There are many great answers being provided here, so rather than duplicate them, I’ll summarize and provide another perspective.
1. Real Ear Measures (REMs) are a guidepost, but not gospel. It’s a starting point that every provider should use, but it’s not the endpoint. You can fit the hearing aids to the target and the patient won’t always like the results. So the fitting should start there so that you know what you’re working with, but at the end of the day it’s just a measure of sound in the patient’s ear, not what they necessarily want to hear. Perception happens in the brain, not the ear canal, so what the patient thinks of the sound is what matters the most.
2. Regardless, fitting hearing aids without REMs is voodoo audiology. Without it, a provider is going on faith that the fitting software is accurate, which it often isn’t. It’s akin to a dentist trying to do fillings without having taken an X-ray. Or a brain surgeon attempting surgery without having done an MRI.
Thus it’s incumbent and essential for consumers to find a provider who uses REMs with every fitting, but is sensitive enough to listen to their preferences.
In my opinion, real ear measurements should be done on every new hearing aid as an objective verification. But this measurement is not the only important aspect of fitting a hearing aid. A good provider will perform objective verification, but not rely solely on that information as justification for setting the hearing aid to prescribed targets. After all, the target outputs we match to during real ear measurements are based on averages, and no one is exactly average. Subjective validation - how the patient feels about the sound quality and loudness of the instrument - also needs to be taken into account, and the hearing aids adjusted according to that feedback.
If you are interested I can give an answer from a French audiologist, things may differ in the US (excuse my English, it is not perfect).
I believe that real ear measurements are seen as optional for some audiologists. Indeed, some of us in France prefer to focus on the sensations of the patient (confort levels with/without hearing aids, localisation of sounds etc.) rather than on the numbers (gain values). I tend to use both but I can understand the limitations real ear measurements have : they can sometimes push the audiologist to have the speech "look at the graphs, your hearing is a lot better, the problem doesn't come from the hearing aids or the settings, it comes from you."
Secondly, when we do real ear measures, we use methodologies (not sure the translation is right, excuse me) like NAL-NL2, DSL V5 etc. But these methodologies have been created based on statistics and the philosophy of the makers ; they are not always the perfect options for every patient.
Thus, some audiologists (like myself) like to use real ear measurements for the benefit of objective measures, or to check inconfortable levels; whereas others prefer to focus on subjective measures as they believe that they better reflect what a patient is experiencing in his day life.
This is why, in my opinion, hearing aids brands don't want to force their clients to use one method or the other.
That is a great question for state legislators and professional licensure boards. Real-ear measurements are a great tool to verify "benefit" relative to hearing aid output in the ear, help identify tricky feedback peaks, as well as quantify an assortment of other hearing aid features.
In my experience, however, performing real-ear measurements and arbitrarily matching hearing aid gain/output to associated fitting targets based off of an inherently subjective and unreliable (10 dB test/retest reliability) hearing test rarely results in a satisfactory and comfortable sound quality for the patient. In our practice we verify benefit using aided-threshold testing and adjust gain to reach target (within reason) at or below 25 dB HL from 500-4000 Hz, but I almost always find myself lowering overall gain to begin a trial at a comfortable sound level for the patient.
Should real-ear measurements be required with every new hearing aid fittings, I don't think so. Instead I feel that conducting (and documenting) an accepted form of verification testing with every new fitting either at the initial fit or during the trial period AND include an explanation of why hearing aid settings are set below target relative to comfort should be required. The patient tells me what they need, not numbers on a piece of paper or a screen.
In the meantime for the consumer, though, do your due diligence and ensure the hearing professional you decide to work with included hearing aid verification in their battery of services. If they don't, regardless of their reasoning, consider seeking out another office.
Real ear measurements are only as good as the accuracy of the actual audiogram, and placement of the tubes in the ears. For open fit aids, the measurements are not recommended (per manufacturer recommendations and the instruction manual that came with my Real Ear tool) Real Ear measurements are helpful, but should not be mandatory simply because they are unnecessary for certain types of losses, and are often inaccurate for low frequency amplification.
We do Real Ear here at my clinic, but not for open fittings. I have also had issues with accuracy and sound quality (per patient feedback) with deep CIC's and IIC's... Other things that can negatively effect Real Ear measurements are the quality of the speakers used and sound output.
