Real ear measurements (REM) and best practices

If you’ve ever wondered why two “good” hearing aid fittings can feel wildly different to a patient, the answer usually isn’t the device, it’s the process. I’m joined by Madison Levine, BC-HIS and owner of Levine Hearing in Charlotte, and Dr. Dave Fabry, Chief Hearing Health Officer at Starkey, for a practical conversation about best practices in hearing health care that actually improve patient outcomes.

We get specific about what belongs in a modern best-practice toolkit: strong case history and counseling, real ear measurement (REM) for verification, and speech-in-noise testing (like QuickSIN) that matches how people struggle in the real world. Dave explains his REM goals (smooth real ear aided response, three input levels, MPO sweeps, LDL/UCL) and why “hitting target” is a starting line, not the finish. Madison shares how her clinic bakes verification and outcome measures into the workflow without slowing the day down, and how data logging turns follow-ups into smarter, calmer conversations.

We also dig into innovation, including how immersive sound simulation with systems like Inventis Symphonia can help demonstrate noise features, personalize settings, and validate a patient’s experience. Along the way we touch on the ear-brain connection, motivation for first-time users, and what to implement tomorrow if you can only change one thing.

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Transcript

Welcome And Partners

Blaise M. Delfino, M.S. - HIS 0:06

Welcome back to the Hearing Matters Podcast, where we explore hearing technology, communication science, and the people and ideas shaping the future of hearing health care and hearing loss around the world. Before we kick things off, a special thank you to our partners. Care Credit. Here today to help more people here tomorrow. Inventis. Inventis is innovation. LA Productions. Tell your story, share your brand, and fader plugs, the world's first custom adjustable earplug. Welcome back to another episode of the Hearing Matters Podcast. I'm your founder and host, Blaise Delfino. And as a friendly reminder, this podcast is separate from my work at Starkey. Now, let's get into the conversation. I'm your host, Blaise Delfino, and joining me today is Madison Levine, Board Certified Hearing Instruments Specialist, and she is the founder and owner of Levine Hearing in Charlotte, North Carolina, and the one and only Dr. Dave Fabry, who is the chief hearing health officer at Starkey, and we're going to be diving into all things best practices. Madison and Dave, welcome back to the Hearing Matters Podcast.

Madison Levine, BC-HIS 1:25

Thank you.

Dr. Dave Fabry 1:26

Thank you so much, Blaze.

Blaise M. Delfino, M.S. - HIS 1:28

So, Dave, you and I have talked about best practices for many years. And I will say, as a friend of mine, but really a mentor first, I've been hearing you talk about best practices since I started in 2012, 2013. So, from your vantage point at Starkey, what are the non-negotiables, if you will, when we talk about best practices today?

Dr. Dave Fabry 1:54

Sure. And even though it's been a long time going into way back machine to 2012 when you first became a hearing care professional, I think the most important thing for people to remember is best practices serve as an important yardstick of the quality of outcome based on evidence to determine what tests should be done by clinicians to achieve optimal results. But as somebody that's been in practice since 1983, best practices should be dynamic. We cannot let, in my opinion, I cannot speak for all of Starkey. We have many different customers and many different distribution groups and membership organizations. And their membership organization is going to define what their best practice is. So it would be arrogant of me to suggest that I know what is non-negotiable from a best practice standpoint, but I will say simply that we need to look to evidence basis, we need to look to clinical expertise, we need to look to patient outcomes and roll all of that in. And it was a long-winded answer, but I do feel really strongly that we should not be paralyzed by best practice at the expense of innovation. We need some way to assess hearing. We need to counsel properly in terms of what options might be available after that hearing assessment. And we believe the audiogram, UCL, maybe MCL tells where it is in the patient's residual auditoria that they like to hear. Some sort of speech testing. We'll get into that a little bit more, I think. I use real ear measurements on everybody to give, not as an end-all, but as a beginning, a starting point to acoustically match the device to the patient's ears. And then I think it's extremely important not to forget about counseling in the ongoing basis.

Blaise M. Delfino, M.S. - HIS 3:41

Madison, you are a private practice owner, and I did some research. Your clinic has hundreds of five-star reviews. And that doesn't just happen. It doesn't just happen overnight. That is really evidence that you and your team are implementing best practices. So in your clinic, what does best practice look like day to day, not in theory, but true execution?

