Turn Down To What?

When you’re driving a car, you have a speedometer that tells you exactly how fast you’re going. You also have road signs that tell you how fast you should be going. You can compare the two and adjust your speed to match the safe speed indicated by the road sign.

Now imagine your speedometer is broken. How do you know how fast to go? You might try to keep up with those around you and unwittingly go too fast. Or maybe you’ll get a little lead-footed when you hit the open road. There’s no denying that fast is fun.

Loudness is fun too. But we currently drive without speedometers when it comes to enjoying sound.

You can put up as many posters as you want to telling people how long they can listen to a certain volume, but how many have any idea how loud the sound they’re listening to really is? At least an experienced driver might have some idea what moving at 100 km/h might look like. How many people know what 80 dB SPL feels like?

When we hear “turn down the volume,” that’s about the same as only having highway signs that say “slow down.” You could be driving 140 km/h, slow down to 130 km/h, and not really be a whole lot safer. Or maybe you’re only doing 90 km/h, slow down to 80 km/h. You were safe already, but now you’re just enjoying the experience less.

What about bringing attention to the possible consequences of excessive noise? Some have tried to use images of hearing aids to discourage young people from listening to music with positive results (if your idea of positive is stigmatizing hearing aids further). What would the equivalent be in our driving metaphor? Billboards full of photos of crashes and ambulances? Maybe that’d change behaviour a bit, but it still doesn’t offer any gauge of how fast you’re currently driving.

A different approach is using devices that limit volume. Just as a car might have a governor that limits its max speed, you can also purchase headphones with a limit on their maximum volume. However, there’s nothing stopping a person from swapping out their current car, or pair of headphones, for one with a higher top end.

Some devices, such as Samsung Galaxy smartphones, offer a “soft-governor” approach. This appears as a warning when you turn the volume above a certain level. I think this helps, but its still far from perfect. I’m not sure a warning light on my dash would do much to slow me down.

There’s no replacement to a speedometer in a car, just as there’s no replacement to actually measuring the level of sounds that might be damaging. In open spaces, such as concerts and sporting events, this shouldn’t be too hard. There are a tonne of sound level meter mobile apps that can do this. In theory, if you know how loud your surroundings are, and you know how well your earplugs attenuate sound, you can easily figure out how long you’ll be safe for. However, there area  couple of hiccups here. These sound level apps are often inaccurate, and your ratings can vary between apps and devices. As well, the ear plug attenuation level is usually a best-case scenario. Few people properly insert earplugs consistently.

The problem gets more complex when looking at headphone use. The volume registered on a sound level meter on your phone is very different than the actual sound level when all that sound is focussed in your ear canal. I’ve maxed out my headphones and held them against my phone’s mic and the sound level app I was using told me the level was fine, but the loudness of these headphones in my ears indicated otherwise. The opposite can happen too. You might have your volume very high, but because of poor-fitting devices, some of the sound might leak out.

In a clinical or research setting, accurate real-time sound level measurements are done with sophisticated measuring equipment like probe tubes and standardized 2 cc couplers. Is there a way to bring this to everyday use? I don’t know. I have some ideas, but I’m not sure how feasible they are. Maybe the solution lies in the hands of those designing and building the next generation of hearable technology. For example, what if Apple’s next generation of Air Pods featured integrated microphones that told your phone in real time how much sound your ears are being subjected to?

 

 

(I apologize if my title, a bad reference to an outdated song, offended your sensibilities. It offended mine too.)

Are We Missing The Boat When if Comes to Hearables?

Hearables are here. All of the big tech manufacturers you know – Apple, Samsung, Bose – and many start-ups you may not know yet – Bragi, Doppler, RippleBuds – are designing and selling all sorts of devices with incredible capabilities. Some of these devices let you focus on conversations in busy environments, maintain clear phone conversations, monitor heart rate and fitness, or countless other things – all at far more affordable price points than conventional hearing aids.

