Your Audiologist is Wrong: Real Ear Measurements are ESSENTIAL for Your Hearing Aids to Work Well

Hearing Aids
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I received a newsletter email and one of the topics discussed in the email was a Youtube video talking about REM and why so many audiologists don’t use REM.

Your Audiologist is Wrong: Real Ear Measurements are ESSENTIAL for Your Hearing Aids to Work Well

As some of you may know, I bought new Oticon Intent 1 hearing aids a couple of months ago from an independent audiologist. I have been very supportive of my new audiologist (despite him not providing REM), because within 2 appointments (in the space of a week or so), he had setup my new hearing aids far better than my old hearing aids ever were. I was able to hear in noisy environments like noisy restaurants and general environments. The previous audiologist took about 8 months to get to the same point and for the first few months the old aids were not really functional. Massive difference with the new audiologist! So I am really supportive of my new audio.

However, while I have found my new audiologist fantastic as I think he really knows his stuff, I am still experiencing the same issues that I had with the previous hearing aids - namely not being able to hear people behind me in the car if they don’t speak loudly, having trouble hearing some people when talking in soft conversational mode (soft voices) and which seems to be a persistent issue with Oticon - a volume/sharpness imbalance between left and right ear where things like microwave beeping etc always seem more present in right ear. As well as other little things, where I am not hearing things that other people seem to hear.

Granted the new hearing aids are setup much better than the old ones and these issues are much lessened. However, I have been feeling lately like we are operating in a black box environment or flying blind - because essentially without REM to verify the fit - neither of us actually know what my ears are actually hearing! I had toyed with the idea of getting a Noahlink device and seeing if I could play with the settings to address the volume imbalance issues and see if I can isolate why I don’t hear things like the clock ticking etc! But after watching this video, I realised that all I would be doing is working in a black box environment doing the same thing my audio is doing - guessing which frequencies I need boosting - instead of verifying what my ears are hearing.

This video got me thinking. Why am I putting up with a situation where I don’t actually know what my ears are hearing, because my audiologist is unable to verify the fit because he doesn’t want to invest in expensive REM equipment? Because let’s be honest, it is the cost that is the real reason why so many audiologists do not support REM - preferring instead to play a guessing game of “how does this sound”. My audiologist is very good - I do hear better with these aids than I did with the previous ones and he managed to get them very well setup within a very short space of time - I can hear very well in noisy environments like restaurants which most people struggle with. So, he has done well. But, they are not optimal because he doesn’t know what my ears hear.

Given that I am still experiencing the same main issues (like not hearing people in the back seat of car) with my new hearing aids as with my old ones (although not anywhere near as bad), it is clear that the Oticon fitting forumula is not accurate for my ears. I suspect that I am significantly underfit for higher frequencies (in probably both ears), but especially left ear.

I really like my new audio and I think he is fantastic and I think he has been really helpful and supportive. So, it has been difficult to accept that I need to move on. I have taken the hard decision to contact another audiologist (who advertise REM and have good Google reviews) and ask them if they could do an REM and they also offer Speech Audiogram (which again my audio does not do). I have asked if they can provide the services, my audio cannot, but if I could continue to work my local audio who is 20 minutes walk away, whereas they are just over an hour’s drive away.

I will update this post, once I have had my REM done and advise whether it actually fixed any of the issues that I am wanting resolved. I am not sure if it will, because I am well aware of many on this forum who have had REM done, yet still go to their audio for many months of tweaking and even bought their own Noahlink devices to self program - so clearly REM is not the end of the road for this process. I actually had REM done on my old aids with the old audiologist and my new aids are still better (without REM), so clearly REM is not everything. But I think I should be able to hear everyone properly in the car and also hear anyone who speaks in soft conversational mode - which is a bit hit and miss for me at the moment. I think the underlying cause is the same - underfit of higher frequencies.

This post is just to say - Even if you are very, very happy with your Audio, if he is not offering REM, then you are not getting the service you deserve. I think my audio is lovely, but I have to accept I am not receiving the best care sadly because I know that I am not hearing all the frequencies that I should be! Be prepared to take the hard choice and fire your audio!

