When a patient leaves a practice satisfied with the service and the hearing aid solution, everyone wins. In this feature, three audiologists give their take on ethics in audiology and how they balance patient needs with the demands of running a sustainable private practice.
One thing stands out as key to practising ethical audiology: assessing and prescribing to each patient’s needs based solely on what’s best for them.
It sounds simple enough but with increasing pressures on business owners, it could be easy for hearing practitioners to focus on sales and appointment targets and become device-centric, while losing sight of the needs of the patient sitting before them.
Independent audiologists Mr Sam Koroneos, Dr Meg Miklosvary and Dr Matthew Callaway haven’t been immune to these pressures, but for them it’s no reason to compromise on the values that underpin their successful independent audiology practices.
They describe what it takes to ensure patients leave satisfied and comfortable with the value of their service, regardless of receiving a hearing device.
Koroneos, the owner of Adelaide Audiology who counts two ex-prime ministers among his patients, is this year celebrating his 40th year of practice, having graduated from audiology at The University of Melbourne when cochlear implant pioneer Professor Graeme Clark AC was head of school.
Koroneos knows from many years’ experience and helping thousands of people that the relationship with a patient is longitudinal, due to ongoing rehabilitation and care over what is sometimes a lifetime and often decades.
Service and that trusting relationship – accumulated over many years and interactions – is what keeps patients coming back, not any particular hearing aid, he adds.
“One loyal patient drives seven hours to see me and tells people he’s on his third wife, but he’s still on his first audiologist,” he says. “Ethical-driven practice is the answer. Whether patients are lower or higher socio-economic status, there will always be people who are discerning enough to realise they need service attached.
“People who are interested in a service recognise that it’s not just about buying the hardware, there’s a longitudinal process involved which is when you get to cultivate relationships with the patient, and in future, the rest of the family comes in. I just love it and feel privileged to have that relationship.”
Koroneos even has several third-generation patients whose parents and grandparents he treated.
“We’re independent, unbiased and not affiliated with any hearing aid provider. This is on our website and we have lots of people say that’s why they chose us,” he says.
Koroneos honed his skills and practise while working in different fields of audiology including at Royal Adelaide Hospital for 13 years and teaching at Flinders University where he helped write the audiology course. “I recently saw former students at the Audiology Australia conference and got such a buzz from hearing them say I had the biggest influence on how they wanted to be as an audiologist,” he says.
He also worked for National Hearing Care, now Amplifon, before opening his practice 25 years ago, while lecturing part-time.
“We do no advertising, it’s nearly all word-of-mouth, although we do have some walk-ins, and we have GPs and ENT doctors who trust us implicitly and refer their patients to us,” he says.
“We also work closely with an ENT practice.”
Koroneos and fellow audiologist Ms Laura Drexler, who also works at the practice and specialises in tinnitus and hyperacusis, know patients referred from doctors have had their ear pathology checked before seeing them.
He believes that before fitting hearing aids, patients should see a doctor to check there are no middle ear issues, conductive issues or asymmetric sensorineural hearing loss, which “could be something nasty like acoustic neuroma”.
“Our patients have seen a doctor to ensure all active pathologies are excluded and when they come to us, they’ve done their due diligence through the medical system and don’t need convincing that they need a hearing aid because they’re ready to take constructive action,” he says.
“That’s what I consider ethical. We’re not forcing anything down anyone’s throat.”
Adelaide Audiology bundles products and care so patients “get a year of us thrown in” along with three years’ warranty from the manufacturer – although some are up to five years. Ethical practice also leads to other organisations trusting the practice and referrals.
“We do a lot of musicians’ earplugs and in-ear monitors,” Koroneos says. “Addicted to Audio in Adelaide sends its musos here. We also do earplugs for pilots referred from the Civil Aviation Safety Authority, and South Australian-based umpires for the AFL as those whistles are loud, and we treat veterans.”
In some cases, the clinic re-purposes hearing aids, donated from families whose relative has died, to clients in need.
“We keep a list of who has donated hearing aids back to us and who we think might need them,” he says. “We give these to patients in need for free.”
A recent hearing aid had been paid for and barely worn when the owner died and his wife passed it back. The practice donated it to a young patient who had developed hearing loss in one ear and tinnitus after surgery as a side-effect of anaesthesia.
“I rang her and asked if she was interested. I said we could supply this to her at no cost, because it had already been paid for and had three years’
A recent hearing aid had been paid for and barely worn when the owner died and his wife passed it back. The practice donated it to a young patient who had developed hearing loss in one ear and tinnitus after surgery as a side-effect of anaesthesia.
“I rang her and asked if she was interested. I said we could supply this to her at no cost, because it had already been paid for and had three years’ warranty. She burst into tears,” he said.
As karma would have it, he ran into her while doing consultancy work. She was overjoyed and had told everyone at her workplace what a great and ethical business he had.
Being generous with appointment time is also key as is lending demonstration models to new patients to try, Koroneos adds.