Thus far, the response from the hearing health industry has been… basically nonexistent? Sure, most of the big hearing aid manufacturers now offer made-for-iphone products, as well as their own accessory devices. Oticon’s IFTTT integration is interesting as well, but thus far, none have introduced anything that could be described as a true hearable. Instead, they’re still limiting themselves to hearing aids that happen to have some of the same capabilities as hearables.

But that’s not really enough in my opinion. Right now the average age of hearing aid adoption is 63, with the majority of first-time hearing aid users are aware of their hearing loss for several years beforehand. This scenario presents a unique opportunity for both hearing aid manufacturers and audiology practices to get their brands into the consciousness of those who are ready to adopt some technology, but not quite ready for conventional hearing aids.

Lets imagine a scenario to demonstrate what this might look like from the manufacturer standpoint. A hearing aid company designs and builds a hearable product that does similar things to other products out there. Maybe it doesn’t amplify in exactly the same way as their conventional HAs, but it addresses the needs of those with milder hearing loss by having programs for hearing in noise, adjustable directionality, media streaming at safe volume levels, and making speaking on a phone easier. The consumers embracing this product become familiar with the brand and hopefully form a strong positive association with them. They download the associated apps to their phones and tablets, and see the brand’s logo every day. Through their increased awareness of this brand, they may become aware of the manufacturer’s other offerings. In their minds, they may arrive at the internal belief of “This product meets my needs for the time being, but eventually I know I’ll need to upgrade to the hearing aid product from this manufacturer.”  In this scenario, the hypothetical customer is not someone who would be purchasing hearing aids at this point in their life, so the manufacturer is not taking away business from themselves. Rather, its likely that if this customer didn’t purchase a product from the manufacturer, they would meet their needs by buying a product from a hearable company.

Many of these points are paralleled when examining the audiology practice’s standpoint. Typically younger patients leave the clinic having been told “Your hearing is poorer than it was, but you’re not ready for a hearing aid yet – let’s just keep an eye on it for now” and no commitment is made on the appointment day. If practices could provide an array of hearable options for the patient to choose from to address their needs discussed above, the client is making a commitment to the practice to return for follow-up services, and will be far more likely to return to that practice when they eventually decide to advance to conventional hearing aids. The absolute extreme example of this scenario is a practice that doesn’t even deal in hearing aids, but just hearables. (This exists already in fact – https://hearology.uk)

So what do you think? Are manufacturers and audiologists missing the boat? Or is jumping into the trend of hearables still too premature?

Raspberry Pi Experimenting: Part I

A Raspberry Pi is a neat little, super-affordable computer that has endless potential uses. For less than $100, and without a ton of technical know-how, people can use them to build anything from weather-monitoring stations, to internet radio streamers, to emulators that let you play your favourite old NES or SEGA games. In fact, some people have even tried building a simple hearing aid using a Raspberry Pi (http://uosdesign.org/designshow2016/group-design-project/the-raspberry-pi-hearing-aid/).

the_raspberry_pi_hearing_aid___design_show_2016-2

A BTE hearing aid powered by a Raspberry Pi.

That last project was what really interested me. I never hoped to produce a $100 hearing aid that could compete with anything available on the market, but I thought that this might be a cool way to learn more about how computers work, computer programming, and hearing aid technology. So about a month ago I ordered a Raspberry Pi to play around with, and hopefully eventually build at least a semi-functional hearing aid device.

