Audiology Counseling and Patient-Centered Care, Part III: Understanding

Kris English, PhD

The University of Akron/NOAC

As mentioned in Part I and Part II of this 5-part series, Stewart et al. (2014) provide a framework to implement Patient Centered Care (PCC), organized around four interactive components. In this entry, we will consider the 2nd component, Understanding the Whole Person.

Understanding: Patient-as-Person

Already we are seeing the interactive nature of each component, since the first PCC component encourages us to “explore” by finding out about our patients. Relative to their hearing circumstances, what are their personal backgrounds, their current situations, and what is important at this time?  A person’s life- and world-context matters for everybody, but particularly for our patients, whose hearing loss can have direct impact on their life and their world. Factoring those contexts into our understanding of the “whole person” is considered “a hallmark of the patient-centered clinician” (Stewart et al., p. 89)

Understanding: Patient-in-Context

The additional layer to this component is understanding the patient as part of an eco-system, in a way.  “Proximal context” generally includes one’s immediate family and other important persons in our patient’s living circumstances. Expanding outward, we would like to know about living circumstances (neighbors, care-givers), employment status and associated listening challenges; social supports within one’s community, and so on. Additionally, “distal context” may be relevant to many patients, if their culture and community play an active part in their life.

“Listen and Learn” — But Don’t Stop!

There is more to the “understanding” component than meets the eye. To be of any value, our understanding must be actively communicated to the speaker. Merely listening and processing the input does not help a patient “feel heard.” We must actively respond. Consider these details from a study that tracked patient comments, subsequent physicians’ responses, and ultimate patient outcomes to get a sense of how important it is to actively convey understanding.

Adams et al. (2012) recorded, transcribed, and evaluated 79 patient-physician office visits. They identified 190 instances of patients expressions of emotional state, coded the physicians’ responses, and then categorized the responses as follows:

  • Responses that focused away from emotion
  • Neutral (Focused neither away from or toward)
  • Responses that focused toward emotion

They also took the additional step of evaluating consequences: what were the outcomes relative to patient care?  The flow chart below tracks the three “response choices.”  When physicians ignored patient emotions, outcomes were unproductive at best: when distance and even antagonism develops, we know we are going in the wrong direction. However, when physicians responded to emotions (i.e., what patients actually wanted to talk about) with neutral or actively focused responses, outcomes were productive: additional discussion led to a confirmation of goals; support was conveyed; patients and physicians understood they were on the same page.

Did Responses Make a Difference?

Of course they did. Let’s assume that physicians in the first column of boxes did hear their patients’ emotional concerns, but simply failed to respond in an active way to let the patients (and the researchers) perceive it. It is quite easy to become distracted, anticipate other topics, notice the time and rush ahead. But missed opportunities have consequences; our efforts to be patient-centered must keep “active understanding” a high priority.

Following are three tips to support our endeavors to convey understanding:

Active Understantding Tip #1: Use Observable (Measurable) “Understanding Responses” 

The following kinds of responses are within everyone’s repertoire; the only concern is remembering to communicate them. Recommendations from the Patient-Centered Observation Form (PCOF) (Keen et al. 2015) include:

  • Use continuer phrases (OK; hmm-mm) and attentive body language
  • Validate emotions (you’re worried about changes; it sounds like you were uncomfortable?)
  • Elicit more input (Could you help me understand with an example? Anything else?)
  • Confirm what is most important to patient (So let me confirm: you indicated the following problems need our attention…)

Audiologists interested in improving this skill might consider partnering with a colleague to observe/count instances of active understanding by using the PCOF.

Active Understanding Tip #2: Include Family

Research (e.g., Singh et al. 2016) consistently supports the value of including family members (“proximal context”) in audiology appointments.  This essay provides some food for thought.

Active Understanding Tip #3: Try Ida Institute’s Communication Rings

This easy-to-easy and literally patient-centered tool helps the audiologist understand not only our patients’ family/”proximal” contexts but also their “distal” contexts. Organizing and prioritizing one’s “communication world” has the double benefit of helping both the audiologist and the patient understand the impact of hearing loss.

 

PCC is a Process

At this point, we see that Patient-Centered Care does not involve a singular change in practice, but rather a commitment to an integrated process. We have applied the first two steps to audiology; the next steps will be examined in Parts IV and V.

The Ultimate Question: Is “Active Understanding” an Evidence-Based Practice?

See Tzelepis et al. (2015) to learn more.


  1. I routinely inquire about a patient’s proximal and distal contexts.

Almost always         Sometimes        I tend to skip this step

  1. I am aware of the risks of not actively conveying understanding about a patient’s emotional responses to hearing loss.

