No worries 
MDB is correct that I am an employee. Prices are set above me, and I do not know whether our clinicâs compensation varies from product to product, nor do I get a bonus for selling more hearing aids, nor do I particularly experience pressure to sell. It was my choice when I graduated to interview only at places that did not use the commission or profit-sharing structure because I was uncomfortable with it. Perhaps because of some level of idealism that was unpractical. But as I have said elsewhere, I am quite privledged to work at a clinic that is hugely charitable in a lot of ways, and my opportunity to provide services pro bono and to pursue educational opportunities has been high relative to other clinicians who are not self-employed.
As for Cosctoâs model, no they do not run on commission, but yes they mark up their hearing aids. The clinicians I know who work for Costco do have sales targets and pressure to meet them varies from clinic to clinic, but generally tends towards being lower than in manufacturer clinics which is sometimes part of the appeal of working there (Costco Canada also offers very high compensation, which is perhaps necessary to overcome a slightly lower quality of work environment, though I understand Costco America compensation is quite a bit lower than average. But they also employ HISs rather than audiologists in many cases). But Costcoâs model also depends on volume. They go out of their way not to serve the sorts of patients who might take extra time, and narrow the scope of the clinicianâs practice to only those types of services that are money makers. There is a reason they knock the tinnitus programs out of their hearing aids.
Yes, maybe, in some cases. Iâve really only been in this field for a short time. Short enough that I still think of myself as a scientist first and an audiologist second. Certianly short enough that my opinions are based on more limited information than more experienced clinicians. I have never worked in a manufacturer clinic.
Manufacturers are probably much better at making money than independents, at least here. I understand that American audiologists do get some business training during their schooling, but in Canada we really get none. All of my classmates entered the program feeling like they were going into a healthcare profession not a business profession, and the school reinforced that. Iâd even say that my school snubbed their noses a bit at ALL private clinics, probably unfairly (especially given that ENT clinics often suffer from exactly the same ethical issues, sometimes worse in light of the power of the word âdoctorâ in the minds of patients). So thatâs the sort of person running an independent clinic, probably fumbling the business end a LOT before they become more practiced. Contrast that against a manufacturer chain that has some high-end business experience behind the scenes and Iâm not sure exactly how that shows up in differences for the consumer. I mean, at the end of the day you canât be a successful business if you have a lot of unhappy clients, right? But as far as I can tell, manufacturer clinics do tend to have a stronger emphasis on sales targets. They also narrow your choice of devices a bit as they of course want you to prescribe their own. (And yes, all of the manufacturer clincs that my friends work for, and all the ones that have approached me, offer commission.) They probably narrow your scope of practice a bit more, too. I think a lot of independent audiologists around here ended up running their own clinic because they chafed under manufacturersâthey wanted to offer more services, they wanted to devote more time to appointments. Manufacturer clinics donât always offer pediatrics, tinnitus management, vestibular assessment, central auditory processing, cochlear implants, etc.
That is potentially a worthwhile difference, too. One might posit that the most curious, motivated students want the widest scope of practice. They do not want to be bored (Costco is boring). So there might be some self-selection for independent versus manufacturer clinics, which of course is muddied by other life constraints that might make someone pick one job or another. I suppose you could also argue that a jack of all trades is a master of none. To what extent does experience in other audiological areas improve hearing aid provision, and to what extent does it limit it just due to time away? Personally, however, I place a fairly high value on an individualâs level of curiosity, critical thinking, drive towards continuing education, and ability to learn new skills.
I also do not know exactly what role HIS vs. audiologist plays in the distinction between practices. Up here, we have a very solid HIS program compared to what Iâve heard from some American States, which frankly sounds like the wild west. That being said, I do not know what attitude is indoctrinated into our HISs during their classwork because of course I didnât experience it. I also feel like the manufacturer clinics in my area that ARE the most predatory (because that certainly varies) do seem to employ more HISs. My guess would be that this apparent difference mostly does not have to do with the attitude of the individual practitioner, but rather that audiologists have more professional power. HISs tend to be younger, they often have less education, they are not as carefully governed by a regulatory board, and so they probably have less ability to push back against a large company that is employing them if they disagree with a particular business practice.
But these are all averages. There are great audiologists and great HISs working in all sorts of environments. Choice of workplace is often limited by life events.
