Clinical Practice

Audiology — moving beyond the medical model to a complementary model

Approaching hearing care from a different perspective.

Audiology as a profession has grown, has redefined itself several times, and sometimes can be limited by its history. Springing from the medical profession, it has been shaped by this treatment strategy, which is to identify a site of lesion, fix the broken system, and move on. All of our diagnostic tests and strategies have grown from this model, and support the Otologic treatment of auditory illness. This is great, and still necessary work, and is a large part of the profession and the development of new audiologists.

How does this work when there is a sensorineural hearing loss that does not have a medical treatment? We have adopted several possible treatments, but the most common is amplification. Two questions that come up over and over are what fitting algorithm do we use, and why haven’t we been able to define a perfect fitting algorithm? When dealing with a perceptual system, we are not just finding a site of lesion and fixing this system, we are manipulating a system that feeds into the brain, which is also trying to optimize performance even when there is a hearing impairment. So we are trying to manipulate a moving target, and dealing with a system that has its own ways of counteracting a hearing loss at the same time that we are changing the input to the system to do the same thing. And the brain has many ways and options on how it compensates for hearing loss, all of which we cannot control or predict.

How can we, as audiologists, improve our treatment methods to help deal with this changing system? Many audiologists have already developed methods for this, with auditory rehab and multiple visits and adjustments to compensate for the changing needs of the auditory system. To make this method easier and more consistent, we need to add to audiology’s methods a new outlook, a counseling and partnership approach that begins with our knowledge and algorithms, but interacts with the patient to better work with the brain and complement its attempts to deal with reduced auditory inputs.

Why is it so hard to match up to the brain’s compensatory processing? Just like we cannot predict what an individual decides to pay attention to, the individual decides what their needs and focus and intention will be. If they ‘give up’ and don’t try to listen, then the processing of the brain will be very different than an individual who decides that hearing is necessary and any information is useful. Who to listen to in a crowd, and what is perceived as uncomfortable are all different within the system. By better understanding what each individual focuses on and what seems to be easy for them, we can provide the information the brain can use to do what it wants to do.

How can we go down this path and begin to move toward this complementary method to work with the brain? We must approach the fitting process using the patient as the guide for what is needed and used by their auditory system. The process needs to begin as a partnership beginning with targets, and making the user part of the process. They must understand and develop an awareness of how they hear, what they are trying to listen to, and what sounds are not meeting their expectations. By using this information in an interactive process, the end user will benefit, the process will be more profitable and successful, and we will better understand expectations and results and the end user will better understand what treatment can do and what limitations still exist. Remember, we are not changing the impaired system but maximizing the use of the impaired system.

Let’s approach amplification with a different philosophy and begin developing methods and guidance to work with patients and understand how to give the brain what it wants. The end results should be better understanding of what the user needs, wants, can use, and how to provide it to them.

Previous comments
  1. Interesting ideas. Person centred service delivery needs to be responsive to physical and biochemical changes in the brain and in the comprehension of reintroduced sound. Look forward to learning more

  2. I really like your work. Thank you for such wonderful articles and updates always!
    I work as an Audiologist- Training and Education at Sonova India and I really refer to all your work .

    1. Thank you Zohaa, I am glad that I can be helpful, and I hope we will continue to develop these ideas and make them useful for clinicians. Do not hesitate to contact us with any questions or requests.

  3. Excellent article! Thanks to the relatively brief history of audiology (and even more decades dispensing devices) compared to human history – we have a wealth of information to draw upon in meeting the modern hearing needs of what can be considered very advanced perceptual systems. As I see it, we already know what it takes to meet those needs more precisely, but most of us choose not to avail ourselves of the extant technology, namely REM and LSM. In your view, what will it take to open our eyes, as professionals, to the possibilities we can create for our clients by applying what we already know?

    1. Thank you Paul for the very nice reply, but I think you are missing my point. REM and LSM deal with the levels reading the TM. It does nothing and knows nothing about what the brain is doing to compensate for hearing loss. These alone cannot solve all fitting issues, which require an understanding of how the individual is already compensating. Then we can tailor our processing to provide the best auditory information to help the brain do what it wants. So REM and LSM are great, but we need that psychological understand combined with those to truly reach the most satisfied and best performning patients.

  4. Thanks for the reply Michael. You are right about measurements alone not being able to solve all fitting issues, but I don’t think I missed your point. All involved with helping human hearing will surely benefit from adopting a more complementary model. I suppose my question could be reframed as statement – as long as most of us remain unaware of the SPL we deliver to TMs, the brains of most end users may never get the chance to do what most brains can do, so those users may never truly get what they want, because we as providers have not given them what they really need.