breakdown in the fitting process an idiographic approach

Chapter Ten

Breakdown In the Fitting Process

An Idiographic Approach To Fitting: A Matter of Perspective

by Steffi B. Resnick, PhD

Steffi B. Resnick, PhD, served on the faculty of Gallaudet University in Washington, DC and was Senior Audiologist with the CityUniversity of New York. She is currently in private practice.

"I am surrounded by exciting opportunities skillfully disguised as insoluble problems ." Anon.

For those of us engaged in the daily practice of dis-pensing hearing aids, there are, in addition to a legion ofdelighted clients, a substantial number of disaffected, dis-appointed, disgruntled, and/or dissatisfied ones . Amongthe unhappy are those who have rejected one or more fit-tings because of what they perceive to be insufficient ben-efit; those who have retained their fitting but use itintermittently, if at all ; those who consider the fitting un-satisfactory but persist in its use because of their financialinvestment, or the pressure (or encouragement) of familymembers ; and those who engage in a relentless quest foran instrument or provider who will restore their hearing asthey remember it, the sound of their own voice as they re-member it, or the sound of music, again, as they rememberit. Among them, as well, are those who reported they werepleased initially, but whose peripheral sensitivity, dexter-ity, cognitive status, processing abilities, or communica-tion environment has changed, producing new difficultiesin the utilization, management, or control of a previouslysatisfactory, or partially satisfactory fitting.

The demands of clinical practice and the goals ofclinical efficacy and fiscal viability dictate that we each

Address all correspondence to : Steffi B . Resnick, PhD, 103 E. Read St.,Baltimore, MD 21202 .

attempt to evaluate, as dispassionately as possible, thedegree of user satisfaction or dissatisfaction with a givenfitting, whether it is retained, or returned, by the client.One may, indeed, adopt the position that identification ofthe variables contributing to an unsuccessful fitting is asuseful as identification of those giving rise to a successfulone. Although the literature tends to emphasize the elec-troacoustic characteristics contributing to improved per-formance and increased client satisfaction with hearingaids, the clinical practitioner repeatedly confronts reportsof dissatisfaction and unacceptably poor device perfor-mance from the user . Thus, the audiologist frequentlyfaces the task of identifying the cause or causes of dissat-isfaction and either rectifying the problems or replacingthe fitting entirely. It falls to the clinician to determinewhether the dissatisfaction is a consequence of one ormore of the following : 1) the provider ; 2) the product; 3)the particular characteristics of the user; 4) the perceptionby the user (and/or the general public) of the productand/or its provider; 5) the process of selection; 6) a mis-match between a provider, a product, and a particularclient ; or 7) unidentified factors. Generating an increasedproportion of satisfied hearing aid users within one's ownpractice requires that one seek to understand and catalog(and thereby avoid) the factors he or she identifies ascontributing to a given unsuccessful fitting or to the ma-jority of unsuccessful fittings.

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RRDS Practical Hearing Aid Selection and Fitting

Dispenser CompetenciesOne may attempt to determine, by entertaining one

or more working hypotheses, the variables contributingto an unsuccessful fitting for a particular user . For exam-ple, as difficult as it may be to accept, one working hy-pothesis is that the unsuccessful fitting reflects on thecompetencies of the practitioner (as evidenced by erro-neous product selection, poor impression-taking tech-nique, or inadequate counseling regarding realisticexpectations for corrective amplification .) Practitionercompetency is a frequently cited cause of "remakes" bymanufacturers (1). The audiologist who judges this hy-pothesis to be correct in one or more instances may electto rectify the situation by becoming familiar with agreater range of products or with the idiosyncrasies of amanufacturer's product line . He or she may embark on anendless pursuit of the virtually infallible impression-tak-ing technique, of the newest measurement strategy, of themost highly touted fitting protocol, or of the most popu-lar user questionnaire, and seek to learn about user vari-ables beyond those treated in the audiological literature.The pursuit of greater competency has innumerable posi-tive consequences in addition to the development of par-ticular skills, of course. It leads to an increase ofknowledge, clinical acumen, and confidence as well as tothe development of a healthy skepticism toward the pro-paganda (negative and positive) and financial incentiveswith which we are constantly confronted by manufactur-ers and audiology "experts ."

Within the profession, the emphasis has been tooffer providers continuing education that tends to be ori-ented toward assessment of auditory pathology and to-ward the introduction of newly developed or revisedproducts and procedures . These programs are generallyoffered by academicians, service providers with a flairfor self-promotion, consultants to manufacturers, andproduct representatives from within the profession. Con-sequently, the information is limited to products and theirselection and is derived from individuals with trainingmuch like our own . Little is available on the impact of anindividual's developmental, cognitive, physical, and psy-chosocial characteristics on selection, fitting, use, and re-jection of hearing aids . Thus, the dispensing audiologistmay find it necessary to venture far afield to address hisor her weaknesses in information relevant to acceptanceand utilization of products by the end user of the aid.

