Gender Biases in Traditional Voice Education

By Liz Jackson Hearns and Brian Kremer

Authors of The Singing Teacher’s Guide to Transgender Voices

Nowhere else in the musical arts are gender roles as staunchly established and upheld as in voice. The binary gender system presides over voice parts, repertoire choices, role casting, competitions, costuming, dressing rooms, and more. Because the established social gender roles of singers have never been deconstructed or recalibrated, the prevalence of the binary system is so ingrained that it often goes unnoticed until someone who does not fit into the system disrupts it. That disruption leaves many voice teachers and music educators at a loss for means to guide their students in ways that support them artistically and help build their careers in such a heavily gendered environment. It also leaves many gender diverse singers, or would-be singers, unable to find or rely on culturally responsive and pedagogically competent teachers, alone in trying to discover their own authentic, true voice. By engaging in discussion and education about gender-inclusive voice care for singers, we can develop new ways of hearing and guiding voices that affirm, welcome, and hold a place for all singers of all genders.

Voice Part Categorizations

One of the more obvious places that gender binaries impact singers and singing education is voice part classification. The traditional Fach system is, in many ways, an antiquated guide for the modern singer, and especially so for a gender diverse singer. Even choral voice parts are delineated and described as they relate to the gender of the singer. Two singers could have identical voice ranges, weight, color, and style; they could sing the same repertoire and audition for the same stage roles, but each might have a different voice part category because of their gender. Does the gender of the singer somehow change the sound of their voice?

Choosing to adopt a particular voice part category requires that the singer choose a gender, essentially. This can be limiting for transgender and gender nonbinary singers because of the traditionally gendered associations that accompany voice classifications. Female low-voiced singers, male high-voiced singers, and gender nonbinary singers are left without any appropriate voice part category. The ensuing confusion on the part of the casting directors may prevent transgender and gender diverse singers from being considered for stage roles, choral contracts, solos, or competitions, because these singers do not fit the mold. Rather than consider the validity and usefulness of the system and make room for growth beyond its outdated modes, educational institutions and casting agencies attempt to box these diverse and boundary-defying singers into established gender norms. Trans singers are then left bewildered with nowhere to belong, and face enormous obstacles to artistic and career development.


Because the singing instrument is the only instrument that creates words, singers are tasked with telling understandable and compelling stories, either as themselves or through character interpretation. The gender identity of the singer may prove to be a factor when deciding if a piece is the right fit, so that the artistic intent of the singer complements the artistic intent of the composer or librettist. Voice teachers may be inclined to suggest repertoire for their students that is either overtly or deceptively gendered, which may be appropriate for the voice quality but grossly inappropriate for the singer. There are very few, if any, pastoral pieces for bass-baritone or songs of sexual and military conquest for soprano. Trans singers may have few options when creating performances or audition books to find repertoire that aligns with both their technical skill and personal identity.

Voice Pedagogy Language

Voice teachers and students form deep personal and artistic bonds inside the voice studio, and it should be a safe place for discovery and exploration for all singers, regardless of gender. Traditional voice pedagogy assumes a level of comfort with one’s body and voice that is likely not present for a transgender or gender nonbinary singer. Trans singers sometimes must overcome the difficulties and limitations that arise from gender dysphoria, especially around voice. Voice is a characteristic through which we categorize people by gender, subconsciously and automatically, and trans people are often acutely aware of the ways that voice can influence how the world sees and hears us. That awareness can lead to extreme discomfort around making vocal sound at all, discomfort with the body as it relates to voice, discomfort or disconnection from sensations in the body, or hypervigilance about parts of the body or the sound of the voice.

Gender-inclusive voice pedagogy can include language that differs from traditional ways of teaching voice by giving agency and autonomy to the singer when learning new skills or taking on new vocal tasks. Gender neutral language also helps alleviate—or at the very least prevents exacerbation of—some symptoms of gender dysphoria for singers, especially when referring to the parts of the body needed for singing or qualities of vocal sound. Rather than describing the sound of a voice as “masculine” or “feminine,” the teacher is challenged to use more specific descriptors, which may actually improve pedagogical efficacy for all students, including trans singers.

First Steps

Transgender voice care is a burgeoning field and serves a population in need of qualified teachers and practitioners. As voice teachers, our responsibilities are to support our students and to help them meet their musical, artistic, personal, and career goals. This often requires us to push ourselves beyond our comfort zones and work together toward changes in the systems that hold our students back. There is still much to learn in this realm of voice, and the first steps involve recognizing and reframing our own subconscious judgments, self-perceptions, perceptions about others, biases with regard to voice, and other factors that we may carry into a lesson with a trans student that could pose serious barriers to that student’s success. The Singing Teacher’s Guide to Transgender Voices aims to aid in the development of a successful vocal pedagogy for the training of transgender singers, help the academic community understand the needs of transgender students as it pertains to vocal training, and engage in a broader discussion about the presence of transgender students in lessons and classes and how this positively impacts teaching, curriculum, and classroom environments.

Putting Theory into Practice through Hands-On Experience

By Bre Lynn Myers, Aud, FAAA

Author of Vestibular Lab Manual, Second Edition

Putting theory into practice can be one of the largest obstacles students and clinicians face particularly when the subject matter appears complicated. Guided hands on practice is necessary in order to obtain the confidence and skill set critical to properly instruct, collect, and analyze data from each test accurately.  In addition to guided practice, it is also helpful when learning something new, to have someone who is able to explain complex ideas with everyday examples. The Vestibular Lab Manual, Second Edition does both. The text begins with an overview of a well-equipped vestibular/balance lab and suggests observation and reflection as a means to begin the appreciation of vestibular diagnostics. Every student interested in learning a skill, be it in the health care field or humanities, should have an appreciation of the “final product” before beginning to dissect each part.  Following the introductory chapters, subsequent chapters break down vestibular assessment protocols piece by piece. Each chapter provides general instructions, tips, and guidance, suitable for practice with any manufacturer’s equipment.

Learning is also more fun and less stressful when you have a friend beside of you. Chapter exercises are designed to be completed with a partner or small group in approximately one hour, allowing for each participant to serve as clinical operator and “patient.” Once students complete the “guided practice” portion of the chapter, reflection and review questions or case studies are provided to reinforce theory with practice. By setting learning objectives, providing a little background and specific goals students and clinicians can move through each chapter at their own pace, freeing up lab instructors to provide specific feedback and address questions as they arise.