What I’ve used so far:

  • A Raspberry Pi 3 B. This latest model has built-in WiFi and Bluetooth.
  • A microSD card.
  • A USB microphone.
  • A micro-USB charger, same as my cell phone.
  • An old pair of ear-buds to transmit the sound to my ears.
  • A network cable.
  • Code! I’m no programmer, so for now I’m working with someone else’s hearing aid code (https://github.com/JonnyM94/RaspPiHearingAid)

Now there are ways to set-up a Raspberry Pi that are supposed to be quick and easy, but I didn’t use these methods. They required having a spare HDMI monitor, keyboard, and mouse laying around, which I didn’t have (and the staff at my local library were reluctant to lend me any). So instead, I did what’s called a “Headless” setup. In this method, I had to manually set up the Pi’s SD card, connect it to my router with a cable, and then access the Pi through my own laptop over the internet so I could see the Pi’s “desktop” as a window on my own. None of this should have been particularly difficult, but it took me a long, long time to make my way through each little step. Unfortunately, many of the resources out there assume the reader has a certain level of computer literacy – more than my own at least. Eventually, I made everything work out and had a functional Raspberry Pi.

However, the more difficult parts were yet to come. The Raspberry Pi software includes some of the necessary programs that my code required, but not all of it. So by trial and error, I slowly figured out what I needed, downloaded the incorrect versions, realized my mistakes, and finally had all of the correct software on my Pi to make the code run. To make sure the sound system worked, I ran a quick white noise program I’d found and was feeling pretty good about everything. However, the code for the hearing aid program wasn’t 100% correct so it took some time to figure out what needed to be modified so that it would actually run. Finally, with the deletion of one errant word in line 116 – it worked!

192_168_2_12__raspberrypi__-_vnc_viewer-2

The Raspberry Pi running the hearing aid program.

…and by worked, I mean it… sorta made noise?

In setting everything up, I confirmed that my microphone was capable of recording high quality sound, and my headphones were receiving sound from stored files on the Pi. However, when I put everything together with this program, I only received a harsh clicking noise that followed the relative volume of the voice entering the microphone, but was basically unrecognizable as speech. After all this, I felt only a little disappointed. To be honest I was pretty thrilled to have produced something with any resemblance of functionality at all.

I’m definitely gonna keep puttering away at this project in my spare time and see what I can do. I’ll try and get in touch with the people who built the code I used (and I suspect they may have been the same crew that actually built the hearing aid shown above too). I’m also going to study their code and try to figure out exactly what its doing, and if there’s anything that can be cut out to try and improve the sound quality. However, I may also try to build up my own code. The code I used had a very complicated compression function, but only a single frequency channel. For a project in my undergrad, I experimented building the opposite – 8 frequency bands but little compression – with Praat. Ultimately my limited knowledge and the limited functionality of Praat didn’t allow for any success with that project, but maybe it’ll be easier here.

So that’s where things stand today. Thanks for reading and I hope you’ll continue to follow along with my successes and failures in this project of mine.

Carrots for Everyone

“The carrot is a long, reddish-yellow vegetable which has several thin leaves on a long stem, and which belongs to the parsley family. Carrots are grown all over the world in gardens, and in the wild in the field.”

This sentence will forever be embedded in my brain. As a child, I would hear this sentence at countless hearing aid fittings, adjustments, and check-ups. As I grew older, and ended up working at the same audiology clinic I’d been going to for years, I continued to hear this sentence as it was played for every single fitting performed there.

This carrot sentence is probably the most common speech stimulus used for performing real-ear-measurements (REMs) on hearing aids, a quick, simple process used to verify that the actual output of the hearing aids is in fact the same output as claimed by the programming software (and to correct the fitting when the software is slightly wrong, which it often is).

It doesn’t take much time and the benefits are significant (here’s a good summary of those benefits – http://hearinghealthmatters.org/hearingviews/2016/real-ear-measurements-are-a-must-for-patient-and-professional-satisfaction/). However, the truth is that less than half of all audiologists regularly perform REMs at fittings. Even when only surveying those who have the equipment, that number improves to just shy of 60%. While fewer hearing instrument specialists report regularly performing REMs, the difference isn’t huge. (See the link at the bottom of this post for a full report on these numbers).

I know there are arguments to be made regarding the time/cost-to-benefit factor here, but if you’ve worn hearing aids and tried them on the manufacturer-programmed settings then you’ll know that these numbers can be way off. However, some manufacturers’s software is much better than it ever used to be. The last pair of hearing aids I was fit with only needed a couple small tweaks to reach targets. Now I know not every fitting will get that lucky, but even if they did, I still believe that performing REMs is a critical part of amplification. Performing REMs is a simple way to clearly demonstrate how the services you are providing meet the needs of the patient.