I cannot say with 100% certainty why REAL Ear Measures are not required when fitting hearing aids, however here’s a list of possibilities that may shed some light on the answer:
1) None of the professional organizations for Audiologists or Hearing Instrument Specialists hold their members accountable for following well known, and long established, “Best Practices,” which includes REAL ear measures.
2) None of the makers of hearing aids requires or trains providers, as a matter of practice, to perform REAL Ear Measures.
3) Consequently, most state's laws do not require it.
So, WHY are none of these entities requiring providers to do the one thing that tons of emperical evidence gathered over decades, leading universities around the world, says leads to the highest user satisfaction and performance?
After my 18 years as a HIS, my best guess is it’s a combination of things.
Human behavior, according to neuroscientists , is almost entirely driven by irrational fears. We’ll try to avoid anything we imagine increases the risk of experiencing failure, or loss of some kind. Because performing REM takes 1) additional time, 2) placing tubes millimeters from the eardrum can be uncomfortable for the client, 3) generates a sound level that’s most assuredly unpleasant for any new hearing aid user, and often unacceptable to experienced users who’ve grown accustomed to the sound of a manufacturer’s “First Fit,” performing REM requires confidence, taking a courageous stand for the client, and commitment to see each client through the sometimes lengthy process of acclimatizing to a new world of sound. And, oddly enough it may take courage to operate outside the “status quo” if you’re the only one in your practice with a commitment to operate with the integrity to follow the “Best Practices.”
Consequently, our behavior is designed to please and gain the approval of our clients and peers. Keeping the boat from rocking is far more important to us than being responsible for operating with integrity and holding our peers and vendors accountable for doing what’s in the best interests of our clients and their “long term” satisfaction.
Everyone has provided fantastic rationales on why Verification, specifically REM, should be a tool in a quality provider's tool box while also citing limitations to REM as a sole means for understanding client benefit. This is why it's of the utmost importance to pick the right provider - look at the provider reviews online, ask them if they perform REM, trust your gut during your hearing evaluation and consultation, ask your friends who they trust in this regard, etc.
Moreover, participate as much as you can in your fitting and follow up appointments. Take notes and tell your provider what you are experiencing and where you still wish your hearing was better. Even ask your family or friends to add their insights. These inputs are crucial alongside verification to make sure the fitting serves you best. In some instances, I have fit the devices to target and the patient couldn't stand the sound quality which required adjustments above/below the client's prescription.
A hearing device is just a computer. Hearing Aid software is just an algorithmic guide to determine the best starting point for you. Without the right provider taking into consideration what he/she learn from verification tools and your experience, the client experience is never what it should be. Your success is hugely dependent on the right product, the right provider, and participation from YOU!
REMs (Real Ear Measures) are not required but should be performed an all hearing aid fittings. Each state has their own licensure rules and regulations regarding REMS.
REMs are a great tool for the hearing professional to verify benefit. It is using real science to verify what we think we are doing in the ear canal. While not all hearing aid users will like the sound quality at the optimal REM, it can be used as a starting point, ensuring you are getting the gain and sound quality that you think you are giving someone. Counseling and patient perception of sound quality are critical to a successful fitting but REMS should definitely be included in all fittings whenever possible.
State and federal laws do no require real ear measurements to be run. How ever most successful practices like ours use it for every patient to verify that the patient is getting the benefits that we are selling. We want our patients to have the best hearing possible and to do that we must make sure the hearing instruments are fitting properly and are set properly. Always ask your professional to see the results of the real ear measurement and asked if they have the equipment and knowledge to run Real Ear Measurements in the office.
I personally feel performance based measures (aided discrimination with and without noise) have more weight clinically. Real ear measurement is an easy test to perform, but what does it actually mean a) to the patient and b)with respect to performance in everyday life with amplification?
My answers to those questions are a) not much aside from giving confidence to the patient and clinician regarding an arbitrary prescription and meeting that arbitrary prescription, then turning it down for comfort; and b) meeting that prescription does not clinically equate to perceived benefit in various (noisy) listening environments.To answer the question, some type of verification must be required, but I have little confidence in real ear as it does not address the performance of the patient in real life. There is only so much power an objective measure has. I find audiologists who are not skilled with evaluating a patient subjectively, lean on objective measures too much and find themselves unable to solve a difficult patient's problems. Patients are not measured in numbers. Speech Pathologists have already figured this out. It takes equal parts listening, measuring and wisdom.
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