Friday Audiogram: Beyond Real Ear Measurement - Why Patient Perception Matters

Ray Woodworth takes us on a deep dive into the nuances of hearing aid fittings, sharing insights from his dual perspective as both a 47-year hearing aid wearer and an industry professional. He challenges the notion that real ear measurement alone is enough for optimal fittings, advocating instead for a balanced approach that honors both objective measurements and subjective patient feedback.

Drawing from his experience of fitting countless patients with custom technology, Ray explains why custom ear molds are crucial for patients with moderate to severe hearing loss, especially in the low frequencies. "When you run real ear measurement with a dome versus a custom, I've seen a 9dB difference," he notes, emphasizing how this can dramatically improve streaming quality and overall sound experience. The anatomical uniqueness of each ear—from curved canals that resist dome placement to surgical modifications that require specialized approaches—further underscores the need for customization.

Most compellingly, Ray shares his personal journey with hearing loss, revealing that despite having measurable thresholds in his right ear, standard target-matching through real ear measurement creates uncomfortable distortion. This highlights the critical importance of patient perception, which can't be captured by measurement tools alone. Using the metaphor of a light dimmer, he explains how patients who have lived with hearing loss for years may need time to adjust to proper amplification, requiring hearing care professionals to balance technical perfection with practical comfort.

What truly sets exceptional hearing healthcare apart isn't just technical expertise or high-tech equipment—it's the humility to listen to patients and respect their subjective experience. "We have to be humble and listen to the patient, no matter how much we know," Ray emphasizes, "because the patient tells us the truth." Ready to experience hearing care that values both science and your unique perception? Tune in to learn more about this balanced approach.

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Chapters

• 0:00 Introducing Best Practices in Hearing Healthcare
• 1:02 The Value of Custom Technology
• 3:01 The Uniqueness of Every Ear
• 4:24 RealEar Measurement vs Patient Perception
• 6:58 The Importance of Listening to Patients
• 8:37 Balancing Objective Tests with Subjective Feedback

Transcript

Speaker 1: 0:00

This is the Friday Audiogram. Let's go Right, let's talk about so. There are best practices in the hearing healthcare industry that we talk about, and best practice, the one that's been most talked about within the last you know, really five to seven years is real ear measurement. But real ear measurement has been around for many years, however, and there's all different statistics on the percentage of hearing care professionals that have a system but actually use it. But let's just go with 30% of hearing care professionals that's probably kind is actually implementing real ear measurement on a daily basis with every single patient. What has your experience been? Fitting patients with custom technology, not only CICs, iics but, rick, with custom receivers? When you run real ear measurement, is it just a game changer when you are customizing, like what?

Speaker 2: 1:01

do you see? That's a good question, Blaze. You know, if you, if you look at, you know, like we know, we look at the hearing losses, If you run really with the dome, you'll see that you can't get a lot of lows, especially if the loss is down at 50 or 60 dB in the low frequencies. And what do you have to do then? You've got to customize it. The reason why? So it gives the lows back. It gives you the lows.

Speaker 1: 1:22

And if you don't customize it, you're cranking up those lows and it's going to sound not good. Yeah, it's not good.

Speaker 2: 1:28

So my point that's a good point that you brought up Every ear is unique, so every impression is unique. When you run a real ear, every ear is unique because the acoustic response of the ear, the nature of the ear, and when you fit a dome on an ear that's a moderate to a severe loss and the dome is too small, you're bleeding out all that information they need, so you're not utilizing the technology they can experience. So anytime you have a loss that the lows are down, especially at 500 and 750, if it's down at 50, 60, 70 dB, you should make a custom case mode and I call that best practice. I believe best practice is you make a custom on a loss that needs lows than doing a double dome or an open dome because you lose the benefit of what they need. So yeah, I think you can see that when you run realer the response. But dome versus a custom. I mean I've seen a nine day difference also when you're streaming the low sound, because the lower frequency is what gives you power and volume Right. The high frequency is what gives you clarity. So if they want to get that bass and that good sound of music, give them the lows by making a custom, especially if the lows are down.

Speaker 2: 2:38

Now, like I said earlier, you can fit people with mild hearing losses with a custom if the ear is big enough and there's some ears, and you guys know this out in the industry. There's some years that don't like domes. They're too curved and they're hard to get in, no matter what size dome you use. So we have all different types of domes but at the end of the day, a dome, an ear, is not a commodity. They're uniquely different and we have to respect that. And I think and I told you earlier that you know I've shot over 100 impressions in one- day 100 impressions in one day.

Speaker 2: 3:09

We had a class here and we're feeding audiologists and dispensers that have hearing loss and there's over 50 people that needed hearing help and we wanted to help them.

Speaker 2: 3:17

So we were till two in the morning just shooting and shooting, and shooting and, man, it dawned on me how unique we are. You know, it was not only the anatomy but the sensitivity. I can go on and on about impressions, because that's my specialty. But you can be a great impression-taking person. But every ear is different. Some ears are more curved so it's harder to place the block. Some ears are really straight. You can go right down the ear with it. So when you learn the skill and you master it, you can go up against anything.