Bringing Active Learning to Cleft Palate

By: Linda D. Vallino, PhD, CCC-SLP/A, FASHA, Center for Pediatric Auditory and Speech Sciences, Nemours/A.I. DuPont Hospital for Children, Wilmington, Delaware

Dennis M. Ruscello, PhD, CCC-SLP, FASHA, West Virginia University, Morgantown, Virginia

David J. Zajac, PhD, CCC-SLP, FASHA, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina

Authors of Cleft Palate Speech and Resonance: An Audio and Video Resource

Individuals with cleft and craniofacial anomalies represent a complex heterogeneous population. Like their medical presentations, their communication impairments can be diverse in nature and severity, the result of various causative factors.  Although some individuals with cleft palate may have normal sounding speech others will not. Some will present with obligatory errors that occur as a direct result of velopharyngeal dysfunction (VPD) (e.g., hypernasality, audible nasal air emission, nasalized plosives). Others will present with learned maladaptive articulations that occur as compensation for VPD (e.g., glottal stops, pharyngeal stops, fricatives, and affricates). Individuals with cleft palate may also present with obligatory errors as a direct consequence of oral structural anomalies (i.e., frontal distortions). Even still, there are those patients with and without cleft palate who produce unusual articulations such as nasal fricatives (i.e., phoneme-specific nasal emission) (Vallino, Ruscello, & Zajac, in press; Zajac & Vallino, 2017). Any one or more of these errors as well as those errors unrelated to the cleft palate can co-occur. Given the complexity of speech problems in this population, the student of speech-language pathology might find this all quite confusing. Misidentification of errors can lead to misdiagnosis and inappropriate treatment recommendations. The challenge to any instructor is how to effectively teach cleft palate, a complex disorder, to students; and create a successful transfer of evidence-based knowledge and skill to real-life clinical practice that will result in optimal care for the clients they will come to serve.


Traditional Teaching of Cleft Palate

A most pressing issue in the area of cleft palate is that clients with this disorder constitute a low incidence population, and many clinicians have limited academic exposure and/or clinical training in this area (Vallino, Lass, Bunnell, & Pannbacker, 2008). The typical, and most dominant, approach to teaching a course in cleft palate speech is pedagogical. The instructor disseminates (didactic) information about the features of the various speech disorders (i.e., resonance, nasal air emission, articulation, phonation) associated with cleft palate and students are passive recipients of this knowledge. Instructors may supplement the material presented with a textbook on cleft palate that includes illustrations using snippets of recorded speech samples of a particular speech feature to which the students simply listen. Presentations of case studies are rare. The students take notes on the information presented, only to recall it on a written examination (Siegel, Omer, & Agrawal, 1997). They are thought to understand the material based on the grade received for the course. As is known, the grade a student receives is not always a valid or accurate predictor of the student being able to apply his or her knowledge (Albanese & Mitchell, 1993).

The advantages of this traditional didactic approach are that it introduces the student to a fairly broad array of speech disorders associated with cleft palate that might not be otherwise covered in any other course, and the instructors have maximum control over the material presented. The disadvantage of this type of teaching is that it is essentially unstimulating, and that information presented this way tends to be forgotten rather quickly. As Jaebi (n.d.) pointed out, the didactic approach lacks student focused learning, emphasis on critical thinking, and process-oriented learning.  Importantly, it lacks interactivity. Students too have different learning styles and preferences, and if the goal in teaching is to make all students successful learners then this predominant one-way approach is not always a good learning fit for all.

The students who sit in our classrooms in 2018 are millennials. They have grown up with and interact constantly with technology, and this is affecting how they want to be taught. For this reason, it only makes sense that technology be used to bring to the student an interactive approach to their learning about speech problems associated with cleft palate. Classrooms are equipped with this technology (i.e., Smart Boards, data projectors and projection screens or LCD/TV monitors, DVD players, audio systems, and capabilities for video conferencing), which can easily provide access to real-life examples. Students learn well and retain information well when they are engaged, when they are active participants in the learning process.

Cleft palate is a specialty in speech-language pathology that particularly lends itself to learning both in the classroom and experientially, through problems and problem solving. The very nature of this “visible” disorder, the complex case histories, and the multiple disciplines involved can present genuine challenges for the student. However, these challenges can be used to actively involve the student in real-life situations.

Creating a hybrid of traditional classroom learning, problem-based learning and experiential learning translates to a student who becomes a confident, competent, resourceful, and effective speech-language pathologist. It’s about creating a student-centered approach to learning.  The goal is to provide the student with the necessary tools and resources to apply the skills learned to real-life practice.

Problem-Based Learning

Problem-based learning (PBL) is a student-centered approach to teaching that uses problem scenarios to promote concept learning and problem-solving abilities (Barrows, 1996; Hmelo-Silver & Eberbach, 2012; Savery, 2006). Its application has been promoted in the fields of medicine and health disciplines, including speech-language pathology (Burda & Hageman, 2015; Whitehill, Bridges, & Chan, 2014). In contrast to didactic teaching in which the knowledge is provided to the student, PBL turns to the student to apply his or her knowledge.  Through a discussion-based approach and questioning, an instructor facilitates students’ critical ways of thinking without providing them with solutions. Students work in collaborative groups to learn what they need to learn in order to solve the problem. They are presented with a case history (or scenario) that involves a challenge—much like in the real clinical world for which they have to provide a solution (see Box 1).

Box 1. Problem scenario (case history)

This is a 6-year-old male with paired bilateral cleft lip and palate. The lip was repaired at 3 months and the palate at 10 months of age. He has a history of otitis media with effusion treated with myringotomies and pressure-equalization tubes. Current audiologic examination showed normal hearing sensitivity, bilaterally. This child has a history of speech therapy beginning with Early Intervention. His speech is characterized by mild hypernasality, pharyngeal fricatives and stops as well as an /r/ distortion. During the perceptual assessment, it was a challenge for him to repeat sentences and he had to be redirected to task several times. The family is concerned about this child’s hypernasality and expressed that his teachers do not easily understand him.

After reading the patient’s history, the students begin by identifying the knowledge they have about the condition. They need to ask themselves, what facts do I already have and what else do I need to understand in order to resolve this problem? The students have to research the areas where they have identified gaps in their knowledge and the uncertainties they must resolve before finding the solution to the problem and making treatment recommendations. During this process, they have to sort through relevant evidence using a variety of resources.

The advantages of this type of learning include developing the student’s ability to make decisions and effectively solve problems, becoming analytical, working as a team, raising awareness of the complexity of issues, developing an ability to extend learning beyond a presented problem, and integrating theory and practice (Gentry, 2000, p. 13).


Experiential Learning

Anchored to PBL, is experiential learning (EL). PBL uses realistic problems to set up the learning leading to a diagnosis and recommendation. EL is a continuous process whereby knowledge is created through an authentic experience (Kolb, 1984). As in PBL, the instructor directs and facilitates. EL is a participatory event and, in effect, a holistic approach to learning in which the student progresses through a cycle of four integrated processes: concrete experience, reflective observation, abstract conceptualization, and active experimentation. (Kolb, 1984).  These features are summarized in Table 1. Central to both EL and PBL is encouraging critical and independent thinking in the student.

