If you were living 100 years ago, there is a good chance you knew
more than a few coopers. Coopers, sometimes fondly referred to as barrel makers, were among the most popular skilled professions in the early 1900s. By 1930, however, coopering was a marginalized profession, nearly non- existent, unless of course, you live in the states of Tennessee or Kentucky, where it thrives as an artisanal craft.
The virtual elimination of a once thriving profession is an example of creative destruction, and there are many examples of it throughout our
modern society. Pager salesmen, typists, and video store clerks are three quick examples from the past 30 years of once relatively prevalent occupations that currently barely exist. “Creative destruction” is a paradoxical term introduced to economics in the 1940s by the Austrian economist and Nobel laureate Joseph Schumpeter (1883–1950). He used the term to describe the special form of economic growth that entrepreneurs bring to capitalism. Schumpeter argued that it was the entrepreneur’s introduction of radical innovation into the capitalist system that was the real force sustaining long-term economic growth, even as it destroyed the economic value of established enterprises that may have previously enjoyed a substantial degree of unchallenged power. The questions for hearing care professionals are twofold: What forces at work in today’s economy have the potential to creatively destroy audiology and hearing instrument dispensing? And, Learn how hearing
healthcare professionals can adapt to more effectively meet the changing demands of the marketplace
Creative Destruction in Hearing Care from Hearing Tests to Smartphones
By Brian Taylor, AuD
Read this article and take the quiz on page 55 for continuing education credit.
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how will audiologists and hearing aid specialists adapt to more effectively meet the changing demands of the marketplace? No one can predict the future, but we can be relatively certain there will be significant changes in the way the two established professions of audiology and hearing aid specialists create value for the hearing impaired population over the next decade. The objective of this article is to review many of the forces that could lead to creative destruction and offer an antidote for overcoming them.
Tablet-based Audiometer Apps Over the past few years, tablet-based audiometry apps have emerged as viable options for completing portions of the diagnostic battery. According to Sanchez et al (2015) one such tablet-based audiometer (iAudiometer Pro) is accurate enough for clinical use, as the researchers compared the iAudiometer Pro app to a professionally calibrated GSI16 audiometer, using three different transducers and found no significant differences in thresholds compared to the GSI 10 audiometer. The iAudiometer apps allows for air and bone conduction testing. Additionally, other versions of the iAudiometer have speech tests as well as special audiometric tests for the pediatric population.
These results, while promising, warrant further investigation, but they do suggest table-based audiometry, given its portability, allows hearing care professionals to more easily provide services in remote areas or they cannot travel to the clinic. Interestingly, Sanchez and colleagues found that while 63% of participants
believed that a table-based hearing test yields accurate results, 86% preferred obtaining a hearing test from a hearing care professional.
Self-guided Hearing Screening Apps In addition to tablet-based audiometry, there are a variety of hearing screening apps allowing individuals to monitor their own hearing without seeing a hearing care professional. Although there is a paucity of data supporting their validity, there is significant potential for self-guided hearing testing apps to allow younger patients to engage in the process of checking their hearing from the convenience of home without the hassle of making an appointment. Similar to automated blood pressure tests, automated hearing screening might be an effective approach to facilitate more active patient involvement at a younger age when hearing loss is milder and less debilitating.
Automated Hearing Aid Algorithms A significant part of digital evolution is the use of signal processing strategies that automatically assess the patient’s listening environment and make adjustments to the signal processing strategy based on the listening needs of the individual. Historically, hearing aids have been programmed and adjusted in the hearing care professional’s office, mainly because considerable expertise was needed to determine the proper adjustments and to effectively operate the programming device. In the future, these time- held procedures may be no longer needed, as adjustments could be made remotely and many of tweaking of the hearing aids parameters could
be accomplished with intelligent, automated algorithms. Arguably, automated algorithms have been in existence for several years, but as their sophistication grows, the ability to program and adjust them may greatly reduce the need of the expert guidance of the hearing care professional.
PSAPs and Hearables* (See IHS statement on PSAPs on page 24) There are a variety of over-the- counter personal sound amplification products (PSAPs) that are slowly becoming known as “hearables.” While PSAPs and hearables are not allowed to be marketed as medical devices for the remediation of hearing loss, many of them are used for this purpose. Also, given the uneven sound quality of PSAPs and hearables, hearing care professionals need to be involved in the process of verifying the quality of their coupling to the individual’s ear. This is especially important for patients with mild loss who might chose to wear a PSAP before transitioning to conventional hearing aids over time. Hearing care professionals would be wise for developing a strategy around getting directly involved in the verification of PSAPs fittings with probe microphone measures. A fee for service could be charged to check the quality of the fit, as a poorly fitting PSAP is likely to result in poor benefit.
