How does that sound? Does that sound better or worse? Are you noticing a difference?
To any dispensing professional who has ever fitted a hearing instrument, or any person who has ever worn one, these are familiar questions. And, frequently, this type of exchange is representative of the extent to which patients are involved in the fitting process. The dispenser asks questions, the patient answers them, and the dispenser makes adjustments to the hearing instrument based on those responses.

Involving the patient in the fitting process can be a challenging proposition. The ability to explain adequately the extent of hearing loss to a patient is frequently diminished by the patient’s ability to comprehend the significance of the tests performed to assess the hearing loss.1 While demonstrative of the problem and useful to the hearing professional, printouts of such typical diagnostic tests as real-ear aided response (REAR) and real-ear saturation response (RESR), for example, can be difficult for the patient to understand in relation to his/her hearing loss.

Visible Speech
The process of communicating with and counseling the patient, particularly during fitting, is largely reliant on subjective feedback. The fitting/verification process is, in part, designed to inspire more confidence in the patient while providing the clinician with a higher level of objectivity and more detailed patient input relative to the performance of the hearing aid in a variety of settings.

The advent of visible speech addressed a portion of this issue. Visible speech is captured during the REAR measurement and uses actual live speech—either that of the clinician or a family member—as the stimulus. Visible speech makes standard clinical real ear measurements more meaningful for both patients and clinicians by clearly illustrating the range of hearing loss. In short, seeing is believing: Seeing the loss leads to believing in the necessity of remediation.

Visible speech empowers the patient with a clear “visual” sense of their hearing loss and aided benefits as they relate to actual speech. It is a dynamic presentation of the effect the hearing loss has on understanding speech by showing how much speech is inaudible. It illustrates why a patient with hearing impairment can hear people speak but not distinguish words, and it allows the patient to understand the limitations of their hearing performance.

The Clinician as Counselor
In our role as counselors to our patients, we seek to provide them with the best clearest information with which to make important decisions about addressing their hearing loss. In that counseling role, it is important to look at all the factors that could contribute to a patient’s decision-making process, including patient buy-in; family buy-in and support; cost-benefit analysis; confidence in the performance of the hearing instrument, and realistic expectations for hearing correction.

In weighing the importance of these factors, consider these questions: What if a family member could hear the way the patient hears? What if, when determining what type, level, and number of hearing instruments to purchase, patients could hear a live simulation of their corrected hearing with a range of devices, and a variety of features? What if patients could see a meaningful depiction of their hearing loss that showed clearly what they can and cannot hear? And, what if during verification, dispensing professionals and patients alike could see a real-time representation of the adjustments being made to their hearing instruments, using live, real ear measurements? Clearly, we would be much closer to a more objective, patient-driven fitting process which would, ostensibly, result in a better fit and a happier patient. The practical benefits of this scenario, to your practice, would include increased hearing instrument sales and overall growth.

Advancing the Counseling Role Using Visible Speech
Interjecting a new level of objectivity to the fitting process was the goal of GN Otometrics when it introduced the AURICAL Visible Speech system earlier this year (Figure 1). The system is designed to enhance patient counseling by providing innovative features that make the fitting/verification process more meaningful to the patient; it engages the patient as a partner in their rehabilitation, encourages ownership of the problem (as well as the solution), and involves family members in decision making.

The AURICAL Visible Speech system includes a wireless SpeechLink 100 binaural measurement unit and NOAH-compatible Visible Speech software that are designed to produce better, more efficient hearing instrument fitting and verification. It features Bluetooth® wireless technology for data transmission and a seamless interface with NOAHlink. It is compact and houses all of its electronics in a body-worn device, subsequently freeing up a great deal of space on the hearing care professional’s desktop (Figure 2). Because it is wireless and small, it is extremely portable, making off-site fittings easier.

Using actual speech as a stimulus for real ear measurements, the system makes the fitting process visible on-screen, so patients can see their hearing instrument at work. A visible speech program provides a meaningful opportunity for patients, and their families, to experience and understand the benefits of all categories of hearing instruments.