Madison Levine, BC-HIS 4:09

You know, Dave touched on so many pieces of this. It is comprehensive. It's not one thing. And I do believe that sometimes best practices get boiled down to one term. Are you doing real year measurements? Are you not? And I do believe very much in real liar. And we actually have five Inventus Reelier trumpets in my office. So we've got one in every exam room. It's easy to access. So that's one piece of it, but there's so much more. Getting incredible history from the patient, asking those really pointed questions so that you understand where they're coming from and what their needs are. That counseling aspect, there is so much in the words that we choose to use that are going to motivate a patient in order to get them to accept the help that we're offering. And then you have to verify that things are really working at the end, that the patients are getting what they asked for. And as Dave said, it's so much an art. There's the science, there's the evidence, you run real year on every patient, and it is a starting point.

Blaise M. Delfino, M.S. - HIS 5:20

Madison, walk us through your real ear measurement workflow. And the reason I really want you to dive into this, Madison, is because there are some hearing care professionals who will say you have to do it at the first fitting. There's some who will say do it at the second follow-up. So what is Levine Hearing's real ear measurement workflow? And what does that appointment look like for your patient?

Madison Levine, BC-HIS 5:47

It certainly is going to be clinic by clinic, right? So my way is not the only way, but we have found doing it on the first fit is very efficient. So when we're getting that equipment ready for the patient to walk out of the waiting room into our exam room, we have real years set up. We've got everything oriented in the room correctly. We've got the devices already connected to the computer. So when the patient enters the room, I try to make things a little funny when they're awkward. So I'll say, I know it's really weird. We're putting you in this position in this chair. Just take a seat. We're so excited to get you fit with your new hearing aids today. How are you feeling about it? So we put them right into position from the first moment. So we're not losing any time. It makes it very efficient. Once they're seated, we're explaining what to expect at this fitting appointment. Then we go, okay, we're gonna run this test. And that's the very first thing that we do. And in doing that, it just makes it kind of takes the awkwardness and keeps it at the front of the appointment. And we get everything wrapped up in less than 10 minutes, and then we're able to get to more of the fun stuff.

Blaise M. Delfino, M.S. - HIS 6:56

I love that workflow of implementing Real Ear on that first appointment because then at least you can toggle back and forth with the adaptation manager if need be, or telehir. But Dave, what have you found? And you are a major thought leader for lack of a better term, but you have seen the evolution of Real Ear while it's the same in concept throughout the years. What have you found to be a real ear measurement appointment that works best for you? Is it still that first fitting, or do you kind of wait for a follow-up? Like what does your process look like?

Dr. Dave Fabry 7:35

Yes, in answer to your question, I I do it at first fitting. I do it in follow-up. I don't wait for problems to occur for doing real ear measurements, because I believe that while real ear is not the end-all-be-all, I want to be very clear on that. I think that if you don't do real ear, it's like practicing by astrology instead of by astronomy. It's still a mixture of art and science, but at least we can put the planet and the moons and get them in alignment. And by that I mean using real ear ensures audibility and ensures what I'm really looking for, independent of the fitting formula. And that's a different topic that we could go down rabbit holes as to whether proprietary or non-proprietary targets. When I was on Madison's side and a manufacturer said, Oh, well, our proprietary targets have been optimized for our technology, I would say, can I verify it? And they'd say, well, no. And then I'd say, well, come back when it can. Well, now it can. And so within the Inventa system, the trumpet that I use as well, I mean have, because of its portability, because it incorporates speech testing, audiometry, and real ear measurements, it's ideal for my type. I'm licensed in Florida, California, Minnesota, and Rwanda. And so I'm very much likely to be on the go at some time doing either remote telehear or doing face-to-face audiometry and real ear measurements for the start and for uh after the fitting. My protocol is and my goal with real ear is very simple. Regardless of what formula I'm using, I'm trying to get a relatively smooth real ear-aided response. That prevents feedback in high-powered situations, improves sound quality for everyone across the board from mild to severe or to profound in degree, and really starts to set up as all hearing aids these days, almost all are nonlinear amplifiers. I use three input levels. I personally use 50 because my room where I do testing is pretty quiet. I mean, some people will bump it up 5 dB or so to get over the noise floor. My room is quiet, so I do 50, 65, and 80. And I use AutoREM. It's another tool that is incorporated within the Inventis system with the Starkey Profit software to enable an automated solution that is faster than what I can do alone, if you will, on manually for those three levels, because it will not only do the three levels, but it will match to within a criterion amount of plus or minus 5 dB of the target and then allow for manual adjustments before I go on. In addition, I always do an MPO sweep and I typically do LDL or UCL, whatever you want to call it, measurements to ensure that not only am I not exceeding the patient's measured discomfort thresholds, because that physical discomfort and acoustic discomfort are two things that will bring the hearing aids back fast for credit. And we don't want to see that. However, I won't say that it's almost as bad, but it is not a desirable contact to just set the MPO of the hearing aid at a level that leaves headroom for the patient, that is, residual auditory area above the maximum output of the hearing aid. If I'm leaving that on the table, I'm taking dynamic properties of sound away from the patient. So simply put, my strategy is to get a smooth, relayated response at three levels, ensure MPO never exceeds loudness discomfort level. I'm trying to provide as broad a frequency response as possible, and trying to use as much of the patient's residual auditory area as possible to keep compression ratios as low as possible, which in my hands is how I achieve the best results from patients. I don't want to have compression ratios that are too high. So that's a little wonky, but I think it's important for people thinking about real ear. It's not, in my opinion, not simply saying, well, I use real ear measurements, and that's part of best practice, but understanding why you're using them is more important.

