The Parable of the Elephant

Angela Loavenbruck, Ed.D.

We all know the story of the blind men and the elephant. There are many versions of the story, and different religions have used it to illustrate various concepts. The basics are the same. An elephant comes into a village and some number of blind men decide they want to know what an elephant is like.

Each man touches a different part of the elephant and, based on whatever they have touched, decide what an elephant is. In some versions of the story, the men put their various stories together and reach some kind of harmonious idea of what an elephant is really like. In some versions, however, they come to blows over their various notions and some wiser (or crabbier) person has to set them straight.

The report issued by PCAST (President’s Council of Advisors on Science and Technology) along with a number of other ongoing discussions about the future of audiology and of the hearing aid industry has made me feel that a variation of the elephant parable is a good analogy for current efforts to examine the hearing health care delivery system.

Crowded Playing Field

Who are the blind men in this instance? In no particular order, they are audiologists, hearing aid manufacturers, PSAP manufacturers (and those who want to join their ranks), government officials responsible for policies, laws and regulations, professional organizations, consumer organizations, and of course, consumers themselves.

I’m not sure there the elephant has enough parts to accommodate this crowded field of interested parties. As a professional, I’m pretty sure both we and the individuals we serve will be better off if we avoid the coming to blows solution.

Sum of the Parts Does Not Equal the Whole

In the Elephant Parable, each participant examines just one part of the elephant and decides what the elephant resembles based on that part. In the revised parable, I think each participant is actually flitting around the elephant, gathering some incomplete data about each part, building a faulty elephant and recommending solutions based on the faulty compilation.

PCAST

PCAST decided that the problem of untreated hearing loss could pretty much be solved by allowing an unregulated category of devices to be sold cheaply over the counter. The devices would only be for “mild to moderate hearing loss” and only those mild to moderate hearing losses that were age-related.

The people with these hearing losses – which actually represent a wide range of possible configurations and function – are assumed capable of self-diagnosis, self-fitting and self-managing the problem. And, oh yes, the test by which they self-diagnose should be available OTC too. Bone conduction testing anyone?

The Eyes Don’t Have It

The PCAST report compares vision treatment to hearing treatment, noting that patients can buy over the counter vision “enhancement” and are trusted to seek medical care for sudden unusual visual events. The committee members did not get the message that the vision-hearing analogy is not appropriate.

The assumption that all mild to moderate hearing losses represent “simple” problems requiring no professional intervention, while hearing losses beyond this arbitrary line in the cochlea require professional help, represents an enormous lack of understanding about the nature of hearing loss.

No Harm!?

The most astonishing claim made by PCAST is equating hearing aids and “consumer electronics” and the statement that “an inherent failure of the product does not provide an increased health risk to the user.”  This statement is in total contradiction to PCAST’s acknowledgement that untreated hearing loss impairs the physical and cognitive health of millions of older adults.

PCAST accepted wholemeal the largely untested claims of the PSAP and Consumer Electronics manufacturers who stand to profit most from the lax regulatory measures.

It’s the Money

PCAST frames the debate as one that is almost solely decided by the device.  Professional services are reserved for some arbitrary notion of hearing loss complexity defined by a line somewhere on the audiogram.  So the committee patted around the elephant and created an animal that looks more like a mythical elephant.

For PCAST’s animal, good hearing is something older people with mild to moderate hearing loss only need to have occasionally during the day – perhaps when they want to hear the TV without harming the hearing of a companion, or in a noisy restaurant, where magically an inexpensive PSAP will accomplish what sophisticated hearing aids still struggle to do.  The rest of the day,  people can just shout, or the person can get along without hearing.

What Did PCAST Miss?

For one thing, hearing is not just for speech, and occasional speech at that.  My observation of many of patients – whether they are old, not so old, really old – is that gradually worsening hearing loss leaves them in an ever expanding silence bubble.  They miss all kinds of auditory events that occur outside that bubble.

Our worlds are full of non-speech sounds that give us subtle information all day about where we are in our space.  Is something or someone behind us, off to the side, coming from another room?  Has the doorbell rung, or the microwave pinged?  Is the cellphone ringing?  Is someone walking up behind us?  Not hearing those sounds leaves uncertainty and imbalance and some measure of unsafeness.

We know that language is impoverished when children with hearing loss fail to hear the richness and subtlety of the auditory world around them – when they hear only the language that is directed to them.  What does years of that kind of deprivation do to the aging auditory brain.  We routinely counsel our patients to wear their aids from morning to night. It is abundantly clear that the best hearing aids are the ones that are worn comfortably and consistently. Where is the evidence that years of occasional use of a PSAP will do anything more than enrich the members of the Consumer Electronics Association.

A Better PCAST Animal and the Other Imaginary Animals

What should PCAST have recommended?  What are the other observers missing?  Next time.