REM and the DIY'er who use a provider initially

First of all, REM doesn’t always improve the HAs’ performance from their initial gain prescription. If the HAs perform up to snuff to begin with and don’t underperform, and/or if the fitting selection and ear canal shape are the ideal choices and ideal conditions as to not drag down the HA’s prescribed performance further, then the clinician will see that the initial prescribed gain curves already matching well against the target gain curves, and therefore no further adjustment is needed. From this point of view, you can walk into a REM session and walk out of it with the exact same result you came in with no improvement, because nothing needs to be adjusted/improved. In this case, REM does not equal “better”. In this case, REM equals “verified to be up to snuff against the target already, no further adjustment needed.”

Now it’s not clear how REM was done in your case. If it was done by an external standalone REM setup, then most likely REM will be performed against a standard fitting rationale, probably NAL-NL2. This is because the mfg’s proprietary fitting rationales is private (a trade secret) and the external REM machine can only work with standard/publicly know rationales.

If the mfg’s programming software (in this case, Phonak Target for you as a Phonak user) can accommodate and support a number of REM equipments, and allow its Target software to work well with these REM equipments, then the Phonak APD proprietary fitting rationales can be calculated by the software target to be APD-based, because this Target software has the knowledge to calculate using APD rationales, while the external REM software doesn’t.

So let’s say you had REM done with an external/stand-alone REM hardware/software setup, then most likely it’s set to the standard rationale NAL-NL2 as the target. Even if the original prescription was the Phonak proprietary-based APD rationale, the clinician has now adjusted to “force fit” it into the target NAL-NL2 standard already.

The standard rationales may not work wonder for everybody. Some who have always used it and are used to its characteristics may prefer it to mfg proprietary rationales. Apparently for you, your ears don’t like the standard rationales for certain reasons. It seems like your ears like the Phonak APD rationale better. So that can explain why you found the REM adjusted result (to NAL-NL2) not as good as the proprietary APD rationale that was most likely used in the “quick fit”.

Even let’s say that you have “virgin ears” and have not been exposed to either rationales, so they couldn’t possibly have a preconceived notion to favor one over the other, remember that standard rationales don’t know much about the hearing aids per se, and therefore a lot of assumptions had to be made about how the hearing aids work in order for the developers to arrive at a more “universal” rationales that got adopted as standard.

On the other hand, the HA mfg who developed their own proprietary rationale specifically made for their own HA brand has intimate knowledge of how their own HAs work, and therefore no assumptions had to be made about how their HAs work (unlike the assumptions that had to be made in the development of the standard rationales). So it’s possible that the HA mfg’s proprietary rationales used in the “quick fit” simply just work better for their brand of HAs compared to the standard rationale that might have been forced fit to your HAs when REM was done. And the proprietary rationale may work better because they fit their own HA’s brand better like a glove.

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REM is not about doing anything in and of itself. It is simply about measurement of the sound that is being produced at (or close to) the eardrum by the HA.

It is intended to provide the audiologist with absolute feedback as to how well or otherwise the prescription is being delivered by the HA setup, taking account of HA build and ear canal geometry.

Accordingly, REM doesn’t care whether a proprietary algorithm was used to program the HAs or if it was done using a NAL/NAL2 protocol.

If everything is good with the HA fitting, regardless of the protocol used, it will give the audiologist REM information that helps him/her to know that the sound at the eardrum is as intended. It will also show if the HA is not performing as intended and/or if the ear-canal is so geometrically different from an average that it is affecting the sound being heard, allowing the audi. to adjust the program to accommodate the differences or to consider that a device may be faulty.

Of course REM isn’t a person so REM doesn’t care about anything. REM is simply a method (considered best practice) to verify how well the HAs, the fitting, and the whole system perform. To verify this, there has to be measurements (hence the mics placed inside your ear canals), and the reference which is to be measured against. The reference is the yard stick, or the target, that tells the clinician whether the whole system performs to target or not.

REM may not care which fitting rationale the target is based on, but the clinician should care to pick out the proper fitting rationale that’s available in the REM equipment which is appropriate for the patient. For example, the clinician shouldn’t pick the DSL Pediatric rationale designed for children and use it as a target gain curve for adults, and vice versa. In this sense, the choice of the target gain curve is very relevant.

Ideally, if the clinician can only generate an NAL-NL2 based target gain curve on his/her REM equipment, then the clinician should have selected the same NAL-NL2 in the HAs’ program so that they match and perform accordingly. Otherwise, let’s say if the clinician choses the Phonak ADP rationale as the default initial prescription for the main program in the Phonak aids, but then does REM using the target gain curve calculated based on NAL-NL2 and adjust the prescribed ADP gain curve to the NAL-NL2 target gain curve, the end result will sound like you’re hearing an NAL-NL2 based program at that fixed volume. But as soon as the volume dynamic changes, the volume fluctuations will behave in accordance to what the ADP rationale dictates, and will NOT behave in accordance to what the NAL-NL2 rationale dictates.