Table 1. Summary of key features of experiential learning (adapted from Kolb, 1984)

Stages Feature
Concrete experience Actively experiencing an activity
Reflective observation of the new experience Active reflection on experiences based on personal experience or what is known
Abstract conceptualization New ideas about the problem are formed or modifications of previous conceptions
Active experimentation Apply ideas to practical experience

Both PBL and EL are indispensable to learning through problem solving and although they would be particularly meaningful in a specialty as complex as cleft palate, they have been insufficiently explored in this specialty.  The strength of learning comes from an integration of these two approaches. PBL provides an opportunity to apply a student’s knowledge to a relevant problem. EL provides the experience through avenues such as audio and/or video recordings which bring the problem to life. It draws the connection between the history and the actual presentation of the problem, and further supports ongoing problem comprehension. Moreover, in contrast to didactic teaching, the instructor’s role in PBL and EL is transformed from one that disseminates all the information and answers to one of guidance and facilitation. Gentry (2000, p. 11) noted that instructors in this role often experience revitalization about teaching and a renewed interest in the topic being presented.

Integrating PBL and EL in the Classroom for Cleft Palate        

The experience of audio and/or videotape recordings can be effective when in teaching a course in cleft palate where it is important to integrate coursework and an experience, while also addressing the learning preferences of the student. The recordings are more than just a speech sample, and when presented alone, are ineffective in learning about cleft palate. The true value of these recordings along with case histories and other supplemental information is the added “real-life” dimension to teaching that is unavailable in textbooks even with their short speech samples. They help explain concepts and act as a trigger for discussion. Because the recordings can be played over and over again or stopped at various points, students have an opportunity to hear those aspects of speech that they may have missed or did not understand the first time and to also engage in further discussion about the problem.

A true experiential learning in cleft palate involves audio and video recordings and all of the steps and processes from PBL and EL. Figure 1 illustrates this type of learning within the classroom.

The first step involves a concrete experience in which an audio and/or video recording of the case is presented. The second step involves making observations and reflecting on what was heard and seen in the experience, facilitated by the instructor, and engagement with peers. Using a white board, a systematic approach to problem-solving can be illustrated. Here, the facilitator or instructor can be helpful in offering guiding questions that lead to further understanding of the problem.  Third, the remarks and discussions lead to abstract conceptualization (analysis) and conclusions about the problem and recommendations. During this time misinformation and confusion about the client and speech can be clarified. The fourth step is to test this new-found knowledge during independent practices using real-world problems and/or clinical placements.  This process is a valuable guide in understanding any case regardless of complexity.

In summary, a hybrid of didactic, problem-based learning, and experiential learning will enhance the training experience of the student studying cleft palate. Audio and video recordings can be effective in this process where integration of theory and actual practice are so vital. The role of these recordings is to provide concrete experience along with other steps in the learning process. Given that there have been so few opportunities like this in the past, we have written our new textbook, Cleft Palate Speech and Resonance: An Audio and Video Resource, to facilitate problem based and experiential learning in the classroom (Vallino et al., in press).



Albanese, M. A., & Mitchell, S. (1993). Problem-based learning: A review of literature on its outcomes and implementation issues. ACADEMIC MEDICINE-PHILADELPHIA, 68, 52.

Barrows, H. S. (1996). Problem‐based learning in medicine and beyond: A brief overview. New Directions for Teaching and Learning1996(68), 3–12.

Burda, A. N., & Hageman, C. F. (2015). Problem-based learning in speech language pathology: Format and feedback. Contemporary Issues in Communication Science and Disorders42, 47–71.

Gentry, E. (2000). Creating student-centered, problem-based classrooms. University of Alabama in Huntsville. URL:

Hmelo-Silver, C. E., & Eberbach, C. (2012). Learning theories and problem-based learning. In S. Bridges, C. McGrath & T. L. Whitehill (Eds.), Problem-based learning in clinical education (pp. 3–17). Dordrecht, the Netherlands: Springer.

Jaebi, I. “Disadvantages of traditional classroom training.” Synonym, Retrieved March 10, 2018.

Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.

Savery, J. R. (2006). Overview of problem-based learning: Definitions and distinctions. Interdisciplinary Journal of Problem-Based Learning, 1, 1, Article 3.

Siegel, P. H., Omer, K., & Agrawal, S. P. (1997). Video simulation of an audit: an experiment in experiential learning theory. Accounting Education, 6(3), 217–230.

Vallino, L. D., Lass, N. J., Bunnell, H. T., & Pannbacker, M. (2008). Academic and clinical training in cleft palate for speech-language pathologists. The Cleft Palate-Craniofacial Journal, 45(4), 371–380.

Vallino, L.D., Ruscello, M., & Zajac, D.J. (in press). Cleft palate speech and resonance: An audio and video resource. San Diego, CA: Plural Publishing.

Whitehill, T. L., Bridges, S., & Chan, K. (2014). Problem-based learning (PBL) and speech-language pathology: A tutorial. Clinical Linguistics & Phonetics28(1–2), 5–23.

Zajac, D. J., & Vallino, L. D. (2016). Evaluation and management of cleft lip and palate: A developmental perspective. San Diego, CA: Plural Publishing.


From Multiculturalism to Critical Consciousness: Updated Concepts for Providing Culturally Responsive Practices at Home and Abroad

By Yvette D. Hyter, PhD, CCC-SLP

Co-Author of Culturally Responsive Practices in Speech, Language, and Hearing Sciences

In the 1990s a new generation of faculty members in Communication Sciences and Disorders (CSD) emerged, ready to infuse courses or to develop and teach courses focused on “multicultural content,” which was the term at the time. There were a limited number of comprehensive texts on how to employ culturally relevant practices as a speech-language pathologist. Many of the SLP faculty who were teaching courses about “multiculturalism,” or “cultural competence,” often utilized texts from other fields, such as education, nursing, or communication and rhetoric, and relied heavily on published articles in disciplines including anthropology, political science, nursing, and social work. It was not until mid-1990s that one of the more complete books on multiculturalism in communication sciences and disorders (CSD) was published (e.g., Battle, 1993, 2012). Nevertheless, as the world has become more complex and smaller as a result of global processes, new concepts and comprehensive practices that consider causal relations are required.

Multiculturalism is a contested concept, but typically refers to including people from diverse cultural backgrounds (Malik, 2015) in program development or service delivery for example.  Multiculturalism as a concept falls short, primarily because it suggests that inclusion (or assimilation) is the principle issue. Although health care providers and educators offer and provide services to all people regardless of their cultural (or racialized class, ethnic, gender, national, or linguistic) backgrounds (e.g., inclusion), services can remain inadequate or irrelevant if we also do not consider how services might be reconceptualized or changed to meet the cultural premises of those receiving services.