Why Real Ear Still Gets Skipped

Blaise M. Delfino, M.S. - HIS 11:32

Thank you for bringing that up, Dr. Fabry, because I think oftentimes we get so overwhelmed with the software and the technology of it. It's like, well, let's start at the basics with that compression ratio and what does that look and sound like, not only for us as hearing care professionals, what we're reading on real ear, but also what the patient is subjectively experiencing. Madison, I want you to answer this next question first, and then Dave, I definitely want you to follow up. We know there's so much evidence in terms of real ear measurement and the importance of it and patient outcomes. Despite all that evidence, why isn't real ear measurement universally adopted?

Madison Levine, BC-HIS 12:54

My suspicion is that there's enough people who believe that data is a myth, but they don't really believe it. So I know that we might argue some people don't think there's enough time to do it, or maybe the investment in the equipment seems high. Those might be the case for some people. I still see on forums and out in the world plenty of people who are saying, ah, I don't really believe in it. So the data's in front of them, but there's mythology around it. Does that make sense?

Dr. Dave Fabry 13:29

I would add to that, and I think, yeah, time, money, I think confusion, because I think they get hamstrung by being told, well, you should use a proprietary formula or a non-proprietary formula, or hooking up the equipment, the automated REM makes it simpler to get to that first space faster than you could do manually, as I said. But I think there is one other element with real ear that is a reasonable objection. And that is it does not measure hearing. And so you can achieve targets on a patient with severe to profound hearing loss and say, yep, I've matched my targets, you're good to go. And they may not be able to understand any of that because as we say all the time, you don't hear with your ears, you hear with your brain. And real ear measurements is an assessment of the peripheral audibility based on the thresholds and then the discomfort, but it does not measure understanding for speech, the most important signal we listen to on a day-to-day basis. And that's why it's a tool. It's not the whole, it's a tool as part of an ecosystem, as part of best practice, but it doesn't measure everything.

Building Efficient Clinic Workflows

Blaise M. Delfino, M.S. - HIS 14:33

And I'm happy that, you know, Madison and Dave talking about it as a tool in your toolkit, that is, yes, number one, we're talking about best practices are best for the patient. It's one of the many best practices. And Madison, you and I had talked a couple of months ago a little bit about best practices, but I love how you and your team create such a great patient experience and patient flow. Now, best practices, again, it's not just real year measurement because that's been the rhetoric for many years in our industry of real year, real year, real year, real year. It's one of many tools. So at Levine Hearing, we're talking cognition, we're talking abbreviated profile hearing aid benefit, we're talking about THI, all of these outcome measures. How do you operationalize best practices without slowing your clinic down?

Data Logging For Smarter Follow Ups

Madison Levine, BC-HIS 15:30

You know, all of these pieces are in the workflow. So when somebody onboards, we're not having to recreate the wheel. It's something that I've added one piece at a time over the years. And my true confession is when I started, about the same time you did, Blaze, I don't, I didn't have the mentorship on that exposure to those best practices. And so I was doing the best that I knew to do at the time. But over the years, I've learned, I've read the research, I've had great mentorship, and I've added one piece at a time to the puzzle. So now where we are at 11 years in practice in this business that I opened, now we've got this very comprehensive plan. But I would say that the place that I find efficiency is not just in the best practices we're doing, it's in the other things that we're doing. So by using assistance, by leaning on my front office and training our support teams, we're able to create so much more time for providers to operate at the top of their scope and provide the best outcomes.