Smartphones Apps The stigma associated with hearing aids probably has some influence on the uptake of PSAPs and hearables. After all, if it looks like a hearing aid it must be a hearing aid. Smartphones
Continued on page 16
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this results in a marked improvement in speech intelligibility when watching TV. They are programmable, so they can be customized to the patient’s hearing loss. Customizable directed audio devices represent a new product category in the industry that patients, especially younger patients with milder hearing loss who might find it appealing because they offer an effective solution for a hearing problem and do not have the unfortunate stigma of a hearing aid. In that vein, devices like hearables, directed audio solutions, and smartphones might provide the untapped mild to moderate high frequency market with products they find appealing. As shown in Figure 1 below, this segment of the hearing impaired marketplace has been largely underserviced by conventional hearing aids.
apps, which there are dozens available, are, like PSAPs, plagued with uneven sound quality. However, they do offer an alternative to traditional hearing aids some individuals might find appealing. Amlani et al (2013) compared the performance of two apps, which essentially turn the smartphone into a body aid when coupled to the ears with headphones or earbuds, to hearing aids at the basic level of technology. Results indicated that on several measures of outcome, including benefit, quality of life improvements and audibility there were not significant differences between the “bare-bones” hearing aids and smartphone apps. Amlani et al (2013) demonstrated that smartphone hearing aid applications have similar electroacoustic characteristics and perceived performance when compared to a traditional hearing aid, and could be useful as a temporary or starter solution to a hearing deficit.
Directed Audio Solutions Directed audio solutions represent the morphing of programmable hearing aids and consumer electronics. One such device, Hypersound (www. hypersound hearing.com), allows patients to enjoy television and other home media activities without disturbing others. These systems work by using an ultra-high frequency carrier signal to transmit audio in a tight, narrow beam over several feet without interference from noise or reverberation. Utilizing the non- linear properties of air, ultrasonic transmission of audio allows listeners situated in the 2-3 foot wide beam, even several feet from the television, to experience more audibility high frequency sounds. For many listeners,
Biotechnology Hair cell regeneration and gene therapy represent some of the future innovations that may transform the practice of audiology. Although still in its infancy, in the future audiologists and other hearing care professional may be directly involved in the regeneration of hair cells within the cochlea. For more details on the potential of biotechnology in audiology, see Parker, 2011.
Interventional Hearing Care As previously mentioned, no one has a crystal ball, but all of us can prepare for a future where audiology and hearing aid dispensing are practiced in a different way. One way to prepare for a different future, one that is likely to be creatively disrupted by cheaper, faster and smarter technology is to examine
Profound or Residual:
75%
30%
Figure 1. Hearing loss segmented by degree. Data compiled from Nash (2013), Lin et al (2011), Lin (2011) and Wallhagen & Pettengill (2008)
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existing gaps in the marketplace and how our professions can add additional value that may not be centered on the selection, adjustment and tweaking of hearing aids, or the ability to conduct a basic hearing assessment. Practicing in a different way involves getting out from your test booth and directly connecting with the community, especially individuals who are beginning to experience difficulties with communication, but remain reluctant to take action. The key to long term professional survival may rest on our ability to intervene with patients at an earlier age when hearing loss is typically milder and easier to manage.
Let’s cut to the chase, here are four pillars of an interventional audiology strategy that are designed to keep hearing care professionals actively involved in the direct care of patients.
1. Exert more social pressure to get non-consulters to act sooner, using self-guiding hearing screening apps to speed the journey to your office.
2. Engage younger patients, many with milder hearing losses by offering them products and services that don’t carry the stigma of hearing aids.
3. Leverage changes in U.S. healthcare system to partner directly with primary care physicians and other medical gatekeepers in the early management & intervention of age-related hearing loss and its co-morbid conditions.
4. Modify or update your clinic approach to patient interaction by focusing on patient-centered communication and participatory care.
Let’s briefly examine each of these pillars of interventional hearing care and how you can begin to bring them to life in your practice. Using positive triggers to action requires hearing care professionals to use advertising that highlights the hidden risk of hearing loss while simultaneously empowering the individual to take action to seek help for a possible condition. Curtis Alcock of Audira has written and lectured extensively on positive
cues to action and how they can be used in marketing. (Alcock’s articles have appeared in prior THP editions archived on the IHS website www. ihsinfo.org.) Figure 2 is an example of an advertising campaign utilizing many of Alcock’s ideas.