Product CharacteristicsOnce having confronted one's own competencies,

one is in a stronger position to examine the products and

practices of vendors, the hearing aid manufacturers, andtheir representatives . The provider will recognize, how-ever, that the enhancement of skills and information is anecessary, but not sufficient, condition for increasedclient satisfaction . It will come as no surprise that manu-facturers provided with a suitable impression will differin their ability to fabricate a comfortable or adequateshell, to deliver an operational instrument, or to providea product that remains operational after 2 weeks of use.Experience with a specific product line from a givenmanufacturer may lead one to suspect that the problemsencountered in a specific fitting (inadequate control inthe fabrication process, inadequate specification of thecharacteristics of appropriate candidates, and/or toorapid a release of a poorly tested or constructed product)reflect the particular priorities of the manufacturer at agiven time. If one finds that to be the case, one maychoose to defer additional fittings from that manufac-turer until the quality control issues have been addressedor to attempt to engage in frank discussion with the man-ufacturer regarding the product limitations . Efforts to ob-tain information from manufacturers about productlimitations or defects can be a frustrating and minimallyproductive pursuit. Product recall for defective compo-nents and poor construction has not been a hallmark ofthe hearing aid industry . Deficiencies of product designand repair may be denied or dismissed as the idiosyn-cratic experiences of a given dispenser. Frequently,marked (but temporary) changes in the quality of prod-ucts are accompanied by an exodus of personnel withwhom one has become familiar or by an influx of per-sonnel previously associated with another manufacturer.Instead of receiving a candid report of the deficiencies,the dispenser may find that a product has disappearedsomewhat mysteriously from the product line or hasbeen replaced by an "improved" or "updated" model.The audiologist is then faced with the unenviable respon-sibility of maintaining the instrument operational for 3 to5 years, so as not to undermine client confidence in hisor her ability to make informed choices about products.The hearing aid manufacturer and product developerseek sales volume; the audiologist, however, must re-peatedly confront product reliability, longevity, repairhistory, quality, and speed of repairs.

Although testimonials of colleagues may be helpfulwhen one is considering a product, their reports must beinterpreted with caution and should be evaluated care-fully within the framework of one's own experience . Theincreasing availability of financing packages offered by

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Chapter Ten: Breakdown in the Fitting Process

some of the manufacturers as incentives for purchasingtheir instruments may prompt greater utilization of agiven product (despite its flaws) than may be warrantedon the basis of product efficacy alone . Colleagues alsomay be wedded to the use of one manufacturer's productssimply because they are unfamiliar with alternatives orbecause the institutional setting in which they operate fa-vors the volume discounts awarded by that manufacturer,or it has chosen to install the fitting software of selectedmanufacturers . In addition, it should be noted that themanufacturer's interest in satisfying a given dispensermay depend on the institutional structure in which he orshe is housed and in the volume of business generated.Thus, the experiences of a dispenser in a large, institu-tionally based setting may not correspond to those of onein a small solo practice. It soon becomes painfully clearthat the reported experience of colleagues, although po-tentially instructive, cannot substitute for direct observa-tion and experience. Unfortunately, acquiring experiencewith a range of products is a costly pursuit that may beonly partially offset by professional fees, as distinct fromthe product costs . It may well be, however, that it is pre-cisely those experiences that are of the greatest value tothe client, since they permit the dispenser to distinguishthe most appropriate product from the rest.

User AttributesHaving assessed the impact of dispenser compe-

tence and product characteristics on the client's satisfac-tion or dissatisfaction, one may wish to consider thehypothesis that the attributes of the user may be the pri-mary determinants of his or her satisfaction in a given in-stance . If this is the case, one must seek to define thosevariables, and address, circumvent, reduce, or eliminatethem as factors in subsequent efforts to provide moresuitable corrective amplification . For example, a user'spoor motor or cognitive capabilities may cause difficultyand frustration in activating a T-switch . In that case, onemay eliminate the T-switch (despite the virtually constantharangue one receives to include all-too-often inadequateT-switches for the sake of assistive listening device(ALD) compatibility and telephone use) . Or these samelimitations may preclude the user's mastery of a less-than-user-friendly remote control . One may select a prod-uct that offers a simpler remote with an easily read visualprompt, or one may select a device incorporating adap-tive or digital signal processing that does not require usercontrol or activation of the program .

