Like the Emperor’s New Clothes … Invisible! Or at Least Tiny or Discreet?

Hearing Excellence Low Resolution-9533Jeanine Doherty, Au.D., M.Phil., M.B.S, B.Soc.Sci.(Hons.)

Hearing Excellence, Christchurch, New Zealand

In Hans Christian Andersen’s (1837) tale, an Emperor’s weavers said they made him some new clothes that would be visible to all but the stupid or incompetent, when in fact they had made no clothes at all. So he walked around naked, yet believed he was attractively well dressed and adequately demonstrating his position of achievement and power.

We must hope that hearing aid manufacturers are not looking at hearing aid visibility with the same deceptive reasoning, for in their push for invisibility as desirable, audiologists and aid wearers could be treated as if a bit stupid. Completely in-the-ear hearing aids were introduced by the manufacturers, in part, as a solution for stigma or the “hearing aid effect” (Johnson et al, 2005) and yet it can be argued that making the devices discreet actually contributes to self-stigma, a belief that hearing loss is a problem that should be hidden (Kelly & Wensveen 2014; Wallhagen, 2009).

Invisible hearing aids have also been shown to produce the highest mark-up factor for both manufacturer and audiologist (De Silva, Thakur & Xie, 2013). It could be suggested that our promotion of invisible aids is a social construction suiting our own benefit.  Or is invisibility also, or solely, an end-user concern? What is a patient’s desire for invisibility driven by? Vanity, stigma, gender, significant-other input? How do we counsel that size really does not matter?

Vanity and Stigma

Most human interactions involve an appreciable chance of being slightly embarrassed, or a slight chance of being deeply humiliated (Goffman, 1959). We spend a lot of energy managing the impressions we make in appearance and lifestyle to avoid embarrassment to the best we can (Scheff, 2013), Cooley (1922) wrote that our perception of ourselves has 3 principal elements:

  1. Our imagination of our appearance to others
  2. Our imagination of their judgement of our appearance
  3. Self-judgement about these imaginings, such as pride or mortification

The four traits of vanity common within sociology, psychology and philosophy literature are consistent with Cooley: (1) appearance concern, (2) concern about appearance perception, (3) achievement concern and (4) concern about achievement perception. Appearance concern and achievement concern are related to personal values, while the two perception components relate to self-concept (Wang & Waller, 2006).

Wang and Waller (ibid.) state that advertising messages use this knowledge to appeal to our need for physical beauty and achievement status. We see the symbolically positive appeal, for example in an expensive handbag or car advert, where customers are told their beauty and/or status will improve with ownership. In hearing aid adverts, we see a negative spin on product visibility; consumers, then, are led to prefer invisibility to protect their self-image.


Cultural differences can affect the impact of these factors, with the individualistic West being more driven by “self-pride” and self-reliance, differing from traditional Asian concept of shame/loss of face and the value of collectivism and social relationships (Scheff, ibid.).  Gender differences have been found only for self-view of “appearance concern,” with women being more concerned about this than men (Wang and Waller, ibid.). Is it then possible that input from female significant-others might promote desirability for invisible aiding for their partner as well, or is it because, as Workman and Lee (2011) found, males and females have equal scores on “concern about appearance perception” by others?


When we say that we do not care what others think, we are kidding ourselves. Rejection elicits physiological responses, stimulating psychological reactions like a feeling of being different. This is stigmatisation in process, for as Goffman (ibid) writes, we are all attempting to be accepted as fellow members of the in-tribe, or at least not to be seen as rejects.

Marketing experts exploit the impact vanity has on consumer behaviour and social behaviour. Consumers select, purchase and use products to satisfy needs (Workman & Lee, 2011). Companies have a responsibility to be aware of the negative marketing impacts they can produce, for example the belief that hearing loss is a source of shame and that patients should choose hidden hearing aids (Netemeyer et al. ibid., Wallhagen, ibid.).

As was discussed in an earlier piece on this site (Doherty, 2016), the only way to overcome stigma and thereby shame is to normalise the stigmatised object.  In audiology, this means having hearing aids as normally observable as glasses and causing no concern for tribal separation between the aided and the unaided. Encountering someone that one can identify with, who is happily wearing aids, can be a powerful factor in influencing perception around hearing aids (Kelly & Wensveen, ibid.).

No health care provider should be just a professional salesperson (Metz, 2016). Audiologists must be aware of the ethics and consequences of promoting product-driven social constructions to patients. Education of patients, their significant others and the general public is the only way to de-stigmatise hearing aid visibility and so make aid use acceptable, normal and unremarkable. Just as social categorisations that produce stigmatised groups are socially embedded and constructed, they are also amenable to change through enhanced understanding (Wallhagen, ibid.).

