Hearing tests--accuracy question

Hearing aids appear to be programmed, at least initially, based on the results of hearing test(s). One test is to raise your hand when you hear a tone, no matter how soft the tone sounds to you. Apparently, even though some tones can be heard very well while other tones are so faint as to be almost impossible to hear, the “test” figures this out and determines one’s hearing level “based on averages.” But we all know that different people handle tests differently. Perhaps there is an “average person” who stays focused during the test for an “average amount of time” and that is factored into the test results. But what if the person being tested is a “Type A” person who remains 100% focused throughout the test and who makes sure to raise his/her hand in regard to every tone no matter how faint that tone sounds. Is there a risk that such a person’s hearing ability will be “over-stated” in the test results and, therefore, the person’s hearing aids will not be as helpful as desired?

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The test tones are 5 dB apart. A normal person has trouble hearing a difference of 3 dB or less. Bottom line is that hearing tests are not super accurate and have to be considered to be a +/- 5 dB accuracy. While your initial prescription curve is based on your audiogram, that is really just a starting point. The next is the Real Ear Measurement (REM), and there is some inaccuracy in that too, but it is better to have it than not have it. You should have a discussion with your fitter as to what you hear and don’t hear after the REM. Manual adjustments are often necessary.

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I think you’re kinda denigrating the “average person” and inappropriately elevating the “Type A” person.
I would think everyone wants to hear as well as they can whether going in with a negative attitude or years of experience with hearing loss. I think testers have their tricks to know if someone is being spurious.
I would only indicate that I hear something when I’m sure. Lots of times I’m really wondering - is that it? is that it? Then they increase the volume a notch and yup there it is and I indicate.
Then there’s tinnitus. I request the non-single-tone so that I can distinguish it from the tinnitus.

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I was recently tested and was trying to respond whenever I thought I might have heard “it.” (They were using multiple beeps because of my tinnitus) They stopped testing my right ear because I was giving spurious results (responding when there was no tone). I was a bit less aggressive with my hand raising and she completed the test with consistent results.

I am not trying to denigrate the “average person,” but I have worked with well over 4,000 “customers” in my career and there are definitely differences in the amount of focus and attention that different people give to different matters, including “very important” matters. I don’t know how to explain it any other way, but people do actually differ in the amount of focus and attention they give to things.

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Hearing test are pretty inaccurate if you compare a test to another. Try checking different audiograms and you’ll find some notable deviations. Your hearing test get influence from lot of factors, including your mood; if you are tired, anxious, depressed… all that will have influence in your perception of sound hence your audiogram.

I’ve transcribe to Excel my last 8 audiograms, the first two are from my doctor (without HAs), the other 6 with different HAs providers and 4 Insitugram made by myself.

As you can see there’s lot of deviation from a test to another. I’ve highlighted in yellow those abnormal readings. I weighted the average, median and stdev and did my own fitting. I’m more happy now than with my 6 previous fittings done by providers.

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Sure. I wouldn’t dispute that. But to classify them into only two groups like that is a sweeping generalization. And then to seem to give one a better weight than the other.
Simply your last line - people do actually differ in the amount of focus and attention they give to things - is entirely fine…in my opinion.

I don’t think it’s all a matter of attention. I focus hard throughout the test, but I also have a tendency to want time to decide, did I really hear something there or not? And while I’m deciding the next tone sounds, so one gets skipped, whether I heard it or not. I have the same problem with eye exams, the dr. flips things back and forth and says, “Which one is clearer, 1 or 2?” and I can sometimes hear the impatience when I’m taking too long deciding.

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I think that even when you do get a good audiogram and you are fit to your prescription with REM and all that, it still does not guarantee that your corrected hearing will be perfectly fit for all listening environments. Good smartphone apps allow the user to adjust hearing parameters broadly, volume, bass, midtones, treble, directionality, noise reduction, etc., so in essence in a gross way, you get to improve your fit later. The Widex app A/B testing, Which sounds better?, A or B, is such a way that the HA software can give the user another crack at fitting. One can imagine an experienced fitter or in the future, AI, examining an audiogram and the user’s feedback or A/B response and finding inaccuracies in the original fit and arriving at ways to correct inaccuracies. So I think the initial audiogram is a very important starting point but it’s not the end of the road necessarily in getting a good fit and in later fine-tuning the responsiveness of one’s HA’s to improve the listening experience in listening environments that in no way match the quiet relaxed environment of a fitting room.