It is also possible that the client's dissatisfaction isnot a function of the characteristics of the instrument buta reflection of the person's own disappointment at his orher dependence upon it . Consider, for example, the com-plaints expressed recently by a disgruntled user, "I hatethis damn thing. I can't do without it . I have to use it allthe time, and now, I suppose, I better get a spare one justlike it ."

It is conceivable, as well, that the audiologist mayregard a given client as simply too difficult to please . Theidentification and management of "troublesome" clientsis treated delightfully by McCollum and Mynders (2).

Increasingly, the research community is addressingquantification of the users' assessment of the benefit de-rived from, rather than their satisfaction with, hearingaids . Users who acknowledge the acoustic benefit de-rived from a given fitting may still judge the fitting un-satisfactory on other bases, or may engage in a seeminglyperpetual quest for a better, or a smaller, instrument . Thesearch for predictor variables that can be used to deter-mine user benefit appears a potentially fruitful area, pro-vided the experimental questions are expanded to addressbroader issues of user satisfaction and usage (3,4) . Identi-fication of those variables for specific groups, such as theelderly, may be particularly complex (5,6) . Efforts toidentify predictor variables may, however, further promptassessment of personality variables, communication en-vironments, and communication strategies (7) . At thepresent time, clinicians have limited access to assessmenttools that can assist them in predicting client satisfactionand use . And it is precisely this satisfaction (and dissatis-faction) that is the frequent topic of conversation amonghearing aid users, nonusers, and potential users.

Clinicians will recognize the particular challengesposed by aged adults who regard their hearing impair-ment as minimally handicapping, but is acceding to thepressures exerted by family members, friends, or bridgepartners who urge them to try an instrument that some ac-quaintance has reported to be satisfactory, or one that hasbeen recently advertised (8) . Such people may comeequipped with consumer information literature from ourown professional association, suggesting to them thattrial of several instruments may be required before theyconsider themselves satisfied. The matter may be furthercomplicated by the financial constraints imposed bymanaged care companies, whose administrators presum-ably believe that they should be appropriately compen-sated for their time but that fitting services should beprovided at no charge . That, unfortunately, may prompt

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the client to regard the provider more as a retail merchantthan as a knowledgeable health care professional.

Perceptions of the ProviderProviders need to evaluate the extent to which peo-

ple's perceptions of them as professionals are influencedby decisions they, or their superiors, may have made toeliminate charges for professional services (includinghearing aid selection, dispensing, and follow-up) . Simi-larly, providers may wish to examine the extent to whichsuch perceptions are impacted by their affiliations withspecific product lines in printed advertising and promo-tional "open house" activities (frequently encouraged bythe manufacturers to acquaint potential "customers" withtheir products) . Providers may determine that, in theirparticular environment, with their particular clientgroups, manufacturer marketing activities do not under-mine the perception of his or her professionalism in mak-ing impartial recommendations guided only by the bestinterests of the users . If the clinician determines other-wise, it may be advisable to eliminate promotion of par-ticular products and to devote more energy instead toprofessional preparation and expertise . The consequenceof such efforts may be recognition by users of the profes-sionalism and competence of the provider.

Selection ProceduresThe clinical provider who thoughtfully reviews the

causes of a fitting failure may modify pre-selection, se-lection, and post-selection procedures accordingly . Or heor she may judge there to be insufficient evidence that achange is warranted . Alternatively, the provider who re-jects the challenging (sometimes arduous, time-consum-ing, and frequently painful) process of a thoroughevaluation of the causes of the fitting failure, may preferto overlook expressions of dissatisfaction, advising theuser that his or her expectations were unrealistic and thatthe user must adjust to the new device . After havingfailed to persuade the client of the veracity of those asser-tions, the provider may simply accept the returned instru-ment and move on to the next client to repeat the process.Or, rather than relying on a personal assessment of prob-lems with the fitting and the myriad factors affecting anyfitting, the clinician may turn to the lofty pronounce-ments of experts who propose to lead one to more suc-cessful fittings through the adoption of a guaranteedapproach, or the utilization of a newly developed, but al-ways highly touted, "revolutionary" product.

If the proliferation of product-related and proce-dure-related publications is any indication of our collec-