(P.S. The author has recently begun wearing a hearing aid following a TBI related loss in one ear. Although it could be hidden by her curls, she prefers to draw attention to it and fascinating discussions result.)


Anderson, H.C. (1837). Fairy tales told for children. Copenhagen: Reitzel.

Cooley, C.H. (1922). Human nature and conduct. New York: Scribners.

De Silva, D. G., Thakur, N., & Xie, M. (2013). A hedonic price analysis of hearing aid technology. Applied Economics, 45, 2315-2323.

Doherty, J.L. (2016). New thoughts on hearing loss and stigma.

Goffman, E, (1959). The presentation of self in everyday life. New York: Doubleday.

Johnson, C.E., Danhauer, J.L., Gavin, R.B., Karns, S.R., Reith, A.C., & Lopez, I.P. (2005). The “hearing aid effect” 2005 : a rigorous test of the visibility of new hearing aid styles. American Journal of Audiology, 14, 169-175.

Kelly, J., & Wensveen, S.A.G. (2014). Designing to bring the field to the showroom through open-ended provocation. International Journal of Design, 8(2),71-85.

Metz, M.J. (2016). Professional ethics and business. The Hearing Journal, 60(10), 3.

Netemeyer, R. G., Burton, S. & Lichtenstein, D.R. (1995). Trait aspects of vanity: measurement and relevance to consumer behaviour. Journal of Consumer Research, 21, 612-626.

Scheff, T.J. (2013). Goffman on emotions: the pride-shame system. Symbolic Interaction, 37(1), 108-121.

Wallhagen, M.I. (2009). The stigma of hearing loss. The Gerontologist, 50(1), 66-75.

Wang, P.Z., & Waller, D.S. (2006) Measuring consumer vanity: a cross-cultural validation. Psychology & Marketing, 23(8), 665-687.

Workman, J.E., & Lee, S-H. (2011). Vanity and public self-consciousness: A comparison of fashion consumer groups and gender. International Journal of Consumer Studies, 35, 307-315.

Education in Counseling and Audiologic Rehabilitation: An Inseparable Linking

ClarkJohnJohn Greer Clark, PhD

The University of Cincinnati

Several years ago, our university went through, what seemed at the time, a major upheaval as we transitioned from a quarter-based institution to the more conventional semester system. In the process several courses in our department that had previously been separate were combined. In subsequent years my teaching of counseling and audiologic rehabilitation have become intertwined which has led to a more hands on, practical learning of both topics.

Preparation of future clinicians within our profession is likely not that different than in other professions in many ways. I am sure that we are not unique in the dilemma that classroom teaching does not always reflect what students practice in their clinical settings. In the 1960s and 1970s we ardently argued that the full management of hearing loss, including the dispensing of products to assist those with hearing deficits, could indeed be done ethically. And we argued that we were the best prepared to provide this service and that we could do it better. I do believe we are better prepared and can fully service those with hearing loss more effectively than other hearing health care professions. However, it is dismaying that we largely adopted the dispensing practices already in place and have not substantially deviated from these over the years to incorporate better use of personal adjustment counseling and to address more fully the rehabilitative needs of patients.

In the classroom, I teach hearing aid fitting and the continued post-fitting needs of the patient with a strong counseling emphasis. My students frequently tell me what I already know: that this is not what is seen in their practicum sites. They seem to have forgotten that I forewarned them of this.

Every Patient’s Story Matters

Clinically, we still fail to engage our patients in the telling of their stories. We believe we can most often predict the impact of hearing loss from the audiogram (Pietrzyk, 2009). But even if we could predict the impact, these are our patients’ stories and our patients have the right to tell their stories to an empathic listener who can guide them through considerations of the impact of the hearing loss through self-assessment measures. While more introspective than other animal species, humans frequently lack the ability to be fully introspective of limitations they do not want to admit or fear to confront. It is normal human nature to avoid what can be perceived as uncomfortable discussions relative to displayed emotions and frustrations. Students need experience in the classroom and in the clinic with broaching these discussions and working toward effective solutions with patients. The teaching of effective hearing loss impact exploration, and using this within motivational engagement work with patients, is now a large part of my combined counseling and audiologic rehabilitation class.

