Our future: Will it be Hearing Spaghetti or Audiology Armageddon?

Hearing Health & Technology Matters
April 11, 2012

This week, I am pleased to present a Hearing View by Christine Diles, AuD. It is a revised version of a post that was originally published March 20 on the Hearing Economics blog at Hearinghealthmatters.org.

David H. Kirkwood, Editor, Hearing Views


By Christine Diles

Christine Diles, AuD

About 20 years ago, Lars Kolind, then CEO of Oticon, transformed the Danish-based hearing aid company by designing and implementing the so-called Spaghetti Organization, one of the first knowledge-based, virtually paperless business structures. Kolind used the spaghetti moniker because the multiple roles each individual played were intertwined with all their colleagues’ roles. He also observed that the design of his organization shared another characteristic with spaghetti: “You cannot describe how spaghetti hangs together, but somehow it does.”

This analogy reminded me of the dynamics of the two different, yet closely related channels of hearing aid distribution: audiologists and hearing aid dispensers.

For 20 years, we have been experiencing a consolidation of hearing aid manufacturers. Audiology and the dispensing of hearing aids have taken many of us from a clinic-based model to more of a retail model. We have manufacturers owning retail distribution both on the surface and underground. We also have Internet retailers, chains, franchises, insurance companies, and “big box” competitors.



What does this all mean for an independent audiologist or hearing aid dispenser? Is there still a place for the “little guy”? How can a bricks and mortar business with rent and employees who need health insurance compete with the big boys or the “drop ship” online retailers? How can independents compete with the deep-pocketed, consolidated outfits and their big marketing budgets? The big guys pour a lot of money and effort into making themselves known to our patients.

Before we audiologists get up on our high horses, let’s remind ourselves that those same large players employ a lot of audiologists. The decades-old Hatfield and McCoy spat between audiologists and hearing aid dispensers is not serving us well in my humble “Doctor of Audiology” opinion. Sometimes I want to stand up and say, “My name is Chris and I am a hearing aid dispenser with an advanced degree.”

Here’s a true story: An audiologist friend attended training while considering a position with one of the hearing aid dispensing chains. The trainer was a former plumber turned hearing aid dispenser. Our friend called us and asked, “Who can we sue for these audiology degrees we got?” No joke. No disrespect meant here; plumbing is honest work when it’s honestly done, as is hearing aid dispensing. Neither can be done well without training and apprenticeship, and, thankfully, consumers are protected by state licensure.

Good hearing aid dispensers know how to do the basic testing and when to refer. If they were comfortable referring to us when it was indicated, instead of wondering whether we are going to criticize their expertise, those patients would be better served.



Hearing aid dispensing is the economic backbone of the profession of audiology and of hearing aid dispensers. It’s how we all make a decent living. If you can’t make a decent living, well you don’t qualify, or at least you won’t last, as a profession. Diagnostic procedures, in most cases, do not pay a clinic’s bills.

Fitting hearing aids is not easy, but not for the reasons we like to claim, in my opinion. Dealing with people who often see the solution that you offer as worse than the problem they have is, frankly, exhausting. Doing this successfully requires more than advanced technology and intensive training and experience. It takes a love of the work and a dedication to those who depend upon us. They can’t teach that in AuD school! Add business ownership to this and we have a heavy lift indeed.

Independent, business-owning audiologists are working very hard at what the originators of the AuD movement preached. Let’s own this profession and not become technicians. Hearing aids, again, are the way to autonomy and prosperity. But, hearing aid dispensers were here before us, and you can’t take someone’s right to work away. That is the opposite of a free market and a free country. I say let the market decide.

All the major hearing aid companies have developed wonderful devices that are not that hard to fit if you do your homework. The hard part is that elusive human factor and making sure that Mr. or Mrs. Jones is hearing well and satisfied with the value–not just the price.

Custom-fitted hearing aids are a high-ticket item. Like homes, cars, dental work, and cruises, hearing aids require that people part with a lot of their money. But where else are people asked to spend thousands of dollars to mitigate a scenario that they don’t perceive as that bad for a solution that really only partially solves the problem? Do we really think that a better hearing test or fitting protocol that takes 8 years of school to learn is the answer? Spending resources to create a division from our trained and licensed colleagues in the trenches just doesn’t seem like resources well spent to me.



Can autonomous providers of hearing care services survive, much less thrive with the changes that are taking place? What are our options?

  1. We can enter into supply agreements with manufacturers that create product choice restrictions in order to expand, send our kids to college, or just pay our bills.
  2. We can sell and work for “the man”; let him worry about the rent, taxes, employees and their health benefits (these business arrangements with suppliers are referred to as “submarines.”)
  3. We can join a franchise or chain and put ourselves into their look ‘n’ feel, cookie-cutter processes.
  4. We can sell out, call it a good run, and retire.
  5. We can do our best to compete in an increasingly difficult marketplace where our competitors are more likely to be our suppliers—and not the hard-working independent dispenser down the street.

Armageddon for independent audiology may not be around the corner. The very same tools that the big boys and chains use are available and affordable to us little guys as well. But to take advantage of them, we need business savvy, expertise,  and technology-driven processes.


Good news! There are forces in our industry that are in place and actually want us to survive! Business support services and practice management software systems allow us to be efficient, track and make fact-based managerial decisions. We have everything the big boys have (except deep pockets), and we also have two very important qualities that they can never have: a level of commitment to personal service that only comes from ownership and the nimble process of a small business.

Recently, our 26-year-old son asked my 56-year-old husband, business partner, and fellow audiologist if he thought private practice would still be around when he was 56. His answer: Yes. There may not be as many of us, but we will survive.

He added, the “big boxes,” the chains, and the “submarines” will probably be here too, but they aren’t for everyone. He believes that there will be a market for personal, cutting-edge allied health care services, at least for a while, if not 30 years.

Not everyone wants to get their glasses, root canals, or hearing care where they buy their tires, pickles, and toilet paper. Many don’t want to go the drug store chain or the mall for such things. A hearing aid at the click of a mouse? Earwax is an audiologist’s best friend!

There are powerful entities with offerings and tools in the Hearing Care space that want us to prosper. There are also some powerful forces that don’t. Let’s keep our collective eyes on those guys. It’s going take a lot of eyes, so, like spaghetti, let’s hang together.


Christine Diles, AuD, and her husband, Bill Diles, MA, an audiologist, own Kenwood Hearing Center, in Sonoma County, CA. Their practice, now 30 years old, has expanded to three full-time locations staffed by audiologists and hearing instrument specialists. Dr. Diles, who is also a consultant to the Product Development Team at Sycle.net, notes that “as the daughter-in-law, mother, and employer of, hearing aid dispensers,” she wants audiologists and hearing aid dispensers to jump into the melting pot and stick together like spaghetti.

  1. This topic of audiology and it’s autonomy continues to something that we, as audiologists, have wrestling with for many years. Dr. Diles’ post reminds me of the 1993 Carhart Memorial Lecture, by Earl Harford, Ph.D. at the annual meeting of the American Auditory Society. He stated that there are two critical interrelated issues facing audiology, both of which involve our relationship with the hearing aid. One is that we we must have a “greater scope and depth of knowledge, training and skills in hearing aid technology and application.” And, secondly, that audiology, as a profession, must have a “large viable independent private practice component,” which is “mandatory in order to gain and maintain autonomy and equality in the health care system”. Without the private practice component, audiology is a “kept profession” and will never enjoy “true professional independence.”

    In the Audiology book triology, Audiology Practice Management (second edition) Chapter 6, Private Practice Issues, my co-author, Teresa M. Clark, and I expanded on this, as well.

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