Let’s make hearing aid dispensing less like Cuba and more like Singapore

By Brian Taylor

Brian Taylor

The year 1959 was memorable for several reasons. After a bitter, protracted fight, Fidel Castro and his band of revolutionaries overthrew the corrupt regime of Fulgencio Batista. Nineteen-fifty-nine was also the year that the nation of Singapore was granted full internal self-government by the British. About that same time, audiologists began conducting many of the assessment procedures outlined by Hayes Newby in the first edition of his classic textbook, Audiology: Principles and Practice.

Most of us are familiar with the long-term consequences of the Cuban revolution: Castro assumed the role of dictator, democracy was suspended, and the U.S. imposed a trade embargo that is still in effect today–more than 50 years after Castro took power. One of the well-known effects of this embargo is the lack of modern conveniences on the island.

For example, it is extremely rare to spot an automobile on the streets of Havana manufactured after 1960. Instead, Cubans must repair and re-repair the same cars that were driven three generations ago in the 1950s during the Batista regime. All this leads to a time warp of sorts, as anyone knows who has visited the island and been astounded by these recycled jalopies.

Because of its similar geography and population size, the fate of Cuba is often compared to that of Singapore. This Southeast Asian city-state enjoys the fruits of a market-based economy, including a vibrant middle class. It has the third highest per capita income in the world, and boasts entrepreneurial spirit that is beyond compare. Cuba and Singapore present a striking contrast between a market-based and a command-and-control economy.

Cars on a street in Havana

DISPENSING PROCESSES RESEMBLE THE CUBAN MODEL

In several ways, the hearing aid selection and fitting process is in a time warp that makes it resemble Cuba, not Singapore. Even though the technology that we fit is unquestionably modern, the tests and procedures we routinely use to select and fit these modern instruments are antiquated and inconsistent.

One could argue that being in a time warp is okay. After all, there’s a certain nostalgic appeal to those vintage cars on the streets of Havana. If the hearing aid industry were enjoying unprecedented high market penetration, a plethora of independently operated private practices, and freedom from disruptive competitive threats, then it would be okay if clinicians went about their daily regimens with patients the same way today as 50 years ago. No one would argue with conducting vintage “best practices.”

Of course, the opposite appears to be the case. Most of us rely on the standard battery of tests—mainly developed around the time of Castro’s Revolution and summarized by Hayes Newby in 1959–to make critical decisions about amplification options.

More up-to-date procedures developed mainly in the 1980s, such as probe-microphone measurements to verify a prescriptive fitting target and the use of self-reports to validate patient benefit, have reasonable evidence supporting their effectiveness. However, only about one third of clinicians use them routinely.{{1}}[[1]] Mueller HG, Picau EM: Hear J 2010;63(5): 27-32.[[1]]{{2}}[[2]] Humes LE.  Hear J 2012;65(3): 8-12.[[2]]

At the heart of so many practitioners’ stubborn refusal to abandon antiquated ways is a lack of fresh thinking and entrepreneurial spirit, which were supposed to blossom with the advent of the Doctor of Audiology degree. One of the promises of the AuD was that it would attract bright new talent into the profession of audiology.

Taylor barn, Holcombe, WI, August 2012.

Before offering an opinion on how we can become less like Cuba and more like Singapore, let me use an analogy from my past. I come from a long line of dairy farmers in Wisconsin. My father was a fourth-generation farmer on a 600-acre tract of land owned by my family since the Civil War. By all accounts the farm was a profitable endeavor for many decades. However, during the mid-to-late 1980s a series of circumstances led to the demise of the farm as a small business. In the absence of fresh thinking and insights from the fifth generation (me!) on how to overcome many of the competitive demands, it didn’t take much time for what you see in this photo to happen.

BECOMING LIKE SINGAPORE

Is audiology, specifically the hearing aid dispensing aspect of the profession, on the same path as my family’s dairy farm? Without fresh thinking and new perspectives entire professions can disappear. Here are three pools of talent that audiology needs to draw from to help dispensing practices become less like Cuba and more like Singapore.

1.   Socially conscience entrepreneurs, a/k/a “the money makers”

Clearly, there is a disconnect between how most audiologists are trained in the university system and how they perform in the real world. The majority of them continue to come from the ranks of frustrated speech pathology majors, and the downside to this is significant. It’s time for universities to eschew the command-and-control ethos of ASHA and work with groups that offer new insights on thriving in a market-based economy.

Every AuD program needs to have at least one faculty member who has a strong and vibrant relationship with the business school at its university. Audiology and business academics need to work together to study and publish the impact various service-delivery models have on both patient outcomes and practice profitability.

Additionally, manufacturers need to create incentives to attract entrepreneurs into the profession. Given the still relatively large profit margins on the per-unit sale of hearing aids, this would seem to be relatively easy to accomplish. Does any one of the Big Six hearing aid manufacturers, which are buying up so many private practices, offer some type of apprenticeship program for ambitious entrepreneurs who want to run a clinic or hearing aid shop? Does any of the existing buying groups offer anything besides services tied to a percentage of each unit purchased. This consultant-for-life arrangement is a disincentive for creative ideas and fosters dependence on the middleman–things that deter the entrepreneurial class.

2.  Medical professionals, a/k/a “the caretakers”

Many medical specialties are suffering from the ill effects of corporate-owned hospitals and pharmacies. Nurses, pharmacists, and even physicians are feeling the burden of having to practice their specialty in the face of overwhelming bureaucracy and reduced reimbursement.

The dispensing of hearing instruments, which continues to rely chiefly on cash payments from patients, offers an intriguing alternative for those who want to practice in the healthcare arena and not sacrifice income. Audiologists and hearing instruments specialists need to explore partnerships with ENTs who want to play a greater role in the dispensing of hearing aids, using a concierge medicine model.

3.  Applied scientists, a/k/a “the gadget freaks”

Academically trained engineers offer a third alternative group of talent that needs to be coaxed into this field. With the rising complexity of hearing instruments, scientists and engineers who know how to apply their training to helping people would bring a fresh new perspective into our field and provide us with invaluable insights on emerging technological solutions for hearing loss. AuD programs, two-year dispensing programs, and corporate-owned hearing aid centers need to work with high school and college career counselors on attracting the scientists to the profession.

The world is full of smart, ambitious people who want to make society better, while at the same time making a very good living. Modernizing how we practice audiology will definitely improve patient care. But unless we can attract high-caliber people, no system–certainly not a command-and-control one, like Cuba’s–will be effective over the long  haul.

Brian Taylor, AuD, is Director of Practice Development and Clinical Affairs for Unitron. He is also the editor of  Audiology Practices and the author of Consultative Selling Skills for Audiologists, published by Plural.