Professional introspection is a primary road to growth and surveys of professional practice offer a window to our performance. Development and refinement of clinical protocols and services over the years have enhanced treatment outcomes for millions of individuals with hearing loss. One means of continually improving services is to periodically survey how clinicians practice. 

In the past, a series of surveys determined which diagnostic procedures and practices were common among audiologists (Martin and Pennington, 1971, 1972; Martin and Forbis, 1978; Martin and Sides, 1985; Martin and Morris, 1989; Martin et al, 1994; Martin et al, 1998). These and other research (e.g., Mueller and Picou, 2010; Wiley et al, 1995) suggest that a majority of audiologists use tests and procedures that are not supported by clinical evidence. 

We recently conducted an online survey of randomly selected members of the Academy focused primarily on clinical practices that support adult hearing rehabilitation. With a survey delivery to 1,220 audiologists followed by two reminder requests for survey completion, the survey yielded only 88 responses. In spite of this disappointingly low response rate, likely attributed to the increasing requests for survey participations that appear in in-boxes, we believe that the responses are representative of practicing audiologists. Those responding represent a variety of practice settings from all regions of the country and reflect a wide diversity in years of practice. The results of this survey provide a glimpse into areas in which audiology could improve to enhance the hearing rehabilitation services we provide to our adult patients. 

Respondent Demographics

Forty-one percent of those responding to our survey graduated with a doctor of audiology (AuD) degree, 14 percent graduated prior to the AuD and currently hold a master’s degree, and 38 percent graduated with a master’s degree and later went back to school to earn an AuD. Eight percent hold a doctorate degree other than an AuD. 

FIGURE 1
FIGURE 1. Percent of Survey Respondents’ Years in Clinical Practice

Ninety-two percent of responding audiologists are certified by either the American Board of Audiology (29 percent) or the American Speech–Language–Hearing Association (63 percent). Eighty-four percent work primarily with the adult population. Thirty-four states were represented, along with six survey participants who practice outside of the United States. These six participants’ responses were included in this survey analysis, as they are members of the Academy and therefore have access to the Academy’s practice guidelines. 

The majority of the sample, or 79 percent, have practiced six years or more as an audiologist (FIGURE 1). Approximately 37 percent reported employment within a medical setting and 32 percent within a private practice (FIGURE 2), proportions commensurate with Academy demographics (AAA, 2016). Approximately 10 percent of survey respondents work part-time defined as 20 hours or fewer per week; 19 percent work more than 20 hours, but fewer than 35 hours; and 70 percent work 35 hours or more per week. 

FIGURE 2
FIGURE 2. Percent of Survey Respondents Employed Within Different Practice Settings

Demographic distribution is consistent with AAA (2016) practice demographics showing the majority of audiologists work within a medical setting (hospital or physician’s office) followed by employment within private practice. 

Survey Responses

Responses were attained relative to patient evaluation, aspects of the hearing aid fitting process, and the provision of follow-up services that might augment communication success beyond that attained from use of hearing aids alone. The following presents responses, along with comparisons, of noted practice conventions to established best-practice patterns.

Self-Assessment Measures

Common procedural terminology defines comprehensive audiometry as air- and bone-conduction threshold testing along with speech-threshold and speech-recognition assessment. From a hearing rehabilitation perspective, clinical guidelines recommend more.

Clinical best practice emphasizes the value of exploring the patients’ perceptions of the impact of their hearing loss (AAA, 2006). These measures are also instrumental in motivational engagement counseling to help patients find their own internal motivation to move forward with recommendations when such motivation is lacking (Clark et al, 2012; Clark and Weiser, 2014). Repeat administration of self-assessment measures following intervention provides needed documentation of the value of audiologists’ work and the benefit treatment has provided to their patients (AAA, 2006). 