Supporting Change/Using Communication Strategies38920759_s

Another area I continually expand is discussions and role-play on the provision of communication guidelines to patients. Communication guidelines for patients and communication partners are one of the most effective tools to address the significant hearing deficit that remains for many patients after being successfully fit with amplification (Kricos & McCarthy, 2007). Research continues to indicate that guidelines are not given as often as they should be (Clark, Earl & Huff, in preparation; Stika, Ross and Cuevas, 2002). Hétu (1996) reminds us that one of the driving forces behind any hearing loss coping process often is to avoid being looked at as different. Hindhede (2011) went a step further when he reported that many participants in his study believed that being considered socially incompetent was more acceptable than the negative identity of being viewed as someone with defective hearing. Given these considerations, can we expect patients to effectively make communication guidelines a part of their lives when we give them a printed sheet of suggestions with little discussion? Will they actively tell others about their hearing loss and the accommodations they may need to communicate more efficiently when all they really want to do is avoid being different form others because of their handicap? Clearly, communication management suggestions must be accompanied by discussions that incorporate active cognitive and behavioral counseling. It is likely that when given outside of a full counseling context, the guidelines we provide are not implemented as effectively as we assume.

Counseling instructors are doing a phenomenal job in preparing our future audiologists. These instructors and their former students need to continue to work toward expanding this information outside of the classroom so that our affiliated preceptors can provide counseling-enriched discussions with patients that better align with what students are learning in the classroom.


Clark, J.G., Earl, B. & Huff, C. (2016). Survey of Audiologic Practices/Trends in the US. In preparation.

Hétu, R. (1996). The stigma attached to hearing impairment. Scandinavian Audiology Supplement, Vol 25(Suppl 43), 12-24.

Hindhede, A.L (2011). Negotiating hearing disability and hearing disabled identities. Health, 16(2), 169-185.

Kricos, P., & McCarthy, P. (2007), From ear to there: Historical perspectives on auditory training. Seminars in Hearing, 28(2), 89-98.

Pietrzyk, P. (2009). Counseling comfort levels of audiologists. University of Cincinnati, unpublished capstone.

Stika, C.J., Ross, M., & Cuevas, C. (2002). Hearing aid services and satisfaction: The consumer viewpoint. Hearing Loss (SHHH, May/June), 25-321.

Taking Audiology Practice in Ghana to the Next Level

UnknownGeorgina Aidoo

Occupational Audiologist

Ghana, West Africa

I have always strived to search for the unique dynamics and realities in Audiology and ultimately discover what makes our patients incomplete without our services and our personal care. I have to face many encumbrances right from the onset of this journey, as being in Africa, and even in West Africa, my developing and third world country has made the trends very challenging, with diverse milestones which all bring learning experiences that are priceless. Pursuing a Doctor of Audiology degree will give me a wide range of opportunities and experiences to develop knowledge, skills and attitudes which will enable me to grow the field and advocate for change.


Audiology practice and management of hearing loss and balancing disorders usually does not command much attention in third world countries, even though various studies and estimates indicate that two-thirds of the world’s populations of hearing impaired people live in the developing countries. In many African countries, the general awareness of Audiology and hearing loss management is low, and lack of resources, ignorance, illiteracy, cultural diversity and national priorities among many other factors relating to technology enhancement and sense of focus has caused a lack of strong advocacy in this area. The Africa continent has a predominantly young population and many are at risk of getting diseases causing hearing loss (McPherson & Holboro, 1985). Overall, it is estimated that in the countries below Sahara, more than 1.2 million children aged between 5 and 14 years suffer from moderate to severe hearing loss in both ears. General prevalence studies show higher rates of severe to profound hearing loss in this part of Africa than in other developing countries.

Hearing problems are a severe handicap, particularly in developing countries where the ability to take part in normal conversations is vital for economic and social survival. However, many are illiterate as well as hearing impaired, and thus unable to communicate by writing and reading. It is difficult to get an exact overview of the prevalence and causes of hearing loss in Africa. Several studies have been conducted but they use different methods and not all are up to date. However, they do serve as indicators and together they provide a general picture of the situation.

Unknown-1The case of Ghana is no different. In spite of the fact that hearing and balancing disorders are common among persons in communities in Ghana, very few studies have been carried out. The pace of development is very slow despite how critical the need is.

It took an extraordinary effort for me to enroll in an Au.D program after saving for almost a decade all in relation with finding the true purpose my commitment to the field, and I continue to explore and advocate in quest of gaining deep knowledge to help spread Audiology, especially in Ghana and West Africa where silence has swallowed sufferers’ desire to seek help.

Audiology Transformation

I am involved in Community Development, Occupational Health and Environmental Management in a mining environment, and an Audiological setting in hospitals and industrial organizations to offer a comprehensive hearing loss prevention program and promote Occupational Health. During my AuD studies, I identified a very deep gap with the help of my Counseling in Audiology Course, which provided strategies, tools and approaches to help bridge that gap. It might sound exaggerating to say that the entire evolving patient centered care concept being developed is rolled out from the central, core and pivot of our practice, and without this sustainability, our practice will be questionable.

