to Empower

 

If clinical audiologists promoted this direction for all hearing loss patients—primarily offering complete, comprehensive information about options after that patient’s clinical visit—how far would this go to giving the patient sufficient information to proceed in an enlightened manner?  You are probably saying “we tried that” and it was not too successful.  Yet, that’s what seemed to be a common request of the consumers on the FTC committees—albeit not in those exact words. Perhaps we didn’t try hard enough or long enough to succeed in this “empowering” process.

Most of the panelists provided very little factual information, the exceptions being the authoritative persons from Consumers Union and the reps from professional organizations.  The likely reason is that there is very little objective, easily available information out there about hearing health care that’s not biased.   To wit:

  • Hearing impaired consumers—85% of whom don’t use hearing devices—don’t use them for lots of reasons. (Consumers Union data—clinicians typically don’t discuss failure rates.)
  • A great number of people who purchased hearing aids return to the office about two times. (Consumers Union data) What does this say about the broadly held argument for the necessity of down-stream return care? 
  • Manufacturer’s advertising may be misleading. (Really?  Need someone explain that advertising is not meant to be educational?)
  • ADA and HIA have info on their websites. So does Consumer Union. Which do you suppose is of more value to the consumer?  Does this reflect positively on our field?

An important take-away from the consumer hearings seems to be that patients want to be more in charge of their hearing health care and there is very little credible information offering the needed data to empower patients.  It would seem that at least one path for audiology is obvious:  more clinical data on each patient might likely prove quite helpful.  Information of an unbiased (non-sales) nature, and a pathway to that information, should be gratefully received. 

So, at least one good suggestion has already come from the OTC/DIY/PSAP controversy. Consider what such an empowerment approach to future hearing care might provide as an avenue for the coming shake-up.

 

feature image from servants aid