TABLE 1. Respondent Use of Pre-Treatment Self-Assessment Measures
PERCENT OF RESPONDENTS FREQUENCY OF USE
15 percent  Always (76 to 100 percent of the time)
13 percent Often (51 to 75 percent of the time)
16 percent Sometimes (26 to 50 percent of the time)
30 percent Seldom (1 to 25 percent of the time)
27 percent Never

Survey respondents were asked how often they used pre-treatment, self-assessment measures. Given that these measures have long been advocated as a part of best practice and given the value that they can bring to the rehabilitation process, it is surprising that only 15 percent of respondents use these measures routinely and that 57 percent report using them seldom or never (TABLE 1).

 An earlier survey by Pietrzyk (2009) reported that less than 10 percent of audiologists routinely used self-assessment measures at the time of his survey and that more than 40 percent believed that they could outline needed audiological treatment based on the hearing test results alone. It would appear that many audiologists practice as if their patients’ perceptions of the degree that hearing loss impacts their lives has little bearing on treatment planning. 

TABLE 2. Respondent Use of Post-Treatment Self-Assessment Measures
PERCENT OF RESPONDENTS FREQUENCY OF USE
18 percent  Always (76 to 100 percent of the time)
15 percent  Often (51 to 75 percent of the time)
11 percent Sometimes (26 to 50 percent of the time)
33 percent Seldom (1 to 25  percent of the time)
23 percent Never

A similar frequency of disuse was reported for the employment of self-assessment measures as a post-treatment outcome validation. The findings in TABLE 2 are only slightly better than those of Stika et al (2002) who reported that only 10 percent of audiologists use post-fitting validation questionnaires.

Pure-Tone Audiometry

Guidelines for pure-tone audiometry have long been in place and have most recently been revised by the American Speech–Language–Hearing Association (ASHA, 2005). These guidelines indicate that supra-aural headphones and insert earphones are both appropriate transducers for threshold measurements by air conduction. That said, the advantages of insert receivers over supra-aural earphones are well established and include greater interaural attenuation requiring less need for masking and less chance for over masking, improved clinical hygiene, and greater comfort. 

Results of this survey indicate that the majority, or 70 percent, of responding audiologists use insert earphones as their primary transducer while testing. This is an increase from the 24 percent use rate for inserts reported in the Martin et al (1998) clinical practices survey. 

The ASHA (2005) guidelines recommend routine testing of 3000 Hz and 6000 Hz for pure-tone air-conduction audiometry to ensure identification of any potential early signs of hearing threshold shifts due to noise. Our survey results indicate that a majority of the sample, or 70 percent, routinely test 3000 Hz and 6000 Hz by air conduction in an initial evaluation. 

Speech-Recognition Testing

The use of recorded stimuli when completing speech recognition measures has long been recommended as the preferred means of testing (e.g., Roeser, 2013). Audiologists are slow to change but improvement in clinical practice is seen in this area over the past 20 years. While only six percent of audiologists reported using recorded materials in the survey by Martin and colleagues (1998), we found that 52 percent of the participants in the current survey use recorded material for speech recognition testing. As clinical audiometers are replaced over time with instruments that have built in, easily accessible sound files, we anticipate these numbers will continue to climb. 

Speech-in-Noise Assessments 

A primary complaint from those with hearing loss is difficulty hearing in the presence of background noise (Kochkin, 2010). Given this, it is not surprising that patients may wonder why their hearing is most often only assessed in a quiet sound booth. Not only does speech-in-noise testing increase the face validity of a hearing assessment, the results provide valuable information for the clinician whose task is to help patients set appropriate expectations for rehabilitation outcome, choose appropriate technologies to improve these outcomes, and assess the degree of benefit received from intervention. 

TABLE 3. Frequency of Use of Speech-in-Noise Testing
PERCENT OF RESPONDENTS FREQUENCY OF USE
15 percent Always (76 to 100 percent of the time)
14 percent Often (51 to 75 percent of the time)
17 percent Sometimes (26 to 50 percent of the time)
39 percent Seldom (1 to 25 percent of the time)
16 percent Never

In spite of the benefits of performing speech-in-noise tests, only 15 percent of those surveyed reported that they regularly test with a competing signal (TABLE 3). When speech-in-noise assessments were completed, the majority of responding audiologists reported using the QuickSIN (48 percent). The second most commonly used measure was the hearing-in-noise test (HINT) at 13 percent with the remaining using one of several other options. 