tive proclivity, we seem constantly to be in search of theperfect product, the unblemished signal-processingscheme, and the flawless selection procedure—each ofwhich is presumed to work for the "majority" of users . Itmay be quite reassuring to adopt products and procedureswhose merit may have been demonstrated to be suitablefor the majority of highly motivated, cognitively and mo-torically intact, individuals with moderate hearing im-pairment with good word recognition ability andrecruitment, who are tested under conditions that lendthemselves to experimental control . To the extent that weadopt the position that the performance and experiencesof unpaid volunteers or paid participants in experimentalinvestigations (who do not purchase the products withwhich they are tested, or purchase them at much reducedprices ones the manufacturers and researchers may de-cline to divulge) will predict the performance and experi-ences of our clients, we may find ourselves increasinglydisadvantaged in our attempts to satisfy a particular indi-vidual . Although we may evaluate quite criticallywhether the audiometric configuration of a given groupof experimental subjects corresponds to the audiometricconfiguration of the person for whom we are consideringa particular fitting, we often do not question whether thecharacteristics of the experimental subjects are compati-ble with those of our own client population or with thoseof a particular individual . We may not identify the partic-ular characteristics and communication needs of ourclient that distinguish him or her from the prototypicalparticipant in experimental investigations of a particularproduct . If we fail to do so initially, we learn over timethat familiarity with the technology and research does notobviate the need for knowledge of the unique characteris-tics of the individual users and their preferences.

From a purely practical standpoint, it may be ofsome assistance to become informed about the sources offinancial support for refereed and non-refereed paper pre-sentations and articles dealing with hearing aids . Suchpresentations and publications are the primary vehicle foracquiring infonnation about the value of various productsand procedures. Therefore, attention should be paid to themotivation for that research . For example, manufacturersmay be in the position of providing post hoc justificationfor their desired claims of product efficacy and may fundresearch to provide that justification . The demands ofregulatory agencies, rather than the adequacy of the re-search and experimental controls, may dictate the re-search design . Under those conditions, the soundness ofthe science may be sacrificed to the exigencies of thefunding situation and to the need for manufacturer ap-

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proval of the protocol . Failure to recognize those realitiesof the "research" marketplace may impair the ability toevaluate the research findings critically to determine theirapplicability for one's own clients.

As audiologists, we may be well trained to evaluatethe auditory function of our clients and to determine theneed for corrective amplification based on a set of some-what arbitrary criteria . Our abilities to diagnose and as-sess hearing impaiiinent are better developed, and derivefrom a more extensive research base, than do our abilitiesto deal with the vagaries of hearing aid selection and pro-vision. Those vagaries, however, do give us an increasedopportunity to exercise our professional judgment, pro-vided we choose to do so . We may choose to accept thatchallenge and seek to expand and strengthen the bases ofthat judgment . Or we may retreat to the security of anewly developed fitting protocol or an easily adminis-tered questionnaire, despite the lack of evidence thatthose approaches enhance user satisfaction . We may findit more satisfying to adopt the position that it is in the de-velopment and exercise of our judgment and skill (de-rived from information and experience) that the successand satisfaction of each individual client may ultimatelydepend. Our responsibility becomes one of acquiring thetools that can assist us in developing our judgment andskill . It then becomes our responsibility to evaluate thevalue of our sources of information with respect to prod-ucts, to examine the validity of fitting strategies and tech-niques, to acquaint ourselves with approaches forassessing and documenting user characteristics and pref-erences, and to determine the unique features of the userthat require adaptation, modification, or rejection of ourcustomary approach.

We often are in the unfortunate position of exercis-ing our judgment based on limited and imperfect infor-mation about the products at our disposal and insufficientvalidation of the procedures for selecting those products.Our sources of product information impact significantlyon our ability to make judgments about product merit . In-variably, product information is received as promotionalmaterial from manufacturers, descriptive articles in tradejournals, visits from manufacturers' representatives,and/or sponsored seminars . We frequently encounter theendorsements of colleagues who report (for a variety ofpersonal, professional, or pecuniary incentives) their un-qualified success with a newly released product . We learnof the unique properties of a particular component fromits developer (who holds the patent) or from the manufac-turer who incorporates it in his product . Unfortunately,

the accolades of colleagues, product developers, or man-ufacturers rarely are accompanied by discussions ofproduct reliability or the characteristics which define theunsuccessful user . Only later, after the less-than-stellarperformance of the product in our practice, do we learnthat some versions used by some manufacturers haveproven less reliable under actual use conditions or thatthe user selection criteria have been made more stringentto reflect the manufacturer's experience with complaintsor returns . Guided by an interest in providing the mostadvanced product, as touted by manufacturer and col-league alike, we may succumb to the temptation (some-times enhanced by financial incentives) to try a newdevice for a select group of our clients . When we en-counter repeated failure or adverse reactions by users, wemay be advised by manufacturer and colleague alike thatproduct reliability issues will be addressed by minor de-sign changes or that the user selection criteria are under-going revision . Thus, the clinician unknowingly, andfrequently unwillingly, has provided valuable field test-ing of the product and has assumed both professional andfinancial responsibility for the endeavor. Recognition ofthis role may prompt one to defer use of the product untilevidence of its superiority is available, and to temperone's future enthusiasm for other revolutionary products.Considered in this context, Dr. Teter's cautions to the dis-penser deserve particular attention:

"When we hear claims of unparalleled su-periority relating to a particular hearing instru-ment surely we must objectively evaluate suchclaims . When any manufacturer or manufac-turer's representative states that a given systemof output control, amplification, filtering, com-pression, or fitting methodology is so superior asto be the only solution—implicating [sic] that notusing it in your everyday fitting would border onnegligence—then we must reflect on such state-ments, as well as reflect on the individual mak-ing the statements" (9).

