You Do Your Thing and I’ll Do Mine: Ethical Considerations In Audiologic Treatment of Hearing Impairment

Angela Loavenbruck
September 15, 2015

In the last several months, I’ve had the opportunity to discuss clinical practice policies of a number of audiology practice sites with both audiologists and AuD students. I’ve also had several conversations with various private practice offices as I attempted to find an appropriate office to which I could refer patients moving away from my practice area.

Among other questions, I’ve asked about typical methods used to determine eligibility for amplification and  methods used to verify and validate fittings. The answers I’ve gotten confirm published data that fewer than 30% of audiologists routinely use standardized procedures to assess audiologic and non-audiologic needs of patients who are eligible for amplification, and even fewer routinely use real-ear measurements and sound field testing to verify hearing aid fitting.

The reasons given for not providing these procedures included: 1) we use the manufacturer’s best fit protocol and adjust it if the patient complains; 2) it’s time consuming, the equipment is expensive and we can’t bill for it; 3) we really don’t need it – our patients are happy and they’re not returning the hearing aids, so the aids must be helping them and 4) my clinical expertise helps me know when a fit is appropriate.

The discussions got me thinking about standards of care, evidence based practice, best practice guidelines, codes of ethics and even our legal responsibilities to our patients. I reviewed current documents available from the American Academy of Audiology (AAA). The most comprehensive document is the Guideline For Audiologic Management of Adult Hearing Impairment developed over a three year period by a AAA Task Force chaired by Michael Valente and published in 2006.


The Task Force created a guideline with 43 recommendations and documented each recommendation with the Level of Evidence found to support it. The goal was to create an evidence based guideline for managing adult hearing impairment.  Valente pointed out that measuring the benefits of hearing aids at the level of the patient and measuring treatment outcomes to document improved function were increasingly important on the national health care stage.

Of the 43 recommendations, the recommendation for real ear verification of hearing aid fittings was one of fewer than 33% that had research support of the highest level of study (randomized control trials) and a high level of consistency of research results.  The recommendations for a formal self-assessment test battery resulting in patient-specific communication needs was also supported by significant data.

It’s important to recognize that all of the studies reviewed for the 2006 Guidelines had been published by 2004.  Since that time, the evidence for the recommendations has undoubtedly increased.

Standards of Practice Unknown-3

Standards of Practice are authoritative statement by which a profession describes responsibilities for which its accountable.  AAA’s latest Standards of Practice document (2012) states that

“the standards outlined in this document represent the expected professional behavior and clinical practice of audiologists.  Standard I A 2 states that “Audiologists implement evidenced-based practices.”

Standard III B and III B 2 require that audiologists conduct evaluations that include…..qualitative or quantitative classification of communication abilities.  Standard IV A states that audiologists establish and implement management or treatment based on assessment results…. and IV C states that audiologists monitor progress relative to the treatment plan to ensure optimal outcomes.

Codes of EthicsUnknown-2

The Codes of Ethics of both AAA and the Academy of Doctors of Audiology are designed to make sure that the highest quality services are provided to patients.  ADA’s Code of Ethics clearly states that members “shall evaluate services and products to determine effectiveness.” AAA’s Code of Ethics is more circumspect, but does state:

PRINCIPLE 5: Members shall provide accurate information about the nature and management of communicative disorders and about the services and products offered.
Rule 5a: Individuals shall provide persons served with the information a reasonable person would want to know about the nature and possible effects of services rendered, or products provided or research being conducted.

Given the strong evidence for the importance of pre-fitting assessment of communication needs and post fitting verification and validation procedures, it’s easy to think that patients would want to be informed about these procedures and be assured that they were part of their audiologic care. Members of both organizations agree to govern their professional activities according to their respective Codes of Ethics, and members also agree to report those who fail to do so.

How Do We Improve Compliance With Our Own Standards?

There is also a steady drumbeat of articles decrying the lack of compliance witbest_practices_barth these standards by the majority of audiologists (Mueller, Abrams et al, Valente). Many audiologists have advised that providing these kinds of services to our patients is the best hedge against the commoditization of audiology – a clear way to differentiate ourselves from other practitioners.

Catherine Palmer has stated that failure to provide real ear and other verification and validation procedures is an ethical violation.  Cynthia Compton, in a consumer article written for HLAA, states that there are two brands of audiologists – those who engage in best practices and those who do not.  Before they schedule appointments, she advises consumers to question whether real ear measurement is done.  If the answer is no, her advice is to find another audiologist.

The question then is how should we proceed as individuals and as a profession –  laissez-faire, live and let live, you say tomato and I say tomahto? Or do we recognize that best practices are what all of our patients deserve and are paying for, and start reporting non-compliant colleagues to the Ethics Boards of their professional organization in order to underline how critical best practices are to our profession?

Featured images courtesy, allthingsgleaming.wordpress,,


  1. Totally powerful, much needed and deeply appreciated by this Phl, SLP, and HLAA Board member. We need more articles like this one and also the one brilliantly written for consumers by Cynthia Compton-Conley in Hearing Loss magazine.

  2. Although probe mics are a valuable troubleshooting tool to find out what is being delivered to the patient’s eardrum, using in-situ audiometry on a per-channel basis (similar to the way CI’s are MAPped & BAHA’s are programmed) is an acceptable substitute, with the important caveat that the fitting software properly uses the collected data.

    It’s also worth noting that when you “fit to target” you are fitting to a rule such as NAL-NL2 or DSL5-I/O that these are derived from statistical analysis of similar patients based on the audiometric thresholds; and as the industry is coming around to understanding, the audiogram is only a crude way of assessing auditory ability: It may be good for an otologist to look at to see how a treatment is progressing, but it’s not good enough to determine CI candidacy or hearing aid parameters.

    Two cases where prescriptive fitting methods blow up are for reverse slope SNHL, where every fitting formula creates upward spread of masking, and also for cochlear dead zones (especially low frequency dead zones), which can occur with pure tone thresholds as low as 50 dBHL, where the loss of neural firing synchrony produces a scratching sound when a pure tone is presented.

    Of course, when ANSD is present, everything goes out the window…

    1. I have come to the conclusion that in situ is superior to rem in that it considers the impedance match of the middle ear to better establish thresholds. I then tweak frequency response while running Quick sin to dial in best word understanding at mcl’s with excellent results!

  3. i believe that fitting to target prescription formula then modification according tho the case is more practical and of course any thing that would affect the gain of the hearing aid in real ear situation are well understood and can be compensated for.

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