Dr. Dave Fabry 16:35

So one tool that I would say is right in the fitting software from every major manufacturer, certainly ours, is data logging. And Madison, I guess I would have a question for you, for your team and you personally. What do you look at? Do you look at data logging? When a patient comes back, that's the first screen that pops up with our software. What specifically, sorry to put you on the spot, but what specifically are you looking for in your data logging for a given patient to help guide you with the discussion that day at the follow-up or regarding their ongoing care?

Madison Levine, BC-HIS 17:09

The first thing I notice is what volume they've been keeping it at. That's where my eyes go first. Bottom right of the screen, I'm noticing are they turning it down every day or are they turning it up every day? And it ignites questions for me about how they're using them. Of course, I'm looking at the hours that they're logging, but I'm also very curious about the volume, the average volume that they're exposed to through the day. I've had such surprises. I've had somebody that didn't tell me that they were driving a truck all day. Like somehow it didn't enter the conversation, and they're averaging 70 plus dB a day. So all of those pieces, it sometimes it's things that didn't come out in my question that then I'm getting an insight into their lifestyle when they come back.

Dr. Dave Fabry 17:58

Yeah, that's great. And you know, I've seen the hours per day use with my patients creep up in the last five years to where I would say the patients that I'm working with are averaging 15 hours a day or more use. Whereas a decade ago it was 10 hours for a happy patient. You said, man, if they're wearing 10 hours a day, they're pretty satisfied. Now that's not enough anymore. I want my patients putting them in the morning and taking them out at night. That's my goal, unless there are reasons that prevent them from doing that for their work or whatever. But yeah, hours of daily use, program use. Um, one of the things that we've only very recently incorporated, we have a feature called edge mode, which in addition to the automatic program, we didn't in the past display in data logging. How many times did the patient activate edge mode? I really like to look at multiple program use and edge mode activations as a measure too of how they're incorporating their hearing aid use. Are they some people just want to set them and forget them, put them in their ears, don't adjust anything. That's their goal. Part of that is my job to figure out what their goal is. But I would say that a lot of people don't scroll down to page two of the Google search and go down to the bottom of data logging, and you'll even see a little bit more information that maybe might surprise you about where they spend the majority of their time in quiet or noisy environments, the acoustic classifications. And when people are saying, well, how can I convince patients that higher tier technology is better? One thing that studies have shown, Dr. Wu at Iowa and colleagues have shown that, you know, as opposed to some other previous studies that said, ah, there's not much difference between low tier and high tier, the conclusion from that study said that for patients who are in more dynamic situations, in noise, in a variety of environments throughout the day, they appreciate the more advanced features. And so if they're in a lower tier and you see that, but they're not entirely satisfied, or it's time to consider new amplification, I think a lot of information is contained in data log that is just staring you in the face. And a lot of times people aren't even scrolling down far enough to see all of the information that is there. But I applaud you for looking at the things that you're looking at.

Simulating The Real World With Symphonia

Blaise M. Delfino, M.S. - HIS 20:07

And what's nice too about looking at the different situations or environments that the patients have been in, we're talking about best practices. That's part of the best practice of patient counseling. But also another opportunity, let's say Dr. Fabry, you know, this specific patient is in the Omega AI 24 level, and they're in very noisy situations, but they just want a little bit more of an edge in those complex listening situations. That's when you, as the hearing care professional and us as the hearing care professionals, could talk about is it a table mic? Is it a remote mic to increase that signal-to-noise ratio? So, best practices is this full ecosystem, and it's how we're showing up for our patients. Really excited because Madison, you and your team are going to be doing some work with the Inventis Symphonia. But so are you, Dr. Fabry. And Dave, let's have you kick this off first. You're very familiar with the system, you're very familiar with the technology, and one of your, I would say, passions in audiology is speech and noise. Like speech and noise is very important. So, what are you, number one, looking at as it relates to working with the Symphonia system and Starkey Omega? And what do you hope to find and even educate patients on?