The only reason audio’s don’t support REM is they don’t want to invest in the cost of the equipment which is quite pricey. That is their problem, not yours!

GO GET REM! GET THE BEST CARE! YOU DESERVE IT!

This post is mainly to encourage others to get REM if it has not been done, because without REM you will never get optimal setup for your hearing. It will basically be estimated and guesswork!

I think all governments around the world should mandate REM because frankly it is unacceptable that most audiologists will not spend the money to verify the fit because we are the ones that pay the price with underfit hearing aids that are not performing optimally! Not good enough.

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“The speech audiogram is made up of plotting the WRS at each intensity on a graph displaying word recognition score in % as a function of intensity in dB HL.” Speech Audiometry: An Introduction | Interacoustics With that link there is also a video explanation.

If I understand correctly this provides information but is not adding to the aid programming?

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In no particular defence if your Audiologist, the Oticon prescription is a bit Meh out of the box.

Looking at it through my Live Speech REM lens, it’s particularly a problem through 3-6KHz with a speech stimulus in moderate background noise. However, to the client they sound ‘good’.

if you’re going to fit Intents, you ‘should’ be aware of their shortcomings in what they do.

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What do you mean by this. Do you mean they over prescribe in the 3-6khz range? I’ve gotten intents recently and the prescription very aggressive.

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My VA audiologist does REM ever time that my aids have any major changes like ear molds, firmware updates, new aids, or the very rare repairs. I have been wearing aids from the VA for almost 20 years.

I should add that the REM is the main starting point then my audiologist will make tje needed adjustments to make my aids work best for me. My audiologist and I have worked together now for about 7 years to get my aids adjusted for my hearing needs. My aids have custom ear molds, my receivers are 105db and yes that is more powerful than the fitting software says that I need. But what the software says I need just flatly doesn’t not allow me to understand speech. My aids are actually adjusted to close to 110% of what my audiogram seems to dictate. This is true across the frequency span of my hearing.

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No, they’re usually way under prescribed in this area.

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I’m obviously a big REM supporter.

But hearing someone in the back seat when you’re driving a car. . . Man that’s hard sometimes even for people with normal hearing.

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I was not expecting to get so many replies. My post was sort of a mix between a rant and a push for people to demand that they get REM. Thanks.

@user490 - As none of the audios that I have seen in the last 20 or more years do WRS or speech audiogram - I have absolutely no idea how it works. But I think it should be done, because it would help to narrow in on the exact consonants etc that I have issues with! So, I am pleased that the audio that I contacted offers this.

@Um_bongo - Thank you so much for your comment as it cements my feeling that yes - 3-6khz is underfit. Those are the exact frequencies that I am not hearing well when I did the Online Tone Generator (wearing my hearing aids). So, I am very pleased to have confirmation on this point. Can you advise how you determined this, because it doesn’t seem that my audio is aware of this although he prefers Widex usually -until Widex released their new aids with this cloud version.

@cvkemp - The nearest audio that seems to offer REM (and this speech test) is an hour’s drive away. This is the big problem - most audiologists do not offer the service! But I am prepared to travel if it is the only way that I will get things resolved. I would agree that REM forces the audio to boost the hearing aids above the audiogram - because this is the feeling that I (and it seems most people) are experiencing - that the hearing aids are underfit and I am not hearing all the frequencies as much as I should be! But, alas very few audio’s seem to offer REM.

@Neville - to some extent I agree with your complaint about not hearing well in the car. However, my sister (sitting in front) has no problem hearing my mother in the back and I have issues (intermittently) hearing some people when people are talking in soft conversational mode (rather than work volume speech), but everyone else is clearly able to hear that person - again I think because I am underfit particularly in the high frequencies. To me, the problem with the car, walking behind people on the street or soft conversational volumes or hearing someone say in the next room - coffee - all have an underlying cause - I don’t hear when the sound is too soft.