Cultural competence, a concept that emerged in the 1980s (e.g., Cross, Bazron, Dennis, & Isaacs, 1989), is more useful than multiculturalism but is weighed down by preconceived notions of competence. The perception is that “competence” refers to skills or knowledge that one acquires, and that those skills can be completed or mastered (checked off), are static, and independent of context or history (Hyter & Salas-Provance, 2019; Willbergh, 2015). This perception of competence has caused many disciplines in the health professions to move away from it in favor of other terms.

Cultural responsiveness, a term coined by Ladson-Billings (1995), seems to be more accessible than multiculturalism and cultural competence. It refers to engaging in practices that are consistent with or relevant to the cultural values, beliefs, and assumptions of a person or group with whom a solution (or clinical outcome) is co-created. In this manner, responsiveness is inherently dynamic, dependent on context and shared historical memories.  Hyter (2014) has conceptualized culturally responsive practices as those that take place beyond the micro level (individual), but also at the meso (community and family) and macro levels (social structures such as economics, politics, culture, cultural institutions, and state sanctioned violence [Hyter & Salas-Provance, 2019, p. 171]). Culturally responsive practices require knowledge that is not always a part of the CSD curriculum such as critical consciousness—the ability to deconstruct one’s own social, cultural, historical, economic, and political situation and co-construct solutions to problems (Freire, 1974); dialectical thinking—the ability to synthesize conflicting perspectives; cultural humility – believing that cultural practices and perspectives different from one’s own are as valuable as one’s own  (Ortega & Faller 2011; Tervalon & Murray-Garcia, 1998); and cultural reciprocity—understanding and using the client’s cultural beliefs to co-construct (with the client) services provided (Kalyanpur & Harry, 2012). Culturally responsive practices also require an elevation of concepts that are already inherent in CSD clinical practice such as critical thinking, critical self-awareness, and reflection.  To truly work at the level of cultural responsiveness or relevancy in the United States or abroad, as a profession, speech-language pathologists and audiologist need to adapt new vocabulary and new theoretical frameworks that will help us question the dominant premises, change the terms of public and professional debate, and address the shared problems of structurally excluded groups with interventions that acknowledge and incorporate their world view.


Battle, D. E. (1993). Communication disorders in multicultural populations. Boston, MA:utterworth-Heinemann

Battle, D. E. (2012). Communication disorders in multicultural and international populations. 4th edition. St. Louis, MO: Mosby

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989) Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center. Retrieved from

Friere, P. (1974). Education for critical consciousness. New York, NY: Continuum

Hyter, Y. D. (2014). A conceptual framework for responsive global engagement in communication sciences and disorders. Topics in Language Development, 34(2), 103–120.

Hyter, Y. D., & Salas-Provance, M. (2019). Culturally responsive practices in speech, language and hearing sciences. San Diego, CA: Plural Publishing.

Kalyanpur, M., & Harry, B. (2012). Cultural reciprocity in special education: Building family-professional relationships. Baltimore, MD: Paul H. Brookes.

Ladson-Billings, G. (1995). Toward a theory of culturally relevant pedagogy. American Educational Research Journal, 32(3), 465–491.

Malik, K. (2015). The failure of multiculturalism. Foreign Affairs, 94, 21–32.

Ortega, R. M., & Faller, K. C. (2011). Training child welfare workers from an intersectional cultural humility perspective: A paradigm shift. Child Welfare, 90(5), 27–49.

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125.

Willbergh, I. (2015). The problems of ‘competence’ and alternatives from the    Scandinavian perspective of Bildung. Journal of Curriculum Studies, 47(3), 334–354.

Finally, a coding and reimbursement book written specifically for audiologists, otolaryngologists, academic institutions, and staff!

By Debra Abel, AuD, editor of The Essential Guide to Coding in Audiology: Coding, Billing, and Practice Management

The Essential Guide to Coding in Audiology: Coding, Billing, and Practice Management is that necessary and essential one stop shop office resource for coding, billing, and compliance written specifically for independent audiologists and their office staffs, for otolaryngologists and their office staffs, and for academic programs, with information contained in one repository that has been historically scattered in other places. This book includes many contemporary topics including the critical tools, codes (CPT, ICD-10-CM, and HCPCS) and guidelines necessary for compliant audiology billing, reimbursement, and payment. Medicare, considered the gold standard by most commercial payers, has an entire chapter devoted to those requirements applicable to the audiologist, often an anomaly in payer policies when compared to other health care professions.

The basic tools don’t end there. With an increase in commercial insurance third-party payers and third-party administrators, those payers often don’t speak the same language as the audiologist, which can lead to confusion and heartburn. Kim Cavitt, AuD, a nationally known audiology coding and reimbursement expert, offers a chapter on insurance that includes a glossary of terms and processes for negotiating if you choose to successfully incorporate these commercial payers into your practice. Stephanie Sjoblad, AuD, a pioneer and expert in successful itemization for hearing aid services in her university clinic that functions as a private practice, brings over 10 years of how-to’s to successfully itemize in your own practice. For those practices considering a transition to this process, this chapter will be a major guiding force. Kim Pollock, another nationally known coding and reimbursement consultant, offers a chapter on managing your revenue, something not usually provided specifically to audiologists in a written format, by one of the most knowledgeable sources who has performed audits and risk management for otolaryngology/audiology practices for many years. The final contributor, Doug Lewis, PhD, JD, MBA, an audiologist with significant credentials, has a chapter on the federal regulations that impact the practice of audiology, a compendium of all those requirements essential to maintaining compliance while offering services. Finally, the concluding chapter is a checklist of the fundamentals and the components needed when one considers and establishes a private practice.

Apart from the chapter devoted to revenue, each data-driven chapter on coding, reimbursement, and compliance, was written by audiologists for audiologists, unprecedented at the time of publication. This is a necessary resource for every audiology office and academic program!

Personal Attitudes about Professional Wellbeing

By Wendy Papir-Bernstein, author of The Practitioner’s Path in Speech-Language Pathology: The Art of School-Based Practice

Within our profession—whether student, professor, researcher or practitioner—we connect with people from a diversity of fields.  Have you noticed how some seem happier than others?  They excel at their work and communicate a sense of enthusiasm, passion and professional fulfillment. It shows on their faces and use of body language, their social interactions, and of course through their work.  Researchers from the field of positive psychology tell us that happiness, whether personal or professional, is driven by the same themes:  we want to make a difference, we want to be useful, we want to connect with something greater than ourselves, we want balance in our lives, and we want community (Haidt, 2006).  It all seems pretty basic and yet it can be our greatest challenge.

