“I Was Unethical and Didn’t Understand it.”
This is a continuation of Part I of “An Audiologist in the Wilderness” by James Curran. Part I appeared in Wayne’s World Blog October 30th, 2011.
James Curran, M.S.
Dispensing Hearing Aids by Audiologists Was Unethical
At that time, until 1976, to dispense hearing aids was considered unethical by the ASHA. The reason given was that the audiologist should not profit financially from the selling of a hearing aid that he/she had recommended for purchase. That is, we were taught that we should give advice to the patient in an objective manner, not swayed in any way by monetary considerations. It was thought if we sold the hearing aid we recommended, we could be easily influenced by our pocketbooks rather than what was best for the patient. Actually, this was a dictum that had been put in place for the reasons given previously, to elevate the profession in the eyes of the academics, for audiology was, after all, a new and very young profession, starting only in 1947 after WWII.
I came to the conclusion that the only reasonable path for the profession was for audiologists to directly dispense hearing aids. Audiologists would learn what they obviously did not know, and most importantly, with our academic training, begin to develop rigorous, reliable procedures and methods for fitting aids that assured efficacious treatment. This point of view was vigorously rejected and resisted by all the university faculties and by the leaders of the American Speech and Hearing Association, for it threatened their standing in the university community, so they thought. I even remember arguing vehemently with Don Schaefer during this period that what he was proposing was unethical, and he said to me in so many words, “You’re dead wrong. Surgeons diagnose serious problems in patients and expect to do the surgery. They don’t refer their patients to other doctors for the surgery to make sure they will not be influenced by monetary considerations. The answer is in the thorough training the profession should inculcate, wherein its members are taught to believe in placing the patient’s needs above their own “
Of course, he was right. If audiology could not educate and train audiologists to make the right decisions, then the profession was a failure. In the end, enamored with the mission and the financial opportunities that lie ahead, I left the University in the midst of writing my dissertation, and opened a dispensing office in Minneapolis in 1967 selling Radioear and Audiotone hearing aids. Shortly thereafter, a few other pioneering souls joined me in the crusade, opening offices in Detroit (John Schuneman), Milwaukee (Otis Whitcomb, who had started with me in Minneapolis but soon left), Denver (Don Northey) and Philadelphia (Mel Sorkowitz).
Consorting with the enemy.
The little over two years I spent dispensing in my retail office were both the most informative and at the same time the most trying I’ve ever spent. In order to get referrals, I visited all the ENT physicians in the Twin Cities to sell them on the new and startling idea of a free standing audiology/hearing aid dispensing facility, and to ask for their referrals. You could count on one hand the number of audiologists who were engaged in any sort of private practice in the country at that time, and none dispensed. I then learned to my dismay that members of the audiology faculty at the University of Minnesota (where I did my undergraduate work) were contacting the same physicians and telling them that I was unethical, and urging them not to refer to me. What was a confused physician to do?
So referrals came slowly. Rejection from most of the local audiologists was palpable, and then one day I opened an envelope from the ASHA, and Ken Johnson, who was the Executive Director at the time and who was adamantly opposed to audiologists dispensing, informed me that on the day I sold my first hearing aid I had violated the ASHA Code of Ethics, and therefore my membership was revoked. Subsequently a notice to that effect was circulated to the membership.
It was difficult for me to accept the idea that I was an unethical professional, when I knew I was properly motivated and operating in the best interests of patients. But I’m not surprised, in looking back, that I felt like an outcast and no amount of self-talk helped rid me of that feeling nor its reality. But I loved what I was doing. I went to dealer’s meetings and conventions, never revealing I was an audiologist if I could, visited with manufacturers and began to assimilate from the “good” dealers how to do things. I started using the Auricon, a master hearing aid from Audiotone, to help me select slope, gain and output in my fittings, an immeasurably valuable help. I spent hours at my bench taking apart hearing aids, cleaning and reassembling them, soldering and installing CROS aids in eyeglasses, learning how to grind, modify and buff earmolds. I read all I could about the different fitting philosophies of the time. Most of all, I began to learn how to encourage patients to accept amplification, and how to fine tune and resolve fitting problems as they arose.