Dr. Dave Fabry 21:37

So, you know, the Symphonia system is I've been using for a relatively short period of time, but it augments some things that I'm doing in the clinic anyway. I do use speech and noise testing, usually the quicksin. I'm also using the ACT, the test that is looking at a non-language-based measure to assess distortion that occurs in hearing that they've incorporated as an option in the trumpet. The trumpet really has a lot of different functionalities built into it. I'm not afraid to use the automated audiometry to save time if I'm doing multiple things. As usually I'm running around with what little hair I have left is on fire, and I'm trying to do that. And I can also monitor the patient and do automated audiometry. I said automated auto-rem, but the symphonia adds a different level. Now, to be very clear, the symphonia is not verification in that it is not measuring what the trumpet does, where it's measuring amplified and really acoustically matching the device and the venting and the microphone. Microphone location effects, the depth of insertion of the buds or the molds to the patient ear, it takes all of that into consideration. What the Symfonia does, and really there have been systems that have tried to do this in the past. Starkey had a system uh 10 to 15 years ago called Surround Town that sort of began looking at trying to simulate acoustic environments. And the benefit is that rather than having to go accompany the patient in their real world, you can simulate a noisy environment. And I use it to do a quick gut check in terms of how do I demonstrate edge mode by putting noise in the speakers and turn it on and off. And you can do live switching between features within our products. You can adjust noise management levels or directional microphone settings on the fly and get some impression from the patient. I have four speakers that I use. It can go anywhere from three to eight speakers. I use four. Because I don't have a huge space. I use it, I recognize that one of the issues is that many clinicians will say, I don't have space for something like this. And that's a challenge. You need about a meter distance between the patient and the speaker. So you need a two-meter space to really do this effectively. But it can really assist you with counseling. It can assist with demonstration of a feature like edge mode. It can assist with personalization of noise management settings or compression settings, as I mentioned. It can be a follow-up. You know, too many clinicians say, I don't want to subject my patient to the feedback stimulus because it might make them uncomfortable, or I don't want to use an MPO suite because it might make an uncomfortable. And then they live in New York City and the patient walks out on the street and there's sirens and everything going by. The clinic, the facility where you control all of the levels is an ideal place to probe the upper levels of input, as long as you're not going to dangerous levels or uncomfortable levels, to really fine-tune. And I think that's one of the differences in what I see as one of the high potential applications for Symphonia.

Blaise M. Delfino, M.S. - HIS 24:47

Madison, your team recently received your Symphonia system. Now, being that Dave just touched on, first and foremost, the space aspect, kind of bring us through for clinicians who may be interested in Symphonia. There's a lot of change management that's going to go on at Levine Hearing. So bring us through that process whenever you're onboarding a new piece of equipment that is part of best practice and also what your team's most excited about, and if you believe that this is going to enhance the patient experience.

Madison Levine, BC-HIS 25:48

So we have been talking a lot about best practices, and we haven't exactly touched on this, but speech and noise testing in the booth is so essential to me. Not just for the information I gather from it, but for the counseling I get to give the patients. And they feel validated. So when they walk in complaining about noise and you only do a beep test, then they look at you like you're crazy. How does the beep relate to the noise? So anything that we can do to create a more immersive experience, patients see it, they understand it, they feel that you are you're listening and you truly are trying to help them when they leave your office and they go back out into the real world.

Dr. Dave Fabry 26:37

Do you ever put patients' families in the booth to do any testing instead of doing under headphones, doing through speakers? Do you ever do that? I've done that before in cases where there's a gap between the family member who's there who doesn't really understand what the hearing loss is like. And like, look, I can whisper and they can hear me as long as I'm looking at them. But why do they need hearing aids? What are you trying to sell me? And then I'll say, okay, let's do that and put them in the booth through the speakers. And they'll say, Oh, I never realized. Not only does it validate for the end user, because they're saying, no one's ever tested me in the environment where I have trouble, but it validates for the family member who says, I never understood just how much trouble they're having. And I've seen tears come as part of doing that example for patients and family members.

Madison Levine, BC-HIS 27:26

Absolutely.