One reason may be that we sometimes think of ourselves as consummate caregivers, and this culture of self-sacrifice is naturally carried over into our work setting.  I remember the moment many years ago when I first thought this idea.  I was on a plane, traveling out of the country.  The flight attendants spoke about safety regulations, demonstrated oxygen masks, and I thought I knew the drill well.  This time, however, I really heard it for the first time.  When they explained how important it was for you to put on your own oxygen facemask first—before helping anyone else with their own—I understood and took it to heart.  After returning to work, I made some immediate changes with priorities and strategies for my own self-care.

Bottom line—our work reflects our personal attitudes about our own wellbeing, as much as it does about the wellbeing of our patients, clients, and students. In fact, these attitudes are an integral component of clinical expertise, and will drive the success of our practice.  The significance of “personal attitudes and qualities” has recently been expanded in both ASHA’s 2014 clinical competency standards as interaction and personal qualities, and in the 2015 revision of standards for accreditation of graduate programs as professional practice competencies (ASHA, 2014; 2015).  Attitudes provide the framework and the context for what happens within the clinical and educational processes, and are thus the most critical “tool” in the profession. As it has been discussed within the medical profession, the most valuable part of the stethoscope is the part that rests between the ears.  And so, prescriptions for our own self-care and wellbeing must be at least as important as care for the people who receive our services (Traux & Mitchell, 1971).

What do we mean by professional wellbeing? While wellbeing is difficult to define and measure, we do know that it involves maintenance of equilibrium easily offset by life’s challenges.  It is sometimes linked to Aristotle’s idea of “eudaimonia”, the belief that the overarching goal of all human actions is to flourish (Bradburn, 1969).  Martin Seligman, another leader in the positive psychology movement, developed a theory about the building blocks for a life that flourishes, which he coined PERMA: positive emotion, engagement, relationships, meaning and accomplishment (2011).  All of this contributes to a feeling of success.  Wellbeing has been compared to quality of life, which is defined by The World Health Organization (WHO) as “an individual’s perception of their position in life in the context of the culture and value systems in which they live in relation to their goals, expectations, standards and concerns” (WHO, 1997).

Paths, roads or ways are metaphors for the possibility that there is a connection between all we are and do.   Our chosen path is the practitioner’s path, where our work becomes about who we are as well as about what we do.  As we think about building, supporting, traveling and ultimately manifesting our path—we create a sense of passage within phases of our professional life that fosters balance, self-care, and reflective practices. As we approach the inevitable forks on our professional paths, let’s reflect upon the values we live by, the qualities and attitudes we embody, and the examples we model for others.  Nothing becomes more valuable than establishing our own set point for wellbeing, and building strategies for maintaining that sacred balance between our personal and professional self.


American Speech-Language-Hearing Association (2014) Standards for the Certificate of                  Clinical Competence in Speech-Language Pathology. Retrieved from                                       Certification-Standards/

American Speech-Language-Hearing Association (2015). Proposed Revised Standards                 for Accreditation of Graduate Education Programs in Audiology and                                 Speech-Language Pathology. Retrieved from                                 Graduate-Programs.pdf

Bradburn, N. (1969). The structure of psychological well-being. Chicago, IL: Aldine.

Haidt, J. (2006). The Happiness Hypothesis. New York, NY: Basic Books

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  Traux, C. B., & Mitchell, K. M. (1971). Research on certain therapist interpersonal skills                  in relation to process and outcome. In A. E. Bergin & S. L. Hartfield (Eds.),                  Handbook of psychology and behavior change. New York, NY: Wiley.

World Health Organization. (1997). WHOQOL Measuring Quality of Life. Geneva,                           Switzerland: World Health Organization.

One of the best things you can do for your clients with right hemisphere brain damage

By Margaret Lehman Blake, PhD, CCC-SLP
Author of The Right Hemisphere and Disorders of Cognition and Communication: Theory and Clinical Practice

It can be difficult to know what to do with clients who have right hemisphere brain damage (RHD): how to assess them, what to treat, how to treat, etc. It’s not surprising, because (a) there is less collective knowledge within the field and (b) there are limited opportunities to acquire the knowledge that does exist. As for the amount of knowledge, aphasia was “discovered” and named the 1860s. In contrast, the impact of RHD specifically on communication and language has only been recognized since the 1960s, so we are behind by a century! As for the opportunities to acquire the knowledge, the problem starts in graduate school. While a majority of graduate programs have stand-alone courses on aphasia, RHD is typically covered as one of several topics/etiologies in a cognitive disorders course. I would venture that a majority of graduate programs have an expert in aphasia on faculty, while only a minority of programs have anyone interested in RHD. It is equally difficult to find continuing education about RHD after graduate school. In the past three years at the ASHA Convention there have been only between 6 to 9 presentations on RHD each year. In contrast, the number of presentations about aphasia has ranged from 177 to 269.

There is not enough room here to provide tips and advice for how to tackle all of the disorders associated with RHD, so I’ll just mention the one that I think is the most critical: talk to families. While SLPs likely talk to families of all of their patients/clients, it is especially important when working with someone with RHD. The purpose is two-fold: first to get information about how the patient has changed following the stroke, and second to provide information and resources to the families.

Getting information from the families about how (and if) the patient is different is essential. When it comes to pragmatics, there is no clear cut-off between being “normal” and being “a bit odd” as a result of brain damage. Add to that cultural differences in how people communicate (both verbally and non-verbally), and it may be nearly impossible in some cases to determine if someone has a pragmatic deficit or not. For example, just the other day I was assessing a man with RHD for a research project. In the small talk at the beginning of the session, I found out that he was originally from Wisconsin, so I asked him what brought him to Texas. He replied, “a 1972 Chevy truck”. If the exchange ended there, and I had no information about his personality from his family, I could have thought, “Aha! Typical RHD, he’s overly literal in his interpretations” and decide that I might want to target pragmatics in therapy. But the exchange did not end, and he followed up that response with an appropriate explanation of a change in jobs. Additional information from his family regarding whether or not that kind of response was a typical pre-stroke behavior would allow me to make a more appropriate decision about therapy goals.

The second part of talking with families is to provide education. They need education about the variety of problems that may occur and who they can contact for help. While families may get information about unilateral neglect from neurologists, SLPs are the ones who can educate families about pragmatics and communication. SLPs are the ones who can explain how RHD can affect theory of mind, cause a person to no longer accurately interpret another person’s intended meaning, understand their point of view, or become more egocentric and self-focused. SLPs are the ones who can explain that changes in theory of mind and emotional processing may result in changes in empathy. SLPs are the ones who can explain that appreciation and use of humor might change after RHD. SLPs are the ones who can explain that deficits in problem-solving and reasoning can affect communication, such that a person may not be able to notice or fix a communication breakdown, or figure out that the breakdown was mostly their fault. SLPs are the ones who can explain how prosody, facial expression, and body language are critical to communication, and that all can be affected after RHD. And most importantly, SLPs are the ones who can explain that they can treat these deficits.

