Real ear measurement vs. in-situ audiometry

Real world experience.

Until I retired at the end of last year, I travelled a lot with the government. I have used many audiologists during that time. Very few were worth the visit. A doctor I use in northeast Florida is the only one I have found that can adjust my HAs properly.

Most recently, I used a newly graduated Audiologist in Kansas. I knew my hearing had changed and needed to see whether I needed an adjustment. She gave me a hearing test in a sealed box. We then went to her treatment room and she programmed my HAs and then completed a real ear measurement (REM). After that she matched the curves produced to the programming in my aids. They sounded pretty good in her sterile (quiet) treatment room.

I left for a month long TDY with my job the next day. Unfortunately, the program she placed into my aids was so awful that they were almost useless. Since I was traveling, I adjusted the volume to its lowest setting and made do until I returned.

Once back, I had her re-program my aids to their original programming. She charged me to undo her terrible programming.

Just having a doctor of audiology doesn’t make you and Audiologist. It is a combination of knowledge, expertise and art.

I hope to get an appointment here in Houston once this China Flu gets under control and have some changes made.


Sorry, I had to come back to this. You’re saying that in situ “involves you” in the fitting and REM “doesn’t” because in one case you do one audiogram and in the other case you do two?

You certainly are an engineer. Oh my goodness.


Jeff, you are absolutely correct about the “art” part of fitting. I starting using REM in the mid 1980’s and became a true believer. But the REM target is just a starting point. The magic comes in to play when the professional actually listens to the patients and has the knowledge to use that input. Manufacturers insitu is an interesting concept but I think it is a cop out to not measuring what goes on at the TM and then using experience and knowledge to give the patient the best hearing outcome.

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The point I was going to make is that there is a level of qualification that no fitter who does not wear aids has. The experience of wearing the hearing aid. @TrueBrit goes to great pains to debunk the scientific approach, and tells an anecdotal story about NAL being all theoretical and yet I don’t believe he has any first hand experience with aids himself.

I would say that someone with actual real world experience who does her own programing such as @Blacky has their own valid forms of qualifications.

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LOL! Indeed. Don’t even get me started on engineers.

@TrueBrit I don’t see it as such. What it does look like to me is that you have an axe to grind.

I would think any professional would use all the tools of the the trade to get the best possible results, especially in a profession that can give people better hearing abilities.

REM takes what, 15-20 minutes, insitu (not even sure what that is) but probably takes even less time. Shouldn’t both be done. How does a professional know what’s going to give them the best outcome until it’s done.

I’m sure in some cases, like mine, these procedures aren’t as important. Audi tells me with my nerve damage I just can’t handle some of the levels REM suggest but I still believe it should be done.



One thing that annoys me with ‘how do you hear me now approach’ is that they think we want to spend unlimited time in their quiet offices.

I have yet to see someone who follows best practices summarised by dr cliff and insists on using manufacturers audiometry as only equipment. You can’t follow best practices with HA alone!

If you have the equipment, use it!
If you don’t have, don’t tell us how it isn’t important /useful.

I don’t have time nor energy to ever again spend months to get something usable.
Rem gives me that with one setup.
And THEN I go out, take notes and complaints and start personalised fitting process.

@jlgreer1 sorry to hear that someone thought that only rem is the solution :confused: I mean, in quiet it works, for other situations other HA features had to be setup for you as well. Like amount of noise cancelling, directionality and so on.
I mean first thing after fit my fitter took paper tissue and rubbed it behind my ears to check those sounds.

Also, I strongly believe wrs (and quicksin) should be done before fitting to see what’s possible, and definitely use them as proper verification that we customers can hear and give feedback what we can or cannot hear. Immediately.

We shouldn’t be sent out of the office after first fit if our wrs with HAs and 65db isn’t in the ballpark of our best wrs without aids. Yes, in quiet. That’s first step. If you have time, you do wrs in white noise and see what you’ve got. Improve.

Having HAs themselves helps, but it isn’t necessary. What is a must is having huge empathy! Without ego issues that they know what works for us And willingness to learn and acquire the equipment that can help you help your patient.

Unfortunately sellers don’t have it, and they don’t invest in equipment because that doesn’t bring profit but cost.

So yeah, I’d say checking if someone follows best practices also checks someone’s empathy and desire to really help you.

My DIY is basically saving myself some trips (and time for my fitter as well), by tweaking those features, or deciding what I want each button to do. Gains per frequency are still in ballpark of my first successful REM fit (I had to have 2 utterly different, and after that we do one as a test each time when I change aids, and omg, I really tested them, m70, m90, 2x m90 rechargeable, 2x m90 13t, 2x p90 13t, now 2x p90rt are left :joy: )

But yes, I had to understand a lot and learn a lot how sound works, how tech works.

What I like in my fitter is that when he doesn’t know something he says it. It was rare, but happened (when we were discussing theory and trying to figure out how it exactly works).

Oh and I’m math - comp sci engineer :rofl: and I’m curious, so I just dig to find out so many whys. In short, I know how to google, read and understand and ask tons of questions. I don’t think those skills are something special.

What I do see is that many sellers have 0 desire in those skills and results.

One more thing, to test wrs without aids, you use those headphones for tonal audiogram.
To do rem and test wrs with HAs you use calibrated speakers at the exact position.

[b] So if you have rem equipment and audiogram, you have equipment for everything useful. Use it.

If your only equipment is HA audiogram, you have zero.

