A plethora of discussion and activity regarding audiologists’ ethical behavior exists, and the American Academy of Audiology has created specific guidelines concerning ethical behavior, including courses at AAA conventions. Completing three hours of continuing education on ethics is required if you are certified by the American Board of Audiology. Many guidelines revolve around dispensing audiologists’ relationship with manufacturers. Accepting gifts, business development funds, trips, and any other kind of incentive from a manufacturer is considered unethical because it might encourage audiologists to purchase hearing aids from that manufacturer, which may not be in the best interest of the patient.
It would not be considered unethical if I negotiated a better price for my hearing aids with a specific manufacturer and I then put the proceeds of that deal into a personal savings account that I used to take a Mediterranean cruise. It would be unethical, however, if the manufacturer invested the money in a special account, and I later spent that money on a Mediterranean cruise. Dollar for dollar, they are the same scenario, and the only difference is the appearance of unethical behavior. Unfortunately, I am old enough to remember when “60 Minutes” chased after physicians who went on luxury vacations courtesy of pharmaceutical companies. It was embarrassing to see a “60 Minutes” reporter push a microphone into the face of an unsuspecting physician sunbathing on a beach in Tahiti.
It appears I am contradicting myself. I start by defending the ability of an audiologist to have a rewarding relationship with a manufacturer, and then I give an example of why it is not a good idea. But I see both sides of the coin. Some manufacturers'reward programs do not have any adverse effects on my patients’ outcomes, but I also understand the importance of appearances.
All the focus placed on the manufacturer-audiologist relationship amazes me when there is a much bigger ethical issue at hand. This field needs to address a concern I have had for many years, something rarely mentioned and that appears to be accepted by our profession: varying levels of technology. I was excited to see Kenneth Smith, PhD, address this in his April 2012 editorial. (HJ 2012;65:2; see FastLinks.)
LIFE STYLE AND TECHNOLOGY CHOICES
Manufacturers offer various levels of technology, and I need to choose, with my patient's help, which hearing aid best fits his needs. I have been in the field for 32 years, and have had the opportunity to work with all six major hearing aid manufacturers. My opinion is that they all do an excellent job; they have to or they would not be able to survive. It is almost irrelevant, with few exceptions, which hearing aid manufacturer I choose because my patient could have a positive outcome with a hearing aid from any of the major manufacturers. The important issue in choosing a manufacturer is making sure, as an audiologist,that I am completely knowledgeable about the hardware and software so I can correctly program the hearing aid.
Choosing which level of technology to use, on the other hand, can have serious implications on how well my patients will be able to hear. The highest level represents the manufacturer's best hearing aid, and incorporates all the features believed to ensure the best outcome. Hearing aid manufacturers have indoctrinated us to believe that the different levels are dependent on lifestyle; that is, a senior citizen who lives in assisted living does not have the same requirements as a corporate executive. Somehow audiologists have bought into this notion, but I disagree. It is just as important for a senior citizen to hear as well as a corporate executive, and if the top level hearing aid will help a corporate executive hear better in a noisy meeting, it will also help a senior citizen hear better in a noisy dining room. Why would we suggest that some people do not deserve to hear as well as others?
The current ethical rules are only concerned with what influences the manufacturer we choose, which is relatively insignificant to patient outcome, but they have no concern with the level of technology, which is highly significant to patient outcome. Technology levels did not exist when I originally started dispensing hearing aids. People paid more for a smaller hearing aid, but at least they were paying for a cosmetic option. Analog and programmable hearing aids were offered at a higher price when they entered the market. Digital hearing aids were also more expensivewhen they first came out —different levels arose from this situation. Now that analog hearing aids and programmable analog hearing aids are no longer with us, these new levels of technology were created. Choosing different levels may have been justified in the past, but now it is not a real difference.
Cost Affects Formula Programming
Unbundling to help consumers understand that our professional skills have value has been in the news lately. (See FastLinks.)The argument is that we need to distinguish ourselves as a skills-based profession instead of a commodity-based operation. Yet we reduce ourselves to a commodity-based business when we present varying levels of technology. I was often told in the past that we need to give patients an option so they can choose what they can afford, and purchasing a vehicle has always been the analogy. Consumers can buy the basic edition or they can get the limited edition. They decide what they want and what they can afford. But why are we using a commodity analogy if we are professional providers and not a commodity-based business? The difference between the basic model and the limited edition has to do with luxury items, such as leather trim or wood grain. I do not think advanced noise suppression or better speech algorithms are luxury items.
A better analogy would be a cardiologist tellinga patient that her heart is not keeping a regular beat and she needs apacemaker. Sheshould know about the best model available for active patients, a less expensive model designed for patients not as active, and a third option that will require her to spend most of the day sitting or lying in bed but will continue to keep her alive. See which pacemaker she picks.
Many manufacturers have developed a proprietary fitting formula for their hearing aids rather than using a general fitting formula such as those developed at the National Acoustic Laboratory, likely because they think their formula works better for their hearing aids than general formulas. One manufacturer will allow you to program the hearing aid with their proprietary formula if you purchase a level 1 or 2 hearing aid, but a lower-level hearing aid is only programmable with the general formula. This means, if you do not buy the more expensive model, they will still sell you their excellent hearing aid, but they will not automatically program it as good as it can be (or should be) programmed. How can that be ethical?
A Difference in Features
Look at the differences infeatures onthe varying levels for any manufacturer. The one that always stands out is the number of bands. The argument is that the greater number of bands allows us to more precisely fit the hearing aid response to the patient's needs. It might be argued that a patient with a flat loss will not need as many bands as a patient with significant peaks and valleys in his audiogram, but hearing aid bands are often tied to noise suppression. The greater the number of bands the more specific the hearing aid can react to reducing noise. I have yet to find a patient who would not benefit from a hearing aid that reduces noise better.
I could go on and on about the ethics of eliminating available features in today's hearing aids. I would be remiss if I did not congratulate all the hearing aid manufacturers for the wonderful newfeatures available to us. It is amazing how far we have come as a result of all of their research and development.
Recently, I had discussed this with the president of a major manufacturer. My suggestion was to eliminate all lower-level hearing aids and only sell his best one at the average cost of all his current hearing aids. Theoretically, that would still bring in the exact same amount of income, and everyone using the hearing aid would be fit with the best one. He thought it was a great idea, and said he wished he had the guts to do it.
I continue to wait for a manufacturer to step forward and have the guts to do it. I also wait for our professional organizations to place its ethical concerns where it makes the most difference for patient outcomes. I hope my colleagues will come to see this as a more important ethical concern than accepting pens from hearing aid manufacturers.
* Check out Dr. Smith's HJ editorial at http://bit.ly/KenSmithHJ.
* Read HJ’s article on unbundling at http://bit.ly/HJcostco.
* Visit HJ’s Student Blog at http://bit.ly/HJStudentBlog.
* Check out HJ’s R&D Blog at http://bit.ly/RDBlog.
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