Hearing Aid Fittings: The Value of Customized Gain and Output Measures – Interview with Lindsey Jorgensen, AuD, PhD

Brian Taylor
Hello, everyone and welcome to another episode of This Week in Hearing. I’m Brian Taylor. Our topic today is customizing prescriptive targets are the hearing aid fitting process that most of us are aware of. And our guest today is Dr. Lindsey Jorgensen. Dr. Jorgensen is an associate professor, clinical director and department chair at the University of South Dakota. Welcome, Lindsey.

Lindsey Jorgensen
Well, thank you, Brian, for having me here. I’m excited to talk about Real Ear. Because, you know, it’s one of my stomping blocks that I wish that we would all talk more about. So thanks so much for having me.

Brian Taylor
Yeah know, it’s great to have another authority on this topic. And before we dive in, I thought, you’re at the University of South Dakota, kind of an interesting place tucked away between North Dakota and Nebraska. Could you tell us a little bit about what brought you to the University of South Dakota, and what you’re doing there?

Lindsey Jorgensen
Absolutely. So I will tell you that I’m not from this area, I love it here. I love the people now that I’ve lived here, but really, the reason I came is because I really wanted to continue research in hearing aids and adults and how we can best help our adult patients and some peds, too. But really, I’m interested in adults, and using hearing aid technology. And I love that research. But my research is really clinically focused. And I wanted to make sure that clinicians on day to day can really take anything that I find and apply it to their, you know, Monday morning. And so the University of South Dakota really allows me to teach and do research and new clinic. And that’s something that’s pretty unique in, in most academics.

Brian Taylor
Yeah, and that’s a real trifecta. Those three things, that’s great. In fact, and we’ll maybe we’ll dive in a little bit later on, I know, just in the last month or so you were one of the authors in the 20Q on Clinical Standards, which is kind of a little bit of what we’ll talk about today.

Lindsey Jorgensen
But I thought we’d break.. you know, those base standards, I think are really important. We can always have these, you know, high shooting ideas of what we should do, but kind of what is our base? I’m really glad we’re talking about that as well.

Brian Taylor
Yeah. And that’s really what in line with what I wanted to have a conversation with you today about, I thought we could start by getting into some of you know, it’s been more than 40 years since prescriptive targets came to into clinics. So maybe you could revamp remind our viewers what it means to fit somebody prescriptively.

Lindsey Jorgensen
So one of those original prescriptive formulas was way back in the 1940s. It’s also known as like the half game rule by Lyberger…barger? Lybarger — Lybarger. I think you’re right think your right. Luckily, he is probably not around to correct me. Probably not. It was proposed that about that half the amount of hearing loss at each frequency would be a good amount to gain and ensure a hearing aid user had good audibility. And work on that prescriptive met methods languished until probably the mid 1980s. I’m gonna chime in here and say we had a couple pretty rough years where the Medresco report came out and the that said that we really should just fit everyone with the exact same hearing aid. Well, that doesn’t really work well for us now does it? Can you imagine fitting the same hearing aid on every single one of your patients with the same prescription? Anyway, doesn’t really make sense doesn’t make a ton of sense. So then research confirmed that really frequency-specific programming really improves speech intelligibility. And really, we should be looking at that. So we still do use kind of a method of that, you know, kind of the half – third gain rule somewhere around there taking into account upward spread of masking and those low frequency inputs. But today’s prescriptive methods are kind of a foundation of linear methods. And the two most common ones that you know we all know are NAL and DSL… NAL aims to make speech intelligible with an overall comfort – soft sounds sound soft, moderate sounds sound moderate and loud sounds sound loud? Well DSLs philosophy is really based upon audibility, and comfort is, you know without having loud sounds be too loud. But really, you know, they’re much more concerned with audibility, and making sure that every single one of those sounds is audible. These two methods first, prescribes specific amount of gain based upon hearing thresholds and uncomfortable levels – age, gender, hearing aid experience, language, you know, and compressor speed. But basically there’s a mathematical basis for each of those. So I will say that on I am going to pause and say that these are both averages, right? So both NAL and DSL are averages and there reasons to choose one or the other, but by definition, average means that there’s going to be some people that want more. And some people that want less and while fitting to target, I would say is incredibly important. We should not be driven solely by these targets. And I know we’re going to get more into this. But um fitting to a prescription In my opinion, is fitting to audibility. And then we adjust it based upon the patient’s needs, but we have to have a starting place. And really, that’s where those prescriptions allow us to go.