@Um_bongo Could you elaborate on why Oticon are doing this and why those specific frequencies? I have always thought that people found Oticon too harsh, because Oticon concentrate on the high frequencies (for clarity) rather than boosting the low frequencies which give you more natural sound. Are we talking about a 10% underfit or 50% underfit? I am really interested in this, because this mirrors what I am experiencing - missing high frequencies.

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I have asked Chatgpt to explain to me what Oticon is doing with the missing frequencies. It seems that it boils down to the fact that Oticon use VAC+ which focus on speech comprehension, but tries to make speech sound comfortable and natural to avoid sharp, hissy or tinny sounds. NAL-NL2 on the other hand focus more on maximising speech comprehension with more crisp speech so that you hear those fricatives etc better. Hmm. I wonder if NAL-NL2 would suit me better than VAC+ as I do feel that I am lacking that crispness of sound.

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Yeah, I guess it’s good to dream but some peoples hopes/wants seem pretty unrealistic. Some of them remind me of the old joke about somebody who broke his hand asking if he’d be able to play the piano. When told yes, he replies “Oh good, I’ve always wanted to.” This isn’t aimed at any individual.

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Well I have Oticon INTENT1 aids and I have worn aids for 20 years and Oticon aids for 15 years. My whole hearing loss has always been my issues with speech understanding. My audiologist for the last 7 years and I have worked to get my speech understanding to the very best possible while wearing aids. We accomplished that about 3 years ago after I went through I believe 14 adjustments in a 2 year period of time. And also during that time I did therapy to allow my brain to accept the hard harsh sounds needed for me to understand speech. My aids have receivers much stronger than tje fitting software says I need. I do not know which fitting formula that my aids are set to. I just know my audiologist and I tried a number of different options. Let me say this, all hearing aid providers set aids for comfort and not optimum performance. Why, because they want the users to wear the aids and not throw them in a drawer. The process I endured has paid off in spades, but it requires patience from me and my audiologist. It required many weeks of discomfort and even headaches. It required many weeks of intensive therapy to better understand speech. It was I am sure expensive but due to being a veteran with service related hearing loss and being disabled the VA paid for the aids, the fitting appointments, and the therapy. What have I gained, being able to be part of the conversations with friends, family, enjoying music. Yes I said music, but I am not a music snob. I can go to meetings, lectures, church services, music concerts, and enjoy being there. I can ho to noisy restaurants and hear in a lot of cases better that normal hearing individuals. I do this all by having only the default program on my Oticon INTENT1 aids, which have custom ear molds. I do have and use ad needed the connect clip, the EduMic, and the TV adapter. I can ride my motorcycle with my aids on and set to the default program. I can drive or ride in my Jeep Grand Cherokee with the windows down. Do I hear every single word or sound? No but I don’t mess enough to not carry on a conversation. I do read lips, something that came naturally to me as I went decades with hearing loss and not wearing aids. I also due to be an analyst read body language. I live in a forest community. I don’t live in a city but do love traveling and going to reunions with my military brothers and sisters. We do this reunions at Presidential Libraries and museums. Life is what you make of it, the more you put in the more you get out. The more of a positive attitude you have the healthier you are. The more of a negative attitude you have the more illnesses you will have.

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No. Only at about half the people here. Definitely not me though. :grimacing:

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Having fit several pairs of them and REM’d the results, Oticon seem to do a lot of ‘gain averaging’ which flattens the peak gain down overall. It’ll sound smoother to the user, but delivering punchy sharpness in the upper parts of the speech spectrum really makes things better in background noise.

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That is definitely the way my aids are set. I now hear sounds I never heard. I actually hear the S, ph, F and others that I hadn’t heard in a long time. The sounds actually hurt at first, but the mor my audiologist worked with the adjustments the better my understanding of speech became. It didn’t happen all at once but over time. The therapy was the key to allowing me to understand words that I didn’t understand and also with helping my brain to accept louder sounds. Over the time of almost two hours the sounds that once were unbearable became easier to accept and understand. Honestly I wish I had the whole process done back much earlier while I was still working. As my career may have not ended when it did.