Assessment of Uncomfortable Listening Levels 

Consideration of a patient’s frequency-specific uncomfortable listening levels (UCL) is considered best practice (AAA, 2006) to ensure the prevention of amplification-induced threshold shifts and maintenance of comfort for amplified sounds, thereby reducing amplification rejection. The use of normative data (Pascoe, 1988) generated by hearing aid fitting software is often recommended as a means to save valuable clinical time that could be utilized better in other aspects of the fitting and rehabilitation process (Dillon, 2012). 

Our survey results revealed 43 percent of respondents utilize normative default data for approximation of frequency-specific UCL for a patient’s given hearing loss. Thirty percent measure UCL for frequency-specific signals and twenty-four percent reported they measure UCL for speech. Three percent indicated they were unsure what they do in this area. 

Verification of Hearing Aid Fitting

It has long been recognized that reliance on hearing aid laboratory fitting software calculation based upon the average dimensions of the adult human ear can falsely represent the accuracy of a hearing aid fitting. Most hearing aid fittings vary significantly from prescribed settings when fitting accuracy is based on software calculations with no subsequent verification (e.g., Aazh and Moore, 2007; Sanders et al, 2015). While probe-microphone verification of hearing aid fittings has been a part of every best-practice guideline for hearing aid fittings promulgated over at least the last 20 years (Mueller, 2014), Mueller and Picou (2010) report that these measures are only routinely made (greater than 50 percent of the time) by approximately 40 percent of audiologists. 

TABLE 4. Frequency of Use of Probe-Microphone Measures
PERCENT OF RESPONDENTS FREQUENCY OF USE
55 percent Always (76 to 100 percent of the time)
8 percent Often (51 to 75 percent of the time)
12 percent Sometimes (26 to 50 percent of the time)
15 percent Seldom (1 to 25 percent of the time)
10 percent Never

Despite research data supporting the use of probe-microphone measures and the fact that these measures are considered best practice in hearing aid fitting, only about half, or 55 percent, of participants in this survey report that they always utilize real-ear, probe-microphone measures when performing a hearing aid fitting (TABLE 4). 

While the findings of this survey are slightly better than the 2010 use rates reported by Mueller and Picou, they are still surprisingly low. While many report that they do not have the equipment available, Mueller and Picou found that 45 percent of respondents to their survey who had the equipment did not use it routinely in their hearing aid fittings. 

Hearing Assistance Technologies 

Hearing aids alone do not meet the communication needs of every patient and many would benefit from use of augmentative hearing assistance technologies (HATs), also known as assistive listening devices. In addition, many patients who are not yet ready for hearing aids find HATs helpful in select situations. As noted by Academy guidelines, treatment begins with selection of appropriate amplification and HATs (AAA, 2006).

TABLE 5. Frequency of Hearing Assistance Technologies (HATs) Discussions
PERCENT OF RESPONDENTS FREQUENCY OF USE
13 percent Always (76 to 100 percent of the time)
38 percent Often (51 to 75 percent of the time)
36 percent Sometimes (26 to 50 percent of the time)
10 percent Seldom (1 to 25 percent of the time)
3 percent Never

When survey participants were asked how often they discuss hearing assistance technologies with their patients, nearly 50 percent failed to present information about HATs with many of their patients (TABLE 5). When asked about personal sound amplification products (PSAPs), 31 percent of survey respondents indicated that some form of PSAP was available through their practice. 

Assessment tools can assist in determining the need for and the selection of the variety of HATs as recommended by the Hearing Loss Association of America (2010). These assessment tools are particularly helpful for patients who often do not provide detailed information about the situations in which they struggle to hear or communicate. 

As with any assessment, a hearing assistance technologies needs assessment (e.g., Clark and English, 2014) guarantees that all important areas are addressed consistently. When survey participants were asked whether they use an assessment tool or questionnaire to facilitate discussion or selection of hearing assistance technologies, 94 percent reported that they do not. 