Fully aware        Sometimes aware           Hadn’t realized it until now

  1. I would find it helpful to review my responses to determine if they conveyed active understanding.

Yes              Not sure

  1. I actively include family members in appointments (per patient preference).

Almost always       Sometimes         I often skip this step

  1. I can explain why “active understanding” is an evidence-based practice.

Yes            Still working on it


References

Keen, M., Caswe-Lucas, J., Carline, J., & Mauksch, L. (2015). Using the patient centered observation form: Evaluation of an online training program. Patient Education and Counseling, 98, 753-761.

Singh, G., et al. (2016). Family-centered adult audiologic care: A Phonak position statement. Hearing Review, 23(4), 16-21.

Tzelepis, F., Sanson-Fisher, R., Zucca, A., & Fradgley, E. (2015). Measuring the quality of patient-centered care: Why patient-reported measures are critical to reliable assessment. Patient Preference and Adherence, 9, 831-835.

Audiology Counseling and Patient-Centered Care, Part II: Exploring

 

Kris English, PhD

The University of Akron/NOAC

As mentioned in Part I of this 5-part series, Stewart et al. (2014) offer a framework to help us understand and implement Patient-Centered Care (PCC), organized around four interactive components. In this entry, we will consider the first component, Exploring Heath, Disease and the Illness Experience.

The very phrase may strike audiologists as odd: after all, we communicate with patients from the onset, starting with the case history. How is that different from exploring? Exploration does include the typical case history (“history, physical, lab”), but that step alone certainly does not encompass the entirety of the patient’s experience. In audiology, patient-centered care also strives to understand patients’ “unique perceptions and experience” of hearing loss: what it means to them, their thoughts and feelings about their experience, how HL is affecting their lives, and their expectations re: hearing help. These concerns are not necessarily revealed while collecting health and hearing history.

We know full well that hearing loss impacts “the self” (self-concept, self-confidence, self-efficacy), as well as family relationships, social interactions, community engagement, leisure activities. Patients may be distressed about these impacts and want us to understand them, or they may not be ready to accept the reality that their hearing is changing. Whatever the starting point, in addition to collecting case history information (by definition “ear-centered”), we are also challenged to find ways to explore our patients’ “unique perceptions and experience” of hearing loss.

What does exploration look like in audiology practice? Good news: it does not involve radical changes. Even better news: exploration adds an additional level of essential human connection to the encounter.

Exploration does involve authentic curiosity and a few key questioning, listening, and responding skills. For example …

“What Brings You Here Today?”

A very familiar start! And also a patient-centered start. However, after a patient’s first few sentences, we reach a conversational crossroads and make a decision: either transition to the “history” piece, or explore a little further to find out what really matters to the patient.

As Stewart at al. (2014) observe, “The reasons patients present themselves to their practitioners when they do are often more important than the diagnosis” (p. 49). What are the reasons? How can we find out? Following are three tips for intrepid audiology explorers:

Explorer Tip #1: Discussing Self-Assessment Reports

When a patient completes a self-assessment, we often glance over the results and then add it to our report with no discussion. If so, we miss an opportunity to explore. Self-assessments give patients a framework to reflect upon and disclose pieces of their lives; the results are a natural springboard for an exploratory conversation. Even if the self-assessment addresses only situational challenges (e.g., work, restaurants), we can invite personal observations: “You indicate here sometimes feeling embarrassed when meeting new people (per HHIE-S, Newman & Weinstein, 1988). Does an example come to mind? Could you tell me more about it?” We might learn what embarrassment means to this unique patient: that it may mean choosing to opt out of social settings, that the experience also includes frustration, discomfort, discouragement, worry. However the patient frames the experience, putting those concerns into words begins a self-help process: patients gain meaning, and eventually mastery, of their situation. The invitation to elaborate may not be accepted but we should still try, because “tell me more about it” is a fundamental patient-centered practice.

Explorer Tip #2: Using Open-ended Questions

Open-ended questions come easily to some audiologists, while others worry about losing control of the conversation. It can take some practice and perhaps asking a colleague for moral support, but it’s worth the effort. Insisting on conversational control is the antithesis of PCC.

Examples of open-ended questions include:

  • “You’ve helped me understand your family’s concerns. What are your thoughts?”
  • “So you are thinking about hearing help – sometimes it helps me to know ‘why now?’ Has anything specific come up?”
  • “A few things you’ve mentioned suggests you might be worried about what other people will think about you using hearing aids. The worry about stigma is something many patients mention. Is this on your mind as well?”

A caveat re: open-ended questions: Not every patient will want to actively participate in these conversations, and they have a right to decline. As van Dulman (2003) puts it, “Listening to patients and having them decide how much they want to participate may actually be the essence of patient-centered care” (p.195).