Blaise M. Delfino, M.S. - HIS 27:27

Madison, you said a word there, immersive, and that definitely defines the Symphonia system. And it reminds me a lot in audio engineering, you have your near field monitors. And you'll normally have two, you know, left and right, and you'll mix and you'll master. But now there's something called the Dolby Atmos, and it's an immersive mixing room. It's an investment on the audio engineers aspect and their part. But whenever you go to a movie theater, and let's just say you were to hear like arrows going from left to right, that's all Dolby Atmos, and that's that immersive experience. So, how incredible is it now to Levine Hearing and of course, you know, Dr. Fabry to not only provide that immersive experience, but Symphonia, you know, it's the symphony. So it's like the patient is being the conductor of their better hearing with you as the provider, co-piloting with them. I mean, that's got to be super exciting for the patient as well. And Madison, I'm curious as a private practice owner, patient retention, referrals, trust. You had said when you first started, and I think it's for everyone, because when you're starting in practice, there's so much newness to the journey, for lack of a better term. And then you start to get into a flow that works for your clinic, so on and so forth. How do you see, and have you seen a measurable difference in patient referrals and trust and retention by committing to best practices, not just real ear, but also oral rehab, outcome measures, all of that?

Speech In Noise Testing That Validates

Madison Levine, BC-HIS 29:12

Absolutely. Yes. I mean, in the early years, so many things were a slap on the wrist. They were things that I learned by failing. Why did a patient return a pair of hearing aids? And I was extremely introspective, you know, kind of beating myself up on what could I have done better? They had a need, I felt I could meet that need, and I didn't. So, how where was my failing? What did I not do to help them keep them? And through the years, I've realized that each one of these pieces is part of the process. I've told my team that there's a phrase that I use a lot to always be selling. And the idea is that patients don't just make a decision to be motivated at the moment that you ask them if they're ready to move forward with hearing care. They are actually building upon that decision from every interaction that you have with them, from your website to the phone call with your front office to walking in the waiting room, the first thing you say to them, the things you say to them while you're testing them, each piece of those interactions is building to that motivation. And so each piece of best practice is doing the same thing. It's helping them move forward successfully, keep them, use them, make their lives better.

Dr. Dave Fabry 30:38

And I also, you know, just pulling on that thread a little bit more with the way Inventus has gone about naming the equipment in their portfolio. As you said, Blaze, is sort of I have the trumpet, I have the drum, which as a fellow drummer, you understand, you know, for coupler measurements, there are still times where I can measure distortion that I can't necessarily hear in situations. They have the piccolo, they have a whole host of different instruments, but symphonia really puts it all together. All of the different pieces of the orchestra add flavor. And, you know, I sum it up simply that, you know, REM, and I want to really emphasize again that Symphonia is not a substitute for REM in terms of the verification of the way I use it, but REM provides evidence of audibility. But the Symphonia, in combination with follow-up care, data logging, et cetera, provides the and it proves really that the fitting is meaningful to the patient, has an impact on the patient. It pulls it all together.

Blaise M. Delfino, M.S. - HIS 32:46

Dave, how do we better communicate the value of best practices to patients so it's not just like more testing, but better care?

unknown 32:56

Yeah.

Blaise M. Delfino, M.S. - HIS 32:57

How do we express that?

Trust Referrals And The Patient Experience

Dr. Dave Fabry 32:58

You know, I think I said that in the last bit that we're gonna use numerous different tests. And like we've talked about here, where it's gonna be some sort of assessing, behaviorally assessment in their hearing through an audiogram, likely. Some people are increasingly looking at loudness measures now that we're working with nonlinear amplification, but we're gonna do a series of tests that that evaluate how you hear. We're importantly gonna do speech and noise measurements to see where you break down. You're saying that you're having difficulty in those environments, but and then the counseling we've talked about as well. I like to think of it as especially for first-time users. And according to the Market Track 2025, 58% of people coming in now because of the baby boom generation, the greatest generation, that they are first-time hearing aid users. And so they are at best struggling with an approach avoidance or an avoidance-avoidance conflict. They don't like that they have a hearing loss. They're not wild about wearing hearing aids. Now we're over 50%. If you roll up everything of people who have a hearing loss, do something about it. So you have to recognize that they're coming in with some apprehension, most people, the first time. And so we need to number one, listen to them, find out what are their fears. Where do they want to hear better? Whether you're using a formal metric or not, this can be done simply with a counseling conversation. I'm a big fan of the stoic epititis. I use two ears and one mouth because we have, you know, so we can listen twice as much as we hear in a clinical environment, not like this podcast environment. I listen more than I speak. And I think it's essential to doing that because you need to understand beyond the audiogram what the patient's going through. And I think what I try to do is impress upon them, not just sticking my nose in the computer and running the test, but listening to them first, finding out what their expectations are, what their concerns are, assessing their hearing in situations where they're having difficulty, fitting the hearing aids, verifying, and then evaluating initially using a tool like the Symphonia, and then following in the data logging and with conversation, how I can continue to improve it. I don't have the expectation that the first fit is the final time that I'm going to make adjustments. But I will tell you that a lot of young clinicians find it hard to resist the temptation as soon as the patient comes back and says, I'm not hearing here, there, or some somewhere else, to not fiddle around in the software. Many times it's not really a programming issue, but something else that you need to get to by listening rather than speaking.