The system also features a hearing loss simulator and a hearing instrument simulator. The hearing loss simulator allows a patient’s family member to experience a simulation of the patient’s hearing loss; the hearing instrument simulator then demonstrates the benefits of amplification, which is particularly useful for those who have never worn a hearing instrument.

When considering the growing role of the clinician as counselor, several features of the new visible speech system bear further examination and will be reviewed in this article: the hearing loss simulator, hearing instrument simulator, visible speech demonstration, and the verification mode. All contribute to moving the fitting and verification process away from the traditional subjective approaches (eg, “How does that sound?”) to more objective measurements, while engaging the patient, and the patient’s family, in a partnership that leads to better fittings and, ultimately, a more satisfied patient.

Hearing Loss Simulator
The hearing loss simulator uses actual live speech—from the clinician or a family member—as the input signal for measuring the aided response. It also has a built-in sound library that demonstrates a wide range of music and sounds, as well as speech from noisy and quiet environments. The software produces a graphic illustration of the simulated hearing loss that can be shown side-by-side with a graphic illustration of a normal audiogram, thus clearly illustrating how the patient’s hearing loss differs from normal (Figure 3). There are also custom overlays which use easy-to-understand icons to depict what kinds of sounds are more or less audible for the patient, such as music, airplanes, birds and conversation.

Involving family—including spouses, children, and significant others—in the fitting process is useful on many levels. The hearing loss simulator is a strong tool for counseling patients and their family on the scope and impact of the hearing loss. For the reluctant patient, family support reinforces the need for aural rehabilitation. For the unaware spouse or family, a sense of empathy for the patient emerges. Together, they can combine forces and commit to addressing the patient’s hearing loss. The hearing loss simulator facilitates ownership of the problem—and the solution.

Patients and their family members carry the hearing loss simulation experience into the “real world,” where they become newly aware of the coping strategies they have developed to deal with the patient’s hearing loss. Acceptance of the hearing loss, as clearly demonstrated to all involved parties with the hearing loss simulator, leads to a more informed willingness to explore available treatment options.

Hearing Instrument Simulator
The hearing instrument simulator in the system demonstrates the benefits of binaural amplification to a patient who has never worn hearing instruments, and is an excellent alternative to using a stock hearing instrument for demonstration purposes. The system applies the NAL non-linear fitting rule by default to the patient’s audiogram and simulates a hearing instrument while the patient is listening to the signal through headphones. It can also be used in conjunction with the hearing loss simulator so that family members are able to gain an appreciation of how hearing instruments will im­prove the patient’s ability to hear.

As with the hearing loss simulator, the hearing instrument simulator provides an excellent “view” of the patient’s hearing with a corrective device. It also demonstrates, side-by-side, the patient’s hearing with and without assistance, so the patient and family members see clearly the extent to which the hearing instruments help. And, as the simulation is binaural in real-time, it demonstrates the benefits of wearing two hearing instruments. It is another step for the patient to take toward ownership of the fitting process. It also contributes substantially to setting realistic expectations for aural rehabilitation. Realistic expectations at this stage of the fitting process facilitate acceptance of the hearing instruments during verification and, ultimately, in the patient’s everyday life.

Speech Mapping for Fitting
The speech mapping module is a window to the patient’s future; it allows the patient and family members to see and experience the range of features available in any level of hearing instrument (Figure 4). It allows the clinician to explain the differences between basic features of hearing instruments, from the low end to the high end. It is useful for demonstrating a variety of functions including volume control adjustments, earmold modifications, multi-channel processing, and multiple memories.1 Having experienced the degree to which their hearing can be corrected with the appropriate instrument and features, it becomes very difficult for patients, and their families, to settle for less.

The binaural neck unit communicates with the AURICAL Visible Speech software using Bluetooth® wireless technology and pre-calibrated intelligent probes. The wireless connection to your computer reduces physical and psychological barriers during the fitting process, thus relaxing the patient.

