Last year, the BBC reported that more and more hearing aid users are programming their own hearing aids. Today, British subject Robert Mandara lays out a compelling case for user programming in the first of his three-part series in The Limping Chicken; and although we disagree with him on several key points, in fact his overall premise is strong.
Hearing Aid Professionals on both sides of the pond should pay close heed, as unlike in Britain where 90% of the hearing aids are dispensed by their troubled National Health Service (with an average 18 week delay and long waits for followup), UK private (“High Street”) dispensers and US Hearing Aid Professionals can address some of the reasons cited by Mandera by simply providing speedy service and implementing the Telehealth paradigm we laid out six weeks ago.
Here is Mandara’s compelling case, with our Editor’s Notes interspersed:
Would you buy a television if the salesman insisted that only he could set the channel, volume, tone, brightness and contrast? Would you be happy to make 3-hour round trips back to the showroom with the TV for adjustments? No? Then why do we surrender control in this way for hearing aids?
We are surrounded by gadgets, iThis and iThat, which we can configure to our heart’s content, yet hearing aid users have almost no control over the most vital item of technology in our lives.
In this article, I set out the reasons why users should be able to program hearing aids themselves. In the next two articles, I will explain what you need and give some tips for how you can do it.
Editor’s Note: At this point we are not planning on publishing the second and third installments of this series. However, the interested reader can go to The Limping Chicken website if they are so interested.
I have programmed my hearing aids and wish that I had done it much sooner. Trust me, I’m a far happier, more social animal as a result.
Editor’s Note: Hearing aid professionals need to realize how important these devices are to our daily existence — Mandara’s statement “I’m a far happier, more social animal as a result” should be on a sticker on every audiometer, NOAHlink, and laptop in the office.
Hearing aid programming consists of two distinct branches:
1. Acoustic programming: Settings which affect the sound – such as gain and frequency response. You could, if you’re crazy enough, potentially damage your hearing by making the wrong settings.
2. Operational programming: Settings which do not affect the sound. Compare these to selecting a ringtone or desktop wallpaper. Why shouldn’t users be able to set these themselves?
Editor’s Note: Although we agree in principle with his two broad categories, we would argue that the second category be divided in half, with one part being the audiological features such as adjusting microphone beamforming, noise reduction processing, expansion, wind noise reduction & such; with the other part being the configuration of telephone connections, wireless accessories, and other assistive listening devices. On the latter subject, we salute GN ReSound and Beltone for their enabling pushbutton user pairing of their Unite wireless accessories to their Verso and Alera hearing aids (much as one would pair a Bluetooth headset to a mobile phone) without needing to return to the hearing aid professional. In addition, the combination of their Phone Clip Plus and their iPhone & Android Control App allows for the balance between ALD and environmental audio to be fine-tuned with the flick of the finger. The other manufacturers require the pairing and adjusting of their accessories to their hearing aids through their fitting software and hardware, which is both an inconvenience to the patient and a time-waster for the professional: In a perverse way, this “lock-in” to the audiologist’s office provides just one more justification for users to self-program.
In no particular order, here’s why you might want to program your own hearing aids:
Economics. By avoiding making multiple visits to your audiologist, you (and also the health service or audiologist) can save time, money and frustration. Besides, if you have bought or begged spare hearing aids in the past, now you’ll only need one, which can be programmed for the left or right side as you need it.
Immediacy. Why tolerate bad sound while you wait to see the audiologist, when you could make the required changes right now?
Editor’s Note: American hearing aid professionals, are you paying attention? Also, as we see later in the article, Mandara in fact has a profound hearing loss, and this population needs “hot spare” hearing aids: This is why US cochlear implant (CI) programs all dispense a backup CI processor for each ear.
Control. Answering the audiologist’s favourite question “How does that sound?” is like trying to paint the Mona Lisa with a broom. For a start, we simply don’t have the adequate vocabulary. You know what you’re hearing; the audiologist can only guess.
Curiosity. Wouldn’t it be easier to say how the sound could be adjusted if you knew the range of adjustments and settings that were possible? In fact you can explore the software without connecting it to your hearing aids. Users who have explored the software will be better able to explain their needs to the audiologist while using the right terminology. You might be amazed at how much information is stored in your hearing aids. Your name, sex, date of birth and audiogram are probably stored. If data logging is enabled, you (or your audiologist) can see how much time you spend using your heading aids and on which programs. Big brother is watching you. You may find features in the software that your audiologist is unaware of. I found sound clips, representing different situations (birds, parties, radio) which are useful for testing out changes. If the software has hearing test functionality, you can measure what you actually hear.