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You are making a blanket statement that just isn’t true. But I agree to one thing the audiologist I have is a rare blessing. And I will add something else, as a retired IT professional that dealt with customers daily or years. Most of them wanted the quick and dirty fix so they could go back to their leisure life. I have also don’t volunteer work at the VA clinics dealing with veterans with hearing loss and have seen the same things they want the miracle fix and not be bothered with any effort on their part. My life and my family taught me that you get out of life what you put into it. I haven’t ever been able to skate through life the way some many people think they should be able to.

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A wonderful Audi who’s programmed your aids the best they’ve ever been, and who doesn’t do REM.

My ears have been heavily reconstructed by surgeries in my youth. Apparently, I barely have an ear drum in my right ear. My excellent audi pointed out that REM requires a mic be poked up against the ear drum. again, my ears canals are bizarre. my audi does REM on request but advised against it for me. I agree. He also thinks that it’s over rated. He relies on adjusting aids to fit the real world experience of the user, which can’t be replicated in office but only aimed at.

Most people also agree that REM is a starting point for further adjustments.

I agree with teh post above that points out that hearing people speaking in the back seat of a car is difficult for normal hearing people as well. In other words, asking an audi to make your aids function at near super human levels is a non starter.

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@Um_bongo Thank you for your feedback. That is definitely going to be my next step. Getting those high frequencies back.

@cvkemp I don’t know whether hearing is worse than mine, but it sounds like it must be as once I got Oticon’s 7 years ago, I found that they worked really well in most environments like noisy restaurants, shops, round the table etc. So, to a large extent it sounds like my ears are better than your hearing. I just seem to be stuck with certain persistent issues - I will follow up on the advice above regarding the higher frequencies boosting that Oticon are not doing because I suspect that this is the underlying cause of my remaining problems.

Everyone else - I am fully aware that no hearing aid will ever replicate normal human hearing. I am not asking for that, nor expecting that. The point I am making about the car example is not really specific to the car, but more that there seems to be a pattern with where I have difficulty hearing - which is basically where the sound is too soft (which occurs in cars because the seats muffle sound etc). All the areas where I seem to experience hearing issues is with low volume.

I can hear perfectly well in noisy restaurants, in the work place in general (as people tend to speak louder at work, than at home) etc so I think my hearing is quite good with hearing aids despite my issues with lack of higher frequencies.

If I am being unrealistic in expecting to be able to hear properly when people are speaking in soft conversational volumes (specific people, that nobody else seems to have any trouble hearing), then please let me know. Forget about the car - my real beef is actually having difficulty hearing when the sound is too soft or too low, especially with people who have a more melodic voice where they don’t stamp out the syllables. If everyone speaks at a normal work volume - I have zero issues hearing anyone. Hope that clarifies what my exact complaint is. I think my problem with the car is more to do with soft volume than the car itself.

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I see REM as a verification that the aids are working as designed. But for me to understand speech and get the most out of my aids the REM is just a starting point. My aids are adjusted by 10% over what my audiogram would indicate. Or I should say to 110% of my prescription settings. It did not happen that way overnight it took about eighteen months of adjustments and also adjusting of myself to endure the extra sounds.

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@cvkemp My previous audio did REM on my old aids. Frankly the new aids are far better configured (without REM) than the old aids are. I agree with you REM is very important, which is why I am going to get it done - in conjunction with discussing with my audio whether Nal-NL2 would be a better fit for me than Vac+. But if the fitting is crap, REM will not help either as it just verifies the fitting.

I think it is very important the people are aware that for REM to be successful, the audiogram needs to be properly fit in the first place, which was obviously not the case with my old aids.

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My brother in law speaks in varying volumes in the same sentence.

He’ll go from LOUD to medium to soft to LOUD again.

I just pickup what I can. If I miss something I care about I ask him to repeat it. Multiple times if I have to.