So unlike what you said, the choice of the proper fitting rationale to be used to calculate the target gain curve in REM to make adjustment to is not irrelevant. One shouldn’t use a target gain curve based on DSL Pediatric to do REM on adult for sure. And if one can only do REM with a target gain curve based on NAL-NL2, for example, then one should select NAL-NL2 as the rationale of choice in the HAs’ program as well, so that they’re better matched and well matched. Otherwise, it can lead to confusion like @DaveL has shared, as to why his REM adjusted result doesn’t sound as good as his “quick fit” result → most likely because they don’t match in the first place, and @DaveL has his own preference of one over the other.

If ADP is chosen as the prescription for the HAs’ program, then if during REM, it’s compared against an NAL-NL2 based target gain curve, most likely it’ll seem like the HAs “underperform” against the target curve, especially in the highs (because NL2 puts aggressive emphasis on the highs for speech, but ADP may not be as aggressive on the highs for speech. So that may simply be because the ADP rationale doesn’t put as much focus on the highs as NAL-NL2 for speech priority, not because the Phonak HAs underperform and don’t match the target. If the target gain curve had also been ADP based, then the likelihood of the ADP-based prescribed gain curve matches better to the ADP-based target gain curve would probably increase.

@Volusiano

My old audiologist quit. He referred me to a list of others. He had tried for two years. We parted friendly.

He never use NAL-NL2. I watched the screen as he worked. I’m not his client anymore, but am using a wonderful company named “Hearing Well Matters”

The last setup with the old audiologist he informed me that my hearing aids would be quieter because my hearing had improved. In fact the audiogram he used is about 10 dB less than previous audiograms he and others had provided. So my hearing was worse from him and the previous audiologist.

I called into Hearing Well Matters yesterday. I requested a new hearing test and setup. That will happen in a week or so…

Have to run. I’ll be back.

DaveL
Toronto

It looks like what you’ve established above is the NAL-NL2 wasn’t picked as the prescribed rationale for you Phonak programs. I can only presumed that the Phonak ADP rationale was picked as the prescribed rationale for your programs.

What hasn’t been established yet is when REM was done by your previous audi, which fitting rationale the target gain curve was based on. But if it was based on NAL-NL2 there (more likely than not), and the REM adjustments were made to THAT target, and now you don’t like that REM result as much as the new quick fit (which presumably is ADP based), then this implies that you prefer the Phonak ADP rationale over the NAL-NL2 rationale.

@Volusiano

I told him for 2 years I couldn’t hear and understand voices in a quiet environment, from a short distance away. Forget about understanding speech in a noisy environment.
He always had a reason why I couldn’t hear.
From day one of ownership I told him I think we’re missing something very simple. I kept a log of issues, and as he asked I sent him emails before appointments. He always was polite. I wish him well.

Before setup is done in a couple of weeks I’ll ask what system they are using, and I’ll ask for Target Full Reports–User Report and Pro Report.

DaveL
Toronto

@Volusiano

He used Adaptive Phonak Digital 2 according to the report I received from the new practitioner.

The last day I visited the audi who supplied my hearing aids 2 years ago, he erased my hearing aids. He did a Target quick fit.

The new practitioner said:

  • the supplying audi with quick fit set domes wrong. I had closed domes (2 small holes). The fit was based on open domes. That was wrong.
  • the supplying audi had not toggled on communication between the two hearing aids. This was with the last visit as we parted. This was wrong. I couldn’t hear

the new practitioner did not do a hearing test. (good reason for that; I’ll get it done soon.)
He used the audiogram that the old audiologist had established. This magically showed I could hear better after all these years.

This is why I’m having a new hearing test and set up done.

I have a claim with the government that supplies my hearing aids. It’s due to exposure to loud noise at work…110 dB at 3M in the power house.
The government reduces costs a couple of ways.
Request for Proposal–cost and limits to 3 companies. I’m lucky one is Phonak; don’t know the others
Sets low rates for parts and service. And claims are lengthy and the supplier has to work really hard to get paid.

My hearing aids are 2 years old; top quality. Government doesn’t normally supply top quality. To reduce costs.
They supply every 5 years. I shall be able to get some in another 3 years.

The new practioner performed miracles. First he took me on as a client when I needed help. Second I can hear! He is much more skilled than the old audiologist is.

Trying to be kind–I think the old audiologist has good intentions, but has no experience with this hearing aid and doesn’t know how to set it up.

The day that the new practitioner set them up my wife’s reaction was:

  • night and day difference (even though it was a quick fit without REM.)
  • What took you so long!
  • and, I needed to take responsibility for the fact that it took so long because after every visit to the old audi she said he didn’t know what he was doing.

DaveL
Toronto

it’s taken 2 long years to be able to hear. It’s been rough and has affected my relationship.

DL

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OK, so it sounds like there was something more fundamentally wrong done by the old supplying audi that gave you poor results then. Glad to see it all sorted out in the end!