Brian Taylor
Right. It’s a good starting point, I think most people would agree. So what’s really interesting to me, Lindsey, is that when we talk about prescriptive formulas, it’s kind of a two step process in the sense that you have to have the person’s hearing thresholds, and you take those thresholds, and they enter them into the software. And that gives you the fitting software, the manufacturer, the fitting, or the software, or the programming system, I guess. And then that gives you these prescriptive targets. So I think of it kind of as a two step formula. And, you know, everybody does 100% of audiologists and fitters out there are doing the first part of that they’re collecting auditory thresholds and entering them into fitting software and getting a gain target output target. But then, if you read the surveys over the years about maybe 40% of people are doing the second half, which is verifying sort of the goodness of the fit with their Real Ear system that they’ve actually hit those targets. So maybe if you could talk a little bit about why only half of hearing aid fitters out there are doing the second half of the prescriptive procedure.

Lindsey Jorgensen
You know, it’s a good question. And something that I’ve spent a good chunk of my career trying to figure out to be honest, and I’m trying different methods of well, maybe it’s, you know, that people aren’t comfortable doing doing this. And so I feel like this kind of opportunity and platform that you’re giving us talking about, it may change some people that that this is not something they learned in school. So you know, I’m nervous, there are opportunities at our professional organization meetings, that will give hands on experience, I’m going to put a small blog at AAA, we will have a hands on lab, in the conference, or in the expo hall, where you can come and we will actually have hands on and say, What can I teach you? There is also a learning lab that I give on advanced features, but that hands on if you just want just to dabble in it and just ask basic questions, no judgments, I will say that that may account for some of them. Now, while you do say 40% that’s also self report. So I have kind of asked some of my hearing aid manufacturers like outside sales, and they say it’s probably more like 25%. So I’d love to say it’s 40%.

Brian Taylor
I’m trying to be optimistic, I guess, but I tend to agree with you, I think it’s the numbers probably a little bit lower than that.

Lindsey Jorgensen
So some of the other reasons that I have heard people say is that the equipment is expensive. And I’m not going to say that, you know, a several thousand piece of equipment isn’t expensive, because it definitely is, but there are data to suggest that you will make that up fairly quickly. Okay, so, you know, we, I will find that my return rate is pretty low. You know, and I and I attribute part of that to that I’m providing these people that the the audibility that they mean second is that, um, you know, my number of follow ups is definitely lower than most people, people who are fit to target I have found don’t need as many adjustments. And so if the outcome is often then from a private practice perspective, which On a side note, we actually run a private practice here out of our clinic, here on campus. So from a private practice perspective, if I don’t have a patient taking a follow up appointment, then that’s another time that I can use for a hearing test to sell another set of hearing aids. So I mean, I guess the other two things that people say is that they believe patient report, and then also manufacturers, well, they’re doing it for me, why do I need to verify? So I kind of want to address those two, little bit separately. And first is that manufacturers say their fitting is based on a prescriptive formula. So why would I need to verify it? I mean, the manufacturer told me that it’s NAL or DSL. Well, study after study obviously, we all know suggest that Real Ear responses were different significantly from the audiometric Real Ear formulas that were put into the manuf. Put in software. This is different. This has also been proven not just for, you know, average speech but for loud sounds and soft sounds and it varies depending upon frequency. And, you know, there’s also been data to suggest that different audiograms that maybe if I put in an average audiogram it would work but other audiograms it wouldn’t and it really just doesn’t hold true. Remembering that the more hearing loss a person has the more dynamic – reduced dynamic range they have. So that could really run into problems. And at the end of the day, the only thing we have control over that improves hearing with hearing aids is ensuring audibility, and the only way we can measure audibility, is through the output of the actual hearing aids on that person, in the patient’s ear.

Brian Taylor
Right, right. So, without audibility, a lot of other things. So many things stem from effective audibility, that is kind of a no brainer. One thing I wanted to kind of touch on maybe in a little bit more detail, and it gets to your point about these differences across manufacturers. I hear a lot of complaints from clinicians complaints that their patients maybe share with them that when they try to fit them to target the patients say that the hearing aids sound too sharp to tinny. audiologist sometimes say that the formula is “too hot”. I’m not really sure exactly what that means. But maybe you could speak to why that happens. What, what that really means – maybe how do you counsel somebody those say those things about their hearing aids being too sharp or too tinny when they match a target?