The cautions to be observed with new productshave their counterparts in the critical evaluation meritedby various fitting algorithms and protocols . We literallyhave been deluged by algorithms for specification of thefrequency response or output limiting characteristics ofthe devices. Interest in them and their respective ratio-nales have spawned numerous research projects and haveoccupied chapter after chapter in texts devoted to fittingboth pediatric and geriatric clients . One might conclude

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that the attention to formulating and justifying prescrip-tive foi mulae (based on threshold or suprathreshold char-acteristics of the client) reflects the enormous importanceof the proper selection of the frequency response or out-put limiting characteristics of the instruments for usersatisfaction. The dispensing audiologist confronted byclient complaints about sound quality and product perfor-mance may find him or herself questioning the wisdomof enthusiastic adherence to a prescribed fitting rule.Plomp's comments on the "uninterrupted flow of papers"devoted to selection of the optimal amplitude-frequencyresponse since publication of the Harvard report (1947)may place the emphasis on fitting rules in a useful per-spective :

"In my opinion, this large number of stud-ies on the selection and fitting procedure of hear-ing aids leads to the following two conclusions.First, the everlasting search for a better ampli-tude-frequency response illustrates the fact thatmany subjects are not satisfied with their hearingaid(s) ; the explanation for this is likely to be theunavoidable noise problem rather than an inap-propriate hearing aid as such . Second, the abun-dance of fitting procedures should be seen asevidence that the amplitude-frequency responseis not as critical as the literature seems to sug-gest" (10).

In that context, the suggestion by Punch that the po-tential value of fitting procedures that allow listeners tochoose an individualized response rather than being pre-scribed a formula-based response (11), assumes particu-lar significance for the dispensing audiologist . Theadvent of digitally programmed instruments and multiplememory devices permits effective implementation ofprocedures based on individual preferences and system-atic alteration of performance characteristics to assist theclient in adapting to corrective amplification . Indeed, theintroduction of digitally programmable, single and multi-ple memory hearing aids, considered in combination withthe absence of consensus on suitable prescriptive algo-rithms, may put the responsibility for response selection(at different points in the adaptation process and underdifferent listening conditions) once again into the handsof the audiologist . Adherence to a given fitting algorithmmay be discarded in favor of the requirement that the userconsiders a given program satisfactory in his or herunique communication environments (12-14) . The audi-ologist who dispenses multiple memory devices may be

guided by the manufacturers' suggestions for responsemodifications appropriate to specific environments, suchas the Speech Audibility and Stability (SAS) Rule offeredby Widex (15) or the comfort programs provided byPhonak (16) . In addition, researchers are again proposingcomputational approaches to determining frequency re-sponse characteristics appropriate to the interaction be-tween audiometric configuration and noise environment(17) .

We may find ourselves again seduced by the ease ofimplementing a computational formula for deteiniiningthe settings of digitally programmable, multiple memoryinstruments . Again, however, we may find that theclient's satisfaction may depend on the audiologist's abil-ity to listen and respond to the user's recitation of thesuccesses and failures of the instrument in the communi-cation environments he or she considers most significant,rather than in a broad range of environments encounteredby the prototypical hearing aid user.

To fill the void left by the rejection of many of therules of fitting based on specification of the optimal fre-quency response, we now are being advised to pursuemeasures of loudness growth as a major determinant ofuser success, and that compression products offer untoldbenefits for persons with hearing impairment . We are ad-vised that we would be more than somewhat remiss if wefail to include loudness judgments in our selection proce-dures. We are encouraged to use measures of loudnessgrowth for nonspeech signals (which fail to consider is-sues of temporal and spatial summation in the loudnesspercept of complex signals) . Again, we are to be lulledinto the comfortable belief that if we standardize themeasurement technique and apply it to all clients, we canoverlook the questionable validity of the procedures.

Ricketts has called into question the value of the"fitting by loudness" approaches that have proliferated oflate . Before embarking on the use of those measures, onewould do well to recall his caveat that:

"Although [ . . . fitting by loudness . . .]strategies are currently being advocated for thefitting of low-threshold compression hearingaids, many assumptions made in their develop-ment have yet to be validated" (18).

