How does a hearing aid dispenser reconcile one's personal needs with a client's best interests? That they are not always in accord is obvious.For about the first 30 years of its existence, the profession of audiology forbade audiologists to sell hearing aids. Anyone who did so would be considered in violation of ethical practice and drummed out of the profession.
The major reason for this restriction was the fear that objectivity would be compromised. There was an assumption that audiologists would be tempted to recommend a specific hearing aid, not on the basis how it met a client's needs, but how much money could be made.
This restriction was eased in the middle 1970s, for both legal and practical reasons. Audiologists felt that simply recommending a specific aid was not enough, but that they also had to personally fit the aid and provide the necessary follow-up services. Many also objected to the assumption that they would violate their professional responsibilities if they financially benefited from the sale of a hearing aid. These audiologists pointed to numerous other professional groups in our society whose members personally benefit from the recommendations they make to their own clients/patients. Why, they asked, should audiologists be treated any differently?
So now professional audiologists do sell hearing aids and they are now in the same position that commercial “hearing aid dealers” were 30 years ago. They have to service their clients as appropriately as possible, but still be able to pay their bills and make a living. I remember a hearing aid dealer telling me about 35 years ago that he had to sell a minimum of two aids a week. One to pay his bills and the other to make a living and feed his family (money went a lot longer in those days!). He said that if someone wanted to buy an aid from him during a slow week, somebody who either couldn't benefit or should be referred to a physician, that he would, perhaps with regret, sell this person a hearing aid. It was not something that he would choose to do but it was either that or go out of business. Even though I strenuously objected to his comments it was, and still remains, a true dilemma. How does a hearing aid dispenser reconcile one’s personal needs with a client’s best interests? That they are not always in accord is obvious.
The fact that these issues are still with us can be seen in two recent publications, one in a trade journal and one in a professional journal. Both of these studies used a survey technique, asking the kinds of questions that, to my knowledge, had never before been asked openly in any systematic way. As I review these studies, I’ll also take the opportunity to express some of my personal views on the topic.
Responses From Audiologists and Hearing Instrument Specialists
In the study reported in the March 2003 issue of The Hearing Journal, audiologists working in various settings and hearing instrument specialists were asked to judge whether a particular scenario was “not at all ethical”, “possibly ethical”, “clearly unethical”, or whether they were unsure. The four scenarios were:
Situation 1: A dispenser accepts a $100 traveler’s check from a manufacturer for each high-technology hearing aid he/she purchases from the company.
Situation 2: A dispenser is given pencils and notepads with the name of a manufacturer’s newest product by a sales rep for that company.
Situation 3: A dispenser attends an out-of-town educational workshop with all expenses paid by the manufacturers sponsoring the workshop.
Situation 4: A dispenser earns credit for each hearing aid purchased from a manufacturer. The credits can be redeemed for a cruise.Each of these scenarios describes a common, existing practice in the hearing aid industry. None depict a situation that is clearly unethical, such as knowingly recommending a hearing aid for someone who doesn’t need one, or fitting an aid on a client with observable pathology in the ear canal.
Rather, the scenarios depict a gray area, one that requires a judgment call by the hearing aid dispenser. It is interesting to see how the different groups responded to these scenarios, as well as some of the personal comments that were made.
Let's dispose of the second scenario first. None of the groups felt that this practice was unethical; rather, it was viewed as a harmless form of advertising, one in which all companies are free to participate. Since most of us convention goers stock our yearly supply of pens and notepads, etc., at the exhibit hall, this is somewhat of a relief. Actually, by the time, this item appears in print, I’ll have restocked my pen supply at the SHHH Convention in Atlanta.
The First Scenario
The first scenario -- the $100 rebate -- is more problematical, and differences between groups were clearly apparent. The group differences not only appear between audiologists and hearing aid specialists, but also between audiologists who work in different settings. Only about a quarter of the audiologists who worked in private practice or for physicians felt that this practice was ‘clearly unethical’, while half the audiologists who worked in non-profit settings felt it was unethical. It seems that audiologists in non-profit settings were somewhat more sensitive to possible ethical conflicts than those who worked in the other settings. Insofar as the hearing instrument specialists were concerned, only eight percent of them felt the practice was clearly unethical. Most felt that there was nothing wrong with this practice.
If I were one of the respondents to this survey, I would have labeled it ‘clearly unethical’, for the following reasons. It is extremely naive to believe that this $100 rebate does not, at some level, influence the specific hearing aid recommendations made by a dispenser. Of course, the manufacturers have an interest in selling their most expensive products. This is understandable and reflects the nature of our economic system. They’ve got to stay in business and they’ve got to compete with other manufacturers. They also do not have the same direct responsibility to individual consumers as dispensers do.