The second pillar of interventional hearing care is to systemically
Figure 2. An example of an advertising campaign using positive triggers to action.
Continued on page 18
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Listening to Television with a Hearing Loss: TV Device or Hearing Aids?
An Interactive Decision Aid
My difculty with the TV is affecting my personal and social
life. My spouse or other family members can’t be in
the same room.
The TV is too loud!
A TV device is less costly than hearing aids
No long clinic appointments needed
A TV device is easy to install, use and maintain
Device only works for TV; other listening situations
may still be difcult, indoor use only
Device overcomes distance and background noise to isolate the TV signal and
improve viewing experience
view TV normally
Hearing aids are expensive, but they can be used in
all situations
Usually, 3–4 clinic visits are needed, to t, ne tune and troubleshoot hearing aids
I will have to learn how to use hearing aids; regular
cleaning and care are needed
Hearing aids are designed to enhance speech
understanding; they can be used in all situations
Hearing aids may not solve my TV problem; I might
need to buy extra devices that connect hearing aids to
the TV
view TV normally
TV Device
Do you responses appear to favor one over the other? With your audiologist, explore your preferences and dislikes.
Discuss them together to aid your decision.
Total
Total
If you dislike a statement place an in the box
I have difculty understanding dialog, especially fast talkers, female talkers
or foriegn accents.
I have difculty when the TV is at normal volume. I can hear it, but cannot understand what is
being said.
The speech is too soft but the music is too loud. I can’t nd
the right volume.
The more items you checked, the more likely it is that you need
help listening to TV
If you feel ready to address the difculties, your audiologist
can help you decide on the next step
All rights reserved © 2015 Jennifer Gilligan



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recommend alternative products and services that do not have the stigma of traditional hearing aids. These offerings may include auditory training apps and directed audio solutions (e.g., Hypersound) that still need to be customized by the professional, while still being an attractive option for patients, especially those with milder losses in need of situational help. In order to effectively educate patients on their options, hearing care providers are encouraged to utilize decision aids, like the one shown in Figure 3. A patient decision aid is a structured tool designed to facilitate knowledge transfer and patient engagement. It can be used to compare the pros and cons of more than one treatment option with more direct involvement from the patient in the decision-making process.
The third pillar of interventional hearing care necessitates the need to directly interact and educate primary care physicians. Given the well-documented relationship age- related hearing loss has to cognitive decline, increased hospitalization and social isolation, hearing care professionals are obliged to adhere to scientifically-defensible principles in order to responsibly educate medical gatekeepers and spur them in to action. The consequence of successfully educating medical gatekeepers is likely to be a significant uptick in the number of adults aged 55 and older who visit your practice for a hearing screening appointment.
To make this appointment valuable to consumers, and not simply a hearing test that can be completed with a self-guided app, hearing care professionals are urged to practice
patient-centered, participatory care. Ultimately, this change from product- centric to patient-centric care in which providers are reimbursed for their time helping patients cope with the
consequences of hearing loss may provide our profession with a new value proposition for consumers.
Figure 3. An infographic that compares directed audio to traditional hearing aids for television watching. Reprinted with permission of Jennifer Gilligan of CUNY-Graduate Center
Continued on page 20
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Known as participatory care, the six steps listed in the center of Figure 4 comprise the foundational elements of patient-centered communication. Participatory care is a model of healthcare in which patients take a more active role in the generation and implementation of treatment options. It is thought that participatory care may be an effective way to address the needs of patients with chronic conditions, such as age-related hearing loss. Participatory care, also commonly referred to as shared decision making, falls in the middle of the patient-provider decision making continuum shown in Figure 5. Traditionally, healthcare services
have been delivered in a paternalistic manner whereby patients assume a relatively passive role in their relationship with the provider. As patients have become more actively involved in their healthcare choices, and, as the internet and other forms of social media have become more ubiquitous, DIY care has become a popular healthcare delivery model in some circles. This is depicted in Figure 5 as the informative relationship, which removes the provider from the essential decision making duties, and leaves the patient to fend for himself. PSAPs in their current form are bought under this informative model.