Lindsey Jorgensen
You know, that’s really hard because you know, most of us think like our patients will know, right? My patients know when things are loud or too loud or too soft and and many of our patients have slowly lost their hearing over time. And so they don’t really remember what normal hearing was like so I did a study a few years ago actually looking to see what people remember of what their hearing was like when they were 20 so I took a whole bunch of older people and said hey, when you were in a bar out of a scale of 1 to 10 How well did you hear and when you were in a restaurant on a scale of 1 to 10… not how they heard today, but how they heard when they were 20. So and then I took all a bunch of 20 year olds and gave them the same questions and I you know it’s really interesting that in general the 20 year olds were pretty honest right? I don’t I hear about it, you know “5 out of 10 when I’m in when I’m in a bar” or “I hear 3 out of 10 and I have to use visual cues” but then the older people were like I heard everything when I was 20. People’s historical memories just not good and, and so part of it I will say is that setting those expectations and most people patients with coming to my clinic have a really long standing hearing loss meaning their brains just aren’t used to it and their brain is really used to that quieter world. This is some time where it’s important that clinicians are not a technician right so if a new hearing aid user is is you know when we fit them to 100% of NAL-NL2 targets and they some people are gonna say that that’s okay and I think this is where that kind of you know, EIQ that emotional IQ that we’re all pretty good at really comes into play. How hard can you push that person right and and i’m you know, I would say you know, the patient that’s that’s sitting there with the tears streaming down their face and going, it’s okay, right, like I’m gonna turn them down and then maybe on their follow up, put them up to target but actually starting where target is you know, and I will always say that my job is 50% hearing aids 50% like marital counseling, but you know, this is the time when the audiologist needs to provide counseling and you really need to be able to read your patient to know you know, do I do I push the patient or not you know, but knowing that I’m them hitting the target at this point and then turning them down either by percentage or by number depending upon what manufacturer you’re using, and turning them down and saying is this an okay place to start? Right? You know, and really giving them the remembering that this is just a starting place, but you’re right in for some patients it is ‘hot’ and ‘tinny’ and ‘annoying’, but you know, knowing how hard to push that patient and I will make a plug here and also say average RECDs are often used, remembering that, you know, if you have a little person, their ear canal may be much smaller. I’m going to make a make a comment on RECDs, saying My husband is six foot three, about 240 big broad shoulders former military man so kind of get that picture in your head. He has teeny tiny teeny, teeny, teeny, tiny ear canals. And I use him as a great example of like, we really should measure Real Ear to Coupler Difference. Because if you were to put an average adult white male hearing loss or an ear canal on him, it is going to be much too hot for him.

Brian Taylor
Right. That’s interesting. So I think what you’re just to kind of paraphrase what you just said it’s really about using good clinical judgment. Yeah, the target as a starting point, I do know that people tend to train around where they start, or to not train or keep the volume around where they start which is important thing to note. So maybe that turned it down too much, but I get what you’re saying about you got to take into consideration with the patient might be telling you. Anyway, what I wanted I meant you mentioned this before, we talked a little bit about it very briefly. every manufacturer and I don’t know where this comes from. It’s kind of interesting to me, and I have to say, you know, even as somebody that represents a manufacturer, my day job is with Signia. As a clinician, I find this to be a little bit puzzling: every manufacturer has their own first fit, and with and they invariably are underfitting especially for soft sounds that are high frequency. I think it changes a little bit as you turn up as the sound gets louder. But what’s interesting is they’re all underfitting for the most part, and the highs, and they all have their own name, which makes it -they have their own jargon. They call it something you know, and I know that everybody has to market, there’s a purpose for that. But if you can maybe speak to how these first fit targets differ from the real, I’ll call in quotation marks “NAL or DSL”? You know,

Lindsey Jorgensen
we don’t actually know what it is. And just be honest, we don’t know what it is. That’s the definition of proprietary, they’re not going to tell us, trust me, I’ve tried. I’ve asked what’s it based on? And then they’ll say, Oh, it’s based on, you know, a verified target. I’m like, okay, but it’s not where it is. And, and I think that at the end of the day, and manufacturers are in it for they’re in it for the money. And I’m not meaning to say that that’s a bad thing, because we all have to make money, but their stockholders are who they are responsible to. And that that’s the reality of of any job, right? Like, I’m not here, just to you know, I need to I need to make a paycheck. Right? Although I love what I do. I’m not gonna say that I don’t. But, you know, I think that we just need to keep that in mind that one of their jobs is to make patients happy. Because patients that are happy, keep their hearing aids. Yeah, well,