For hearing aid dispensers to accept this reward, however, does raise questions regarding possible conflicts of interest -- theirs against their client. Obviously, dispensers who engage in this practice feel that they are also acting in the best interests of their clients; how can they feel otherwise and keep their self-respect? But I’m also sure that consumers would feel more confidence in the recommendations of a hearing aid dispenser if they could feel that decisions were going to be made on the basis of their hearing needs and not the dispenser’s bottom line. The ethical challenge here is not between the manufacturer and the dispenser, but between the consumer, who wants the best hearing aid at the lowest price, and dispensers who wants to maximize their own income.
Some information from another survey, appearing in the March 2003 issue of The Hearing Review, is pertinent to this point. This survey points out that while there has been a 3.5 percent drop in hearing aid sales in 2002 compared to the previous year, at the same time revenues increased by 8 percent to 12 percent. What this reflects is the increased number of high-technology hearing aids now being sold compared to previous years.
So while the industry is selling fewer hearing aids, it is making more money. Moving clients from lower price aids to higher priced ones is exactly the motive behind the practice of providing these $100 rebates, when you consider the fact that analog behind-the-ear hearing aids average about $800 and digital completely-in-the-canal hearing aids average more than $2,500.
Of course, one could argue that the increased number of high-technology aids now being sold is a function of their technical superiority, that they can help hear people hear better. That possibility certainly exists for some consumers, but in these instances why is it then necessary to offer the rebate in the first place? If a person could clearly benefit from a specific high technology aid, shouldn’t it have been strongly recommended anyway? Further, I would suppose that even more high technology aids would be dispensed if the price were reduced by this SI00 (perhaps even more if a further reduction were made!),
The Fourth Sceneraio
The results of the fourth scenario - gaining credits for a cruise - are very similar to the practice of providing rebates. In this scenario, the focus is on the quantity of aids ordered from a specific manufacturer rather just high-technology (and most costly) hearing aids. Again, audiologists from different work settings judged the situation somewhat differently. Close to half of the audiologists from non-profit settings felt the practice to be clearly unethical, but again only about a quarter of the audiologists working in other settings felt the same way. Clearly, audiologists in non-profit settings had the most stringent view of ethical practices - although audiologists in general were far from unanimous in evaluating this scenario. As with scenario one, almost all hearing instrument specialists had no problem with the practice (only 3 percent felt that it was clearly unethical).
The most common rationale given by those who felt the practice was ethical was that this was a common practice in business. If a salesperson exceeds some quota, they get rewards. It happens all the time in business and I, personally, have no problem with the idea in most instances. I do have a problem when this concept is applied to hearing aids. Hearing aids are not just another product, just another appliance to be sold. A hearing aid is required to help people improve that most basic of human attributes, communication with others. We trivialize the sense of hearing, the role that it plays in our lives, when we conceptualize a hearing aid as “just another product”.
It is not necessarily a bad practice for hearing aid dispensers to focus exclusively on one product line. Many companies provide a full range of electroacoustic alternatives within their own models. Most consumers can probably get their needs met with one of the numerous aids produced by a manufacturer. And there is merit, too, in being so familiar with a product that a dispenser can realize its full potential by ensuring appropriate programming. It takes time to master the nuances of a modern hearing aid.
However, there are problems as well. Not every company can boast every potentially desirable feature available in the full range of aids now on the market. In trying to garner credits for the cruise, it is possible that many dispensers would compromise the best interests of their clients to gain the reward. That is, they may select a hearing aid that lacks an important feature for a client simply because the rewarding company doesn’t make hearing aids with that feature. Of course no hearing aid dispenser would openly admit that he or she makes this compromise, even to himself or herself, but then human beings rarely have difficulty rationalizing any course of action they want to take!
The Third Sceneraio
Scenario three is the most ambiguous, where a manufacturer sponsors an out-of-town workshop for dispensers. Only 10 percent of the audiology group in non-profit settings, who made the most stringent ethical ratings in the other three scenarios, rated this practice as clearly unethical. Less than 5 percent of the other audiology groups and the hearing instrument specialists felt that this scenario was clearly unethical.
I also believe that it is not unethical. Hearing aid dispensers do have to keep up with developments and this is one way that it is done and it can be quite effective. Manufacturers and their representatives are the true experts when it comes to their own products and there is no doubt that dispensers can learn much from them.
It is also a practice that does not favor any particular manufacturer. All have the same opportunity to provide training workshops to dispensers. The fact that expenses are paid is not an essential objection to the practice. Many manufacturers provide these workshops in conjunction with a national convention, while others make a practice of sponsoring regional workshops where they can describe their newest hearing aids. In my opinion, the positive aspects of this practice clearly outweigh any potential conflicts of interest.
But we shouldn’t delude ourselves either. Manufacturers are not just providing an educational program out of a purely altruistic impulse. They are vitally interested in convincing dispensers that their products are the best ones in the business. In other words, they are not lust educating, they are also marketing their goods to the group who can have the greatest impact on increased sales. And, naturally, the cost of all their marketing strategies, including the rewards program, are ultimately reflected in the price consumers pay for hearing aids.