Shared-decision making (or participatory care), on the other hand, requires the professional to actively guide patients through the stage of health behavior change. (For an introduction to the stages of change model see Leplante-Levesque’s recent article in The Hearing Journal .)
In today’s era of consumer-driven healthcare, participatory care appears to be popular among baby boomers, especially those with chronic medical conditions. Practicing participatory care requires a relatively high degree of healthcare literacy on the part of the patient and involves the use of shared decision making by both the patient and hearing healthcare professional. Shared decision making, which is an essential component of patient-centric communication, is the process in which the patient and the hearing healthcare professional exchange information about the scale and scope of the patient’s condition, express the preferences of intervention options and collaborate on the implementation and evaluation of a solution. Shared decision making and participatory care cannot be supported without adequate information provision (Poost-Faroosh, et al 2015). It requires a hearing care professional, skillful in motivational interviewing and other interpersonal communication abilities, to guide patients through the process of behavior change. To learn more about motivational interviewing readers are encouraged to visit www.motivationalinterviewing. com and read the works of industry experts Kris English, Jill Preminger, Gaby Saunders, John Greer Clark and Michael Harvey.
Figure 4. The six components of participatory care and five steps of patient-centric communication.
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As the American healthcare system evolves, moving toward a model emphasizing preventive care and management of chronic conditions, there will be ample opportunities for professionals to become more actively involved in delivering care to younger patients, many with milder hearing losses. Practicing the six steps of participatory care, shown in the center of Figure 4, will require less focus on technology and more
care professionals would be wise to develop skills in these five areas.
• Ensure patient comfort. In addition to providing physical comfort through the use of ergonomically correct chairs and providing an inviting ambience, it is vital for professionals to foster emotional comfort too. Basic interpersonal skills such as good eye contact, an engaging smile and a warm,
to receive help. Insights into the patient’s perceptions of readiness and motivation on a quantifiable scale help hearing aid specialists match the support, feedback and guidance depending on the patient’s self-rating. For example, patient A with a low self-rating on the readiness to accept treatment would warrant a much different set of tactics than patient B who has a high self-rating and is read to move ahead with treatment. In this example, patient A would probably benefit from much more exploration around why treatment uptake would be beneficial to him and his family. The role of the hearing care professional in this case is to help the patient “paint the picture” of all the potential benefits of help.
• Acknowledge and understand the patient as an individual. Using customizable, open-ended assessment tools like the COSI or TELEGRAM (Thibodeau, 2004) are an effective approach to individualizing the initial discovery of the scale and scope of the patient’s challenges. Additionally, it is helpful to focus on specific behaviors, which are a consequence of the hearing loss that the patient may be willing to change. For example, if the patient expresses concern that he is avoiding certain listening situations because he cannot hear, devise some goals and strategies that will allow the patient to become more actively involved in these places with your guidance and support. Taking a deeper dive into the individual needs of the patient and the associated behavior resulting
Figure 5. The continuum of patient-provider relationships
emphasis on guiding patients through the process of behavior change. It will require professionals to become less reliant on the crude tools such as the audiogram and more adept at using interactive practices, such as goal setting when making important treatment decisions with respect to the individual.
The five attributes of patient centered communication, summarized from the work of Canadian audiologist Laya Poost-Faroosh below, can be utilized to optimize the individual’s experience in your clinic. Of course there are no guarantees, but hearing
authentic manner help establish a safe and emotionally inviting atmosphere where patients can feel comfortable.
• Consider patient motivation and readiness. Rather than using the audiogram results as a guide, professionals are encouraged to ask patients simple scaling questions to ascertain the degree of readiness and motivation to receive help. A scaling question asks patients to self-rate on a 1 to 10 scale (1 is no problem, 10 is a great deal of problems) how motivated or how ready they are
Patient-Provider Relationship
Patemalistic: 1. Passive role for patient
2. Works well when patients have limited information and an acute problem
Informative: 1. Professional provides information and patient makes decision independently
2. Information can be outsourced to call center or website- direct-to- consumer example
Shared-decision: 1. Patient and professional work together 2. Works well when patient has long-term, chronic condition 3. Collaboration on options, goals and results
Continued on page 22
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from untreated hearing loss takes more time, but in the end that added time is more likely to result in a patient that feels they were profoundly heard by their hearing care provider.
