Why are real ear measurements not required on all new hearing aids sold?

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 simple terms REM (Real Ear Measurements) verify the output of the hearing aid near the patient's eardrum based on audiogram's indicated prescription.  While that is a useful tool to verify the hearing aid is working correctly what it does not do is take into account the patient's perception of the sound.  Over my years of practice I find many people who need more than the prescribed setting and many others who want less than the prescribed setting.  New patients are not usually going to be comfortable at prescribed settings until they have gone through several months of accommodation process, stepping the hearing aids up a little at a time until the goal is achieved.  I've seen many patients who were not happy at all with settings based on REM alone.  In my mind it is far more important to listen to the patient and be able to ask the right questions and make adjustments for that patient to hear the way they need to hear.   

They absolutely should be! In some states they are required to be performed within a certain time period of the fitting of the devices or at the time of fitting. Each state has their own licensure laws which regulate the terms associated with the dispensing of hearing aids. In addition, depending on the state, audiology and hearing instrument specialists have different licenses with different terms defined. While it should be regulated, at this point it is varied state by state and not regulated on the federal level. It would take an act of Congress to have this changed from the state and then federal level. Standards for best practices do mention the use of REM as they are highly correlated with patient outcomes and satisfaction.

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.

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 measurement is considered best practice, but the challenge is that there are multiple ways to measure it. If we were able to come up with a consistently standard test protocol that could be applied using a variety of real ear measurement systems, it could become more consistently regulated. The lack of consistent regulation of hearing aid sales from state to state makes this the responsibility of the patient to ask their hearing care professional whether this verification procedure is used in the office for new fittings. Our clinic does real ear measure verification on all new fittings and whenever a change in hearing thresholds are noted on established hearing aid users. 

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.  

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.

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. 

Real ear verification is a critical and invaluable tool to verify a hearing aid response and should be considered a requirement for the proper fitting of any hearing aid.  It is an established verification measurement for best practice.  Obviously, it needs to be coupled with validation and patient satisfaction but without this critical information, there are many unknowns such as gain at various frequencies, the unique nature of the unaided canal response, as well as maximum power output documentation.  Since we perform a series of real ear verification measures at every fitting and at some follow up appointments, the ability to establish a baseline, document performance, monitor the rehabilitation process and when needed to compare against this at future appointments, I see this as invaluable.  There have been multiple times that without real-ear verification, a patient would have been under fit, over fit, improperly fit, or a fit would have resulted in complete dis-satisfaction.  It's a well-documented, safe, easy, fast standard of care that can aid the provider even in comparing original versus new hearing aid technology or for comparison of technologies purchased/fit elsewhere.  I would consider either non-use of real ear verification or even irregular use as a red-flag for consumers who depend up the professional to properly prescribe, fit, verify, validate, adjust, follow-up, and monitor the rehabilitation needs of their patients.  

Why every hearing device is not fit with real ear measurements is a question I have asked myself for many years.  Thank you for bring this point to consumer awareness!  There are "best practice" guidelines in place but currently no credentialing to hold providers accountable.   This will soon change.  The Academy of Doctor's of Audiology (ADA) has been working to create a credentialing process for all Audiology practices.  In the meantime,  it us important to be an educated consumer and to ask the right questions. Hearing Tracker is one of the greatest consumer resources.  There are other emerging consumer sites such as findhearing.com and of course, Dr. Cliff and his wonderful videos.  Stay tuned because big changes are coming. 

REM is a very usefull tool to verify that your fitting is within dynimic range although it is not needed for fitting. You can also verify your fitting with other ways like word discrimination score for example. REM is just the fastest and most accurate way for Verification.

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. 

Requirements vary from state to state. Any state could add this requirement at any time they choose. The reality is that the equipment to perform real ear measurement would need to sharply decline in price to avoid seeing a steep hike in retail prices if practices were required to buy the equipment, receive training to perform REM and to take the time to perform the procedure at each fitting. Because there is alot of pressure to lower retail pricing, I think it is unlikely we will see any states requiring this going forward. Hopefully insurance companies can take the lead in this regard. That would provide a financial incentive for more practices to invest in the equipment rather than lose their insurance referrals. 

Real ear measurements are an excellent tool that should be used for hearing aid fittings, unfortunately it is not a required tool in every state (YET). While there are other tools for verification it is considered the best practice and should be implemented for all hearing aid fittings. Prior to purchasing new hearing aids it is 100% okay to ask your audiologist what they use to verify hearing aids being fit.  

All hearing aid fittings should include real ear measurements. When shopping for a professional ask if they do real ear and also ask if they test auditory processing testing. If real ear is done on every patient the professional will become an expert at using the results. These tests cannot be done with online hearing aids and are essential for success along with scheduled followup care. All hearing aids and all professionals are not alike. 

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.