The system is NOAH compatible and features an “OnTop” mode which shows real-time adjustments of the fitting software (Figure 5). NOAHlink can be run side-by-side with the visible speech software, so the patient and family members can see the adjustments, as they are being made; it allows the clinician to fine tune the hearing instrument(s) based on the patient’s audiogram and live speech. The sounds that are being missed, heard, under-amplified or over-amplified are clearly depicted.

In their 1992 article, Cunningham et al1 capture the essence of why we should verify hearing instrument fittings:

By the time the fitting/verification process session is completed, the patient and significant other understand implicitly that the hearing instruments are tuned so precisely that further adjustments are rarely needed. Because we front-load our time and technology at the fitting appointment, we have significantly reduced the need for costly follow-up tweaking visits.1

AURICAL Visible Speech is designed to make hearing aid fittings practically foolproof. It simplifies and expedites the execution of REM, as its only concern is what is delivered to the tympanic membrane. It uses real, live signals for real ear measurement, thus moving fitting from a simulated experience to a real-world experience. In essence, the system shows you what the manufacturer’s algorithms don’t.

Because the patient and family member witness the adjustments, live, and experience the adjustments, live, they have greater confidence in the hearing instruments’ ability to perform up to expectation—the expectation that was set earlier in the fitting process. Because the patient has been an active part of the process, the ability and willingness to take ownership of his/her hearing loss, and its solution, is more strongly entrenched. The chances of the hearing instrument spending more time in the patient’s ears, as opposed to a drawer, increase because of this sense of ownership.

Counseling and Practice Growth
The new visible speech system is suitable for all environments and clinicians, regardless of practice focus. From a patient-oriented perspective, problems become opportunities as the system offers a tool for convincing patients of the benefits of hearing instrumentation. This conviction has the potential to lead to more binaural sales, where such correction is appropriate, which contributes to practice growth. Setting of, and delivering on, realistic expectations drives patient satisfaction and results in fewer follow-up visits. Time saved in follow-up visits can be rededicated to new patients and new fittings, which also impacts practice growth.

From a business-driven perspective, the system is designed to be convenient, intuitive, easy-to-use, and requires the same work flow for all fittings. The learning curve is minimal and facilitated by a counseling wizard and drop-down menus. Direct comparison of fittings and features provides patients with useful information for their cost-benefit analysis—typically resulting in more features versus fewer. Once patients get a sense of how well they can hear with the hearing aids that are best suited for their hearing issues, the benefits begin to outweigh the cost in their decision-making process. Use of real ear measurement when fitting and fine-tuning takes the subjective “guesswork” out of the process, thus expediting the fitting and yielding fewer follow-up visits.

The office or practice that incorporates a patient-oriented perspective will appreciate the opportunity to differentiate itself with advanced technology and new counseling abilities. The system’s portability makes off-site fitting and troubleshooting substantially easier, and allows the clinician to go to the patient. The system is modern, professional, and “smart,” as it facilitates sharing between clinicians and practices.

Patient satisfaction is our ultimate goal as hearing care professionals. It leads to fewer returns and fewer follow-up visits, thus saving the practice both time and money. Engaging the patient in an interactive fitting process with a technologically-advanced approach like the AURICAL Visible Speech can make great strides toward achieving that patient satisfaction. Involving a family member as part of the process, in the way this system can, provides support for both the patient and the clinician; that family member typically becomes a vocal advocate for advanced aural rehabilitation, which frequently results in more high-end fittings and more binaural fittings.

By eliminating much of the guesswork historically associated with fitting, and moving from a subjective to an objective fitting approach, we have the potential to advance as counselors. As a result, the patient is more willing to take ownership of his/her hearing issues and their solutions, which ultimately contribute to satisfaction with the entire hearing health care process.

1. Cunningham DR, LaoDavila RG, Eisenmenger BA, Lazich RW. Study finds use of Live Speech Mapping reduces follow-up visits and saves money. Hear Jour. 2002;55:43-46.

This article was submitted to HR by Megan Quilter, MS, a clinical support audiologist with GN Otometrics, Chicago. Correspondence can be addressed to HR or Megan Quilter, MS, GN Otometrics, 125 Commerce Dr, Schaumberg, IL 60173-5329; e-mail: [email protected].