For me it all came down to trial and error. My Audi and I worked for 8 months to get my aids so I can hear the best that I can hear. What I am saying is that I had at least one appointment every month for 8 months to get my hearing aids set for my needs. In that 8 months we reset all setting and started over twice. In the end my aids look something like the prescription, but completely different in the recommendation as for as speech in noise, and soft speech. Everyone is different and there is no cookie cutter way to do the set up.

I like your table. This sort of averaging of multiple tests is actually a nice way to get more accurate results, it’s just clinically unweildy. I hope you just removed provider 5’s test though.

There is certainly variability within the test, primarily from transducer coupling to the ear and patient signal detection criteria which can fluctuate. But typically, for patients with stable hearing, tests results are far more consistent over time relative to how patients feel they are based on their experience of the test. Tinnitus patients in particular feel that their tinnitus interferes with the testing far more than it really does.

Your chart is very accurate for me as well.
The prescription is only as good as the audiogram.
As CVKemp says, it still comes down to fine tuning to get the best out of a set of aids. I really believe this is a huge percentage of failed fittings. The lack of software knowledge or pure laziness by the fitter and also the lack of tuning knowledge but the hearing aid patient. I am sure there is much more to this that I don’t understand but this is the way I see it.

I understand what Karen is getting at. I’m a very analytical person, mechanical engineer, “type a”, ISTJ… I’ve had similar thoughts through this experience.
I used to get yearly tests through work (industrial settings) and I always used to feel that they were incredibly ‘sloppy’. If i can hear noises coming into the booth from outside, how do we know those noises aren’t blocking some of the sounds and skewing the test?
In theory, I suppose, they repeat everything enough times to be able to statistically throw out the data that’s tainted, but still… not pure.
More recently, I just was tested and fitted for hearing aids. I felt the audiologist did a much more thorough test…but I still had the feeling it was less than perfect.
Then later, the program is tweaked based on conversations about my perceptions…ok so some particular sound is tinny to me through the aid…so she tunes a freq down a bit…sounds better… but how do we know that the tinny sound isn’t really how the thing sounds in real life?
Then I complain about brushing noises form my hair rubbing…so another freq is turned down a bit…which surely by the way will affect other nearby freq responses too.
A few more iterations tuning bits up and down.
It’s just a little bit ‘sloppy’. Seems that the whole end result may be very ‘off’ from reality.
and further more, I find that it’s all focused on ability to hear speech.
but what if hearing ambient sounds accurately is more important to me?

In the end though, I recon it’s all about statistics, and throwing out anomalies…

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My greatest frustration during hearing tests is the instruction that “If you hear anything you must/should press the button.” To me that makes no sense. If all I hear in the higher frequencies is a very faint unintelligible faraway blip and I press the button in order to be a good follower of directions, exactly what is it that the machine and the tester thinks I am hearing? Those are the frequencies I want amplified so I can understand what the speaker in real life (not the machine making just an extremely faint noise) is saying!
In the past I have been a good little boy and followed those instructions, with the result that thereafter I have to plead and beg to have amplification increased in order to hear and understand female voices. In my most recent test I did not press the button for sounds which were no more than a mile-away mosquito taking a half breath and the comment after the test was “Oh I see that your hearing has deteriorated a bit.” Maybe this time I won’t have to fight to hear with my new hearing aids. Was I a bad boy to do that?

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Thanks for the good discussion. Yes, I have some “issues” with the current tests (if I raise my hand when I can barely hear a faint tone but also raise my hand for tones I can hear reasonably well, won’t the results “over-state” my hearing ability?). Some of my audiologists have said, “No,” that doesn’t happen because an “algorithm” is used. I do not know how the algorithm is programmed, but one audiologist indicated it is based on “averages,” so that is where my “average person” comment came from.