Educating families about RHD is especially important because some deficits may not become apparent until the patient goes home. For example, an egocentric perspective and limited empathy for others might be considered normal for anyone in the hospital after a life-changing event such as a stroke, so it may not be identified as a deficit until the patient goes home and his spouse observes a lack of empathy in everyday situations. A patient also may seem to have a blunted sense of humor that in acute care may not seem unusual given the situation, but it may become really obvious when she goes home and her husband can’t joke with her like he used to, or conversations just aren’t “normal”.

When these kinds of changes become apparent, most families won’t think, “I should ask for a referral to a speech therapist”, because the person’s speech generally is fine. SLPs need to provide that link for them when they have the chance, so that when the deficits become apparent, the families will know where to go for help.

Despite the limited number of evidence-based treatments, I believe that SLPs can provide effective treatments to adults with RHD. Our knowledge about pragmatics and cognition can go a long way in addressing the deficits that limit participation in activities important to our clients. We just might increase interest in RHD, which would lead to more research, more experts in the field and more opportunities to learn about the problems, which in turn would spark more interest, lead to more research, and on and on.

Effective Mathematics Interventions

By Margaret M. Flores, PhD, BCBA-D, Auburn University
Co-author of Making Mathematics Accessible for Elementary Students Who Struggle: Using CRA/CSA Interventions


According to the National Center for Educational Statistics (2016), the 2015 National Assessment of Educational Progress showed that 18% of fourth grade students performed below basic levels of achievement, meaning that they did not demonstrate mastery of fundamental skills. Students’ mathematical difficulties begin with understanding numbers, basic operations and their novice conceptions lead to further difficulties with complex operations and fractions (Fuchs et al.; Jordan & Hanich, 2003; 2016). Students who struggle in mathematics comprise a diverse group which includes students with identified disabilities as well as students without disabilities (Powell, Fuchs, & Fuchs, 2013). There is a critical need for effective implementation of interventions that have been shown to be effective through research. One effective approach that can be adapted across mathematical concepts is the concrete-representational/semi-concrete-abstract sequence (Miller, Stringfellow, Kaffar, & Mancl, 2011; Witzel, Furguson, & Mink, 2012; CRA/CSA).

What Is CRA/CSA?

The CRA/CSA sequence in an instructional approach to mathematics that emphasizes conceptual understanding prior to procedural knowledge and fluency. There are three phases: concrete, representational/semi-concrete, and abstract. The concrete phase of instruction involves the use of objects to complete mathematical tasks or solve problems. During this phase, teachers explicitly teach concepts through the manipulation of objects. The representational/semi-concrete phase continues to focus on the development of conceptual understanding, but problems are solved using pictures and student-made drawings. Once students demonstrate understanding of the target mathematics concept at the representational/semi-concrete levels, they learn to solve problems using just numbers, the abstract phase. During the abstract phase, the focus of instruction is on procedural knowledge and fluency. The benefit of including the CRA/CSA sequence into mathematics interventions is that the concrete and representational/semi-concrete phases provide students with needed remediation in their understanding of whole numbers, the base ten system, operations, and rational numbers (fractions). The physical manipulation of objects, drawing, and visual aid of pictures fill in the gaps that exist in their prerequisite knowledge and understanding about mathematics. Another benefit of these physical and visual aids is that they assist students in making meaning of mathematical language and using language to explain their computation or problem solving.

CRA/CSA and Number Concepts

The CRA/CSA sequence has been shown to be effective in teaching young children and elementary students number concepts. Researchers used CRA/CSA to teach preschool students, with and without disabilities, counting skills. This included number sense in the form of visual counting or recognizing that four objects were represented by the numeral four without physically touching the objects (Hinton, Flores, Schweck, & Burton, 2015; Hinton, Flores, & Strozier, 2015). Elementary students also successfully learned how to count this way using CRA/CSA. In addition, Hinton and Flores (submitted) taught rounding skills using CRA/CSA. Using base ten blocks and drawings representing base ten blocks, students learned how to round numbers to the nearest ten and hundred. After abstract instruction using just numbers, students quickly and accurately completed rounding tasks. Mercer and Miller (1992) taught place value to elementary students with and without disabilities using CRA/CSA.

CRA/CSA and Basic Operations

Miller and Mercer (1992) and Mercer and Miller (1992) taught elementary students, with and without disabilities, basic operations using the CRA/CSA sequence. This included addition, subtraction, multiplication, and division. Using objects and drawings, students learned the conceptual meaning of each operation: addition is combining, subtraction is separating, multiplication is combining of groups that are the same size, and division is the separation of groups that are the same size. After instruction at the concrete and representational/semi-concrete phases, students learned a simple strategy to assist in computation using just numbers. This set of steps served as a reminder to (a) attend to the numbers and the operational sign, (b) remember that problems can be drawn if the student has not memorized the fact, and (c) write the answer. Students who participated in this large study become fluent in basic operations and their accuracy in computation increased significantly.

CRA/CSA Complex Operations

Researchers also used the CRA/CSA sequence to teach regrouping skills associated with addition, subtraction, and multiplication (Miller & Kaffar, 2011; Mancl, Miller, & Kennedy, 2012; Flores, 2011; Flores & Hinton, in press; Flores, Hinton, & Strozier, 2014; Flores, Schweck, & Hinton, 2014; Flores & Franklin, 2014). Difficulties faced by students within each of these studies were related to poor conceptions of numbers and the base ten system. The concrete and representational/semi-concrete phases of instruction involved the use of base ten blocks and drawings that bolstered students’ understanding of numbers and why regrouping is necessary in when adding and subtracting large numbers. These studies included students with and without disabilities and led to significant gains in accuracy and fluency.

CRA/CSA and Fractions

CRA/CSA has been shown as an effective way to teach rational numbers or fraction concepts (Butler, Miller, Crehan, Babbit, & Pierce, 2003; Flores & Hinton, submitted). Butler et al. studies the necessity of including a concrete phase within instruction. Students successfully leaned to make equivalent fractions, but those who used fraction blocks prior to drawings performed better than those who only received instruction using drawings. Flores and Hinton taught elementary students equivalency using CRA/CSA as well as comparison of fractions to decimals. At the concrete phase, students made fractions using fraction blocks as well as sets of objects. At the representational level, students shaded shapes and marked number lines. In both studies, concrete and representational/semi-concrete instruction allowed students to understand the proportional nature of fractions which led to their mastery of more complex concepts such as equivalence and relations to decimals.


The CRA/CSA sequence has been shown to be effective across a variety of elementary mathematics concepts. The materials needed are simple; base ten blocks and counters are readily available in elementary schools. However, it may be difficult for teachers to implement and replicate the research as journal articles are not written in ways that provide detailed descriptions of each lesson component. Therefore, in order to close the gap in mathematical achievement, there is a need for more user-friendly guides for implementation of the CRA/CSA sequence.