Brian Taylor
I think what you’re getting to and I it’s a valid point, I think that manufacturers have a different motivation, maybe than the fitter. I think for the manufacturer, it’s about bringing a product to market that’s quality, that’s consistently good. And then somebody on the other end of that has to be able to tweak it or fine tune it, customize it to the individual those things to work in glove,

Lindsey Jorgensen
and they do expect us to tweak it. I mean, that’s why they give us the software. And then they also expect the patient to be able to tweak it maybe a little bit, but not nearly what we can do. And so this is what makes us audiologists, really at the end of the day, I will say that we need to be optimizing for our patients, because that’s what they expect. They’ve told me a problem. And I think that this is a you know, I get asked, and I assure assuming we’ll get to it at the end about kind of us versus over the counter. But a patient that comes to me, often does not come for a device, they’re coming for a solution. How do we get to that solution? They’re happy, in general, but patients don’t come to me saying I want this manuf… most of them. Some of them do.. I want this manufacturer and this product. And most of them say to me, what product can help me get to the solution of communication competence? Yeah, I think that personalization is what we’re going to try and do.

Brian Taylor
Right. Like I said, I think the manufacturers role is to furnish a high quality device to the clinician and to provide a well fitted solution. Maybe that’s a good way to

Lindsey Jorgensen
absolutely, and I will tell you, you know, our clinic protocol, which I’m willing to share with anybody, our clinic protocol, but one of the things that we do is when we get a hearing aid, we actually run the full ANSI specs on it and compare it to what the manufacturer turned into the FDA. Because at the end of the day, what the manufacturer turned into the FDA is a quality high product. You know, it is so much better than the things that currently can be purchased as a PSAP. Like I mean, really the products that we’re getting, have the ability to really help majority of our patients. But that manufacturer first fit I really think of as a first fit, it is a place to start. It’s a place to start.

Brian Taylor
Well and the other thing that I’ve said is, imagine if you lived in a world where the manufacturer sent the hearing aid to you and it was just completely turned off without any first fit at all from the manufacturers perspective because so many unfortunately So many clinicians cut corners most of those hearing aids would come back and they would say the hearing aid is dead it’s not working so maybe you have to have some you have to have it somewhere in the ballpark and I guess that’s what the first fit gets you Yeah. And then it’s up to the audiologist or the the hearing aid professional to tweak it so it’s optimized to your point I mean,

Lindsey Jorgensen
I think that that the manufacturer is actually just trying to make your job easier right like they could send it to you full on and then say good luck or they can send it to you like you said dead and say good luck. But I really think of that first fit as here let me at least like lob ball you something to hit from. Yeah, just in case you’re kind of in a general area so it’s not quite as much work for you.

Brian Taylor
Right and then it’s ultimately up to the audiologist to get it right at the end. While we mentioned the first fit and every manufacturer has their own first step they have a different name for it it’s usually you know fairly below the NAL target I also noticed that most manufacturers have their own version of the NAL when you go into the software it looks like it might be the true or the real NAL but I know based on a couple studies over the years it’s even though it says it is the NAL on the software it may not be so could you maybe speak to that

Lindsey Jorgensen
well I mean and so the first thing I want to say is depend.. know what your manufacturer is doing right so for some manufacturers if you change it to like first or to NAL or to DSL are those things from the manufacturer proprietary it’s worth noting if that actually will disable some of the other features that the manufacturer has activated so that’s going to be my first caution before just going away from the manufacturer first fit proprietary name to you know NAL or DSL or or whatever one you choose just know if that is deactivating some of the internal features so I will tell you my default is to leave it to the manufacturer proprietary and then just adjust from there to the target I want but you know study after study like I mean just Valente in 2018 Mueller I mean there’s been study after study that has shown that that real world performance in set you know that it just doesn’t doesn’t meet the true function of that of that NAL target and I will tell you that the Valente article um so it’s Valente and Kristi Oeting and Brockmeyer and Smith and Kallogjeri, I think. Um, but they reported that nearly eight I think it’s around 80% of patients actually preferred, programmed vs versus first fit. I think they can actually hear things, right. So we’re verified that things were audible to them, surprise, they can actually do better. So, you know, I think that, although patients initially may kind of say, gosh, this is too loud. And then I use my emotional IQ, and I say, Is this an okay place to start, and then I explain to them why most of my patients do walk out the door at Target. But with the knowledge that I am willing to move away from that, just go try it for a couple of weeks. And the reason, you know, I will say is that, you know, if you had a patient that had to walk to work every day, and you gave them a bike, they’re gonna think the bike is the greatest thing that’s ever been invented. But they don’t know that there’s a car. So they may think, Oh, my gosh, this is too much, but let them try it out. But also, like I said, know that some of your patients, you have to back off and work your way up to that, right. So I guess I don’t really know, right? If you if you had a million dollars to invest in r&d, I mean, don’t get me wrong, but at the end of the day, they’re still providing us a very quality product, right? But that NAL and DSL is still going to be a tweak on what is the NAL because it’s not in your patient’s ear.