Blaise M. Delfino, M.S. - HIS 35:31

Dr. Fabry, so many, so many questions there that I actually want to ask Madison. Madison, Dr. Fabry touched on the fact that there's a lot of baby boomers who are addressing their hearing loss. And I believe in the latest market track, Dr. Fabry, you'll have to help me out with the statistic. It used to be patients would wait seven to 10 years to address their hearing loss. That has now decreased in time, correct?

Dr. Dave Fabry 36:00

Yes. Yes, it has. It's down almost, it's down, I want to say three to five, if not four to six years. So it's come down a lot. And as a result, the average age from a first-time hearing for a first-time hearing aid user has dropped precipitously. And that is due to, I think, the practitioner creating that need. I think it's the technology has improved. And I think boomers are not as stigmatized by hearing aids and what they look like, but rather have higher expectations for what they can do and they connect hearing care to overall health care, whether they express it or not. They want to make sure they're as connected to other people in retirement as possible. And so there's a generational shift that has led to a reduction in the time from assessment to action, a reduction in age, because we say, look, I don't want to use it or lose it, and all of the associated comorbidity between hearing and other health conditions. And I want to, I want to remain socially active. We all know that is the key to healthy aging.

Communicating Value Without Over Testing

Blaise M. Delfino, M.S. - HIS 37:04

Well, and speaking of being socially active and keeping our brain active, Madison, you gave a recent TEDx talk. That's all part of best practices. First and foremost, bring us through that experience. And number one, that wasn't just about Levine Hearing, but this is part of a larger campaign, which all has to do with best practices, and that has to do with advocating for better hearing because when you hear better, you live better.

Madison Levine, BC-HIS 37:36

Absolutely. The title of my TEDx was The Ear Brain Connection. And when I pitched it, I was just seeing little bits of content out there about it. There were some providers talking about it within our circles. We heard it a lot in the audiology profession, but patients seemed surprised every time I brought it up. It didn't feel like it was part of the education they were receiving out in the world. And I was seeing just little bits of it come through. And I felt like I wanted to create something short to the point. It's eight minutes long that could be shared with family members, shared within clinics, easy to digest, and would hit all the high points of the current research, of the impact of hearing loss on our total health, ultimately on our longevity. Because, you know, we don't just want to be here for a long time. We want to be here for a good time, right? We want to keep our brain about us. So having that opportunity to create that piece of content is incredible. And I don't want to say it's because of that content that I'm seeing the shift within my clinic, but it's coinciding with an explosion of education about the ear brain connection this year. I would say more than half of my patients are walking in the door and they're asking me to elaborate on it before I even bring it up. So I'm finding it so motivational for people.

Blaise M. Delfino, M.S. - HIS 39:11

Which is so exciting because when we're talking about the patient experience, and of course the adoption rate has decreased the time in which patients are waiting. Madison, as a private practice owner, what do those conversations look like with your team? Number one, to ensure the best patient experience possible. Because when you go on Google and you see how many five-star, you have hundreds of five-star reviews. I mean, that is transfer of information, process of duplication, comes from leadership. What is in the water at Levine Hearing? Like, what are what are you doing? What are you implementing as a leader to ensure best practices are always top of mind?

Madison Levine, BC-HIS 39:55

I'm definitely leading by example. And I will tell you, I tested out a couple years ago stepping out of clinic almost completely. And I was doing a lot of community education, I was doing a lot of speaking within the profession. And I decided I needed to have more of a presence in the clinic to be that leader that's showing them by example how we do things. You've touched on the patient experience. I feel like I need a title that just that's what I am. I'm the patient experience, you know, operator. But part of what I do is I have them shadow me. So when they onboard the first two weeks is only shadowing. So they're not seeing their own patients at all until we feel that they have kind of drank the Kool-Aid, as you say. Secondly, we do weekly meetings. So we don't do monthly. We have tried a daily huddle. Currently, we're not doing that. We're doing a weekly meeting with providers. And that gives me an hour once a week to either do training on something new in the profession, in the software, or to do training on what I consider best practice care, which is it's comprehensive.

