The problem with proprietary targets is that they are proprietary.
For what it’s worth, Oticon strongly encourages REM. Up until recently, there were no REM machines that could match to proprietary targets and Oticon recommended verifying VAC against NL2 (which just turns VAC into NL2). When asked directly “Do you recommend using VAC+? Do you think it’s better? Do you think your hearing aids work better in VAC+?” the answer I got was “No, we don’t care.”
The vast majority of hearing aid features across manufacturers are available in their NL2 and DSL fits. It USED to be the case that a lot of the features turned off, but it is generally not the case now. The exception is Oticon’s floating linear window which cannot be turned on for DSL because DSL is very prescriptive about compression levels–it might be on their NL2 fit though, I can’t recall.
Generally, proprietary targets provide less gain (and less audibility) than independent targets, often at both high and low frequencies. I can tell you this because I have made direct comparisons within the last year across all major manufacturers. The exception, again, is VAC+ which provides extra gain at 2 kHz compared to NL2 and DSL adult targets (not DSL child targets).
Could you direct me to any authoritative source that suggests: “ The solution to resolve underfitting to any rationale is to do REM.”? By adding a “period”, I guess you were implying it’s the only valid approach? If so, given that not any audi is equipped with or practices REM, how could they solve the underfitting problem? Or were they just letting the manufacturer’s software do a poor fitting, knowingly, and let the clients blame the manufacturer? I don’t think this makes any medical or business sense. But your explanation as to the incompatibility between REM software and manufacturer’s proprietary fitting formula is interesting. I’ve tried Aurical’s REM with ReSound HA. Does it also work on Oticon or Phonak’s exclusive, proprietary software like VeriFit on Oticon as you suggested?
I’m sorry, I wasn’t quoting any authoritative source when I made that statement. I just use common sense to arrive at that conclusion myself, and I don’t think you necessarily need to have some kind of authoritative source to back up everything you say anyway.
That’s because by definition, “underfitting” can only be concluded (that you’re being underfitted) if and only if you can compare the whole system performance’s against some kind of reference, which is the target gain curve in this scenario. Otherwise, how else would you know that you’re in an underfitting situation in the first place if no reference is available to compare against?
And if you don’t use an objective third party system like the REM equipment with the microphones placed into your ear canals to take the measurement, then how would you measure the whole hearing aid system’s performance (the aids, the fitting, your ear canal being the whole system) in the first place?
Yeah OK, you can measure it with your personal brain hearing perhaps by doing some judging or comparison to your memory, or your preference, of how it should sound, but that wouldn’t be an objective measurement system anyway, would it? And the clinician can’t read your brain hearing anyway, so it’s just more objective for him or her to use the calculated target gain as a baseline reference to start the adjustment process there.
Keep in mind that that is probably not the end point, but only the starting point. Many clients are probably going to come back to their HCP to request more adjustments to their personal preferences that can start deviating from the target gain, so the REM against the target gain is not the end that’s set in stone anyway.
Well, scientifically speaking, it’s probably the only scientifically valid approach as a starting point. But it’s not the ONLY approach. because like I mentioned above, you can also use your own ears/brain hearing/memory of how things should sound/your preference to be the judge as well. It may not be objective and scientific as REM, but it’s still better than nothing.
For DIY folks who don’t have access to an HCP to get REM done, they probably just do an in-situ audiometry as a poor man’s substitute to the unavailability of REM, then just do their own adjustments until they’re satisfied with their aids’ performance. Ultimately, your own satisfaction to how the hearing aids perform is what matters in the end. REM provides a good clean starting point to what the HA mfg says you should hear, but that’s only the starting point, not necessarily the end point (which is your own satisfaction).
So DIY’ers can usually still reach that end point in the end despite not having the REM facitity to provide them with a good starting point. DIY’ers have the luxury of being able to do lots and lots of trial and error testing at any point they like, so their end point level of satisfaction is most likely higher than users who rely on their HCPs anyway. Nobody likes to bug their HCPs a thousand times and would settle for being happy enough after a dozen visits to their HCPs, but DIY’ers can literally do a thousand adjustments at home if they want, and it can even be an on-going thing as their preferences and goals change over time.
As for your question about the clinicians who choose not to use REM as a best practice, I guess I can relay my own experience when I bought my Oticon OPNs from a private clinic ran by an HIS. At that time I didn’t know what REM was and she didn’t do REM for me by choice (I guess that was her way of cutting corners to save her time). Later when I learned about REM, I went back and asked her why she didn’t do REM for me. She said well, she DOES have the REM equipment, but she doesn’t automatically do REM in the first go-around because she wants to see how the client reacts to their first fitting first. If they’re all happy as a clam, then it’s all good. If they would like some minor adjustments here and there, then she’d tweak it for them. But if they continue to have more issues and are not happy and keep coming back for more adjustment requests, then that’s when she would do REM because it’s then more likely an underfitting situation.