Indeed the very value of these compression instrumentsand the basis of the "surge in sales" is being called intoquestion (19,20) . That, apparently, has not dampened theenthusiasm of the Independent Hearing Aid FittingForum, which advocates the inclusion of frequency spe-

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Chapter Ten : Breakdown in the Fitting Process

rstripped the abilities of the audiology community to capi-

cific loudness judgments as part of a comprehensive fit-ting protocol for the fitting of nonlinear instruments(21,22).

Technological advances in hearing aid design(which reflect industry-based efforts) appear to have out-

talize on them and to employ them successfully. Theattention of those doing "applied" research appears to beoriented primarily toward the assessment of the relativeefficacy of various signal-processing strategies or of theadvantages of advanced signal processing over conven-tional linear instruments (usually the client's own instru-ment), documentation of user auditory characteristics,and the refinement and application of user questionnaires(23) .

Increasing attention is being paid to the use of ques-tionnaires for the quantification of perceived acousticbenefit, as part of the emphasis on accountability . TheAbbreviated Profile of Hearing Aid Benefit (APHAB),has gained well-placed popularity as a convenient andclinically practical vehicle for quantifying the frequencyand type of acoustic problems encountered under unaidedand aided listening conditions (24) . Concerns have beenraised, however, regarding the efficacy of the APHAB forassisting in the clinical selection of amplification (25).Like word recognition measures, questionnaires maylack the sensitivity to differentiate between alternativeadaptive, or digital, signal-processing strategies, and mayserve simply as a vehicle to document that the user real-izes some advantage of using corrective amplificationand to organize the data gathered in a convenient way.The provider may wish to evaluate, prior to adoptingthem as part of his or her standard clinical protocol, theextent to which available questionnaires address issuesrelated to user physical comfort, to time required by theuser to achieve mastery of the product, to ease of inser-tion and removal, to battery life and ease of battery re-placement, to cosmetic considerations, to productreliability, to ease of telephone use, to problems withfeedback, and to other factors that the provider may viewas critical to client acceptance, use, and satisfaction . In-deed, the suggestion has been offered that the communi-cation benefit derived from hearing aid use is "extrinsicto the hearing aids themselves" and is determined by thenoise and reverberation characteristics of the communi-cation environment, the distance to the talker, and thecharacteristics of the communication partner (26).

Although the literature is extensive on the docu-mentation of audiological status of the client that should

precede provision of a hearing aid, evaluation of the myr-iad nonauditory characteristics affecting the individual'sinterest in, and acceptance of, amplification has beenscanty at best . Considered in that context, the judgment,experience, and expertise of the provider may assumesubstantially greater significance in achieving user satis-faction than the merits, real or purported, of the productitself. In addition, clinical experience suggests client sat-isfaction with a given product may reflect the practi-tioner's ability to identify characteristics, preferences,and limitations of the client and to select the product orproducts that meet his or her needs . Schweitzer (27), ad-dressing hearing aid fitting in the context of private prac-tice, suggested that hearing aid fittings may be enhancedby developing "some intuitive wisdom about the person-ality features that may contribute to greater success witha client" (p . 39) . Perhaps it is our responsibility to de-velop more than an "intuitive wisdom ." Indeed, is it pos-sible that client variables, such as cognitive status, thepresence of a significant other in the home, and the de-mands on the person for communication efficiency are ascritical, if not more critical, in determining hearing aiduse and client satisfaction . If that is the case, then one'srole as a clinical provider is expanded to include identifi-cation of factors affecting the client's active and positiveparticipation in the adjustment process, and of the per-sonality characteristics important to the client's evalua-tion of the product, the process, and the provider. Theexpansion of the provider's role dictates his or her assess-ment of the user's communication environment and theuser's cognitive ability to utilize and to appreciate thebenefits of corrective amplification . The expanded role isa more complex one, demanding that the provider beguided, but not restricted, by generally accepted clinicalprocedures.

Indeed, the clinical provider, faced with the daunt-ing task of hearing aid selection, may adopt a position,likely to be regarded as heretical by hearing aid manufac-turers and "measurement-driven" members of the audiol-ogy community, that the presence of significant hearingloss is not the sine qua non of hearing aid provision . Theprovider may choose to provide fewer individuals withpersonal corrective amplification and to restrict provisionto those whose potential for satisfaction and whose de-mands for effective communication are the greatest . Per-haps one could increase the proportion of satisfied userswere one more selective in identifying hearing aid candi-dates and more rigorous in limiting the instruments one isprepared to provide .

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About 20 years ago, an analytic approach was pro-posed that sought to address and weight the factors ofuser motivation, self assessment of communicative im-pact, attribution of communication difficulty, age, userflexibility and adaptability, and dexterity in the predic-tion of client success with hearing aid use (28) . Althoughthe Self Assessment of Hearing Handicap has receivedsubsequent attention (29), and has been used for the eval-uation of hearing aid benefit, its implications for determi-nation of hearing aid candidacy have not been explored.