Brian Taylor
And it’s what 30 or 40, maybe 50 years of science that shows that when you hit those targets, things fall pretty nicely into place. But you bring up a really interesting point about sticking with the manufacturers first fit, then and then just matching the target from there. You know, most manufacturers I know have some type of signature feature or proprietary features that work well together in combination, and you certainly don’t want to turn those things off. But at the same time, you want to make sure that things are loud enough or audible so people can actually hear the benefits of those features when they’re working.

Lindsey Jorgensen
I mean, our patients complained about speech and noise. And if it’s not audible, your directional microphones are not going to help.

Brian Taylor
Right so you got all these other features that really aren’t even being driven. Because sounds aren’t audible anyway. I think it’d be interesting for our for our viewers to hear what your clinical protocol is so. So if you want to share

Lindsey Jorgensen
absolutely, we have it written out, I’m willing to email it to anyone and partly because we have students. So I’m going to pause and say that we do run our clinic as a private practice. And our private practice does require that we make a certain amount of money to pay salaries. So I mean, it it really is that and our students learn about billing and coding and things like that. So one of the things that we do is when a hearing aid comes in, we run a full ANSI spec on them. And then we run directional microphones because the number one thing that our patients complain of is hearing in noise. And the only way that currently that we’ve really shown to improve speech in noise is directional microphones. Now, I’m not saying there aren’t other things that help you know, digital noise reduction, purely in and of itself, the mics are the only thing that we have really shown, like I said, D mics might help with or digital noise reduction, might help with reducing efforts and all those things. But currently, we don’t really have a measure, a true measure of effort. So I think, you know, so we check, we check and see specs, compare it to the spec sheet that was provided to the FDA about that hearing aid. And then we run d mics. So that’s kind of on the front end, we also,

Brian Taylor
what do you mean, I just wanted to make sure that we’re all on the same page, if you say run D mics, you’re talking about some sort of a measurement in the test box.

Lindsey Jorgensen
Yeah, sorry, working, we run, we run a test box measures. So we first fit the hearing aid. So we connect it then I will say that some manufacturers make it quite easy to run ANSI spec, and some make it a little bit more difficult. Some have a button that you can click to say, I’m going to run you know, my my full on gain measurement. And others, it is a little bit more difficult. Looking at some equivalent test function, those things, we then first fit and our reason of doing that is I mean, we’ve all had the hearing aid that you just can’t connect to the programmers and the patients sitting there. So part of our other reason is to do that. And then the other part that we do is we so then we run directional microphones. So we forced the hearing aids into directional microphones. So we’re not testing adaptive directional, we’re not testing whether the hearing aid will switch we’re really just truly testing to see if we see a separation of a the speech from the noise and a front to side measurement.

Brian Taylor
Right? That’s interesting. I think it’s Do you see differences across manufacturing, it’s sometimes you have to drive or put more louder, more intense sound into some hearing aids to get them into directional mode?

Lindsey Jorgensen
That’s a really, really good question. And so one of the reasons we forced the hearing aids into directional, usually by putting it in some kind of speech and noise speech in restaurant, because many, many manufacturers or every manufacturer has their own proprietary setting on how their hearing a will go into directional microphones Exactly. find that interesting. Yeah, and it is interesting. So one of the reasons that we have chosen to do that is that then it would be a different protocol for every manufacturer, where I need 0 dB signal to noise ratio with this input, or I need a plus five. And so we have found that just forcing that hearing aid into directional gives us some much more consistent protocol. And so that’s why we we do that, because using an auto switch, right, where you let it run until it switches into directional was actually really difficult because we use such a variety of manufacturers here,

Brian Taylor
right? Yeah, no, I get that. So can maybe that’s, that’s good, it’s really good that you shared that any other parts of your protocol that you’d like to share with our viewers.

