Because you have to say yes to a tone? Just like you already did during the audiogram? This is the weirdest logic for arguing that in situ is better.
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AFAIK all those are forms of REMs. Thereâs not just one REM but if I remember correctly like 8 of them, no?
Check here what I think should be covered, under tests:
https://hearing-balance.natus.com/products-services/aurical-freefit
I also always try to emphasise that I think about REM based fittings using speech.
Which are the only ones that seem relevant for actual fitting and getting WRS out of HAs as per expectations.
When my fitter starts, he does several things before we get to speech part. From what Iâve gathered, all those are various REMs.
Is it possible that @Um_bongo and @TrueBrit youâre screaming against REM with noise, while Iâm screaming for REM with speech all this time?
Eg that weâre basically screaming for the same thing but terminology got lost in the translation?
From here:
So what is it at the end, live speech mapping is using REM or not?
This tells me that yes, or?
@Neville which one you think when you say REM fitting?
They say that 1 in 3 people donât use their aids (based on some study).
For me thatâs a proof that all those fitters donât deliver useable results.
I knew only one other person in real life who got HAs, and after several fittings, she just put them in the drawer, she was too tired of guesswork and they didnât helped her.
But letâs first sort out terminology 
The two situations are totally different.
OK, letâs stand back a bit and review the situation from afar,
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The first in situ system I know of is the Widex Sensogram from 1996.
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In-situ systems are still being used today, by almost every manufacturer.
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As far as I know, nobody has ever suggested replacing the standard hearing test with in-situ tests.
Taking all this together, one can only assume that:
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in-situ tests perform a useful purpose
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in-situ tests are not equivalent to standard hearing tests.
Iâm not sure what your point is with that. I am not saying that an audiogram and in situ measurements are the same, what Iâm objecting to is this idea that in situ somehow âinvolves youâ in a special way that makes it better than REM. In situ provides a measurement of how the fit of a particular hearing aid in the ear impacts detection of a sound relative to the standard audiogram. REM does the same thing with a more direct measureââinvolvingâ the patient a second time doesnât make any difference. And then beyond that, REM allows you to confirm that the hearing aids are actually doing what they claim they are doing, which in situ does not (which also, on a group level, allows for the development and refinement of prescriptions and the advancement of our field). As far as I can tell, this âin situ involves your brain and processingâ is a nonsense feature that was probably developed for marketting. But maybe weâre just not communicating clearly and I actually have misunderstood your original point.
To me REM is anything that involves putting microphone next to the eardrum and taking measurements using an independant, calibrated instrument. There are various measures that can be taken for various purposes, some more or less useful depending on the context.
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wow, thanks for the discussion.
I think the majority see REM as a starting point. It also makes perfect sense for me to choose a starting point that is objectively ok.
I had to replace the cables for the rics, because these were too short. With this short cables and in-situ @home revealed that all the tones were too quiet. A fitter should see that i think.
At the same time, I once again started the discussion whether REM would bring something or not. His arguments were that the manufacturersâ formulas were secret and that he could not verify the result. I said okey, but he doesnât have to verify it. Oticonâs Genie software provides an interface for the Aurical System and processes the feedback automatically.
After a while we made the test and he compared the result from the HA with NAL-NL1. He wanted to prove me that the manufacturerâs formula is okay. Clearly there were deviations, which according to him, are of no consequence. braindead
And why should even Oticon advocates REM adjustment and add extra functions into the software when it is pointless?
A question that my fitter cant answer ^^
I will discuss it again with my ordinary contact on Friday. Iâm curiouse how it work out. I always try it with step-by-step arguments, but REM seems always senseless in this company and program the HA as it is convenient for the customer.
The best thing is always âhow do you hear me nowâ what Blacky mentioned.
Last time I didnât hear a difference if I wasnât focused on it. Which was also called âgreatâ because then the sound is not intrusive. A mindset that I donât understand.
What do you think about an open supply? I think closed is simply better, because the entire filtering of the hearing aids works better.
Really not sure what you mean by âopen supply?â Are you talking an open fit vs a more occlusive fit? If so, advantages of open fit are a more ânatural sound.â Disadvantages are that not as much gain can be applied, especially at lower frequencies, more issues with feedback, noise reduction systems are less effective. More occlusive allows for more gain with less feedback and more effective noise reduction at the expense of possible âocclusion.â More occlusive has many advantages but depends on how well the individual tolerates the occlusion.