The multiplicity of issues impacting on hearing aiduse may have been too complex for the audiology com-munity to address in a systematic way . In a recent specialissue on hearing aids in Ear and Hearing, only one arti-cle was devoted to nonauditory measures to estimate thebenefits provided by amplification (4) . There is, how-ever, encouraging evidence that researchers increasinglyare addressing features other than peripheral auditorysensitivity in their assessment of auditory function, par-ticularly in the elderly. That research is finding a forum inpublications readily accessible to clinical providers(30-33).

There is an increased recognition of the impact ofdisruption in central auditory processing on the audio-logic management of the geriatric person (34) . A largerissue, perhaps, is the individual's overall level of func-tion, cognitive ability, manual dexterity, and visual acu-ity. We have been cautioned to consider the"biopsychosocial variables" when deciding on the reha-bilitation potential (i .e ., candidacy) of an older hearing-impaired adult (35 p . 492) . We similarly have beenadvised that the variability among aging persons must beconsidered and that counseling should be "tailored to theunique listening needs, skills and strategies of the indi-vidual" (36 p . 352). We have been in the position of rely-ing on our observations . Formal assessments typically donot occur within the context of hearing aid selection anddetermination of hearing aid candidacy . Simple measuresof cognitive status form part of the physician's clinicalarmamentarium (37), and are being applied in audiologyresearch studies to establish eligibility of potential partic-ipants . Perhaps they should be an integral part of ourclinical armamentarium as well.

The astute reader will recognize, of course, that noformulae or standardized protocols have been profferedfor increasing client satisfaction and reducing break-downs in the fitting process . Lest one be left with the im-pression that I consider the possibilities for generating anincreased proportion of satisfied users of amplification an

unattainable goal, I offer the following approaches thathave assisted me in developing an idiographic approachto hearing aid selection in the context of an independentaudiology practice.

L Cultivate relationships with other knowledgeableand experienced audiologists from other areas of thecountry who have experience with a broad range ofproducts and are prepared to engage in a frank ex-change of information regarding the merits andshortcomings of those products . Beware, however,the practitioner who emphasizes his or her success,admits to few failures, and devotes excessive dis-cussion to the number of products dispensed and tohis or her profit margin or bottom line.

2. Invest in software and hardware and in the educa-tional preparation required to dispense a broadrange of digitally programmable products . This ca-pability may serve to restore excitement in theprocess of amplification selection and to examinecritically and with minimum cost the assumptionsunderlying hearing aid fittings . The flexibility toalter a variety of electroacoustic characteristics andto engage the client actively in the process of selec-tion and adjustment imbues that process with a de-gree of precision and professionalism previouslyunavailable.

3. Attend continuing education offerings and consultreference material to acquire information outsidethe audiology arena that may prove useful for un-derstanding the physiological and psychologicalcharacteristics of the population served . Judgmentsregarding potential corrective amplification devicesmay be made more efficiently and expertly whenconsidered within a general framework of informa-tion about the user and his or her similarly agedpeers . For example, I have found the Merck Manualof Geriatrics (38) and texts by Whitbourne (39) andKemp et al., (40) to be particularly valuable in plac-ing the hearing impairment and its amelioration insuitable context for the aging adult.

4. Trust to your intellect and your experience to deter-mine the products best suited to your client . Investi-gate the benefits of alternative approaches anddiscard adherence to procedures of questionablemerit and validity . Question the pronouncements ofexperts and the hyperbole of advertising . Attend tothe maximization of user satisfaction and user bene-fit, and limit the provision of products to those per-sons whose motivation, psychological status, and

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environment make them suitable candidates forhearing aid use.

5. Provide clients with alternative sources of informa-tion about products and procedures so that they canassist in defining their specific requirements, needs,and preferences and are aware of the implications oftheir choices . Among the reference materials I haveused are texts by Erber, Hays, and Shimon (41-43).

REFERENCES

1. Allen P, Kelley S, DeDyse R, Sorenson E, Borta R . Reducingremakes . Feedback 1995;6 :29-31.

2. McCollum HF Jr, Mynders JM . How to recognize (and handle)the troublesome client . In : Hosford-Dunn H, Dunn DR, Har-ford ER, editors . Audiology business and management . SanDiego, CA : Singular Publishing Group ; 1984.

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4. Gatehouse S . Components and determinants of hearing aid ben-efit . Ear Hear 1994;15 :30-49.

5. Schum DJ . Responses of elderly hearing aid users on the Hear-ing Aid Performance Inventory. J Am Acad Audiol1992;3 :308-14.