It is my goal to cause a quality transformation in the field of Audiology in Ghana and beyond using all the truth, practicalities and best practices I have discovered in and around the globe. This I know will be difficult because the demand of health resources in our country is such that advocacy, management and prevention of hearing loss and disorders relating to the ear and balance even among school children takes low priority, let alone adults.

I really want a change that will eradicate all stagnant mindset about Audiology Care and how we know how to care for our patients already and bring in minds that are well positioned to embrace a patient-centered approach to audiology care. We will leave no stone unturned and eliminate prejudice and mediocrities that fight against our goal to render services that are patient-centric and team-based.

Finally I will not leave us as clinicians and services providers and professional in Audiology out. We also have our needs and stressors in our homes and environs, and even tough challenges we encounters with our dear patients and how they affect our delivery and how we will manage us to be able to give without measure and not suffer our souls out. In the end we want to reach if possible all wins for all parties involved in the journey.


McPherson, B.O., & Holboro, C.A. (1985). A study of deafness in West Africa. Journal
of Paediatric Otolaryngology, 10,115-135.

Teaching Counseling in Audiology: Are We There Yet?

Karen Munoz2Karen Muñoz, EdD

Utah State University

The importance of counseling is well recognized for the vital role it plays in audiology service delivery. There are text books devoted to counseling (e.g., Clark & English, 2014), and continuing education opportunities for interested professionals. Counseling is included in audiology scopes of practice (ASHA, 2004; AAA, 2004), and audiology preferred practice guidelines (ASHA, 2006). It sounds like as a profession we have this covered. But do we?

Even though there is agreement on the foundational role counseling plays in audiology service delivery, the lack of depth in professional practice guidelines leaves expectations for graduate training vague. Counseling competencies, just like other skills audiologists learn, need intentional instruction for knowledge and skill acquisition. Similar to student learning for other evidence-based audiology services, bridging of knowledge is needed between coursework and clinical experiences. For this to occur, clinical supervisors need to be intentionally practicing and teaching evidence-based counseling skills. Without careful attention to counseling training, it is unlikely that graduate students will be purposeful in their approach to counseling. You may be thinking, of course counseling is happening, why would this be a problem that needs attention?

Counseling Skills: Not a GivenDay2.5

Patients have shared their experiences with audiologists and it is clear that counseling ability does not just happen to develop along the way. Parents have reported gaps in the information and support they received (e.g., Larsen et al., 2012; Muñoz et al. 2013). Hearing aid uptake among adults with hearing loss is low (Kochkin, 2009), but influential factors are not well defined. There is a need for further research to better understand the influence of factors such as audiologists’ counseling skills, patient self-efficacy, and overall type and quality of interactions between the audiologist and patient (Knudsen et al., 2010). Recent research has also raised concerns with how counseling conversations are happening in audiology. Analysis of audio-recorded appointments with adult clients considering hearing aids revealed that audiologists responded to client psychosocial concerns with technical information, ignoring the emotional content of concerns raised (Ekberg et al., 2014). During history-taking, in a related study, audiologists often interrupted the client early on, and then maintained verbal dominance during the appointment (Grenness et al., 2014).

Patient Centered Care

Patient-centered care is widely recognized as an important feature of healthcare delivery that can lead to improved outcomes and adherence with recommendations (Robinson et al., 2008; Zolnierek & DiMatteo, 2009). Patients seeking audiology services, not surprisingly, also want services that are patient-centered (Laplante-Lévesque et al., 2014). It may seem that being patient-centered should occur if the practitioner values it and is aware, but awareness alone is not sufficient for changing behavior (Muñoz et al., 2015). Counseling is more than being a caring and compassionate professional, and while the skills needed to provide effective counseling are not necessarily difficult to learn, they are not intuitively implemented. Just think about a time when you did not feel heard, or were not given an opportunity to voice your thoughts, or were told how to fix your health concern.

Focus and Feedback

Effective use of counseling skills requires knowledge about behavior and factors that influence behavior (yours and your patients), opportunity to practice implementing skills, and performance feedback. In other words, it needs to be intentionally taught,conversation-bubbles-illustration-970x450_28517-2 just like other skills in audiology such as completing a diagnostic test or troubleshooting hearing aids. Teaching counseling in our graduate training programs needs to be approached from an evidence-based perspective. Audiology would benefit from clear evidence-based counseling guidelines that provide a consistent message about the purpose, indicate needed knowledge and skills, and training considerations for classroom and clinical experiences. Teaching counseling in audiology is in need of attention and further research to improve educational practices, implementation of skills, and most importantly, to positively influence client and family outcomes.


American Academy of Audiology. (2004). Scope of practice.

American Speech-Language-Hearing Association. (2004). Scope of practice in audiology. 

American Speech-Language-Hearing Association. (2006). Preferred practice patterns for the profession of audiology.