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All development of target prescriptions have been based off a standard method of measuring an audiogram which instructs you to respond to the softest tone you can hear. I would recommend not pretending that you cannot hear things on your hearing test. Don’t worry that you might be responding to things that are not there; the audiologist is the one presenting the tones and if you raise your hand when they present nothing that is not going to factor into the test. They are also skilled enough to determine whether you raised you hand in response to the tone they presented or whether you just happened to raise your hand contemporaneously. Just follow the instructions and let them take an accurate test. Further, if you are faking much of your hearing loss they audiologist will know and will employ methods to counteract your faking and probably end up in pretty much the same place except that now they will be irritated with you with you for wasting their time, and it’s hard to provide your optimal standard of care when you are irritated with your patient.

If you facilitate accurate testing and then later want the volume of your hearing aids cranked up, by all means ask for it to be cranked up.

I’m thinking that the whole idea is to identify the thresholds of hearing at each frequency step. They come down and back up a time or two…or more? For each one to statistically clean out the bad data

Remember though, they are only testing frequency steps, and not even coming a little bit close to testing every frequency…so it’s all just some sort of approximation anyway.

but then I’m no audiologist or acoustician…so what do I know?

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What about this idea as a possible additional hearing test? Have the tester go more slowly with each tone and allow the test subject to respond to each tone by saying one of these words: faint, normal or loud. It won’t be 100% accurate either because some tones might sound to the person as if they are in between two of the categories. But it seems like that sort of test could provide more detailed information for purposes of programming the hearing aids. I’m just “thinking outside the box.” People who are in the field can probably come up with a better test than I have proposed. I am just frustrated because the last two pairs of hearing aids I purchased (two different brands and two different audiologists—both sets very expensive) have not helped me hear that well, despite many, many follow up visits for fine tuning.

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no matter how it’s done, it’s always going to be subjective to some degree until they tap into our brain … and I feel confident that doing anything adding another layer of subjectivity (low, medium, or loud) isn’t really necessary and till wouldn’t make it more objective…especially given what the goals of the tests are.

I really do believe that these concerns over accuracy (that I share with you by the way) are not much more than nit picking for us extreme “Type A’s” over-thinking it. I’m among the worst offenders of over thinking it, so I feel qualified :slight_smile:

I don’t have my head totally wrapped around it, but I do think that these tests as they are standardized, have a particular goal in mind and probably accomplish it very well as they are done. They have strategies to positively identify the bad data to reveal the minimum threshold for each tested freq. I personally feel confident that a good audiolgist can identify a person’s minimum threshold for each tested freq. fairly well within the scope of whatever our perceivable hearing ranges are.

I’ll make up numbers here…but let’s say for example that IF our ears can’t detect a difference of less than 5dB…meaning a 45dB level sound the same as a 40dB to the human ear so does it really matter if your minimum threshold for that frequency is 41.20dB or 41.25dB? Same holds true that even if our ears can detect that small difference, if the technology of the hearing aid can’t produce a difference to that fine of a level then there’s not much point in testing to that degree of precision.

With things like this I have to occasionally remind myself that a lot of very smart and educated people have been focused on this whole thing for a very long time… so don’t be too fast to second guess. That said, I do like the mental exercise of thinking these things through.

Also, I have to remind myself that the industry’s goal seems to be all about understanding speech…and making adjustments in whatever relatively coarse ability the human ear has to differentiate between a particular frequency/volume and some other…all for the goal of understanding speech.

So, accuracy of hearing other sounds is sort of secondary. It matters more if I can “understand” my daughter, than it does that the sound my steps make when shuffling on carpet sound to me as they really do to a normal hearing person…

Personally, I would like it if more equal importance could be put on things…but that’s the way the industry seems to be focused.

Damage to the ears results in a loss of “soft” perception, particularly for more severe losses. Perception of “moderate” and “loud” are a bit more flexible (i.e. something that sounds loud to you at first may come to sound more moderate over time, with some limitations). But part of our perception of volume comes from how many hair cells are active, and as the cochlear amplifier becomes more damaged its movement become less selective and more cells are activated together (in the past I’ve used the analogy of playing the piano with your elbows rather than your fingers). So at a certain point, it becomes a choice between whether you want to hear a sound or not hear a sound, not whether it is perceived as “soft”–it’s either there and louder than you remember, or it’s not there. As most people have more damage at higher frequencies, this tends to be a frustration particularly with “sharper” sounds.

In my experience, most people think (or are left to think) that this is a fault of the hearing aids rather than the interaction between hearing aids and a damaged system.

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