Explorer Tip #3: Listening and Waiting

Whether from self-assessments or spontaneous conversation, we hope to engage our patients and learn how we can help. As they answer our question, “What brings you here today?”, patients tentatively drop their guard, begin to feel accepted, and decide whether we can be trusted. That trust must be in place before patients decide to move forward.

As we know, listening requires our full attention (no multi-tasking); therapeutic listening also requires us temporarily to refrain from advice-giving and problem-solving. It is often not in an audiologist’s nature to “let a patient feel the way she feels,” but patient-centeredness is based on this principle. When patients express gratitude for our time and attention, we may find ourselves saying “all I did was listen,” but we will also know why it helped.

If you think you already understand how someone else feels or what they are trying to say, it is a delusion. … There is always more to learn. (Stone et al., 2009, p. 170)

Worried about silences? Think about them as waiting; it can make a difference in our comfort level.

The Ultimate Question: Is “Exploring” an Evidence-Based Practice?

See Zolnierek and DiMatteo (2009) to learn more.


  1. During my first conversation with new patients, I can recognize the “conversational crossroad” when it approaches.

Almost always         Sometimes        Not Sure

  1. I am comfortable using a self-assessment to explore a patient’s experiences living with hearing loss.

Almost always         Sometimes               I haven’t tried this approach

  1. I am generally comfortable using open-ended questions.

Almost always         Sometimes               Not usually

  1. By the end of an appointment with new patients, I have learned something unique about them.

Almost always         Sometimes               Not usually

  1. I can explain why Patient-Centered Care is an evidence-based practice.

Yes      Still working on it


References:

Newman, C., & Weinstein, B. (1988). The Hearing Handicap Inventory for the Elderly as a measure of hearing aid benefit. Ear and Hearing, 9(2), 81-85.

Stewart, M., Brown, J.B., Weston, W.W., McWhinney, I.R., McWilliams, C.L., & Freeman, T.R. (2014). Patient centered medicine: Transforming the clinical method (3rd ed.). London: Radcliff Publishing.

Stone, D., Patton, B, & Heen, S. (2009). Difficult conversations: How to discuss what matters most. NY: Viking.

van Dulman, S. (2003). Patient-centeredness. Patient Education and Counseling, 51, 195-196.

Zolnierek, K.B., & DiMatteo, M.R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47, 826–834.

Audiology Counseling and Patient-Centered Care, Part I: Introduction

Kris English, PhD

The University of Akron/NOAC

ke3@uakron.edu

 

In 2001, the Institute of Medicine recommended six goals to improve health care, by taking steps to ensure that health care is:

  • Safe: avoiding injuries to patients from the care that is intended to help them.
  • Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
  • Patient-centered: providing care that is respectful of and responsive to in­dividual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
  • Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
  • Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
  • Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Patient-centeredness is especially relevant to this web forum, since it assumes a set of therapeutic skills in interpersonal communication.  But although the IOM provides this working definition, the following concerns can be found in health care literature:

“Patient-centered care (PCC) is a poorly conceptualized phenomenon and can indicate anything from soothing room design, emotional support of patients, customization of meals, to support of patient decision making. This inconsistency across the clinical and research literature makes the application of PCC difficult” (Hobbs, 2009, p. 52).

“The term person-centered care (PCC) has been frequently used in the literature, but there is no consensus about its meaning” (Morgan & Yoder, 2012, p. 6).

“A clear definition is lacking” (Rathert et al., 2012, p. 351).

“The implementation of PCC has been hampered by the lack of a clear definition and method of measurement (Robinson et al., 2009, p. 600).

“We still don’t know how to do [PCC] or how to teach it” (Cassel, 2013, p. xii).

A bit alarming! However, since 1995, patient-centeredness has been expertly addressed by Stewart et al. (mostly recently in 2014), and in my humble opinion, their text serves as a gold standard: not only do they clearly and comprehensively define patient-centeredness, but they also show the reader “how to do it” and “how to teach it.”

To date, patient-centered care (PCC) has been only indirectly addressed in audiology, likely resulting in the same problems with clarity mentioned above. However, clarity is needed now more than ever, as audiology strives to elevate its relevance in health care “beyond the audiogram” and “beyond technology” by returning, as many say, “back to our roots” as fully-rounded and value-added care providers. For our patients’ sakes and for our future as a helping profession, we must commit to and effectively practice evidence-based patient-centeredness.