Thatâs true.
Verification is available only for those formulas, NAL, DSL and such.
What is weird is that he thinks that he should fit by manufacturer formula and not NAL-NL2.
However, one think what Iâve found for phonak marvel/paradise is that if you pick non manufacturer formula in HA (and then you can do REMs) you wonât get one thing - different attack and release times. Theyâre available only on their proprietary formula.
I forgot which setup theyâve chosen to implement, fitter doesnât have the ability to influence that. And I donât know what is the default for other formulas, I just remember reading their article about attack and release time and realising that they intentionally didnât implement that on other formulas, only their own. Bastards 
Goggle âattack release times phonakâ and youâll find it fast.
But also, finding is that those other attack release settings arenât for everyone. So, Iâd say manufacturer formula (for phonak) might maybe have sense to use on group of customers for which that was shown to make a difference, while on everyone else should regular formulas be used, since they can be verified.
Edit
NAL-NL2 has more bass
NL1 has less, and is more focused on speech, but was changed for NL2 because people werenât happy with it
In my case where I want to completely remove bass to remove distortion it brings, NL1 did better.
Here is the dilemma I have with REM vs. Manufacturer first fit vs. Insitu. from a clinician point of view
prior to my current role I worked for years with Widex, who strongly promote the sensogram (in-situ measurement). When completed correctly this measurement typically provides a much larger low/mid-frequency response compared to what Nal-NL2 recommends. Furthermore, unless a fairly closed fitting is completed Widex, with its traditionally poor feedback management (cant comment on latest chip as havent fitted) could certainly be adjusted to âmatchâ target however this requires deviating heavily from the Widex recommended sensogram settings and matching the high frequencies meant that the aids became very unstable (imagine two chirping canaries sitting on top of the ears)
Moving forward I now work with Signia, Resound and Phonak/Unitron. Phonak prescription tends to be fairly close to NL2 targets, Resound isnt too far off either. Signia however is way off, in particular when open-fitting.From what I can see their proprietary prescription tends to provide a lot less gain, particularly for an open fitting first time user. Once again I can easily match target, however when I do the patient complains that the aids are way too sharp and loud. In fact, the proprietary Signia formula tends to get the most consistent positive responses from the patient.
I always run REM / Live Speech Mapping for every fitting, but the dilemma I face as a clinician is what do I choose? Do I fit to what the manufacturer has researched themselves (and likely set up all parameters of their aids to work based upon that research) or do I push the hearing aids to match target, but then have to potentially compromise on patient comfort and their own preferences for sound quality. I cant help but worry that when I am making significant adjustments to how the manufacturer software sets the aids then those aids are really just moving further away from what is going to work best for the user based upon manufacturer design.
Anyhow, I suppose thereâs no real answers to any off my questions because user perception of amplification is very subjective. Personally I end up fitting hearing aids based on a bit of all of the above - but always trying to provide the user with what I think will suit their preferences in the best possible way.
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My fitter said that widex canât be fitted with rem
My conclusion is that they heavily process the sound or something.
Iâd say best approach is to measure WRS without aid (on headphones and whichever db are needed) and then use whatever formula is needed to achieve at least such WRS with aids and sound at, what, 65 dB. In quiet, through the speakers.
Also ask client if they want comprehension or comfort.
In case they donât care about comprehension, then not chasing WRS is fine.
But if they want comprehension then hitting WRS is a must, but doesnât need to be done at first time, so adaptation and slowly pushing someone into their targets.
Also, for flat loss or high frequency sloping loss but not too steep ones, it is probably equal whatever you choose as starting point.
But for anything complicated, Iâd definitely start with non manufacturer formulas first.
Neither widex nor phonak manufacturer formula worked on me, even after some tweaking. Widex worked but tweaking was insane and long, so end result didnât have any resemblance with the original curve and I wore tulip dome.
When other person tried, again starting from manufacturer formula and vented mold, and a bit tweaking - results after 2 months was that I hear better without that aid than with it.
Whilst phonak rem fitted (speech mapping) on NAL NL2 and vented mold was miles better than anything from manufacturer (both phonak and widex), but still, worse than my target WRS. What hit WRS was NL1 and open dome, believe it or not.
Maybe he doesnât know where you can change the formula in the genie software used by oticon.
Stil, I canât understand the argumentation.