Master of one. Audiologists program many types of hearing aid, use many software applications, serve many patients and have limited time. I say that they’re jacks of all aids, masters of none. You, on the other hand, can focus on one hearing aid, one software application, one very special patient, and can invest as much time as you like. Be the master, not the slave.
Real world. Sounds in the audiologist’s room don’t represent the real world. Program for the real world where the dog’s barking, the kids are screaming and the kettle is boiling, not for the quietest little room you’ll ever encounter.
Editor’s Note: We wholeheartedly agree with Mandara on this point: Even with crude noise simulations in the sound booth, it is no substitution for in situ adjustments in the actual environments where the patient is having trouble. This is where The Hearing Blog’s Telehealth Initiative, Starkey’s “T2″ DTMF (Touch Tone) remote adjustment, and Apple’s “Made for iPhone Hearing Aid” (MFI) become valuable additions to the savvy Hearing Aid Professional’s arsenal.
As for Mandara’s contention about real world sounds not in the hearing aid professional’s room, we agree. Short of the professional coming to the actual location of the difficulty (workplace, classroom, etc…), about the only way we’ve seen to get even close is to go to the Listening Studio¹ at the Center for Hearing and Communications² in Lower Manhattan:
Continuing with Mandara’s article…
Try features before you commit to them. Modern hearing aids can do amazing things! At the more exotic end of the scale, they can talk to each other, switch between programs automatically and even lower the high frequencies so that you can hear them. Features usually have drawbacks as well as benefits. Wouldn’t you be happier to test them if you knew that you could turn them off as soon as you knew that they weren’t for you? If you make the wrong choice in the fitting room, it can take weeks to have features deactivated.
To accessorize. I bought Phonak’s iCom and iPilot accessories for my hearing aids. Audiologists are supposed to pair accessories to your hearing aids but it’s very easy to do it yourself.
For the best sound. Audiologists are under pressure to program quickly and, if the patient seems sort-of happy, that’s usually good enough. To be fair, audiologists are doing an impossible job. In the old analogue days, they just twiddled a couple of screws. Now the adjustment possibilities are infinite. Probably every hearing aid on the planet (including mine) isn’t optimally programmed. Why wear a hearing aid on sub-optimal settings? If you can extract the very best sound, you’ll hear more and inevitably be happier. Pimp your soundscape and unleash the hidden potential of your hearing aids!
This is where, in our experience, self-programming blows up, especially the second way with musicians and engineers:
- First and foremost, there is a tendency to adjust the frequency response and gain to where it sounds best, and .NOT. for where speech discrimination is optimized, especially in noise. More specifically, this manifests itself as too much low frequency gain being used, wrecking speech perception in noise. That being said, there is an important exception with the Music program, where we believe all patients should make these adjustments themselves after basic instruction, even if they are being fit by a Dispenser or Audiologist: Ask them to show you how to adjust the response for your music program, and then play your favorite music while tuning the settings to where it sounds best to you;
- Second, there is the tendency to see the audiogram, and to want to mirror the thresholds with that much gain, i.e. if the threshold is 40dB HL, to select 40dB of gain — Which will blow out the user.³ Instead, various prescriptive formulas are used, such as DSL5-I/O, NAL-NL2, and our favorite, CAM2 (CAMEQ2-HF) from the Auditory Perception Group at the University of Cambridge.
Continuing on with the last of Mandara’s points…
Because you want to. If you have ever wished to seize the controls, are computer literate, experimental, patient and have some understanding of sound, self-programming is quite probably for you. If, like me, you were being advised to have a cochlear implant, you can prove to yourself whether hearing aids really have nothing more to offer you. In my case, I found that I hadn’t reached the end of the road at all.
This is where objective speech perception testing in both quiet and noise is really needed, as Mandara is profoundly deaf: Even with his self-programming, he may still get much more benefit from CI’s. For someone with up to a moderately severe hearing loss, however — And with the proper professional guidance in person or at least via Telehealth – hearing aid self-programming can be quite useful.
1) To learn more about CHC’s Listening Studio, see A Hearing Test Made for the Big City in The New York Times (5/17/09);
2) The century-old Center for Hearing and Communications in Lower Manhattan was originally the New York League for the Hard of Hearing 1911-2008;
3) The exception to this is with a purely conductive hearing loss, where the gain is in fact set to the air conduction thresholds. Depending on the fitting prescription used, the formula is about 50-60% of the sensorineural component + 100% of the conductive gap.
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