Lindsey Jorgensen
Um, so I think that you know, then the patient comes and we do we do a real ear to coupler difference. And we save that in the patient’s file so that then we don’t have to run it every time. And so I’m going to talk for a minute about an adult fitting, and then how we do a child fitting a little bit differently. So an adult, we do a 65, we do a soft, moderate and loud, so we do a 65,55,75 and 65, 50, 80 is fine, and then we always run an MPO. In our clinic, we don’t typically measure UCLs or LDLs in the booth. So we recognize that what is in the software is not the patient specific and so what I will say one of the things we do when we run UCL or MPO of the hearing name, is we actually look at the patient because many most manufacturers actually will take that MPO and have it really low. So one of the things that I always you know want to do is I jack up the MPO to give me a little bit more headroom, a little bit less depression, and I want to make sure it’s not too much for the patient. I promise you, if a patient is near their UCL, they give you a face. And so I always I always say to the students, and I, myself, don’t look at the screen, when I’m running that MPO, or that 90dB output, I’m looking for the face. And then we teach the patient, I will say that we then take the hearing aids off the patient and run on a multi curve. So that then we have in our computer, our electronic medical record, how the hearing aid is functioning at a soft, moderate and loud in our test box, right? We use that for the future, not more, not for today. So what I do is I have that hearing aid that you know, 100% target or whatever, three or four or whatever manufacturer you’re using, fit into target, ask the pain to stop my I’m happy with where I am within about 5 dB of my target if possible. And then I’m pause and then ask the patient how they’re doing take it down, however I need to, and then run the hearing aid in the test box. And that’s our protocol for for how we fit at typically hearing.

Brian Taylor
Yeah, quality control. And so a couple interesting points you made that, I don’t know a lot of clinics that do an RECD on adults, but I can see the value of that when you’re individualizing. And you have that in there sort of in their chart as a blueprint of you know, what, how that how it’s individualized for the person

Lindsey Jorgensen
if you run it once especially on adults, you don’t need to run it again. Right? So there you have it there, I can see that the left and the right are the same on most adults. So as long as you run one you should be okay. So what I did, I will say that our protocol is that when we do the audio, we run o ReCD on that day. And that’s because in a child, I tend to pre fit in the test box, using the patient specific or RECD. Because sometimes when a kid comes in, they’re in full meltdown mode, and they’re just not gonna let you do it on the year. So I’d like to have at least like that starting point, right? You know, a little bit closer to their targets.

Brian Taylor
Anyone that’s fitted kids knows what you’re talking about.

Lindsey Jorgensen
I also have to so I have a two year old, six year old and you never know what kind of mood especially my two year olds gonna be?

Brian Taylor
Yeah, yeah. No, no doubt about it. But it’s a I can see how an RECD would be helpful on adults with tele audiology to fit them remotely if you had to. Yeah, absolutely.

Lindsey Jorgensen
You know, and so I you know, the data suggests that, that if you don’t run RECD, on adults, you’re probably going to be okay, using average about 80% of the time,

Brian Taylor
right. But if you have it, then you got to use less than that variability even more. The other thing that you said that is interesting was you focus on output. You know, we talked a lot about gain curves. But you mentioned and I know there was an article published a few months ago, I think was in the Hearing Review showing that most manufacturers are well under the probably the prescribed output of any given patient that we are under fitting our patients for loud sounds. Do you want to speak a little bit more about that?

Lindsey Jorgensen
Sure. I mean, for me, it’s actually about if we’re not fitting the loud sounds, you’re actually hyper compressing your signal. Yeah, your squeezing everything. that’s actually why I really fit to moderate soft and loud. Because loud, should be loud, not uncomfortable. I call it ACT, right? Audible, Comfortable and Tolerable. And that’s the way the students kind of here learned is I want you to act audible, comfortable and tolerable. loud sounds are loud, yeah, there’s a car. And that’s okay. But if you under fit those loud sounds, you’re really going to end up hyper compressing that hearing aid. And I will tell you my first lecture in in hearing aids, one is basically why hearing aids ruin speech, because at the end of the day, we’re taking all of these sounds that are occurring in English and squishing them into a smaller area. That’s the function of a hearing aid, we need to make the sounds audible but unfortunately, remember, because of recruitment, our top end doesn’t go anywhere, right? So if you aren’t utilizing that patient’s entire dynamic range, you’re gonna end up compressing speech more than they need,

Brian Taylor
right? They already have a narrow dynamic range to begin with. And now you’re making it even worse if you don’t fit the entire soundscape.