But this is the way our economic system works. Manufacturers are doing exactly what they must do. It is up to the dispensers who attend these workshops to evaluate the information they are receiving. The main ethical burden is on the dispensers and not the manufacturers. It is the dispenser who has to decide to recommend specific hearing aids to people, not the manufacturer.
Responses of Audiologists and Consumers
In the study published in the September/October 2002 issue of Audiology Today, the responses of consumers to various potential conflicts of interests were compared to those given by audiologists. This study actually preceded the one reported on above and covered many more possible scenarios.
However, they appear to be basically variations on the four scenarios already outlined above. In the Audiology Today study, the respondents were asked in regards to a particular practice: I nothing wrong with it; 2) may not be in a patients best interest; 3) borders on unethical; and, 4) clearly unethical.
In their responses, consumers were much more leery than audiologists of the business practice of extra rewards earned for the sale of specific hearing aids. Thus significantly more consumers objected to the practice of providing SI00 rebates or earning credits for gifts than were audiologists (less than 5 percent of consumers thought these were all right compared to 32 percent of the audiologists). The same pattern can be seen in all the questions covering other types of rewards (cruises, earning credits toward equipment, a professional development plan, etc.).
It seems clear that consumers look more skeptically on various kind of “freebies” associated with the sale of hearing aids than do audiologists. 1 suspect that this view is grounded on consumers concerns that a significant reward program may unduly influence hearing aid recommendations. This does not mean that consumers object to audiologists (or hearing instrument specialists) making a decent living!
The disparity between consumers and audiologists was least apparent when the perk related to continuing education, open invitation parties (e.g., at conventions), or all-expenses-paid workshops on a manufacturer’s products. in all instances, however, audiologists felt a bit freer in accepting these perks than consumers thought they should. As it happens, this is not only true for audiologists, but physicians as well. A similar study conducted with physicians found the same disparity in consumer views regarding the perception of ethical practices. This is particularly true in regards to recommending specific pharmaceutical, prosthetic devices, etc.
In none of the potential conflicts of interest investigated in this or the previous study is any evidence presented of actual harm to a client (though one could easily define paying much for a hearing aid than necessary as “harm”). Instead, consumers seem to be mostly concerned that their interests would not be the dominant focus in any service they receive from the hearing aid dispenser. It is, of course, understandable that consumers put their needs first when they place themselves in the hands of any health care professional. But, in a fee-based health delivery system, there is never going to be a complete concordance of interest between a provider and a recipient. Which is why some ethical code is required.
Some Concluding Comments
Consumers have a very simple perspective on all of this: all they want to do is to pay the lowest possible price for the best possible hearing aid, selected for them by the most qualified individual, who provides them with all the necessary follow-up services. Or, the audiological equivalent of motherhood and apple pie. Now this is a dream scenario to strive for!
I do not believe, however, that we can begin to approach this optimal goal if the primary stress continues to focus on the product, that is, the hearing aids themselves. As long as hearings aids are viewed as just another consumer product, then they will persist in being marketed the same way as other consumer products.
Thus, there will continue to be reward programs for salespeople who sell more or more expensive hearing aids, in the same way automobile salespeople are rewarded. But, as already noted, hearing aids are more than just another consumer appliance.
When someone needs a hearing aid, it should be the referring condition that is focused on, i.e., the sensory deficit of the hearing loss, and not just the aid. In other words, the hearing loss must be viewed as a health related issue, ordinarily requiring more “treatment” than just sticking some device into the ear canal. 0f course, a hearing aid is usually necessary in such instances; it is just not always sufficient to remedy the problems people face.
People must be evaluated on their need for other types of assistive devices besides hearing aids. They need information about their hearing loss and about other ways to reduce the impact of their hearing loss in all kinds of situations, such as utilizing visual cues and various coping strategies. The psychosocial implications of the hearing loss need to be evaluated and addressed.
In other words, people with hearing loss need just the kind of attention that SHHH has been recommending for years, as embodied in our positions papers, such as the ones on Hearing Aids, Hearing Assistance Technologies, Hearing Aid Orientation Programs., and Telecoils.
If hearing aid dispensers were to comply with these position papers, then much of the apparent ethical conflicts between the dispenser and the client could be dissipated.
Mark Ross, Ph.D., is an associate at the Rehabilitation Engineering Research Center (RERC) at the Lexington Conter, New York. This report is supported, in part, by GRANT #H133E980010 from the U.S. Department of Education, NIDRR, to the Lexington Center.
Mention of products or companies by the author does not indicate SHHH endorsement, nor should exclusion suggest disapproval. Since everyone's communication problems and needs vary, SHHH suggests consulting with your hearing health professional.