We want to understand speech, we don’t care about pure tones. Test us with speech! [/b]

And don’t come here saying how it’s the same or even worse saying how audiogram alone is enough no matter which device does it.

Come here to learn from us and gain ability to help your patients properly.)

Unlike many people who come in person, we here did invest our time in learning something about it.

Manufacturers also encourage using REM verification, I personally heard on some courses on

And we know that rem verification works only for those formulas.
So yeah, that’s my proof that point of manufacturer formulas is to reduce returns because many fitters have no clue what they’re doing and manufacturers try to compensate for incompetence.


I went to CI evaluation to check if my cochlea or nerves were damaged (to know if when my hearing gets worse I’ll be able to receive CI or not), and they said that as long as you have word recognition, your nerves are working fine, it’s cochlea.

They didn’t give me numbers, but I think there’s none, I mean, they said that when I drop below 50 as best wrs I’m CI candidate, but nerves are still fine as long as I do have some comprehension.

I’ve just checked your profile. Yeah it looks like left ear really has damaged nerve. But your right one has ok nerve.
I’d focus on right one for comprehension, and with the left one, just give it something to increase overall loudness in the brain and that it doesn’t distort everything.
You’re among those ‘need a ton of trying and guesswork’.

However for right ear I’d also try rem fitting.

Also, google about ‘is it worth to fit bad ear’, in terms of bilateral or unilateral. Conclusion is that it is definitely worth going bilateral because our brain extracts the information even if it is incomprehensible. I read some medical articles with concrete explanations why it works, but I forgot the details.

Hell, that was my argument for going 2 HA even if I have normal hearing in left - but to give brain sound input at the same time and similar ‘color’ when I stream (and to get the most of speech in noise since now I have 4 mics working on it). And I definitely enjoy and understand more with both ears receiving the streaming than if I’d only listen with normal ear. Especially in terms of effort to comprehend.


Did you forget your old login details, or did they get lost in the change to the new board?

Bored on a Friday night?

Unfortunately there’s been a move to cognitive dissonance in lots of these arguments. It’s tedious to cover the old ground for each batch of users.

Nice to see you’ve adopted the ‘Black Art’ approach to fitting too :wink: The problem is for most board members that they can jump the wrong way on the counterintuitive stuff. I remember having a time convincing you about some of it in Cheltenham.

I left the old board when I realized that several posters arguing with each other were the same person! There’s a special term for that sort of troll but I can’t remember what it is!

Yep, I probably did believe in The Mathematical Approach a bit too much in my early days …

I have returned mainly to get an opinion on the latest Phonak Paradise and the GN One aids … but I have then been sucked into other topics …


You don’t have to believe my scepticism - others in the audiology world also have doubts …

"Somewhat surprisingly, the scientific evidence backing verification and validation is limited and weak, despite recent endorsements by various experts in audiology and in the hearing-aid industry"

In another comment I mentioned the difference between Verification and Validation.

REM confirms that the sound levels match those required by a mystical algorithm … but Validation confirms that the system actually provides the client with benefit.

As this comment’s headline suggest, the Validation part is not yet proven.

See: Cover story: Verification and Validation: The Chasm between... : The Hearing Journal

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I recommend listening to Nick Abbott’s show on LBC. Great listening on the weekend late evening.

He’s on your wavelength.

I do sometimes.

At first, I thought it was a bit odd … but then grew into it!

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Except that in situ audiogram isn’t mentioned as validation procedure in this link you’ve shared.

Again, speech.

Audiogram that HAs provide is pure tone. Afaik.

Rem based fitting by using speech is useful.
Pure tone audiogram isn’t.

@Um_bongo somewhere mentioned that rem using noise isn’t useful and I wholeheartedly agree!
I was stunned finding out that someone thought it might work.

We need speech based tests and evaluation and fittings!

And this link looks more about how many fitters are following best practices (tiny amount) and less about how their clients are really happy with the outcome of their poor fittings. I’ve seen also statistics how many people wear their HAs less than few hours, or not at all, because they don’t find them useful.
All of that means they haven’t been properly fit.

Yes. Live Speech Mapping.

REM to a target using test tones is fantastically irrelevant with any aid that does ANY speech processing. Which basically precludes ALL the digital aids made in the last 23 years.

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  • REM style processes have been around for some 30 years

  • A minority of dispensers actually use REMs

This suggests to me that REMs don’t really deliver amazing 100% sure-fire results … otherwise, by now they would be used everywhere as a matter of course.

Sudden thought : this argument is fairly academic at the moment …

With COVID-19 floating around for say the next one or two years dispensers will be VERY reluctant - or not permitted - to get close enough to clients to fit REM probes.

In many cases fittings will be 100% remote - away from any REM system.

In-situ testing will however be safe to use.


The REM stops just outside your eardrum.

The in situ test carries on going and actually activates your hearing mechanics and nerves and subsequent brain processing.

Depends on your location, really. I did REM all day yesterday. During the full lockdown we were doing speech mapping with RECDs in the testbox in advance of remote adjustments.

But yeah, Covid sucks and screws everything up. My sympathies if you are in an area with a lot of cases.

15-20 minutes seems long to me, but it depends on the person and how many manual programs you’re setting up. It takes 15 seconds to run the speech passage, and my system does it bilaterally. So, a minute to run the four primary measures that I want. Say, a minute for set-up. I don’t typically run it 13 more times before getting things set the way I want, nor do I run all four measurements during the adjsutment phase. In situ usually takes longer.