Lindsey Jorgensen
Absolutely utilize the patient’s entire dynamic range if you can, because at the end of the day, that’s going to reduce or improve intelligibility.

Brian Taylor
Right. What’s interesting also here when we’re talking about is these things about hitting a target. These can’t be duplicated by over the counter devices. It takes it takes a professional to, to tailor the response to the individual. Absolutely. Could you speak a little bit maybe as we wind things up here? You know what’s your take on OTC? how can how can hearing care professionals differentiate themselves in a world where a person could buy something and then fit themselves?

Lindsey Jorgensen
So I think that’s a really really good question and, and i think that that as I have had more experience with a device that, that will be an over the counter hearing aid at some point the more I am confident in my ability to provide services as an audiologist The process of teaching patients right and really having that connection is what separates us in general that process of verification so I, I really am what, more than the device and I will tell you that we do bundle here but we itemize bundle and so the hearing aid costs this much and I am this much I’m willing to share that with other people not the prices but actually how we set that up but I myself am the same price across all of our levels of technology it’s likely that we here will provide an over the counter type device at a much reduced cost but I’m going to sell that as you know you’re going to get this device and you know I’m here as a general support to you but reality is there’s not much I can do with this hearing aid you know, we we’ve kind of kind of a one size fits all Yeah, and we kind of tossed around these ideas of kind of how we do it and you know, it is true that many of these over the counter products are going to do kind of what what will be like an in situ audiogram the patient hears that beeps through through the hearing aid and then it may either put them into one of several profiles or it may you know actually kind of do what is a semi a first fit. Right But you know, hopefully I will say that audiologists will see an OTC as an opportunity to maybe tap the market of those people that aren’t getting our services already and that’s kind of I don’t know if you remember there was the scale there was the article by Palmer and Hurley and Solidar maybe one or two other people quite a few years ago that said on a scale yeah a scale of 1 to 10 How bad is your hearing? and they use that to determine how much counseling you had to provide the people to then you know, would they purchase a hearing aid and I really think that this is going to tap those people that were on the bottom end of that. Once again people don’t see me for a device people see me for a solution.

Brian Taylor
Yeah, no, that’s a great point. And that article by the way, I think was published in JAAA in 2009. I know it well because it’s a really practical article that I think every clinician should know about. Now I know before we started recording you had a big thick book there that you were I think maybe propping your computer I’ll

Lindsey Jorgensen
probably my computer up on here

Brian Taylor
want to share that book I think it’s

Lindsey Jorgensen
sure my computer down here so you could all see I keep this on my desk, the modern hearing aid essentials. Um, you know, I will say that this is one of my favorite books. My other favorite book is the compression for clinicians. Um, you know, those are kind of the

Brian Taylor
well, since we’re sharing textbooks, I wanted to share one with you that I don’t know it’s this one. I don’t know, this goes back to the 80s. It kind of dates me. This is a book on when we talk about customization I think of customizing. This is a Studebaker and Hotchpur,

Lindsey Jorgensen
that’s a great book, I have that one over in my in my stack as well. But when I

Brian Taylor
think about customization, I think about customizing the physical fit and then customizing the game and the output.

Lindsey Jorgensen
And there’s one more that I’m gonna show is the speech mapping and probe mic. book. That’s another great one as well. So

Brian Taylor
yeah, so now that we we’ve exchanged library books we can we can end our session, Lindsey anyway, any final words for our audience?

Lindsey Jorgensen
You know, I think that if your fear is that it costs too much remember that it that you have to think in the long term setting yourself apart. If you’re just trusting a manufacturer, you know, then what sets, what makes you an audiologist? Remembering that Real Ear is a starting point, but it really does depend upon you really meeting that patient where they are, and and some people are going to want more and some people are going to want less and that’s okay. It’s as long as you know what that hearing aid is doing in your patient’s ear is what makes you a professional.

Brian Taylor
Good to know. Well, Lindsey, again thank you for your time. Great to have you on This Week in Hearing. I hope to catch up with you again in the near future.

Lindsey Jorgensen
Thank you so much for having me. It’s been great talking to you. Yeah, likewise,

Brian Taylor
so long.