Ekberg K, Grenness C, & Hickson L. (2014) Addressing patients’ psychosocial concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiolology, 23, 337-350. doi:10.1044/2014_AJA-14-0011

Clark, J.G., & English, K.M. (2014). Counseling-infused audiologic care.Boston: Pearson.

Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2014). Communication patterns in audiologic rehabilitation history-taking: Audiologists, patients, and their companions. Ear & Hearing, 36, 191-204.

Knudsen, L.V., Oberg, M., Nielsen, C., Naylor, G., & Kramer, S.E. (2010). Factors influencing help seeking, hearing aid uptake, hearing aid use and satisfaction with hearing aids: A review of the literature. Trends in Hearing, 14(3), 127-154.

Kochkin, S. (2009). MarkTrak VIII: 25-year trends in the hearing health market.

Laplante-Lévesque, A., Hickson, L., & Grenness, C. (2014). An Australian survey of audiologists’ preferences for patient-centeredness. International Journal of Audiology, 53:sup1, S76-S82.

Larsen, B., Muñoz, K., DesGeorges, J., Nelson, L., & Kennedy, S. (2012). Early Hearing Detection and Intervention: Parent experiences with the diagnostic hearing assessment. American Journal of Audiology, 21, 91-99.

Muñoz, K., Blaiser, K., & Barwick, K. (2013). Parent hearing aid experiences in the United States. Journal of the American Academy of Audiology, 24(1), 5-16.

Muñoz, K., Nelson, L., Blaiser, K, Price, T., & Twohig, M. (2015). Improving support for parents of children with hearing loss: Provider training on use of targeted communication strategies. Journal of the American Academy of Audiology, 26(2), 116-127.

Robinson, J.H., Callister, L.C., Berry, J.A., & Dearing, K.A. (2008). Patient-centered care and adherence: definitions and applications to improve outcomes. Journal of American Academy of Nurse Practitioners, 20, 600-607.

Zolnierek, K.B.H., & DiMatteo, M.R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Med Care, 47(8), 826-834. Doi: 10.1097/MLR.0b013e31819a5acc


“Not a Day Goes By That I Don’t Think About Listening with My ‘3rd Ear’”

(Recent comment by an AuD graduate who has been practicing for several years)

Judith Blumsack, PhD

Associate Professor Emerita

Auburn University

Those of us who teach counseling to Au.D. students can look to a variety of sources as we develop coursework. Descriptions of approaches used by professional counseling educators, colleagues in other health professions who are teaching counseling, and our own colleagues are available to us, and efficacy studies in audiology are beginning to appear (e.g. English & Archbold, 2014). During the time I taught counseling, I used a variety of learning activities. I have no efficacy research to report, but perhaps my experiences with these learning activities and my thoughts about them might be of interest to readers of this forum.

Inviting Visitors to the Class: Patients

Patients Can Be Guest Speakers

Patients and Parents as Guest Speakers

One of the learning activities I used involved inviting patients to visit the class. Each semester, through networking, I located patients who would be willing to join the counseling class for our afternoon group meeting. I should mention that our class met once each week and was three hours long to avoid constraints imposed by the standard 55 minute class session. In scheduling patient visits each semester, I arranged for one of the visitors to be an adult with hearing loss and one visitor to be a parent of a child with hearing impairment. We began each session by briefly introducing ourselves individually and asking the visitors to then do the same. The visitors, though, would keep talking. They would tell us things they thought would be helpful for students to hear. These visits were all memorable, and sometimes they were very moving. The visitors understood that the purpose of their visit to our class was to create a situation where they would be the teacher while the student, with no white coat on, could truly be a student and not a student clinician. Students were encouraged to ask questions. The visitors knew that they could decline to answer a question if they wished, but it is notable that, without exception, the visitors seemed to welcome the opportunity to share their experiences. Here was a situation where listening and understanding was the very purpose of the encounter, not testing, not interpreting results, not making recommendations…….just listening. It was my hope that the students would learn not only about the specifics of that visitor’s experience, but that they would see that patients have much to teach them.

Inviting Visitors to the Class: Professional Counselors

Continue reading

Counseling Assumptions/Explaining The Audiogram

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC


Back in the day (mid-1980’s), like all Master’s degree students in the US at the time, I took a typical course in Adult Aural Rehab. For some reason I remember this little pop quiz:


I was ready for the question and jotted down the answers:

  1. take a case history
  2. conduct tests
  3. report test results
  4. make recommendations.

I got an A on the quiz, confident I had the world by the tail, eventually graduated and worked in the field… and immediately realized that my answers, although not wrong, were not enough. I was assuming that all patients were ready to accept my recommendations and would follow up accordingly. And of course, that was not happening. There were days when only a few patients moved forward with hearing help. Patients were far more complicated than I had expected, and I wasn’t factoring in any of those complications. I didn’t even know what those complications were.

