Audiologists: Don’t Shoot the PCAST Messenger

Michael Metz, PhD

Editor’s note:  As public policy recommendations continue to fan the flames of hearing healthcare disruption, stakeholders of all persuasions enter the fray and take positions.  In today’s post, Michael Metz, PhD (a self-confessed contrarian) suggests that hearing healthcare providers should look to errors and excesses of our profession when assigning blame, rather than shooting the PCAST messenger.

Readers can look forward to more from Dr. Metz in January, when he commences a monthly Contrarian Column  in HHTM’s Hearing Views section.

First Take on the PCAST Recommendations

As a general “jump-off” point, and were I a consumer (I am), I would agree and appreciate the recommendations that they put forth in the PCAST report.  If it is true that some people do not get a copy of their audiogram following any type of hearing test, I would be dismayed.  Even if an audiogram is not very good, due to haste, equipment restraints, poor patient cooperation,  or so many other factors, perhaps allowing someone else to go over it might increase the likelihood that audiogram would improve.  It never hurts to have someone critique one’s work.

If it is true that some people get hearing aids from a company that effectively “locks out” others from viewing the parameters of the amplifier, that seems to me to be similar to offering a patient a “secret” medication that could not be evaluated by another clinician.  I am told that such situations do exist and I can only conclude that those who construct such a situation or allow for such a lack of transparency are really not in a clinical business at all.

A committee that did not find problems in the hearing health industry would likely be thought as incompetent or ill informed.  Such problems that are mentioned in the filmed report summary — lack of transparency, high cost, regulations that are no longer practical, waivers signed by the majority of patients/consumers, lack of “red flag” management, and so on — do little to encourage the continuation of our hearing health care system as it presently exists.

One “dog being kicked” in this discussion is likely the distaste of audiologists in private practice who would like to see the current system remain untouched.  While most of us dislike disruptive innovation in our field, perhaps the one thing most likely to occur in almost any field is the disruption that occurs with progress.

Betrayed by Our History

Having set this stage, we would then ask why PCAST did not pay anymore attention to audiologists in arriving at the decision to make the recommendations that they did.  That is, why didn’t they pay more attention to the needs of audiologists when considering hearing health?  Why did they ignore our contribution to the therapeutic needs of most patients with hearing loss?  Why don’t they believe us when we tell them that we are in the best position to find, assess, and treat sensory hearing loss?

How can smart people like Dr. Christine Cassel and PCAST ever arrive at the position she and her committee have taken?  A cursory look at the past few years might give some clues.

1. Most all of the “audiology” trade journal articles, information, promotion, and the like, have involved the “new technology” of hearing instruments—how all these new technologies would help the patient in various listening situations. Very little information in trade journals has been directed towards anything else.  This is the task of trade journals.  It is the task of refereed journals in particular and the field in general to verify, disprove, criticize or otherwise evaluate these claims.  Claims should not be adopted by clinicians on the basis of trade journal ads alone.
2. Much of the literature in the refereed journals has been concerned with cochlear implants, investigations into the cellular, chemical and/or biological function of the auditory system. Relatively little has been published suggesting new methods of assessing the hearing function, treating the hearing system, or the clinical necessity of appropriate intervention. Yes, there have been some good clinical tools developed for the purposes of assessing hearing aid use and generally they hit a wall when it comes to application in many audiology practices where they are not incorporated into clinical use.  One may argue that reimbursement is difficult and that money is the final deciding factor in adopting.   Payment is certainly an important consideration, but it’s not difficult to see how an outsider would conclude that technology, and not clinical services, is the driver for audiologic care.
3. Our literature further suggests that many audiologists as well as non-audiologist dispensers do not use standard practices to apply the technologies to their patients. As an example, perhaps some articles do make the point that while probe measurements for hearing aid fittings are increasing, the use of these measures was less than common in the past and, despite their being recommended as “standard”, they are still not employed universally at present.
4. Device manufacturers have heavily dominated almost all of the “audiology events”. Conventions, continuing education, regional meetings, etc. have essentially been showcases for device technology.  I recall escorting an invited person to a past AAA “AudiologyNOW” meeting and him being so impressed with the commercial displays and involvement that one of his most cogent comments involved his hope that the federal government did not see this meeting as a conflict of interest for our entire field.  Casual observation of any PCAST member of past meetings may have easily lead to the same conclusion.
5. A cursory examination of the employment of audiologists would suggest that they are primarily involved in the fitting and sale of hearing devices. A deeper look into our field might show that the VA, Big Box stores, ENT offices as well as independent audiology practices spend the majority of their time selling devices and very little time in other activity.  This impression is further supported by most of the data in MarkeTrak.  PCAST might have read these figures too.
6. A long look at industry figures from the past show that, despite all factors, the use of hearing aids is relatively stable when compared to the number of people with hearing loss. Wouldn’t that imply that neither technology nor what little therapy is used has much effect?
7. A glance at the industry of selling hearing aids would probably leave the observer with a conclusion that there is little difference between and audiologist and a hearing aid salesperson. As a field, we constantly find ourselves in a position trying to explain and justify these differences—to patients, to insurers, and to PCAST.  I suspect that our justifications in the past do not hold up well when viewed by the public, including Dr. Cassel.

Painted into a Corner

Dr. Christine Cassel and PCAST arrive at conclusions that we do not like.  As a user of hearing instruments, I can testify that the fitting of the devices and the audiologist doing the work make a huge difference in success, at least when it comes to the audiologists I know who use these things.  Some of us patients need more assessment and help than others.  I also believe that with a little ingenuity, our field could come up with some clinical factors that would indicate when and how much assessment and/or therapy is needed with any patient.  Some of these measures already exist.  I suspect that the majority of audiologists, even if they are aware of their existence, are not utilizing them.

A third year AuD student once challenged me for being negative towards Audiology.  She did this because I criticized the dependence of our field on the selling of hearing devices.  I have been an audiologist for almost 50 years.  You can call me old fashioned, but I think my field has strayed from the path we first took.  We seem to be more concerned with sales figures than with accurate, definitive assessment and realistic, effective clinical intervention.  Had the PCAST report been available at that time, I could have used it as a reference for my position.

I think we can assume that Dr. Christine Cassel and PCAST members are probably pretty astute.  They may not have listened to many audiologists who would advocate audiology’s position other than they did, but if they looked closely at our past, it should come as no surprise that they concluded as they did.  Our history betrayed us.  Our lack of paying attention to the details of clinical assessment and rehabilitation has painted us into the corner where we now find ourselves.  It would seem to me that we have no choice but to accept the situation as it is and work from this point forward.

Dr. Metz 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.

feature image courtesy of black enterprise