In a time where patients have more options than ever for where and how they can access hearing services and products, audiologists need to work extra hard and add additional value to their services wherever they can. If you run REMs, and find that you don’t need to make even a single change, you’re still adding value to your patient’s experience because you proved that your service and product reached a real, standardized target illustrated on the screen of whatever device you use to perform REMs. You can’t quantify that bit of value, but it absolutely exists.

Further, I think this same concept of “adding value by proving your work” can be extended to other services. Why can’t every  otoscopic examination incorporate the use of video otoscopy? Instead of telling patients their eardrum looks healthy, show them. Instead of having patients try their new hearing aids in the real world, put them in the sound booth and redo whatever speech test you did during the initial evaluation. Demonstrate that your  services have made a clear, quantifiable change to their hearing.

In today’s competitive market, audiologists need to do everything they can do demonstrate their skills and add easily apparent value to their services. Adding more carrots to everyone’s experience is one easy way to do just that.

http://ovidsp.tx.ovid.com/sp-3.23.1b/ovidweb.cgi?WebLinkFrameset=1&S=NDEJFPCFGADDHGEJNCHKJGLBEBOIAA00&returnUrl=ovidweb.cgi%3fMain%2bSearch%2bPage%3d1%26S%3dNDEJFPCFGADDHGEJNCHKJGLBEBOIAA00&directlink=http%3a%2f%2fovidsp.tx.ovid.com%2fovftpdfs%2fFPDDNCLBJGEJGA00%2ffs046%2fovft%2flive%2fgv023%2f00025572%2f00025572-201005000-00005.pdf&filename=Survey+examines+popularity+of+real-ear+probe-microphone+measures.&link_from=S.sh.22%7c1&pdf_key=FPDDNCLBJGEJGA00&pdf_index=/fs046/ovft/live/gv023/00025572/00025572-201005000-00005&D=ovft

Updates for 2017

Hey all, thanks for your continued reading and support. No big write-up today, I just wanted to update a few things going forward. This fall I caught a pretty good wave of productivity, with two blog posts a week for a while there. From now on, you’ll probably only see one each Monday as I get busier with school and other stuff.

As well, you might see the topic of this blog change a bit. I’m going to try to blog less about advocacy. There are already lots of great bloggers out there working to raise awareness and compassion around those with hearing impairments, and I feel like I don’t have much more to contribute on those topics. Instead, I’ll probably write more about the business and technology sides of audiology and hearing science, which I am more passionate about, especially in the context of the changing industry that exists now. I have a few exciting ideas and projects coming up and I’m looking forward to sharing them with you.

All the best in 2017 everyone!

(P.S. If you’re a member of Speech-Language and Audiology Canada, please remember to vote in the current board of governors election. I’m running for Director-Student and would love your support!)

Bundle Up

“Unbundle” – its a huge buzzword in audiology right now. Check out any hearing-related blog or publication made by audiology professional associations and there’s no doubt you’ll find people talking about this topic.

For those who aren’t familiar with the concept, I’ll try and explain briefly. Currently many audiologists and other hearing professionals sell hearing aids as part of a package. The patient pays a set dollar amount which typically covers the hearing aids, hearing aid accessories, the cost of the hearing evaluation, the time spent on the initial consultation, the time and use of equipment for fitting the hearing aids, the time to adjust the hearing aids, the time spent counselling and teaching, device maintenance, cleaning, and minor repairs. However, often the patient does not see all of this, and views the price that they paid as the cost of the hearing aids only. As a result, there is a public perception that the cost of hearing aids is super-inflated, with consumers believing that hearing professionals are making enormous profits off of the sale of hearing aids.