There was no terminology for my approach at the time, but now I know it can be called audiologist-centered (i.e., it was all about me). Consistent with my quiz answers, I expected to direct the appointment, while the patient passively followed my lead. I didn’t intend to be disrespectful or dismissive of the patient’s role, but I held a naïve (some would say paternalistic) assumption that patients had no say because they didn’t know what I knew, and I knew best. In reality, of course adult patients are anything but passive: they are autonomous beings and they will make decisions with or without our involvement (Tauber, 2005).

In contrast to my first efforts, patient-centeredness is a concept that has now made it to “center stage” (Epstein & Street, 2010) and is considered one of the Institute of Medicine’s (2001) six key elements of high quality care. The IOM defines patient-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (p. 6). This kind of care requires dialogue, not monologue, and even further, the ability to develop relationships and partnerships. Today, my quiz answers would be worth a “C” grade at best.

Other Assumptions?

Another assumption that surely should be reconsidered is related to my third answer above (report test results), specifically regarding our beloved audiogram. As important as it is to us, should we assume that all patients are also equally fascinated? More than twenty years ago, Martin (1994) challenged this assumption, and yet in a recent workshop, a participant mentioned that in her 20 years of practice, it had not once occurred to her to ask this question. So let’s think about it:

  1. Do all patients really want a crash course in audiology?
  2. If not, what do they want from us?
  3. If they do prefer specific information, how do we know if we are sharing information effectively?

As we apply patient-centered principles to our audiologic practices, it seems long overdue to examine the practice of unquestionly explaining the audiogram to every patient or caregiver. Apart from habit and training, why do we do this? Is it really necessary? Is it actually meaningful? Should we give patients a choice, or do we truly believe they cannot leave the appointment without a tutorial in audiogram interpretation? Is the exercise a worthwhile use of time?

questionsWhen we examine this “auto-pilot” practice, even more questions emerge. What would happen if we do give patients a choice, and ask if they would prefer a “big picture” summary or the details?   If they choose “big picture summary,” will we freeze up? Do we use the audiogram as a prop, or can we put our test results to one side, use simple terms to clearly relate the findings to their initial concerns, and move on?

Patient-Centeredness = Patient Choice

Undoubtedly, some patients will appreciate the time spent reviewing test results, and will understand them. But we cannot assume this is always the case, and to date we also cannot consider it an evidence-based practice.  As a deeply-held tradition, reconsidering its value causes a surprising amount of angst.  But the point of patient-centeredness is, it’s not about us!


Epstein, RM & Street, RL. (2010). The values and value of patient-centered care. Annuals of Family Medicine, 9(2), 100-103.

Institute of Medicine. (2001). Crossing the quality chasm : A new health system for the 21st century. Washington, DC: National Academy Press.

Martin, F.N. (1994). Conveying diagnostic information. In J. G. Clark & F. N. Martin (Eds.), Effective counseling in audiology (pp. 38-67) Needham Heights, MA: Allyn & Bacon.

Tauber AI. (2005). Patient autonomy and the ethics of responsibility. Cambridge, MA: The MIT Press.

New Thoughts on Hearing Loss and Stigma

Hearing Excellence Low Resolution-9533Jeanine Doherty, Au.D., M.Phil., M.B.S, B.Soc.Sci.(Hons.) of Hearing Excellence

Christchurch, New Zealand

Two models of disability, the medical model and the social model, currently represent the opposing ends of the continuum of what defines disability (Berger & Lorenz, 2015).

The medical model sees disability as an individual’s bodily event and so concentrates on aetiology, diagnosis, prevention, and the treatment of the physical, sensory and/or cognitive impairments. Past scholars of disability often took this negative deviance medical approach; bioethicists and eugenicists have spent most of their energy on justifying the morality of preventing or even eliminating people with disabilities by the use of prenatal testing and abortion, or by withdrawal of care (Parens, 2001).

The social model of disability, at the other end of the spectrum, moves away from the impairment itself to consider the socially imposed barriers for the disabled, such as inaccessibility and unequal rights. It also considers the prejudicial attitude (i.e., stigma) that is constructed around any disability and results in sub-ordinate social status and a devalued life (Berger & Lorenz, 2015; Bickenbach et al., 2014). The social model evolved from the disability rights movements in the UK and USA in the 1960’s and 70’s, and carries the notion that a society should embrace all members and address socially imposed barriers.

Regardless of which model is used, stigma seems to be a universally understood experience. Stigma occurs as a process by which people stereotype, label, judge, and then discriminate against others who are different (While & Clark, 2010) and so they spoil any sense of normal identity for the other person.