Even with the oticon formula there should be a visible change in the
target view. And that should prove him wrong?
Maybe i should leave and try it somewhere else.
I donât know if Genie supports REM measuring for speech mapping, for that itâs usually used the SW from the measuring device.
But yes, geanie should support choice of formulas and then you pick one on aids, pick the same on the verification sw and run it.
Phonak adapts targets also directly in target sw when you switch between formulas, eg gives you gains as they calculated.
But, it is definitely worth investing time into finding fitter who follows best practices summarised by dr cliff.
Maybe itâs cumbersome at first to filter them out, but will save time, nerves, energy and money.
Iâd call, send email, go there, whichever is easier for you and ask what beside audiogram they do to ensure that theyâve fitted aids to the best of their ability for your hearing loss. And then listen. If they donât mention stuff, you ask. If they try to say how itâs not needed, or obsolete, say aha and end the call, not worth the time.
My last fitter did REM on my Phonak Naida B using NAL-NL2. With this approach the highs (>2kHz) were much too loud. And even loud noise at around 1kHz was still too loud. After I bought those aids I did insitu with NAL-NL2 for myself. It was better but still bad for loud input (G80). With DSLv5a and especially APD/C (manufacturerâs formula) it was ok as a starting point. For me.
In short: REM is not a holy grail. It can be a starting point. But the more important thing is that a fitter has to carfully listen to his patient and know what the hell is going wrong.
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Part of the issue is doing the REM to a target rather than a weighted Speech level.
The other problem is that within NAL/DSL etc, thereâs competing ideologies in place in respect of whether all parts of speech deserve equal prevalence and amplification.
Another problem is that the stimulus tones used are often identified by your HA as gibberish, so they donât turn the sound up as they do for speech.
Anyone who is adamant that this prescriptive system is the only way to go either hasnât fitted that many hearing aids in the real world or is just a fanboy of a particular REM system. Used judiciously REM is very helpful, but just like driving a Tesla and not looking at the road, if you blindly rely on what the machine says, youâll come unstuck at some point.
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I donât think anyone is saying REM is the best way to go, but I think itâs way better than using the Quickfit approach as a starting point.
Iâm really new to the hearing aid business and Iâm trying to find some good aids. But 2 out of 3 âfitting expertsâ have never checked how much of the sound is reaching my eardrum. In addition, one was surprised that I have problems when the ric cable was too short/long and the open mold does not radiate well into the ear canal.
For these cases and for control, I see it as a good way. Above all, an inexperienced person does not know which frequency range is important if he has not heard it for a long time.
A problem with this âhow can you hear meâ approach.
My Costco fitter set up my KS9âs with REM. I didnât like the result. I went back for what I thought would be a simple change but was still unhappy with the result. So I bought a Noahlink Wireless, made some DIY silicone earmolds, reprogrammed my aids with Audiogram Direct and am very happy with my current fitting. The KS9âs are the third set of aids Iâve programmed with AD and all have worked well.
It may be that my lack of technical knowledge means that Iâm missing some potential benefits of my aids, but my main goals are to understand my wife and understand dialogue on the TV. Iâm happy with the results from my reprogrammed aids. (age 80)
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The VA uses REM. They seem to have complete faith in it. I was told by an Audiologist there that they only use NAL/NL2. When I asked about DSL5, they said it was pediatric only, which isnât true. But, if they only use NAL/NL2, they might not know about the adult version of DSL5, which I prefer to NAL/NL2. REM doesnât work for me. My recruitment makes a REM fitting unbearable. I have seen mention of doing REM fitting while using SR2. That might work, but I doubt it, because of the recruitment. I agree that REM is a good starting point, and works well for a lot of people. Phonak says that Audiogram Direct has been tested and proven to be an accurate method. I have reservations about it, but used it for my own fittings.
Curious if you know what differences between the fittings or audiogram were? Was there a bone/air gap on your Costco audiogram?
You donât have a bone/air gap. (It refers to a significant difference between the two different types of tests they do) Really donât know why youâre so much happier with your fitting with Audiogram Direct. The audiograms are very similar.
There is a good 10 dB difference across the board that I can see. The Audiogram Direct has a little more detail.
I would suspect the original fitting was very loud to the OP. The details in especially the left Audiogram Direct fitting could really help speech IMO. Better details in the right too.
Glad the OP is happy.