Blaise M. Delfino, M.S. - HIS 41:14

It's comprehensive. And I love the fact that you're meeting once a week for an hour because that again is performing at the top of your game and ensuring that all of your teammates are rowing and walking in lockstep because when everyone's walking in lockstep, between the front office staff and I know, Dave, you're giving a talk on the importance of the patient care coordinator because they are the most important team member in clinic. Thank you for sharing that experience, Madison. Dave, what advice would you give to providers who know that they should be doing more in terms of best practices, but haven't really made the shift yet?

Dr. Dave Fabry 41:53

Don't be complacent and don't think just because you've established best practice, when I became an audiologist, real ear measurements was not a part of best practice because there was very early days and they didn't exist. I picked up uh very early, I was an early adopter of real ear measurements and spoke about it a lot and continue to do so. But you know, you have to recognize that when you begin practice, hopefully, uh, I don't want to have the same equipment 40 years in that I had 40 years ago. It shows that we're stagnant. And like I said, I'll come back to a statement I made at the beginning, and I feel very strongly about this. Best practice is essential to ensuring that you have a roadmap. But that roadmap shouldn't be limiting your ability to consider the use of innovation. Now, that means you have the responsibility, as Madison does, of staying up on the literature, getting feedback, measuring your metrics in the clinic with your patients to see if the people that are using oral rehabilitation, real ear measurements, speech and noise testing, are they having lower return for credit rates, higher satisfaction and benefits? Are they coming back satisfied with fewer follow-up visits? You know, there's a whole host of ways that you can measure this, but don't let best practice be handcuffs, because that in today's world, I mean, if you know, if you use ChatGPT a year ago and you use it again today, it's a very different experience. And the answers you're getting were very different. And, you know, we're facing disruption from everywhere, but the only thing that cannot be commoditized is when you demonstrate caring for the patient and their unique needs and expectations, and that's what gets you five-star reviews.

Blaise M. Delfino, M.S. - HIS 43:39

Madison, if every provider listening right now could implement just one, just one best practice starting tomorrow, maybe that they're not currently implementing today, what would it be?

Madison Levine, BC-HIS 43:53

You know, I'd love for them to start saving for reelier if they don't have it. So just start putting your pennies aside because you can't push that off too far. But if you could do one thing today, if you're not doing speech and noise testing, if you're thinking, ah, you know, I'm doing speech testing, I've got my air bone, I've got enough. I would say it's so much more powerful than people realize. It's so short, it's so easy to do a quicksend and the patient appreciates it. You probably will see your close rates go up and and you're gonna acquire information that you cannot get from those other tests.

Blaise M. Delfino, M.S. - HIS 44:31

Absolutely.

Dr. Dave Fabry 44:31

Totally agree. That's the one at the top of my list, too. And I feel a burden of responsibility because Mead Killian was a good friend of mine and he passed away this last year. He developed the SYN speech and noise. He always had a little cheeky humor, but he developed the original SIN test. Then he came up with the quick sin, which was faster. I was also friends with Robin Cox, who developed the R SIN test that improved the reliability. I was friends with Sig Soly, who developed the hearing and noise test. And I'm friends with Matt Fitzgerald, who has picked up the banner at Stanford for speech and noise testing, and he's taking it to levels that really haven't been explored before in terms of the massive number of patients that they're seeing at Stanford and demonstrating the utility of speech and noise measures. But we all stand on the shoulders of giants, and I have a responsibility to my friends to pick up because all three of those are deceased and they can't anymore. But I think it's invaluable and it doesn't cost a lot. Save your money for real ear. Start using speech and noise because it has high face validity and functional utility.

Blaise M. Delfino, M.S. - HIS 45:38

Well, Madison, Dr. Fabry, thank you so much for joining me again on the Hearing Matters podcast, talking about how best practices are best for the patient. You're tuned in to the Hearing Matters. Hearing Matters Podcast. Again, today we had Dr. Dave Fabry, Chief Hearing Health Officer at Starkey, and Madison Levine, Board Certified Hearing Instrument Specialist. She's also the founder and owner of Levine Hearing in Charlotte, North Carolina. Until next time, hear life's story.