Speaker 2: 3:44

I'm one of the few and I'm going to proudly say this, I'm one of the few that enjoy shooting surgical ears. I like surgical ears, I like the challenge. Bring it on. So I see big cavities, I've seen finisrated ears, I've seen mastoidectomies, I've seen atresia, I've seen stenotic ears. I've seen pretty much all of it and I've learned that it humbles you when you see so many ears and how unique they are, because you and I talking and you meeting people, you have no idea what the ears look like unless you look in there or shoot an impression and it just mind boggles me how different we are from ear to ear. So that's one of the reasons why you hear about RealEar, because RealEar measures that unique ear and every ear is unique. I like Relio. Relio is a great tool to use and I think it's a great starting point of what the patient's needs are, based off their hearing loss. And you know we use formulas and every factory has their proprietary formula. We have E-STAT and I don't know what Phonak and Oticon's proprietary formula is. So we have all these different formulas and we run Relio and you get to see the response and you match target. But there's something to be said about that we don't talk about and I want to talk about it because it's so important.

Speaker 2: 4:52

I've had a hearing loss all my life. I've been wearing hearing aids since I was eight years old and I'm 55. I'll be 55 next month and I have threshold in my right ear. If you look at my audiogram, I was born with a pretty significant hearing loss. My right ear is down at 90 dB across the board. My left ear is about 40, 50 in the lows and 70, 80 in the highs, so it's a little precipitous. If you run really on my right ear it's going to distort and it's so uncomfortable, even though I have thresholds.

Speaker 2: 5:27

The key to fitting successfully is not only your ear but it's perception. The perception of how we hear is so important. So that's why there's some offices and I'll be quite honest with you that don't run radio but they listen to the patient perception of loudness. You can I've had really one of them many times I've used it. You can do best, target match and look beautiful, but the patient says it's not loud enough. The guy's been wearing hearing aids for 20 years. He's a power junkie, he loves volume.

Speaker 2: 6:01

So what do you do? You turn it above target Because the patient's telling you it's not loud enough. So you've got to have both. Yes, you've got to have real ear and you've got to have perception of what the patient's telling you, because I see things that I can't explain. You know, sometimes we run real oh, it's too tinny, it's too sharp, they're hyperacoustic, they're sensitive to high frequencies. So you've got to roll it off a little bit. You can't just leave it there and say, oh, get used to that, they're not going to want to wear it because it's too tinny, it's too much.

Speaker 2: 6:25

So the example that I use is the light dimmer. You know, when you go into a dark room and you turn that light on. It's normal. But to you it's so bright Because, you got to remember, an average person waits six to seven years to get hearing help. That's the average. And all of a sudden you turn the hearing aid on and you map it. They're going to say whoa, whoa, whoa, whoa. This is a little much. So we use a dimmer, we kind of dim it down. We got compression, we got all these features that we can use to comfort the patient. Compression was made for comfort. That's why we have it. But I think sometimes we put the dimmer a little too low, sometimes we put too much compression and what that does is it doesn't make the sound as bright.

Speaker 2: 7:06

So I use an example of a dimmer, of a light. So I tell people, just dim it down a little bit, even though you're not at target, let them get used to it and they can always turn it up. So what I'm trying to say is this I've seen real ear measurements ran where it's too tinny or it's not loud enough or they don't feel like it's, they don't like the way it sounds, and I've seen it where you run it and it's beautiful and they love it and they walk out and they're happy. So I've seen both sides of it, but you got to understand both. If you understand both, I think you're more successful than just doing real ear all the time.

Speaker 2: 7:36

So there's a lot of subjective, not just objective, measurements that we have to talk about, because we have billions of neurons in our brain that are firing. Do we really understand what they're hearing? The patient tells us, not the computer or formulas. The patient tells us. So I've learned, working here as many patients I've seen, that we have to be humble and listen to the patient, no matter how much we know. We have to be humble and listen to the patient, no matter how much we know, because the patient tells us the truth.

Speaker 2: 8:00

I'll give you an example. If you make a custom mold and by all means I'm not perfect, believe me, I've made a lot of mistakes in my life but if I make a perfect mold but the patient says it's uncomfortable, I'm not going to tell them to go walk out and get used to it. I'm going to modify it. If a patient's reeling really and they say it's not comfortable, I'm not going to set them to walk out. I'm going to modify it for their perception of what they hear, not what the computer tells me.

Speaker 2: 8:23

So I've seen it over and over again that people say reeling is the best thing, which is great, don't get me wrong. But it's not to serve a bullet. It's a great tool and I think it helps a lot of people and I think we get great responses. I think it's awesome, but you've got to listen to the patient. The patient is just as important as really, and I think that we need to do both and make both as important, not just really. So again, the reason I'm getting so into this is because I've seen it over and over again how patients tell me too teeny, too loud, too soft, too echo, occluded, whatever, all subjective Right, and we do a lot of objective measurements speech and noise, real ear you know all the tests that we do and I think we don't pay attention enough to the patient and what they're telling us.