I opened a satellite office in Duluth to which I traveled to and from each Friday, except for the times when, after closing the office, I did follow up calls in Bemidji, or Two Harbors, or other outposts up in northern Minnesota. More than once I had to stay overnight and return home Saturday morning. Some of my patients were in nursing homes or were non-ambulatory requiring long trips out of that office. Once I found myself in a little backwoods town where the patient, referred to me by a local physician, was bedridden and lived in a home without electricity. Fortunately, I had a battery driven audiometer with me.
Needless to say, the aids of the time (the Sixties) were Model T’s compared to today. They were usually fitted with closed molds, often with deep canals, nearly always monaural. (Audiologists considered the fitting of two aids borderline unethical.) Vents were used but kept fairly small or feedback ensued. Two response alternatives might be available in a few selected models; low cuts, if available, were in the order of 5 dB or less. BTE aids were quite large in size, eyeglass aids were popular but required the dispenser to learn how to adjust and fit eyeglasses, battery life was short, internal and external feedback was endemic, and ability to make OSPL adjustments uncommon. The irony of it all was that the majority of my patients presented with mild-to-moderately severe high frequency sensorineural losses, yet the aids of the day were best suited for flatter, more severe losses.
Nevertheless, my fascination with the complex issues of providing useful amplification grew. Fortunately, about the time I started dispensing, the hearing aid world was just becoming aware of a newly discovered idea: by leaving the earmold open, either by using an extremely large vent in the earmold or by delivering the sound into the ear canal through a tube, the low frequencies of the response would drop out, but the high frequencies would remain. The only way this could be accomplished without feedback was to separate the aid in half, putting the microphone in one eyeglass temple and connecting it by a wire to the receiver and amplifier in the other temple (CROS). With this arrangement, high frequency losses, the most prevalent form of hearing loss configuration, could be easily fitted, even if only monaurally. But that was light years better by comparison.
Sales of eyeglass aids began to rise due to CROS fittings. And articles began to appear in the professional journals showing that discrimination scores would actually improve dramatically as a result. It’s hard to believe, but it was conventional audiological wisdom at the time that the best discrimination score the patient could possibly obtain would be under TD-39 supra-aural earphones. It was expected that when a hearing aid was fitted usually the scores would stay the same or be poorer. So open mold, open canal fittings became the rage, just as today. As Jerry Northern said laughingly one day, “You could fit a CROS aid on a telephone pole and it would probably work.” I wallowed in the warm realization I finally had a method in hand for providing excellent amplification to a majority of the population I was seeing and I was actually able to deliver what I promised.
After being rebuffed by most of the audiologists in the area, I found that I understood more and more the dealer side of things. Early on, the Beltone dealer in Minneapolis came up to my office to visit, welcomed me, and said: “The way of things between competitors is this: I will fit some of your customers, and you will fit some of mine. That’s the way it has always been so it’s not useful to fight each other, since we have more in common than not.” That was a revelation, for until that time I had regarded dealers, due to my training, with hostility and distrust. As I grew to know my dealer competitors better, and relied on them for help and information, I realized, like all human beings, they should be regarded with respect. I learned to differentiate between those improperly motivated, or abysmally ignorant, and those who tried to conduct their businesses with dignity and responsibility towards their patients.
The ASHA had embarked at that time on a crusade to bring hearing aid dispensing in the U.S. under the control of audiology, using the VA dispensing system as a model. Although previously there had been ongoing disputes at the local and national levels between audiologists and the hearing aid dealers about licensing, these issues began to really heat up. I was enlisted by the Minnesota dealer organization to lobby on their behalf with legislators, and I undertook my responsibilities seriously. I knew that the bill being proposed was inadequate and very unfair to dispensers, and that the audiological community, so few in number, in no way was ready to assume overall responsibility for dispensing in Minnesota. Of course, I had serious reservations about what I was doing. I believed the lack of an effective dealer licensing law was a continuing obstacle to elevating competence in dispensing, but the bill under consideration had no chance of providing a remedy.
Part III of “An Audiologist in the Wilderness” will continue in one of the following blogs. Look for: “Into the Jaws of the Beast.”