Best practices and ethical guidelines in audiology support the use of real ear probe measurements.{{1}}[[1]]Much of this post was contributed by my colleague Jennifer T. Lamfers, AuD[[1]] But, how many practitioners use it in their practices? Some conduct real ear measures on every patient, using the measures to adjust hearing aids to reach target gain to ensure audibility. Dispensing audiologists are well educated, many with clinical doctorates, yet only approximately 40% use real ear technology to measure and demonstrate aided benefit to their patients. If the technology is good enough to make it into the guidelines, why is utilization among knowledgeable professionals so low?
Two common responses to that question are equipment cost and time required to perform the procedure. No doubt, the equipment is expensive and the procedure is usually bundled into the cost of the hearing aids so it does not generate revenue. And real ear does take time. 
Time and money are compelling arguments, but there are other arguments for the importance of real ear measures in the fitting process. Real ear measurement is considered especially vital in pediatric fittings by many audiologists. Best practices recommend a simulated version of real ear, which quickly measures the resonance of a child’s ear and uses that information to fit the child’s hearing aids to target gain. This approach is preferred in pediatrics because it is quick and allows adjustments without the cooperation of the child.
Reimbursement provides another argument for incorporating real ear measurements into daily practice. Such measures may help with third party payments by providing an objective validation of hearing aid fittings.
Yet another reason–and one of the main reasons I use real ear –is that is provides face validity to the patient and spouse, or other family and friends that participate in the fitting process. Real ear can help patients and others learn about the fitting processing by enabling them to see the overall correction of hearing on a computer screen, as well as the effect of hearing aid adjustments on the real ear measures. It is also useful in our practice when working with RIC hearing aids and different types of ear tips.
Starting next week, Scot Frink, MS will become co-editor of Hearing in Private Practice. He has contributed other posts to Hearing Health Matters. We are excited to have more to share and welcome Scot to this page!
Oh, I’m gonna just jump right in because I can’t wait and you have such a good topic here, Judy.
For me, the are so many compelling reasons to do real ear testing that a hearing professional who doesn’t do it owes a refund to the patient. Those who argue against mail order or online sales of hearing aids since the hearing aids “are not professionally fit” better be doing real ear themselves since to do otherwise would be the worse–in my opinion–than these alternative providers. At least the mail order companies are usually charging a price closer to what they deserve when they don’t do real ear.
While manufacturer software can be good, it’s not great, and definitely not perfect. If it was, they wouldn’t need us and would sell directly to the consumer out of the box. But to rely solely on the manufacturer software to “get it right” is still guesswork if you don’t actually know what’s going on in the ear canal, and there is no way to be sure without real ear. What is on your computer screen from the manufacturer is not always what’s going on in the ear itself. It’s just a promise.
Regarding the other arguments against real ear:
1. “Equipment costs too much”–not anymore. It continues to drop, and there is now some relatively inexpensive (<$3k) equipment.
2. "Time is money"–it takes maybe 5 minutes per ear. The amount of time you save by more accurately fitting the patient should save you more money than the 5-10 minutes it takes to complete the real ear test.
3. "I don't have enough space"–the aforementioned $3k equipment is USB-based and can fit in any drawer. Just plug it into your PC or laptop and you're ready to go. My goal is not only for every patient to have real ear done, but at this cost it is realistic for each practitioner in my office (all seven!) to have their own so that they don't have to share. We have three so far, and the fourth is on order.
Regarding Judy's agurments for real ear (ALL VALID!):
1. Seeing is believing. Show it to your patient. Better yet, prove it to yourself.
2. Reimbursement IS possible. I believe V5020 is the proper code for it. Whether the insurance company actually pays depends.
In Oregon, we instituted mandatory verification measures in 2006: the patient must have objective verification completed by the audiologist or dispenser within the first 30 days (real ear testing or aided sound field discrimination and puretones).
Then again, you can pass a law, but whether people follow it is another question. To me, it just makes good business sense. And cents.
Very good info! Thank you Scot. Do you know some of the companies that have the <$3K small equipment?
Sorry for the delayed reply; I’m still getting used to blogging. We actually have been using the equipment for over a year with excellent results. We have three units so far, and I’ve ordered a 4th. We have a total of 7 practitioners (6 audiologists and one dispenser; 2nd dispenser in training), so my long-term goal is for each person to have their own. At these prices, it’s not hard to do.
Also worth mentioning is that there are some specific tax incentives for both equipment acquisition and credits for equipment that help with the Americans with Disabilities Act compliance for your office, in effect bringing the cost down even more. Every business owner should take as much advantage of these programs as possible–better to reinvest the money back into the business than to give it to Uncle Sam.
Is it OK to mention specific manufacturers and products here? If so, I’d be happy to share. I think the pricing may vary a bit, but it is below $3k for sure.
If you had several you looked at you can mention, but you can always mention what works for you. People can make their own plans on what works for each of them. I do find it is sometimes hard to start the search for new technology when you are not exactly sure what you are looking for. Thank you Scot for helping us start our search.
Until I had read this I didn’t know that only forty percent of audiologists use real ear measurement. In my opinion, those that do show that they care more about their patients than themselves, which I think shows they’re trustworthy. I’ll have to look more into real ear measurements.