Butler, F. M., Miller, S. P., Crehan, K., Babbitt, B., & Pierce, T. (2003). Fraction instruction for students with mathematics disabilities. Learning Disabilities Research and Practice, 18, 99–111.

Flores, M. M., Hinton, V. M., & Strozier, S. D. (2014). Teaching subtraction and multiplication with regrouping using the concrete-representational-abstract sequence and strategic instruction model. Learning Disabilities Research and Practice, 29, 75–88.

Flores, M. M., & Franklin, T. M. (2014). Teaching multiplication with regrouping using the concrete-representational-abstract sequence and the strategic instruction model. Journal of American Special Education Professionals, 6, 133–148.

Flores, M. M., Schweck, K. B., & Hinton, V. M. (2014). Teaching multiplication with regrouping to students with learning disabilities. Learning Disabilities Research & Practice, 29(4), 171–183.

Fuchs, L. S., Schumacher, R. F., Long, J., Namkung, J., Malone, A., Wang, A., Hamlett, C. L., Jordan, N. C., Siegler, R. S., & Changas, P. (2016). Effects of intervention to improve at-risk fourth graders’ understanding, calculations, and word problems with fractions. Elementary School Journal, 116(4), 625–651.

Jordan, N. C., & Hanich, L. B. (2003). Characteristics of children with moderate mathematics deficiencies: A longitudinal perspective. Learning Disabilities Research & Practice, 18, 213–221. doi:10.1111/1540-5826.00076

Mancl, D. B., Miller, S. P., & Kennedy, M. (2012). Using the concrete-representational-abstract sequence with integrated strategy instruction to teach subtraction with regrouping to students with learning disabilities. Learning Disabilities Research and Practice, 27(4), 152–166.

Mercer, C. D., & Miller, S. P. (1992). Teaching students with learning problems in math to acquire, understand, and apply basic math facts. Remedial and Special Education, 13(3), 19-35. doi: 10.1177/074193259201300303

Miller, S. P., & Kaffar, B. J. (2011). Developing addition with regrouping competence among second grade students with mathematics difficulties. Investigations in Mathematics Learning, 4(1), 24–49.

Miller, S. P., & Mercer, C. (1992). CSA: Acquiring and retaining math skills. Intervention in School and Clinic, 28(2), 105–110.

Miller, S. P., Stringfellow, J. L., Kaffar, B. J., & Mancl, D. B. (2011). Developing computation competence among students who struggle with mathematics. Teaching Exceptional Children, 44(2), 38–44.

Witzel, B. S., Furguson, C. J., & Mink, D. V. (2012). Number sense: Strategies for helping preschool through grade three children develop math skills. Young Children 89–94


Book excerpt – James Jerger: A Life in Audiology

The following excerpt is from the autobiography, James Jerger: A Life in Audiology

American Academy of Audiology

The AAA is now in its 28th year. Younger members may not appreciate what it has meant to our profession. Before the Academy was launched in 1988 we were the step-children of the American Speech-Language-Hearing Association, commonly abbreviated as ASHA. We followed their code of ethics, accepted their certification programs, attended their conventions, and published in their journals. How this came about was essentially an accident of history. Most of the earliest audiologists were people originally trained in speech science and speech pathology. As such, ASHA was their natural home and they were comfortable within its ranks. Raymond Carhart’s doctoral dissertation, for example, concerned a model of the human larynx.  But as younger people became audiologists they did not share the common bond with speech science and speech pathology so typical of their mentors. As the field of audiology grew, some of the younger members began to ask whether we might not be better served by creating our own national professional organization. Expressing this view, however, met with stern disapproval. Our elders insisted that fragmentation must never happen, that we must always remain one profession because you could not separate hearing from speech and language; they were all part of the unique process we call “human communication.”  I always thought this argument specious. For example, you cannot separate the brain from the foot: they are both part of the whole body, but there are quite distinct medical specialties to treat their disorders. Certainly the more you know about language and speech the better, but that doesn’t mandate that you belong to their professional organization.

In any event, opponents of fragmentation failed to appreciate that ASHA itself began as the American Academy of Speech Correction (AASC) by fragmenting off from the National Association of Teachers of Speech (NATS) in 1925. NATS in turn was formed by splitting off from the National Council of Teachers of English (NCTE) in 1914.

In 1958 I was elected to ASHA’s executive board. At one of our meetings, I suggested that we consider setting up special interest groups that would lend some separate identity to various clearly distinguishable groups within the organization. There was much shoe shuffling, and some support from the aphasia people, but little general willingness to pursue the topic. A fellow board member, one of the revered elder statesman in audiology, came over to me as the meeting broke up, put his hand on my shoulder, and said, “Jim, it will never happen. They are afraid we will split off.”  Actually the idea of special interest groups within ASHA did eventually happen, but only after we had formed AAA.

Nothing much transpired for the next few decades, but matters came to a head at the 1987 ASHA convention in New Orleans. Rick Talbot had organized a session on “future trends in audiology.” There were five of us on the panel: Jay Hall, George Osborne, Charles Berlin, Lucille Beck and me. Each presented a thoughtful glimpse at what the future might hold in their particular area. I was the last speaker and my message was simple. I said, “I think it is time for audiologists to form their own professional organization” The response from the audience shocked me. There was a deafening roar of approval, which I truly had not expected. I think that everyone on that stage was also amazed.

Back in Houston I asked colleague Brad Stach what he thought of the idea. He was leery at first, but came around when I drew an analogy with an umbrella organization like the American Medical Association, under which each medical specialty had its own organization, its own publication and its own convention. In retrospect the analogy is not quite apt, but it convinced Brad to take up the cause. We put together a list of 35 audiologists that we considered leaders in their respective areas and sent each one a letter of invitation to come to Houston for a two-day meeting to discuss the possibility of forming a new organization “of, by, and for” audiologists. Only one invitee declined. The rest arrived, at his/her own expense, ready to consider the idea.

We met in the ballroom of a hotel just across Fannin street from the Methodist Hospital. The first morning was chaotic. It was difficult to believe that the group could ever agree on anything. By the end of the second day, however, there was general consensus that the effort at least ought to be attempted. In 2009 I wrote, in my book Audiology in the USA, the following:

 “The first year of the Academy’s existence, 1988, was an uncertain time. The founders were not at all sure that their efforts would succeed. They knew what they wanted to do, and where they wanted to go, but recognized, with some trepidation, the formidable forces arrayed against them. The primary concern was, of course, the ASHA.  It already counted, at that time, more than 8000 audiologists among its roughly 60,000 members, and was not disposed to view this defection in a collegial manner.”