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7. Garstecki DC, Erler SF. Older adult performance on the com-munication profile for the hearing impaired . J Speech Hear Res1996 ;39 :28-42.

8. Brooks DN . The effect of attitude on benefit obtained fromhearing aids . Br Soc Audiol 1989 ;23 :3-11.

9. Teter D . Audiologists and mint jelly. Hear Rev 1995;32-4.10. Plomp R. Noise, amplification, and compression : considera-

tions of three main issues of hearing aid design . Ear Hear1994;15 :2-11.

11. Punch JL, Robb R, Shovels AH . Aided listener preferences inlaboratory versus real-world environments . Ear Hear1994 ;15 :50-61.

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14. Keidser G, Dillon H, Byme D . Candidates for multiple fre-quency responses . Ear Hear 1995 ;16 :562-74.

15. Ludvigsen C, Weise P, Westermann S . Fitting of multiprogramhearing aids, taking into account speech audibility and stabilityof the hearing aid : the SAS rule. Verloese, Denmark: WidexAPS . Widexpress, No . 3, 1994.

16. Bachler H, Vonlanthen A . PiCS comfort programs : signal pro-cessing to support your manner of communication . PhonakFocus, #27, 1994.

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21. Cox RM. Using loudness data for hearing aid selection : theIHAFF approach . Hear J 1995 ;48(2) :10, 39-44.

22. VanVliet D. A comprehensive hearing aid fitting protocol . Au-diol Today 1995 ;7(5) :11-5.

23. National Institute on Deafness and other Communicative Dis-orders and the Department of Veterans Affairs . First biennialconference on advancing human communication : an interdisci-plinary forum on hearing aid research and development; 1995.

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25. Paul RG, Cox RM . Measuring hearing aid benefit with theAPHAB : is this as good as it gets? Am J Audiol 1995 ;4 :10-3.

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28. Rupp RR, Higgins J, Maurer JF. A feasibility scale for predict-ing hearing aid use (FSPHAU) with older individuals . J AcadRehabil Audiol 1977 ;10 :81-104.

29. Schow RL, Gatehouse S . Fundamental issues in self-assess-ment of hearing . Ear Hear 1990 ;11 :6S-16S.

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31. Humes LE. Speech understanding in the elderly . J Am AcadAudiol 1996 ;7 :161-7.

32. Humes LE, Watson BU, Christensen LA, Cokely CG, HailingDC, Lee L. Factors associated with individual differences inclinical measures of speech recognition among the elderly. JSpeech Hear Res 1994 ;37 :465-74.

33. Chmiel R, Jerger J . Hearing aid use, central auditory disorderand hearing handicap in elderly persons . J Am Acad Audiol1996;7 :190-202.

34. Strouse AL, Hall JW III, Burger MC . Central auditory processin Alzheimer's disease. Ear Hear 1995 ;16 :230-8.

35. Weinstein B . Needs of the geriatric population . In : Alpiner J,McCarthy P, editors . Rehabilitative audiology : children andadults . Baltimore, MD : Williams & Wilkins ; 1993.

36. McCarthy PA, Sapp JV. Rehabilitative considerations with thegeriatric population. In : Alpiner J, McCarthy P, editors . Reha-bilitative audiology : children and adults . Baltimore, MD:Williams & Wilkins ; 1993.

37. Folstein MF, Folstein SE, McHugh PR. Mini mental state: apractical method for grading the cognitive state of patients forthe clinician . J Psychiatr Res 1975 ;12 :189-98.

38. Abrams WB, Berkow R, editors . The Merck Manual of Geri-atrics . Rahway, NJ : Merck & Co ., Inc . ; 1990.

39. Whitbourne SK. The Aging Body. New York: Springer-Verlag ;

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1985.40. Kemp B, Brummel-Smith K, Ramsdell J . Geriatric rehabilita-

tion . Boston, MA: College-Hill Press ; 1994.41. Erber NP. Communication and adult hearing loss. Melbourne,

Australia: Clavis Publishing ; 1993.42. Hays J . Hearing loss : questions you have—answers you need.

Allentown, PA: People's Medical Society ; 1994.43. Shimon DA. Coping with hearing loss and hearing aids . San

Diego, CA : Singular Publishing Group, Inc . ; 1992 .

STEFFI B . RESNICK, PhD has been in private practice inBaltimore, Maryland for a number of years . She received herdoctorate from the University of Oklahoma . Dr. Resnick didpostdoctoral work at the Johns Hopkins School of Medicine,was Senior Audiologist with the City University of New York,and served on the faculty of Gallaudet University, Washington,DC. Dr. Resnick's major interest are in the areas of hearing aidselection and fitting, and electrophysiology .

breakdown in the fitting process an idiographic approach

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