• Provision of useful and actionable information. As a general rule the information you provide that patient needs to be in alignment with their stage of readiness. The Stage-of- Change (or Transtheoretical) Model recently summarized by LaPlante- Lesvesque (2015) suggests that hearing impaired patients are likely to be in one of the following stages: pre-contemplation, contemplation, preparation or action. Patients are likely to progress through the stages of change in the order listed above. Currently, the University of Rhode Island Change Assessment (URICA) self-report has been used to identify the individual’s stage of change, however, given its 32-question length, the URICA is probably feasible to conduct clinically. That doesn’t mean identifying a patients stage of readiness cannot be ascertained during the interview process. One quick way to gather some helpful information about a
patient’s stage of change is to use the one question shown in Table 1. By asking the patient to check the box next to the statement most accurately describing their current status with respect to their hearing, the hearing professional can estimate how ready the patient may be to take action resolving the handicapping conditions caused by their hearing loss.
“Which of the following statements best describes your attitudes and beliefs about your hearing ability today”: (check one circle). Note that the third, far right column is not visible to patients.
The important consideration is that the actions taken by the hearing care professional to help the patient must be congruent with the patient’s stage of change. For example, if the patient checks the top box placing him in the pre-contemplation mode, it is wise for the professional to avoid talk about treatment options – even in the event of a significant hearing loss of the audiogram. Further, identifying the patient stage of readiness is an effective springboard into deeper dialogue around behavior change.
Let’s say the patient checks the box corresponding to the contemplation mode, this could be a cue for the professional to explore some of the reasons why it might be important to seek help for their hearing impairment. More research is needed on how this one-question approach aligns with the URICA and the stages- of-change model, however, it does provide useful information about the patient’s self-perception of readiness to seek help and take action.
• Facilitate shared decision making. The final patient-centered attribute is the ability to enable shared decision making between the patient and hearing aid specialist. In addition to the previously mentioned use of patient decision aids, shared decision making implies that you have an assortment of treatment options from which to choose. Putting shared decision making into practice does not mean scientifically-based principles are abandoned. The science behind fitting hearing aids and other devices are more important than ever before.
Baby boomers and others classifying
I don’t have any problems or concerns that need changing. Pre-contemplation
It might be worth it to work on my problems and concerns. Contemplation
I am very close to doing something about my problems and concerns. Preparation
I am currently working on addressing my problems and concerns—that’s why I am here. Action
Table 1. One question stages-of-change assessment
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this requires the hearing care professional guide them to the action stage of change. Additionally, many of these younger patients, seeking first time help are likely to have milder communication challenges, thus traditional hearing aids may not be of interest to them, at least in the earlier stages of their loss. Rather than telling these patients to wait, interventional hearing care professionals (who put patient-centered and participatory care skills into practice) will be providing treatment choices which may not be traditional hearing aids.
Apps like the iAudiometer and devices such as Hypersound that have an edgy consumer electronic look and feel may captivate the new, younger help seeker. Alternative treatment choices may be even involve the delivery of a product and could be therapy-driven approaches to behavior change. As the healthcare landscape continues to evolve, hearing care professionals must continue to offer value to the marketplace by offering a wider range of treatment options. Introducing
themselves as healthy agers take a more active role in their healthcare choices. Anecdotal reports are consistent with this finding, as a recent poll of A.T Still University School of Health Sciences students who are also active clinicians report a substantial upswing in the number of patients under the age of 60 seeking help and information for their hearing. If it is indeed the case that younger individuals are seeking hearing care services it is logical for many of them to be in pre-contemplation or contemplation stage, and therefore, Continued on page 24
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these alternative options starts with the consistent use of patient- centered communication skills and participatory care. In today’s digital age, the irony is that our future as hearing care professional is predicated on our ability to master the basic human skills of communication and trust. n
The views expressed in this article are those of the author and do not represent the opinions or advice of the International Hearing Society. According to the FDA, personal sound amplifiers (PSAPs) are not medical devices, nor are they to be marketed to people with hearing loss. IHS advises hearing aid dispensing professionals to use caution in attempting to modify or fit personal sound amplifiers and to ensure they are following all applicable state and federal laws.
Brian Taylor, AuD is the Senior Director of Clinical Affairs at Turtle Beach/ Hypersound. He is also the clinical audiology advisor for the Fuel Medical Group. Brian is an adjunct professor for A.T. Still University Arizona School of Health Sciences, and editor of Audiology Practices, the quarterly journal of the Academy of Doctors of Audiology. He serves as the treasurer for the Accreditation Commission for Audiology Education (ACAE) whose mission is to assure the public that AuD programs graduate competent audiologists trained to the highest standards. Over the past decade, Dr. Taylor has held a variety of positions within in the industry, including stints with Unitron and Amplifon. He can be contacted at brian.taylor.aud@gmail.com
References
Amlani AM, Taylor B, Levy C, Robbins, C. (2013). Utility of smartphone hearing aid applications as a substitute to traditional hearing aids. Hearing Review, 20, 13, 16-18, 20, 22.
