"So, This Patient Shows Up in my Office with…"

"So, This Patient Shows Up in my Office with…"

by Michael J. Metz, PhD

If you feel that this has ethical implications you are right on! Ask an audiologist if they see patients who have purchased hearing aids via the Internet and you will get all sorts of answers. Some will say that they don't see these patients because they won't make enough money. Or they refuse services because the patient may have the "wrong" hearing aid, or they don't want to "encourage" patients to seek help from a "non-professional" source. One often heard comment is that it is unethical to sell hearing aids online. The answers vary tremendously, but many of the answers have a common underlying theme—audiologists don't seem to like the Internet when it comes to patients and hearing aids.

I suppose there could be a lot of reasons for disliking the sales of prostheses through the Internet, but there are also some issues that perhaps those who loudly protest have not considered. For one, there are many audiologists who argue that using one supplier for all their patients is just fine. After all, almost every hearing aid manufacturer makes enough instruments that about every kind and degree of hearing loss can be managed by fitting one of their products. So, if you are one of those who use a single manufacturer for the majority of your fittings, and since every manufacturer makes enough instruments to fill all hearing losses (almost), the logical conclusion is that most patients can purchase instruments from almost any manufacturer and have the likelihood of being adequately fit with this/these instrument(s). So much for the "wrong hearing aid" argument.

How about this: how does a patient know what to purchase over the Internet? Suppose someone on a phone spoke to the patient, listened to the nature and degree of the hearing loss, and made a recommendation based on the history, complaints, etc. that were discussed over the phone. I guess it comes down to the question "can good information be delivered over the phone?" Talking to an audiologist over the phone is arguably better than responding to a newspaper ad for those really cheap hearing aids. While neither of these methods are what I would recommend, it may be possible for an audiologist on the phone to determine such things as: Has the patient been seen by some professional? Or, do they really know the nature and status of their hearing loss and are now shopping the Internet for pricing? For all we know, these patients may just be dissatisfied with the clinician or salesperson that made a recommendation for amplification.

That leaves the one consideration that everyone so dislikes to discuss—the price of my hearing aids. Most audiologists bundle hearing aids and services into one price to the patient. And, when faced with a patient's need for services alone, seem to be reluctant to offer services without also having delivered the devices. I can think of a couple of reasonable reasons for refusing to see a patient who comes to your office with Internet-purchased hearing aids. Perhaps, the audiologist does not have the software or the experience with that particular make/model of hearing aid. Perhaps those instruments are not typically used in that clinic. I would think that these are good, clinically-based reasons for sending that patient elsewhere. I would hate to think that a good clinician would deny clinical services just because they didn't sell the hearing aids. I don't like to think about it, but I am pretty sure it happens more often than it should.

What do you think happens to this patient who is turned away with his or her Internet aids? Do you think they send them back to the Internet and seek out these clinicians who wouldn't see them otherwise? So you think that they finally receive some sort of help from another source? What do you think is the likelihood of good clinical services from this secondary source? Do you suppose that some of them finally find "clinical" help from someone other than an audiologist? If, heaven forbid, they fail in their attempt to get help from amplification, where will the blame fall? If, heaven forbid, they succeed in using hearing aids, who or what will get the credit?

I think that audiologists who do not see patients referred by the Internet are missing a chance to do more good than they think. Not only are they in a position of clinical advantage—they can't loose if they do things correctly. They bill for services, demonstrating the benefit of rehabilitation available only through an audiologist, but, if things don't work out well for the patient, they have a chance to either make it better or lay off all the blame onto someone (the "other" guy who recommended those Whistletones) or something (that "wrong" hearing aid) other than themselves. What could be better?

As for the ethics of Internet hearing aid sales, the Code of Ethics of the American Academy of Audiology states:

PRINCIPLE 1: Members shall provide professional services and conduct research with honesty and compassion, and shall respect the dignity, worth, and rights of those served.
Rule 1a: Individuals shall not limit the delivery of professional services on any basis that is unjustifiable or irrelevant to the need for the potential benefit from such services.

Even if the audiologist can honestly determine that the patient cannot be helped with hearing aids purchased anywhere, including through the Internet or the Sunday newspaper magazine, it would seem that to deny any clinical services to these patients could constitute a violation of the ethical code. At the very least, the audiologist owes the patient access to whatever clinical skills can be brought to this circumstance, and, in turn, the audiologist has a right to charge for such clinical help. That's why we're here, isn't it?