Audiology Aides

The use of support personnel has long been endorsed by professional audiology associations as a means to increase productivity and reduce costs of service delivery (AAA, 1997; ASHA, 1998). A dozen years ago, Sullivan (2004) reported that 28 percent of Academy members took advantage of the support available through employment of audiology aides. Our data suggests that this rate of use of support personnel has not increased substantially with only 32 percent of survey participants indicating they work with an audiology assistant or technician.

Provision of Audiological Rehabilitation Services

The remainder of survey questions examined how frequently services were provided that might help patients attain greater success than might be attained through amplification alone. Given that communication is most often an exchange between two or more individuals our first question asked how frequently a primary communication partner was present during patient appointments.

Communication Partners 

TABLE 6. Communication Partner (CP) Involvement in Audiologic Rehabilitation Process
PERCENT OF RESPONDENTS FREQUENCY OF CP INVOLVEMENT
27 percent Always (76 to 100 percent of the time)
38 percent Often (51 to 75 percent of the time)
24 percent Sometimes (26 to 50 percent of the time)
8 percent Seldom (1 to 25 percent of the time)
3 percent Never

Patients’ primary communication partners should be actively involved in the audiological management of adult hearing impairment to gain a greater appreciation of realistic communication expectations and to learn ways they can further enhance successful communication. When our survey participants were asked how often they ensure that a primary communication partner (CP) or family member is present at the time of an evaluation and/or fitting, 27 percent said always (TABLE 6). This low figure is consistent with the report from Stika and her colleagues (2002) who noted active spousal involvement approximately 20 percent of the time. 

Provision of Communication Training 

Hearing therapy, or communication training, should be integral to a more comprehensive delivery of audiological services (AAA, 2006) and has long been endorsed by the primary consumer advocacy group for those with hearing loss, the Hearing Loss Association of America, as a recommended adjunct to hearing aid fittings (HLAA, n.d). 

TABLE 7. Number of Appointments in the Hearing Aid Procurement Process
SKAFTE (2000) SURVEY CURRENT SURVEY
1 visit—1 percent 1 visit—2 percent
2 visits—18 percent 2 visits—13 percent
3–5 visits—77 percent

 

 

 

3 visits—44 percent
4 visits—28 percent
5 visits—11 percent
6 or more visits—4 percent 6 or more visits—1 percent

Our survey results are consistent with past results from Skafte (2000), demonstrating that the predominant protocol for hearing aid dispensing has not changed much through the years with the process completing most frequently in three visits or fewer (TABLE 7). Greater numbers of audiologists are providing discussion of communication strategies than in the past (TABLE 8). However, given the limited time encompassed in three to five clinical appointments, one might suspect that discussions are not in depth and may not entail detailed examples of implementation strategies or an exploration of patients’ comfort with using these strategies. Certainly, any discussions would be enhanced with the provision of supplemental handouts to reinforce key points, yet it would appear that these are not provided as often as they could be (TABLE 9). 

Clear Speech Training 

TABLE 8. Provision of Augmentative Communication Strategies*
PERCENT OF RESPONDENTS FREQUENCY OF USE
Percent of Respondents Frequency of CP Involvement
42 percent Always (76 to 100 percent of the time)
30 percent Often (51 to 75 percent of the time)
23 percent Sometimes (26 to 50 percent of the time)
5 percent Seldom (1 to 25 percent of the time)
1 percent Never
*Note interpretation caution.

Clear speech is a specific communication strategy which has been demonstrated to provide an increase in perceived intelligibility advantage as the listening environment becomes more challenging (Uchanski, 2005). Cassie and Tranquilla (2010) found that even minimal instruction with a communication partner could result in a more clear speaking style improving a patients’ speech understanding by 11 to 34 percent. Despite its importance, when audiologists were asked how often clear speech techniques are discussed with patients, only 19 percent said they always discuss clear speech techniques (defined as greater than 75 percent of the time) (TABLE 10). 