In reaction to this, some hearing professionals have begun selling “unbundled” hearing aids – with many others calling on all hearing professionals to do the same. In this model, the patient pays for the hearing aids at a cost much less than the typical bundled price point, but must pay for any additional services separately. Many are in favour of unbundling as a way to make hearing aids more affordable for the masses. As well, its often seen as a fairer pricing model. If you need more time with a professional, you pay for it; if you don’t, you save money.

I can fully understand these arguments, but I have a major concern. Is it truly ethical to sell unbundled hearing aids? Hearing aids cannot be fit as simply as eyeglasses – they require an extensive fitting process, and multiple follow-up visits to make adjustments that will lead to the best possible hearing rehabilitation. They also require a great deal of counselling and training for the patient to experience the most positive results. Is it appropriate for a hearing professional to sell a product knowing full well that the patient may choose to not return for ongoing care in order to save money? Should we be okay with the fact that patients could experience discomfort, substandard levels of amplification, or ultimately stop using their hearing aids because they choose not return to the clinic to correct these issues? In a bundled model, we recognize that a higher level of money is spent by the patient in exchange for hearing aids that will meet their needs to a high level of satisfaction. In an unbundled model, we grant patients the option of paying less money, but with a greater chance that we are failing to meet their needs at all, or even cause negative effects.

No one is going to an orthodontist to purchase discount do-it-yourself braces. No one is going to a physiotherapist to buy a book of possible exercises they can perform post-injury. No one is purchasing medicine from a pharmacist and figuring out the best dosage, method of administration, and side-effects for themselves. So why is it in the best interests of patients in need of hearing care to be free to take the bulk of care into their own hands? Why should hearing professionals be compliant in this process?

I worry that what I’ve written thus far may make me sound a tad extremist in my beliefs. However, I do believe that change is necessary in audiology, and new pricing models have a role to play in that. Maybe unbundled hearing aids could be withheld as an option from children, seniors, and other vulnerable populations. Maybe there are different levels of bundled services that could be purchased – the bare minimal featuring just real-ear measurements and a single follow-up appointment, while more expensive packages could include comprehensive post-fitting speech-in-noise testing. Maybe a bundle should only include the first 18 months post-fitting, with additional care at a pay-per-use basis.

One thing I will fully acknowledge is the general for hearing professionals to be more transparent. If professionals are going to charge patients in a bundled model, the patient should be aware of what the bundle consists of. Instead of quoting the cost as only hearing aids, the professional should give the patient some idea what proportion of the total cost goes towards the devices themselves, the testing, and follow-up care. Call it a “transparent bundling” model if you like.

Other notes:

  • Can we stop using the term “sell” in relation to hearing aids? Rarely do people say that pharmacists “sell” medicine. They fill prescriptions, which doesn’t just include the exchange of a medicinal product for money. Pharmacists have to be aware of the medical impact that the drugs they provide have, know how they interact with other medications, counsel the patient on proper administration and many other things. Hearing aids and the accompanying services required for good hearing care are as vital a health service as prescription medication to many.  Therefore, let’s try and use “fit” or “provide” instead of the S-word – because hearing professionals do so much more than that. (Maybe manufacturers could stop employing “Salespeople” and employ “Product Representatives” instead – many other industries practice this.)
  • $8000 is often given as the cost of a pair of top-end hearing aids in a bundled pricing model. Hearing aids are usually expected to last around 5 years – making an estimated daily cost of $4.38 for hearing aid use, $4.74 if you include the cost of batteries, and $5.01 if you incorporate spending $500 on repairs over the lifetime of your hearing aids. While this is no small amount, its certainly more digestible than spending $8000 up front. I wonder if the potential exists for a hearing aid leasing or subscription service?

How do you feel about this topic? Agree? Disagree? Let me know!

Get Connected in 2017

The internet is pretty neat. That’s not an unusual statement itself, but using the internet to stay connected to the field that you’re be working in, studying in school, or personally affects you may seem unusual to many.