Laplante-Levesque, A., Hickson, L., & Worrall, L. (2012). What makes adults with hearing impairment take up hearing aids or communication programs and achieve successful outcomes? Ear and Hearing. 33, 79-93.
Lin, F. et al (2011). Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci. 66: 582-590.
Lin, F. et al (2011). Hearing loss prevalence in the United States. Arch Intern Med. 171.
Nash, SD et al (2013). Unmet hearing health care needs: The Beaver Dam Offspring study. American Journal of Public Health. 103, 6, 1134-1139.
Parker, M (2011) Biotechnology in the treatment of sensorineural hearing loss: foundations and future of hair cell regeneration. Journal of Speech, Language & Hearing Research. 54, 1709-1731.
Poost-Faroosh, et al (2015) Comparions of client and clinician views of the importance of factors in client-clinician interaction in hearing aid purchase decisions. JAAA. 26, 247-259.
Sanchez, C. Ortiz, E., & LePrell, C. (2015) Tablet audiometry: accurate enough for clinical use? Poster presented at American Academy of Audiology annual meeting, San Antonio, TX
Thibodeau, L. (2004). Plotting beyond the audiogram to the TELEGRAM, a new assessment tool. Hearing Journal. 57,11, 46-51.
Wallhagen, MI & Pettengill, E. (2008). Hearing impairment: Significant but underassessed in primary care settings. J Gerontol Nurs. 34: 36-42.
Take the continuing education quiz on page 55.
IHS Continuing Education Test 1. An example of a profession that
has already undergone creative destruction is
a. hearing aid specialist b. cell phone sales person c. audiologist d. pager sales person
2. A client who states that they are very close to doing something about their hearing problems and concerns would be considered to be in this stage of readiness:
a. pre-contemplation b. contemplation c. preparation d. action
3. A recent study by Sanchez revealed that this percentage of people prefer to obtain a hearing test from a hearing care professional
a. 36% b. 63% c. 68% d. 83%
4. Professionals who adopt a participatory care methodology of approaching patients will
a. become less reliant on the audiogram b. place more emphasis on the
behavioral change process c. place less focus on technology d. all of the above
5. Creative Destruction a. is an economic term introduced in
the 1880s b. describes the economic growth that
entrepreneurs bring to socialism c. states that long-term economic
growth is fueled by radical innovation
d. none of the above
6. As it relates to creative destruction, hearing care professionals would be wise for developing a strategy around getting directly involved in the verification of PSAPs fittings with probe microphone measures.
a. true b. false
7. Hearing healthcare professionals will experience significant change in how they create value for the hearing impaired population over the next decade.
a. true b. false
8. Using self-guiding hearing screening apps is likely to slow a prospective client’s journey to your practice.
a. true b. false
9. Participatory care is a model of hearing healthcare where
a. patients take a more active role in the generation of treatment options
b. patients take a less active roll in the implementation of treatment options
c. patients are guided in a paternalistic manner in their treatment plan of action
d. none of the above
10. A patient decision aid is a structured tool designed to
a. facilitate knowledge transfer b. increase patient engagement c. compare the pros and cons of more
than one treatment option with more direct involvement from the patient in the decision-making process
d. all of the above
For continuing education credit, complete this test and send the answer section to: International Hearing Society • 16880 Middlebelt Rd., Ste. 4 • Livonia, MI 48154
• After your test has been graded, you will receive a certificate of completion. • All questions regarding the examination must be in writing and directed to IHS. • Credit: IHS designates this professional development activity for one (1) continuing education credit. • Fees: $29.00 IHS member, $59.00 non-member. (Payment in U.S. funds only.)
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Charge to: o American Express o Visa o MasterCard o Discover
Card Holder Name __________________________________________________________________
CREATIVE DESTRUCTION IN HEARING CARE
(PHOTOCOPY THIS FORM AS NEEDED.)
Answer Section (Circle the correct response from the test questions above.)
1. a b c d
2. a b c d
3. a b c d
4. a b c d
5. a b c d
6. a b
7. a b
8. a b
#