If I were to rewrite that last sentence today, I would undoubtedly use more colorful language, so I had better not try. That passage does illustrate, however, what I perceived to be the most important reason to break away from ASHA. Speech pathologists outnumbered audiologists in the ratio of about 8:1. But, profession-wise, speech pathology is, and perhaps always will be, based on an educational model, whereas audiology is based on more of a medical model. At that time the bulk of speech pathologists worked as therapists in the public schools of America. They worked primarily with children. Most held only the bachelor’s degree.  Our profession, on the other hand, is more like a medical model. Most of us are engaged in clinical services, either in private practice, or in medical environments. At the time we started the Academy, most audiologists held the master’s degree, and there was already pressure to upgrade to the doctoral level, which we have since accomplished with the AuD degree (a move, incidentally, with which ASHA did not initially share our enthusiasm.) Many of us felt that we would never be able to achieve the much-desired doctoral level degree until we were free of dominance by ASHA.


Compression did not begin with digital hearing aids

By Theodore H. Venema, PhD
Author of Compression for Clinicians: A Compass for Hearing Aid Fittings, Third Edition

My career in this field began in 1987 as a new audiologist at The Canadian Hearing Society in Toronto. All hearing aids were analog and provided linear gain, although a few compression circuits floated around too. These used output limiting compression, with its high knee-point and high compression ratio. The knee-point was adjustable, which in turn adjusted the maximum power output (MPO). It was a way to limit the MPO without the use of “peak clipping,” which caused distortion.

Wide dynamic range compression (WDRC) entered the scene with a cannonball splash right around 1990. The action of the outer hair cells (OHCs) was now understood by clinicians as being distinct from that of the inner hair cells (IHCs). As we all know today, the OHCs enable the IHCs to sense soft incoming sounds below around 50 dB SPL. WDRC was thus seen as a rather “intellectual” type of compression, in that it electronically sought to imitate the role of the OHCs. With its low knee-point and a low compression ratio, the focus of WDRC is to elevate the “floor” of hearing sensitivity, rather than to limit the MPO or “ceiling” of loudness tolerance. It is no coincidence that otoacoustic emissions—also known to arise from the action of the OHCs—suddenly emerged as part of clinical practice.

Compression in today’s digital hearing aids hasn’t really changed all that much from then. We continue to use both output limiting compression and WDRC. The point here is that the analog hearing aids of that time (late 1980s, early 1990s) used either one type of compression or another. Clinicians had to know their compression types because their hearing selection for any client depended on this knowledge. Manufacturer fitting software did not yet exist. Today’s digital hearing aids are programmed exclusively by software. Once the audiogram is entered through Noah, the hearing aid signal processing is automatically programmed to provide whatever compression is deemed necessary. We’ve become “dumbed down,” because we no longer have to know how to apply the compression. The manufacturer fitting software takes care of all that!

The cables, the cables, the cables…

The emergence of the cables actually began in the very late 1980s, with the first “programmable” analog hearing aids. A cable from a computer (or more often a handheld programming device) was plugged into a socket on the faceplate of an ITE or on the backside of a BTE. Adjustments were made via this “digital screwdriver.” This seemed like a really “cool” alternative to manually adjusting hearing aid settings by trimmers, trim pots, potentiometers, whatever they were called. We simply turned these clockwise or counterclockwise, in order to raise or lower the MPO, gain, low-cut, high-cut, etc. I used to laugh that if the original settings were somehow lost, one could simply set all the trimmers halfway; that way, one could maximally be only half-wrong.

Back to the cables, it is truly amazing just how many different ones exist, even for the product lineup of any one manufacturer! This issue is not at all new, and I am not the  first to complain about that. I must admit to feeling a little odd though, when hanging a weird looking hook around the client’s neck with cables connected to the hearing aids positioned in the client’s ears. The next step is to sit in front of the computer, hoping and praying the manufacturer’s fitting software will read the hearing aids.

Manufacturer fitting software, fitting software, fitting software…

Fitting software emerged at the end of the analog era (mid 1990s) and flourished with the advent of digital hearing aids in 1997. Of course, with each manufacturer, the fitting software is completely different. Oh, there are some similar traits among them, but the look, the feel, the labels, and also the quirks and exceptions, are different for each manufacturer.

Digital technology and software certainly do add flexibility; they also however, invite their best friend, complexity. There are so many parameters involved with fitting now: noise reduction amounts and types, directional microphones and associated polar plots, feedback suppression adjustments, linking binaural hearing aids, and don’t forget about the battery indicator beeps! It gets better; we in separate programs, make combinations of the above-said parameters, in order to specifically address various different listening situations, such as quiet, conversations, and traffic.

Has anyone seen ANSI? Where did it Go? Sometime during the late 1990s, with the advent of digital hearing aids in 1997, ANSI slipped away. It happened in the middle of the night. Since the 1950s for hearing aids, ANSI was intended to be a measurement standard for hearing aid hardware, which consists of the microphone, amplifier, and receiver (aka speaker). Add a few capacitors, resistors, inductors (and trimmers to adjust their behaviors), and you still have nothing but analog hardware. Such was the consistency of analog hearing aids. ANSI ruled in the analog land of hardware, but now fitting software rules. Quaint concerns about OSPL90, Reference Test gain, Harmonic Distortion, and Equivalent Input Noise have almost faded from view. Today it’s all about software. Most clinicians today never bother with ANSI because they are just trying to figure out the fitting software.

The dongles and Bluetooth paraphernalia…

On a semi-annual basis, the goals and deadlines of their product management cycles dictate that manufacturers must pound out new and updated products. The cacophony of their escalating product releases has become deafening. What’s more, hearing aids now come with all kinds of dongles, Bluetooth remotes and gadgets to be used with other devices that work with the phone, television, etc. Of course, these have to be “paired” together to work with the hearing aids. Despite the best efforts of manufacturers to explain things, it does make me feel a bit like “Ted the Cable Guy.”

Clients commonly come back to the office with bags containing unused cords, boxes, television streaming devices, and dongles. It can be quite difficult to get elderly people to make sense of it all! Bottom line: Clinicians today are still constantly “putting out fires,” much like they always did in the past.


It’s obvious that hearing aids today are far better than the squealing, beige “banana-shaped” BTEs of yesterday. The disappointing thing, however, is that the rate of client satisfaction has not risen at the same rate as hearing aid development and complexity. The unwanted byproduct from complexity is confusion, felt by both clinicians and clients.

We have made amazing strides in technology, digital algorithms, and features. The downside is that it has all come at a cost, literally and figuratively, to clients and clinicians. With all the recent progress, I’m not sure clinicians feel that fittings are easier today than they used to be. I also do not believe the monetary cost of hearing aids compared to eyeglasses is at all well understood by clients. Is anyone really surprised at the recent emergence of (and governmental support for) an alternative, namely, those low-cost personal sound amplification products, also known as PSAPs?