(This long, meandering post was obviously fuelled by weekend morning coffee.)
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I, for one, appreciate your participation here, and find your advice very useful. I just wonder why you donât have the âproviderâ label on your avatar. It would lend you a little more credibility, Like a doctorâs white lab coat. 
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Oh, it went on automatically when the forum changed, but then I found that I could remove it and I did so. I dunno, it made me uncomfortable. I donât necessarily want people taking my word on authority. This is me kibbitzing in my off hours. Iâm probably less careful here.
But thanks.
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I usually avoid reading long posts, however I read yours and I appreciate your candor. You made several good points. I believe you were spot on regarding Costco.
My HIS told me she is salaried. In addition to hiring HIS, Costco promotes from within their employes. My understanding is an employee trains under the direction of a licensed HIS. I donât have any details regarding this training program. HIS are licensed by the state in Florida.
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So, that would lead me to conclude that many of the people fitting hearing aids at the Costcos in your area have no theoretical knowledge about the auditory system, nor about hearing aids. They do not know about options beyond what Coscto offers directly and therefore do not know when to suggest other solutions or assisstive devices or when to refer out a patient who does not match their (hopefully quite strict) referral protocol. The do not have any training in aural rehabilitation. They do not know what evidence-based practice IS, nor understand why it might be important. They cannot stay up to date on relevant literature because they have no training in how to read it. Also, given a system like that where the weakly trained are training the untrained, there is high risk of errors in practice being transmitted through time.
I wonder what the difference is between Costco Canada and Costco America that results in Coscto Canada staffing with only audiologists (at least in my province) while Coscto Florida trains their own providers.
(Also, imagine pharmaceutical companies training their own doctors. Christ.)
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That was a rhetorical question, sorry. The internet can be difficult with no accompanying intonation and facial expressions. A clinic that is tied to particular brand of product, whether via foundational funding or discounts for pushing the brand, or whatever makes them beholden to it, even though they may be owned by an individual(s) are, arguably, stretching the definition of private. Perhaps independent ought to be added to those who are free to use and fit whatever they believe will be of the greatest benefit to the patient.
Ainât that the truth. Your post was a great read BTW.
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In Australia the manufacturer chains pay commissions to their staff but so do some of the ENT owned chains. This is to attract staff because they cannot compete as easily with Salary + Commission. There was a big expose a few years back here and a radio station interviewed a number of stakeholders and exposed some of the tactics being used. I guess Costco has taken quite a chunk of business since then but the basic problems still exist.
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When the brightest and most talented are no longer able to operate freely and make a living they turn to other fields where that freedom is available and the field they vacate is reduced to mediocrity.
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Perhaps an audiologist degree is required in Canada. In my experience, being an audiologist does not mean you can competently fit hearing aids I have had aids fitted by audiologists & HIS. One of my worst experiences was from a recently graduated audiologist. She thought she knew more about my hearing experience than I did.
The Costco I have visited most is run my an audiologist who supervises some HIS & HIS trainees. An HIS initially fitted me there. I much prefer the HIS over the audiologist but the HIS moved to a different state.
Sure, there are lots of great HISs. I thought I had implied that in my earlier post.
Are you in Florida? And was your HIS trained up in Coscto rather than going to school for it?
I an in Virginia, but that Costco is in North Carolina. I understand they tok some sort of training course. The HIS I mentioned moved from North Carolina to Georgia and worked at a different Costco there.
Costco has a policy recommending one see an ENT physician within six months of their hearing evaluation.
I went to an ENT Doc before I went to Costco to rule out any serious medical problems. He removed a wax plug from my left ear and recommended I get a hearing test. I went to Costco and got the KS8s. I can hear a lot better but I wonder if Iâm getting the maximum benefit. In retrospect, the fitter did a cursory REM to verify the factory setting but made no adjustments. Knowing what I know now from Dr. Cliffâs videos and reading this forum, I believe the REM wasnât done properly. I think the probes were not placed properly in my ear canals. Iâm with a different fitter now who is certified and has years of experience. She is great and takes time to answer my questions and she has made some adjustments. However, she doesnât do REM.
Iâm not bashing Costco. I think they provide a needed service at a reasonable price. Bottom line, as has been expressed many times in this forum, the individual doing the fitting is the most important factor in getting HAs.
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