The Contrarian: Got (Milk) Tests?

Gael Hannan
March 8, 2016
Michael Metz, PhD

Michael Metz, PhD

In this month’s edition of The Contrarian, Michael Metz poses some questions about testing procedures that all audiologists might want to ask themselves. 





For a couple of decades during the early years of modern audiology (after the fifties), it seemed like there was a new test introduced at least a couple of times per year.  These new procedures would elicit discussions, purchase orders, and quick adaptations in most clinical environments.  No one wanted to be left behind by new tests that added to our quickly developing protocols. We seldom use many of these “first” differential site-of-lesion tests today as even better tests have replaced them.  The SISI, ABLB, MLB, Bekesy, TDT, PB Rollover, DLI, WATCH, Stenger, Doerfler-Stewert, and many more have been thrown into the dusty protocol trunk in the attic.  We have replaced some of the old tests with procedures such as OAE, Impedance/compliance measures, ABR, middle and late electric component average testing, tests for CAPD and tinnitus, various probe measures, and SNR tests—some of which are even used regularly by some audiologists.

As most of these early tests were phased out for later procedures, more emphasis was placed on the costs, in money and time, and reimbursements.  This is the normal course for any field or profession moving forward.  Despite the fact that the newer tests were (are) more valid and reliable, many audiologists use a limited number of them.  More than a few audiologists seem to have lost sight of the most-asked question presented by most patients. Argue as you will, most patients show up wanting to know what’s wrong with their hearing and then, what can be done to fix this problem.  Perhaps some of us got so hung up on the “fixing” that we forgot about the “finding out”.  Sometimes our only “finding-out” test is a pure tone audiogram and some words-in-quiet tests, hopefully a recorded version.  Bilateral, symmetrical sensory hearing loss is pretty common and therefore pretty boring.  Given the few alternatives in the “fixing” part, perhaps knowing more detail about the “what’s wrong” part would be informative to the patient.

In support the “finding out” statement, consider the following:

–When was the last time a new diagnostic test was incorporated into your “usual” or typical clinical battery?

–For what purpose would you routinely test speech in quiet with a PB list?

–Have many clinicians stopped billing insurance for audiograms or other tests because the insurers pay little or nothing?  (Ever consider that the audiogram is at least 75 years old and pretty much unchanged in three quarters of a century?)

–Have many looked carefully to determine how “new” procedures are placed on the insurance company’s list of “we should pay for this”?  (And, does this list of “reimbursable” constitute the cutting edge of the field?)

In a recent on-line article (December 3, 2015), The Insider, part of Hearing Review, quoted an article taken from the Dec. 1, 2015 issue of The Lancet that was published in that journal on 11-28-15.  This article listed the 10 research priorities for mild-to-moderate hearing loss in adults. Six of the ten priorities involve hearing aids. One item mentions diagnostic testing.  Recall the old saying “measure twice, cut once”?  Or, perhaps the Brits assume that all necessary diagnostic tests have been completed for each patient.

Interesting questions arise. Has audiology become so involved in amplification that many audiologists do not do sufficient tests to completely define a patient’s hearing loss? When and under what circumstances can a complete investigative protocol be eliminated in any audiological examination?  How much do you really need to know about a bilateral, symmetrical sensory loss?  Does a “new” test have to be reimbursable before it is used?  Conversely, what constitutes the “cutting edge” of audiology?

If you were to make a list of clinical tests needed by the audiology field, similar to the one that appeared in The Lancet, what would be on the list?  What types of tests would better serve “autonomous audiology” in the long run?  Or in the short run for that matter?

And, because of our emphasis on “fixing”, how has audiology been affected by its lack of “finding out”?  Isn’t this the prime area in which the field has little competition? Don’t we spend quite a few graduate educational hours here?

How does audiology set itself apart?  What is the audiologist’s responsibility for “driving” the profession regarding investigative testing?  What responsibility does our professional organization assume?

I would think that, if we were planning correctly and for the “long run”, diagnostic investigations to determine “what’s wrong” should be at the head of our list.

But, that’s just my thinking.  You could discuss this over lunch, at a professional meeting, or with your colleagues. And, why don’t you take a minute and put some of your thinking below in the comments section.


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.


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