Provision of Individual/Couples Communication Training 

TABLE 9. Provision of Communication Management Handouts
PERCENT OF RESPONDENTS FREQUENCY OF CP INVOLVEMENT
19 percent Always (76 to 100 percent of the time)
23 percent Often (51 to 75 percent of the time)
35 percent Sometimes (26 to 50 percent of the time)
17 percent Seldom (1 to 25 percent of the time)
6 percent Never

Our survey results revealed only 15 percent provide any formal, aural rehabilitation training with their patients. Of this number, half provide sessions only infrequently or no more than three times a year. Respondents who do not provide communication training sessions were asked why they choose not to provide these services. The majority, or 47 percent, selected that they do not have time to provide this service, 20 percent do not feel prepared or comfortable providing this service, and 33 percent do not think it is cost effective for their practice. It is part of audiologists’ responsibilities to provide patients with this service when needed or to refer the patient to an audiologist who is comfortable providing these services. Many resources are available that provide useful guidance for audiologists in the delivery of both couples and group hearing therapy (e.g., Clark and English, 2014; Idainstitute.com; Wayner and Abrahamson, 1996). 

At-Home Augmentative Training 

TABLE 10. Provision of Clear Speech Instruction
PERCENT OF RESPONDENTS FREQUENCY OF PROVISION
19 percent Always (76 to 100 percent of the time)
36 percent Often (51 to 75 percent of the time)
25 percent Sometimes (26 to 50 percent of the time)
2 percent Seldom (1 to 25 percent of the time)
5 percent Never
13 percent Not sure what clear speech techniques are

Computer-based training can help patients to improve overall listening strategies and listening in noise skills or to use available visual cues more effectively. Our surveyed audiologists were asked how often they recommend home computer-based training to improve communication such as those provided through Listening and Communication Enhancement (LACE), Read MY Quips, or Lipreading.org. Only one percent said they recommend this more than 75 percent of the time (TABLE 11). 

Community and/or Online Support Groups 

Recognizing that support groups can be beneficial to audiological treatment success for some patients, the Academy guidelines (AAA, 2006) recommend that groups be available to patients. Support groups provide ongoing encouragement and advocacy for individuals with significant hearing loss and their families. It takes very little of an audiologist’s time to introduce patients to the available local or on-line support groups that provide opportunities for individuals with hearing loss to connect with other individuals  and families, as well as provide access to additional information  and/or resources. 

TABLE 11. Computer-Based Aural Rehabilitation Training Recommendations
PERCENT OF RESPONDENTS FREQUENCY OF PROVISION
1 percent Always (76 to 100 percent of the time)
8 percent Often (51 to 75 percent of the time)
16 percent Sometimes (26 to 50 percent of the time)
41 percent Seldom (1 to 25 percent of the time)
33 percent Never

Survey results revealed that 45 percent of respondents make patients aware of consumer support groups such as the Hearing Loss Association of America. This is considerably higher than the roughly 20 percent reported by Stika et al (2002). As with the provision of communication strategies, the higher numbers in this survey could reflect the fact that Stika and her colleagues surveyed recipients of care and that information may need to be provided in a more meaningful context for later recall. But it does look like an improvement in this area.

Conclusion

Previous studies revealed that clinical practices implemented in the field of audiology may do little to differentiate how hearing aids are dispensed by audiologists when compared to commercial hearing aid dispensers (Mueller, 2003; Kochkin, 2002). This sheds light on the importance of audiologists’ need to reflect on their own practices and ensure that they are providing services supported by clinical evidence. By implementing professional-practice guidelines and ensuring that audiologists follow evidence-based protocols, audiologists will differentiate themselves from competitors and foster professional autonomy.

Palmer (2009) points out that audiology’s code of ethics is clear that failure to follow best-practice guidelines is a violation of professional ethics. The continuation of inferior practice patterns that do not ensure best outcomes negatively impacts both patients and the profession. Patients expect that professionals are using the latest technologies and established best-practice protocols to ensure satisfactory outcomes. Our survey results suggest that we are clearly improving in our attempts to provide the best rehabilitative care possible. We still have room for further improvement.