Treat the complaint and get results
Northern Territory audiologist Dr Matthew Callaway, an alumni colleague of Koroneos, agrees that if practitioners do the right thing by the patient, the rest will take care of itself.
“Our practice is all about getting results first. I’m very specific with our audiologists, if they can treat the presenting complaint of the patient, empathetically and correctly, clinical ethics will be integral to that,” he says.
“We’re health professionals first and our audiologists are all of the same philosophy. We treat the presenting condition, manage the issues, and whether that’s devices or other forms of treatment, they’ll choose the best pathway for that.
“No clinicians at our clinics are paid commission or incentives but they make decisions based on what is going to work best for the person in front of them.”
Dr Callaway draws from years of experience working in hospitals in Adelaide and Darwin, for Bernafon in research and development in Switzerland, and in his own practice in the NT since opening it in 1998.
His business, Arafura Audiology, has four clinics – three in Darwin and Alice Audiology in Alice Springs – and with 11 staff members, serves areas reaching to Katherine and Gove Peninsula in Arnhem Land.
The question of how to balance patient needs alongside running a sustainable private practice is a big one, Dr Callaway says.
“People still occasionally come in and say, ‘You’re just going to sell me a hearing aid, aren’t you?’” he adds. “I respectfully inform them that they’re here because they have a hearing problem that they need treated and if they want to just be sold a hearing aid, they can go elsewhere. I’ve never had anyone walk out.”
His audiologists are motivated to get the best outcomes for their patients, Dr Callaway says. “We discuss regularly as a group, what’s necessary for the client may not be what’s best for you.”
He feels there’s too much value placed on devices though.
“The audiologist, for a long time, has been undervalued in this process, and we became very device centric. We’re starting to see, including with the Hearing Services Program and other funding sources, a move away from that slowly, towards recognising the service more and the device less,” he says.
When people come for an initial assessment with his practitioners, they have a discussion and evaluation before broaching what treatment might be.
“There are no glossy ads around hearing aids,” he says. “It’s more about a professional opinion based on diagnosis and findings, then we’ll discuss whether a device or an instrument is indicated, or whether other means of treatment may be equally appropriate such as assistive listening devices or communication tactics.”
If it’s a hearing instrument, the patient returns for another hour-long appointment where the audiologist details their specific listening needs and expected outcomes.
“We make a combined decision on what’s going to work from their point of view and what clinically we see as the optimal match for their treatment requirements and listening needs,” he says.
One part is considering their budget, even more so now. “We’re seeing a lot of people who, four or five years ago, would just say you’re the expert, fit me with what you think is going to work best and what I need,” Dr Callaway says. “Now, they’re asking about other options that may require lesser financial investment.”
Patients, who are mainly middle class, come in having done research. “We make a clinical decision on what they’re going to have in conjunction with a rehabilitation program so their expectations are clear including for follow-up.
“If people are invested in their clinical care, they’re more invested in wearing their hearing aids regularly and successfully, as opposed to a free clinical trial. Trials are infrequent in our clinic, instead clinical pathways decide.”
The practice has a relationship with clinical specialists at all major manufacturers. It uses some more than others, usually depending on technology, and all clinicians are expected to stay abreast of releases and developments.
Most manufacturers visit them at least annually and practitioners receive online updates. Distance to metropolitan launch events is challenging but Zoom, online launches and webinars help greatly with keeping up on latest technology.
Some manufacturers do some things better than others, and some don’t offer particular products, such as CROS hearing aids. “We need to have that scope across manufacturers to ensure we cover all opportunities and options for our patients because everyone’s hearing is different,” Dr Callaway says.
The front office team is also vital in ensuring ethical practices are followed. “Our front office teams are versed in support areas and rehabilitation programs,” he says.
“There’s at least three follow-ups once we fit devices to make sure a client is optimised via objective testing and subjective reports. After that, they’re welcome to come back any time for battery replacement, servicing, repair, and Bluetooth troubleshooting, which is a huge part of what we do nowadays.
“In some respects, we joke that we’re as much IT professionals as we are hearing professionals today.”
The recall system ensures all hearing aid users, whether HSP or private patients, receive a reminder to come in and check their hearing and their hearing aids. An annual discussion includes if they are still meeting key listening goals.
Patients know they can come in anytime to discuss any issues with the front-of-house teams and see an audiologist if they need, Dr Callaway adds.
The practice also has many tinnitus patients and clients with noise-induced hearing loss, due to a big local presence of defence forces and veterans.
Three front-of-house staff members have external training in hearing health care and are qualified audiometric officers so understand ear anatomy, hearing tests and implications of hearing loss. This understanding and empathy for patients contributes greatly to practice ethics, Dr Callaway says.
His clientele usually don’t walk in off the street but make an appointment, are referred by a medical practitioner, a specialist, an important other or word of mouth.
Charging fees for expertise
Dr Callaway believes in charging fees for service. “This is how we started our clinic. We were looked at strangely 27 years ago, but we place value on our expertise. Audiologists train for six years before they can get Medicare and QP (Qualified Practitioner) numbers to practise,” he says.