I personally think that her answer was a cop-out, and she just didn’t want to do REM on the first fit simply because she was lazy and wanted to save time, because time is money. But maybe she tried avoiding REM and found out that she was able to get away with not doing it more often than not, and her clients are still happy for the most part and only require minimal follow-up adjustments, so that’s the approach she took with REM. Had her clients been underfitted more often than not and required a lot more time from her to do a lot more subsequent adjustments than she’d like, then maybe she would have decided to do REM right up front as a best practice instead.
Remember that it’s not always the case that all clients will be underfitted for sure without REM. I know many HCPs (like our esteemed HCPs in this forum, and Dr. Cliff and many others on YouTube) embrace REM as a best practice that should always be done, and that’s really the right thing to do. But the reason my HCP for the Oticon OPN told me she chooses not to do REM up front, even though she claims that she has the REM equipment, is because based on her personal experience, she didn’t find as much underfitting situations with her clients when fitting them to big name brands to begin with. Whether she’s being truthful about that or not, only she would know. But apparently she’s decided that it makes more business sense for her own practice to forgo REM as a first fitting step best practice.
Even if I hadn’t gone the DIY route after my experience with her, I still would not have wanted to come back and do any more future business with her after I learned that she doesn’t embrace REM as a best practice.
I don’t really know much about REM compatibility, so I googled a compatibility list for the Oticon Genie 2 Autofit feature and I get the following result from an Oticon webpage:
Volusiano is exactly right. A third party reference so that the manufacturers can’t obfuscate things.
Let also me note that REM is also the only way to know what is being “overfit”. There are systemic deviation in manufacturer NL2 prescriptions from NL2, but overall they tend to be fairly minor. They are also predictable. The bigger deviations come from the physical coupling and shape of the individual patient’s ear canal. If REM is not done, the clinician doesn’t know where the problems are. So then the patient comes back and says, “high frequency sounds are tinny and loud”, for example, and the clinician just lowers the high frequecy gain across the board, removing the associated high frequency audibility, while if they had done REM they would have known that there was just a peak at 3 kHz, and they could have JUST adjusted there to solve the perceptual problem and maintained audibility elsewhere. Or as another example, a patient comes back and says “this is loud” and the clinician tried to counsel on them giving time to adjust, but has missed the fact that due to the patient’s very small ear canals the gain (which is based on an average ear) IS really too loud. REM is also the only way they will know if there are potentially damaging peaks in maximum output, but because a lot of manufacturer’s set the MPO conservatively (because a lot of clinicians don’t do REM), it is also the only way the clinician will be comfortable cranking the MPO up (because they KNOW it is within safety limits) and decompressing the sound. This is just off the top of my head. REM also picks up on malfunctions that are inaudible to the clinician and the patient.
I agree with Volusiano that DIYer have a benefit because they have a better opportunity to make many small changes over time to be very precise about their sound. Humans are incredible pattern detectors given time and big pools of perceptual data, even for things that are difficult to express verbally. Buuuuut. . . They are also at a higher risk of prolonging their own auditory deprivation. Hearing aids sounding clear and comfortable right out of the gate for a user who has been living for 10+ years with a significant hearing loss is not the expectation. Imagine a scenario where someone removes a cast from their leg and rather than going to a physiotherapist to push their recovery, they continue to avoid any movements that aren’t comfortable. That person may never regain optimal range of motion in that leg. If a DIYer turns up the gain and it sounds bad, is that because they are over-fitting themselves (maybe dangerously, although DIYer are really more likely to underfit than to overfit), or is that because they need to allow their brain time to readjust? So while I support DIY, I typically feel that one’s first set of hearing aids should be through a provider who does REM and will try to optimize their audibility. Once they are used to hearing again, then DIY should be fine unless there are hearing changes.
I wholeheartedly agree with this. DIY should be for seasoned hearing aid wearers who have worn hearing aids for years and know exactly what they want and how they want it. It shouldn’t be for beginner wearers who haven’t had any kind of baseline expectation because they haven’t worn properly prescribed hearing aids for long enough to know the difference.
I would think that the differences are based on the electronics and speakers used by the different manufacturers. Would you expect the computer settings on a Volkswagen to work the same on a Land Rover? Of course not. Each has to be tuned differently.
if hearing aids were identical the settings would be the same but hearing aids are not.
