When it Rains, it Pours
As if the events discussed in my previous posts were not enough, this time period (the 1970s) coincided with “renegade” and “unethical” audiologists talking about selling (sanitized by referring to this as “dispensing”) hearing aids for profit, and both the dispensing and audiological communities working to legitimize (protect their turf) their disciplines via licensing laws.
The audiological community was attempting to establish, expand, and legitimize their traditional employment activities of 1) clinical, or diagnostic audiology, 2) teaching, 3) auditory rehabilitation, and 4) audiological research {{1}}[[1]] Johnson, E.W., Audiologist, hearing aid dispensers and the hearing impaired public, Audecibel, Winter, 1969, pp. 14-19, 22, 23[[1]]. The hearing aid dispensing community sought to certify and protect their established position as retail businessmen. It was not a time for the thin-skinned, and battle lines were drawn that, when looked back at now, show how ideological, dishonest, defensive, and unprofessional groups can become when attempting to protect their turf.
During this time period, audiologists, for the most part, were likely to refer patients to those dealers that they felt most comfortable with and who would follow their hearing aid recommendations. The irony is that many of the recommendations by audiologists would have been better fitted based on the dealer’s experience.
Many rains start with a drizzle
Many rains start with a drizzle. So, it was with audiologists wanting to expand their scope of practice (terminology not used then) and hearing aid dealers wanting to secure their livelihood in selling hearing aids.
Already in 1967, audiologists harbored dissatisfaction with procedures followed in dispensing hearing aids, as was recognized by Panel VI in ASHA 1967 publication “A Conference on Hearing Aid Evaluation Procedures” {{2}}[[2]] ASHA Reports No. 2, American Speech and Hearing Association, September, 1967[[2]]. This document recommended that audiologists take a more direct role in the dispensing of hearing aids, and asserted that this involvement would help fill the responsibility audiologists should have in providing complete aural rehabilitation.
A consistent story being advanced within the audiological community was that many problems existed with delivery procedures. One example of what was considered malpractice was that 82.4% of hearing aid dealers responding to a survey (1964) indicated that medical examination was not necessary for all persons who wished to purchase a hearing aid. The implication was that many persons who purchased hearing aids were fitted without benefit of proper assessment that could have been aided by medical and/or surgical intervention. Dissatisfaction was also expressed with the fact that control of hearing aid fittings rested in the hands of individuals whose primary concern was commercial, and that they had minimal training or knowledge of the population served. It was also frustrating to audiologists that clients seldom returned to the clinic for a follow up following hearing aid recommendations to a dealer. As audiologists we believed that our service and advice were indispensable, only to find out many years later that the client could tell that the dealer knew something about the day-to-day care and feeding of hearing aids, whereas the clinic seldom did. Decisions to return or not to return were most likely made by the client, based on their experiences. And, the nail in the coffin of hearing aid dealers – the selling price of many hearing aids was much greater when compared to manufacturer’s cost!
Hearing Aid Dispensary
The Hearing and Speech Institute of Hamilton, Ontario initiated a program in October 1969 that essentially put all decision making in the hands of the audiologist. The basic concept was as follows. Following appropriate otologic and audiologic evaluation–and only after such assessments were completed, hearing aids were made available to patients at actual cost. Hearing aids were purchased from only one manufacturer. Actual cost was determined by adding the wholesale cost of the hearing aid to a calculated fee encompassing the dispenser’s salary and necessary operating expenses (a person to dispense the hearing aids, rent, equipment, telephone, stationery, postage, etc.). Operating expenses were estimated, based on previous year’s expenses, and the number of hearing aids that would be fitted. Using this approach resulted in “considerable saving to patients served” {{3}}[[3]] Weber, L., and Head, B. A new concept in dispensing of hearing aids, National Hearing Aid Journal, January 1971, pp. 9, 28-29[[3]]. Hearing aids were sold under cash terms only (no financing), with a three-to-four-week return appointment. This was considered strictly a trial period. Any returns during this time were for full cash refund, minus the cost of the earmold. (No explanation was ever forwarded about how refunded hearing aids were resold). Also, only the dispenser’s salary was included in calculation of operating expenses. No portion of monies received for hearing aids was paid to either the medical specialists or to the audiologists. The person “hanging” the hearing aid (what they called the hearing aid dispenser) was selected based on personality, not on any direct hearing aid experience. A one-week training session with the manufacturer prepared that person fully for the task at hand. The program demonstrated that audiologists could become more involved in dispensing hearing aids without direct commercial involvement and without profit intent.
Following the lines of a “hearing aid dispensary,” an entire panel at the November 1970 ASHA (American Speech and Hearing Association) convention in New York was devoted to this matter. Three of the principal speakers were Dr. Kenneth Berger (Kent State University), Dr. James Shapley (Veterans Administration, Seattle), and Dr. Earl Harford (Northwestern University). Dr. Berger recommended a significant improvement in the level of cooperation between audiologists and dealers as the first step in answering this question satisfactorily. He reviewed the well-known areas of conflict and granted the dealer the role of fitting/selling hearing aids, but cautioned against dealers “playing audiologists” while performing this role. Also on the panel was Larry Weber, who discussed in detail the non-profit methods used by the Hearing and Speech Institute of Hamilton, Ontario in dispensing hearing aids to its patients – the program described in the previous paragraph.
Dr. Shapley was more outspoken in his opposition to audiologists selling hearing aids. His reasoning related to the possible effects it would exert on his public image and doubts it would raise to his unbiased professional decisions. Dr. Harford stressed that positive actions had to be taken by doctors, audiologists and dealers alike to strengthen the confidence of the patient within all three groups, and that what the audiologist really wanted was better and closer control over the patient through all stages of his/her rehabilitation. This triad of presentations was printed in full in the National Hearing Aid Journal in 1971 {{4}}[[4]] To sell, or not to sell – that is the question! National Hearing Aid Journal, January 1971[[4]]. Featured with these was an article by Larry Weber and Brenda Head of the Hearing and Speech Institute of Hamilton, and comments by Tony Mynders, a veteran Philadelphia dealer and NHAS (National Hearing Aid Society) stalwart. Mynders asked a very pertinent question: “Where does professionalism end and commercial selling begin?” Dr. Berger summed up the existing and future status of the continuing conflict between the audiologist and dealer by stating: “None of the audiologist-dealer irritants will disappear unless men of goodwill in both groups sincerely and openly discuss them, and work for their relief. Surely, it is not too much to hope that, with the hearing impaired individual’s needs in the forefront and intramural rivalries kept at a minimum, the irritants can be resolved agreeably.” {{5}}[[5]] Bolstein, M. ASHA…To sell, or not to sell, that is the question! National Hearing Aid Journal, January 1971, p. 5[[5]]. So, in general, the need to help each other was there – somewhat – but the desire was not.
Unfair Competition?
It should come as no surprise that the “Hearing Aid Dispensary” program following the Hamilton, Ontario direction was considered by businessmen as being an unfair type of competition. Some audiologists agreed with the approach, but one could almost hear the wheels starting to turn in the minds of others wondering why they did not at least take a “little profit” for the work involved, other than just a dispenser’s salary.