“We’ve always unbundled services so people are aware that they’re paying to see a clinical specialist. The hearing aid is worth so much but my expertise is also worth so much. One way we remain profitable is that there’s no such thing as a free hearing test – you’re having a diagnostic expert evaluation.
“We have never had people baulk at our professional fees.
“I am a strong advocate that your clinical expertise is valuable – put more weight on your expertise. Put more value on the clinician rather than all the value on the product,” he says.
To ensure all staff are aware of their value, the practice presents its monthly profit and loss summary to the team.
“There’s no push on anyone to fit more hearing aids,” he stresses. “It’s about treating the patient but it’s for them (audiologists and client services officers) to be aware of what their expertise is worth and how many dollars an hour our clinics need to make to open the doors and cover costs of sustaining the business.
“The audiologists need to be rewarded for their expertise and paid fairly without having incentives put in front of them.”
Ethics course for students
A former intern at Dr Callaway’s Darwin practice, audiologist Dr Bojana Šarkić – then Discipline Lead and audiology course coordinator at La Trobe University – approached him a few years ago with the idea of a business and ethics subject for the university’s Master of Clinical Audiology program.
Her vision was for students to learn how to set up and run a practice, understand business fundamentals, and most importantly, deliver ethical, patient-centred care. She says she approached Dr Callaway specifically because his Darwin clinic exemplified those values in action.
“She said students needed to understand what running a practice really involves – from KPIs and patient loads to why certain clinical and commercial decisions are made,” Dr Callaway says. “Bojana wanted them to see that it’s possible to run a successful business without compromising patient care, and that ethical practice should be the foundation—not the exception.”
Dr Šarkić, alongside fellow lecturer Ms Michele Le, remains committed to preparing students for the realities of independent and corporate audiology environments through a strong foundation in ethics and practical business knowledge.
In Gippsland, Helix Hearing has grown from one clinic 35 years ago, to seven across Gippsland, two in Melbourne and one in Tasmania. Dr Meg Miklosvary, audiologist and clinical director, took over the practice 10 years ago with her husband Andrew.
They brought Gippsland Audiology (as it was then known) from audiologists, founder Mrs Sue Clutterbuck and her husband Mr Neil Clutterbuck. “When opening the practice, the environment for private practice was very different from what it is now,” Dr Miklosvary says.
“It was considered unethical to even contemplate ‘selling’ hearing aids outside the government services, no matter how it was done. Sue opened the clinic as an independent provider, meaning all solutions were available to patients at a sustainable price. No free services were offered.”
Dr Miklosvary says everyone knows there’s no such thing as a free lunch and believes the same applies in audiology. “If you’re providing ‘free’ services, someone is paying for the time and resources somewhere along the way. The same philosophy continues today,” she says.
Stable workforce enforces ethics and values
Helix Hearing remains independent and patients pay for all services received except for in-house cleans provided by the front-of-house team. Having a stable workforce in the clinic helps build loyalty not only within the team but with patients, she adds.
“Patients want the option of coming back to see the same clinician year in, year out and at Helix Hearing we’ve been fortunate to retain many excellent team members – clinicians and front-of-house staff,” she says.
“Despite change in ownership, and a name change to Helix Hearing 18 months ago, patients continue to remain loyal to the clinic as they can see the same ethics and values continue.
“We have standards for how we want to offer our services and we stick to them. Sometimes this is not the most cost-effective but it ensures our standard of care to our patients does not slip.”
It also means team members are not put in positions where they feel compromised in how they can practise. However, growing the business comes with the benefit of economies of scale which helps to buffer the cost as additional sites open or are acquired.
For Dr Miklosvary, ethical provision of hearing aids comes down to seeing each patient as an individual and assessing their needs solely based on what’s best for them. The business offers all solutions to patients, as not one hearing aid manufacturer will suit everyone, plus a range of technology levels and budget requirements.
“Finding the most appropriate device for an individual is important, the ‘best’ hearing aid, i.e. top-level technology, may not be the best hearing aid for a particular patient,” Dr Miklosvary says.
“We don’t have sales targets, nor pay commission, for any hearing aids sold or limit consulting time as these pressures cause bias and mean the clinician is not acting in the absolute best interest of the patient.”
Dr Miklosvary believes that unbundling the cost of services from hearing aid pricing has been a huge step to validating the value of audiologists’ time and expertise. Patients understand the cost of appointments and value the time spent in clinic, she says.
“When this is bundled with a hearing aid cost, patients do not see the value at the time of fitting, and often not down the track when they require ongoing care,” she adds. “It also provides patients with potential to claim rebates from their private health fund or Medicare when appointments are charged per attendance.”
Front-of-house team members are trained in basic repairs, cleaning and connectivity troubleshooting which patients appreciate being available five days a week.
Patients receive all information they require to use and maintain their hearing aids in initial appointments after fitting. Once benefit is established, they’re advised to make additional appointments, are followed up with a phone call eight weeks post-fitting to ensure everything is progressing well with their rehabilitation, and a survey is sent six months post-fitting.