This post is aimed at being a starting guide to getting connected with the areas of audiology and hearing online.

Blogs and Websites

livingwithhearingloss.com – Shari Eberts is an awesome hearing loss advocate and her posts are great for anyone feeling anxious about a recent diagnosis.

hearinghealthmatters.org – This website does everything. From health, to science, to advocacy, to the business side of things, just about every topic relevant to a hearing professional or individual with hearing loss can be found here.

www.hearinglikeme.com – This Phonak-run site constantly has great posts with support and guidance for those living with hearing loss at all ages, often written by those with a wealth of personal experience.

www.hearingtracker.com/blog/ – Aside from offering a place for users to share reviews of specific hearing aids, this site also runs an excellent blog with the latest in industry news and trends, much of which will likely be interesting to those who use hearing aids as well as professionals.

getsuperhumanhearing.com/blog/ – Gianluca hasn’t been blogging for that long, but he is super thorough in his advice and guidance for those dealing with hearing loss.

www.audiologytalk.com – While their blog does a decent job at sharing the latest news in audiology, their podcast is what you should really be following. Once a month, John, Dean, and Mindy break down what’s happening in the industry and in research labs around the world.

Hearington.Wordpress.com – This blog tries to blend information, opinions, and ideas from the realms of audiology and hearing impairment. Its the best.

(Blogs are great, but it can be a hassle to try and follow many sites without relying on social media. Your best bet is to follow these sites on Facebook, Twitter, LinkedIn or whatever platform you prefer to stay up to date with their latest offerings.)

Social Media

Hearing Hacks (https://www.facebook.com/groups/1036749189734536/) – A neat space for individuals who wear hearing aids to share their thoughts and ideas on how to improve the devices and the lives of those with hearing loss.

Audiology Happy Hour (https://www.facebook.com/groups/AudiologyHappyHour/) – An audiologist-specific page full of discussions, rants, and raves. Sometimes discussions in the comments get a little heated, but its a great place to hear how professionals from all over feel about industry changes.

www.instagram.com/phonak/ – I’ve mostly avoided manufacturer-based content so far, but Phonak’s Instagram page is a must-follow for anyone involved personally or professionally with hearing loss.

Reddit

Reddit has something for everyone, including those with an interest in hearing. The site is broken down into subreddits which can be followed when you make an account. /r/Audiology, /r/HardOfHearing, /r/Hearing, and /r/Deaf are all great for connecting with others and following news involving hearing.

Others to Follow?

Regardless of what platform you choose to use, here are some other people you should absolutely follow to stay on top of things.

Your Professional Associations – No matter your level of involvement, you should absolutely follow your national and regional associations to stay aware of what’s going on in the profession where you live.

Deaf Groups – Often, this population is ignored by those who aren’t a part of it. Following local or more wide-ranging deaf groups can help you understand their needs and concerns.

Manufacturers – Those who build hearing aids, cochlear implants, and other hearing technologies may not be the most unbiased in the content they produce, but they tend to do a good job at letting you know about the latest technologies available.

Final Note

I am am audiology student who also happens to have a hearing impairment; I recognize that there aren’t a lot of us in this sliver of the Venn diagram. These areas do tend to overlap heavily, but if you feel like some of the sources I’ve shared above aren’t relevant to you that’s probably a perfectly valuable claim.

However, I do think that it is critically important for professionals (and aspiring professionals) to be aware of the questions and concerns facing those with hearing loss as well as the variety of voices out there working to help others. (In some ways, I think that the fact that these sources exist is perhaps a testament to gaps in audiology patient care.)

Additionally, if you are someone who has a hearing loss and wears hearing aids then knowing about changes happening in the industry will make you a more informed patient and improve your hearing experience.

I’m not saying that everything here will be interesting to everyone who only checks off one of the hearing impairment / hearing professional boxes, but I do think that we can be better educated if take in as much information as we can.

Are there any great content producers I’ve missed here? Probably! So let me know below and we can all benefit.