Goffman (1963) outlined three causes of social stigma:

  • overt, external deformations;
  • personal trait deviations such as mental disorder or addiction;
  • tribal/cultural deviations from a norm in terms of physical appearance like skin colour, dress style, religion, or behaviour.

Goffman added that stigma is the phenomenon whereby an individual with an attribute is deeply discredited by their society and therefore rejected as a result of the attribute.

Understanding Our Reactions

We are drawn to the unanticipated and the inexplicable in an effort to make sense of the experience, a universal part of our cognitive architecture that natural selection has bequeathed us (Garland-Thomson, 2006). We also experience aversion to others who do not fit into Goffman’s (1971) concept of normalcy. This aversion is a primitive response, demonstrated at the minimum with glancing or staring as a sifting mechanism to define safe or “otherness” status among those around us. For example:

I used to travel with a fellow Board member who had one of the first cochlear implants in New Zealand, which is very obvious as he has no hair to hide it. Walking through airports with him was fascinating as I watched others observe, try to decide what it was, understand/comment to their fellows about it and then finally return to their own activities. Before it could be socialised out of them, children had no concern about direct enquiry of David – “What’s that thing on your head, mister?” Being stared at by an adult can mean a lack of understanding, or at worst a social disregard, but children have the “curiosity excuse,” and he loved to take the pieces off his head and explain them to the fascinated child, while the parent often squirmed in embarrassment.

Although on the surface innocuous, staring is actually a strong reaction towards another person and excites the brainstem’s primitive level neural activity (Garland-Thomson, 2006), which is part of our fight or flight system. Stigmatic judgements are made with such fast glances and decisions. The inclination to stigmatize others has long been documented; for instance, in Roman times thieves and slaves were visibly tattoed to identify them as non-equal human beings.

Stigmatising another person can not only make the stigmatised person suffer negative consequences but can, conversely and perversely, enhance positive feelings of membership of the stigmatising tribe by the rise in self-esteem and sense of power that “doing others down” can bring (Falk, 2001). This tribal group-think against the stigmatised person has been used to justify terrible attacks seen worldwide, in which a stigmatised person – often intellectually disabled —  holds little value and so can be beaten or killed as they are considered sub-human.

31970396_sThe Impact of Labels

 When a label or stigma is applied to a person/group, there is a surrounding negativity or taint which engenders feelings of lesser worth in those subjected to the labelling. Being the subject of stigma can adversely affect the behaviour of the stigmatised by changing their emotions and beliefs (Major, 2005). The stigmatised person can become isolated, and then depression and lack of self-esteem can follow (George, 2015). Internalised stigma also leads to decreased hope and self-efficacy, and a poorer general quality of life (Nabors et al., 2014). This impact is not unique to hearing loss – just think about our seniors who have age labels, hearing loss, vision loss, cognition loss and physical disability labels to carry. Continue reading

Audiologist-Centred Patients Are the Outcome Goal of Patient-Centred Audiologists

Jeanine photo 2015

Jeanine Doherty, Au.D., M.Phil., M.B.S, B.Soc.Sci.(Hons.) of Hearing Excellence

Christchurch, New Zealand

Loyalty of patients to their Audiologists is a “win” for all parties. In a business sense, loyalty means repeat business and word of mouth referrals from current patients and both of these are less expensive than attracting new business (Morgan & Hunt, 1994). Thus, a relationship-based strategy builds a firm’s competitive advantage (Morgan & Hunt, 1994; Sumaedi et al, 2015) and patient- centered care can clearly fit this bill.

As a clinician, my experience is that it is the long-term relationship with repeat patient visits that helps make my career so rewarding and keeps me engaged; and for the patient the trust relationship they develop over time with their audiologist must make their interactions much more rewarding emotionally.

Audiology can learn from the general business, especially the service sector, literature and from this customer loyalty has been found to have two main components (Cater & Cater, 2009):

  • Affective (emotional) commitment, which develops from trust and social bonds (liking each other and learning about each other and so includes listening to patients), with trust the more important by far. Health is a “credence category service” and trust is very important in such a context (Chang et al, 2013). Humans also have an additional resistance to change which acts as a loyalty antecedent (Silva, 2015).
  • Relational (rational) benefits such as access, marketing and pricing can lead to perceived satisfaction, but satisfaction ranks second to emotional commitment in establishing loyalty.


This Cater and Cater (2009) dual-factor model of motivations of general service industry loyalty includes all the factors in the audiology specific model developed by Grenness et al (2014). The themes from their patients’ data show that they seek individualised care, clinical procedures including information sharing and shared decision making, and the recognition of the importance of the players who make up the therapeutic relationship (i.e., audiologist and patient). These themes would fall into Cater & Cater’s 1st emotional commitment category and show the importance of meeting the emotional need of patients to allow a successful and loyal patient/audiologist relationship. Continue reading

Reflections on Response to Change

CarolyneCarolyn Edwards, M.Cl.Sc., M.B.A.

Auditory Management Services

Toronto, Ontario Canada

Most of us as human beings do not invite change into our lives as a natural part of each day. The reality is that we fall into pattern and that pattern is comfort and security. We do anticipate some natural progression in our work or personal life but when unexpected events change the course of our lives, most of us resist that change at the outset.   The way we resist change takes many forms.   We can stay in denial or surprise, we can blame others or we can fight against the change. Specifically resistance may come in the form of delaying – give me more detail, flooding others with the details, intellectualizing, moralizing, OR impulsive action – everything is suddenly fine, I need a solution fast, blaming others without warning OR sustained confusion or denying the impact (I’m not surprised).   Over time, if we accept the changes that have occurred, we can find a flow, and change becomes an ally rather than the enemy we originally perceived.

Resistance is the outward expression of fear – I am afraid – of being vulnerable, of having to change, of losing control, of not knowing what to do, of being different and being rejected because of the difference. Each of us has our own fears based on our life experiences, and yet the underlying fear of the unknown is understood by all of us.

Listening to our clients’ responses is essential to determine where they are in the process of change, because the reality is the diagnosis of hearing loss brings change.

Addressing Resistance5276781_s

When we are resisting change, we cannot hear others and often we cannot hear themselves either. We may be aware or unaware of our resistance; we can feel the fear and don’t know what it is.   Resistance becomes the only way we know how to communicate at the moment. As professionals, when you are observing resistance in your clients, it is often more effective to address the actual behavior at the outset than the fear itself. For example, the behavior may be the inability to attend the scheduled appointments, the lack of questions, a parent’s inability to follow through with agreements to work with their child, a child’s rejection of support, the desire to talk about the same concerns repeatedly, the disinterest in follow-up appointments, or an adult’s consistent use of amplification or assistive listening devices. The underlying fears will often emerge out of those discussions. Continue reading

Patient Education: The Flip Side of Audiologic Counseling

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Audiologic counseling is like a two-sided coin: one side attends to patients’ emotional and psychological struggles, and the other side, to their need for clear, relevant, and compelling information. Goleman (1995) would describe these two goals as communicating either with the “feeling mind” or the “thinking mind.” The concept of “being of two minds” is a familiar one, but communicating with a patient’s “thinking mind” (more specifically, our efforts in patient education) hasn’t attracted much attention in audiology.

Patient education can be taken for granted,  but that would be a grave mistake. If not careful, we might apply a range of ineffective practices, such as:

  • Using words our patients can’t process;
  • Providing more detail than patients can remember;
  • Conveying information unrelated to patients’ questions;
  • Providing information without helping patients apply it to their lives.

Let’s ponder that last point for a moment. Information designed to “help patients apply it to their lives” elevates patient education to a new level of responsibility. We are not only talking about providing information, but also using information as a vehicle for change.

This concept is relatively new. Falvo (2011) notes that while “many people think of patient education as the transfer of information … the real goal is patient learning, in which patients are not only provided with information, but helped to incorporate it into their daily lives” (p. 21). We are being invited to redefine this process, to evolve from a monologue of information-giving into an interactive framework for change.

The concept of “effective patient education” can be new territory for many audiologists. How do we find our way? This article outlines a suggested checklist to guide us, applying classic teaching/learning principles culled from exemplar patient education materials.

A Checklist for Audiology

Patient education has a familiar starting point: knowledge dissemination.

Knowledge Dissemination. We have much information to share about test results, anatomy, etiologies, genetics, recommendations, treatments. However, as part of effective patient education, this step is just the first of several considerations. Even as we disseminate information, we cannot assume the patient understands us, or will remember what we said accurately. Let’s consult this checklist of concerns:


As we disseminate knowledge:

Does our patient understand us? In addition to the problems with professional jargon, we must remember that when a patient is upset, the amgydala in the brain activates “flight or fight” responses (increased heart and respiration rates, etc.). While in this state, the frontal cortex (the center for analysis and reasoning) is inaccessible. We might be talking to a brain that, for the time being, cannot learn. How to test for understanding? The easiest way is to ask: “Would you like a detailed explanation, or a big-picture summary? Do you prefer information conveyed verbally, or in writing, or both?” And later, “To be sure we are on the same page: could you share with me your understanding of the situation?” Asking the patient to repeat what they understand is called the “teach-back method” (Agency for Healthcare Research and Quality, 2010). Continue reading