This entry is the first in a 5-part series designed to compile what we know about PCC in audiology, as well as identify what we don’t know. The next four entries willl explore the concept of patient-centeredness in audiology practices, using Stewart et al.’s (2014) “interactive components” as a framework:

 

Exploring Heath, Disease and the Illness Experience 

  • Unique perceptions and experience of health (meaning and aspirations)
  • History, physical, lab
  • Dimensions of the illness experience (feelings, ideas, effects on function and expectations)

Understanding the Whole Person

  • The person (e.g., life history, personal and developmental issues)
  • The proximal context (e.g., family, employment, social support)
  • The distal context (e.g., cultural, community, ecosystem)

Finding Common Ground (July 2017)

  • Problems and priorities
  • Goals of treatment and/or management
  • Roles of patient and doctor (audiologist)

Enhancing the Patient-Clinician Relationship (August 2017)

  • Compassion and empathy
  • Power
  • Healing and hope
  • Self-awareness and practical wisdom
  • Transference and countertransference

Each module will include an informal self-assessment, plus encouragement to connect with a like-minded colleague to discuss, test out, and grow into new patient-centered practices.  A seemingly small change such as not describing the audiogram to every new patient merely out of habit tends to make us very uncomfortable. Support from colleagues can help us step out of our comfort zone.

Invitation: If the reader is interested in contributing to this topic, please send a note to the email address at the top of this page.

References:

Cassell, E.J. (2013). The nature of healing: The modern practice of medicine. New York: Oxford University Press.

Hobbs, J.L. (2009). A dimensional analysis of patient-centered care. Nursing Research, 58(1), 52-62.

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

Morgan, S., & Yoder, L.H. (2012). A concept analysis of patient-centered care. Journal of Holistic Nursing, 30(1), 6-15.

Rathert, C., Wyrwich, M.D., & Boren, S.A. (2012) Patient-centered care and outcomes: A systematic review of the literature. Medical Care Research and Review, 70(4), 351-379.

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

Stewart, M., Brown, J.B., Weston, W.W., McWhinney, I.R., McWilliams, C.L., & Freeman, T.R. (2014). Patient centered medicine: Transforming the clinical method (3rd ed.). London: Radcliff Publishing.

When Patients Look Away, Do We Keep Talking?

 

Kris English, PhD

The University of Akron/NOAC

We get so busy. We have much to accomplish in an appointment, slightly on auto-pilot but the conversation seems to be going well, and then …

 

…the patient (or parent) breaks eye contact. She looks at the floor, or her hands, or the door (no mystery what that likely means), or at nothing in particular. Do we notice? If we notice, do we pause? Or do we keep talking and ignore the nonverbal cue?

Patient and parent interactions seem so routine, it is easy to overlook the underlying dynamics, although medicine has studied them for years (Finset, 2016).  A starting point for audiology is the consideration of eye contact – a simple concept but not much discussed in our literature.  So let’s consider it now:

Question #1  How many times during an appointment does a patient or parent break eye contact? As a profession, we don’t know. As professionals, we probably have never noticed.

Question #2  Why do patients break eye contact? What does it mean when a patient looks away from our face, or withdraws from our joint attention on devices or forms? We can’t be sure, but the patient is probably thinking about/feeling something new. Perhaps he is trying to process what we are saying. Perhaps a wave of emotion has interrupted his ability to concentrate. Perhaps our conversation triggered a memory, a doubt, a worry, a question, a regret, a recognition of embarrassing-but-real vanity (Kajimura & Nomura, 2016).

Question #3  What do we do when a patient or parent looks away?  As members of Western culture, our instinct is likely to keep talking, because we are socialized to move the conversation forward and avoid awkward silences. And yet as we do so, we must realize that (1) we are wasting effort because the patient is not listening, and (2) we are missing a potential opportunity to help. At this moment, something weighs on this person’s mind and heart, and if allowed an extra moment, he may wish to share it. However, by forging ahead, we unwittingly violate a basic principle of patient-centered care. Continue reading

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. Continue reading

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.

References

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!

References

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.

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:

Slide1

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

When We Think “Adult Patient,” Do We Also Think “Family”?

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Whether we scan our bookshelves, review our folders, or – more likely – enter keywords in a search engine, we are likely to find the terms “family” and “hearing loss” almost exclusively associated with children and their parents. Interestingly, apart from a few exceptions (e.g., the National Council on Aging), adult patients with hearing loss are not immediately linked to the context of family. We have valuable information on the role of our adult patients’ communication partners (e.g., Preminger & Lind, 2012), but it seems important to point out that family means far more than communication. Historically, family has also meant moral, financial, and logistical support, “a feeling of belonging … honesty, trust and unconditional love.

Perhaps audiology has paid little attention to what it means to serve adult patients in a family context because we assume it is a “given.” However, some recent research indicates we should give this topic deeper consideration, and not take our practices for granted.

By “Family,” We Mean …45891913_s

Families are universal in all cultures, but definitions vary widely. A simple, popular, and inclusive definition is “two or more people who consider and define themselves as a family.” Another inclusive definition is “any group of intimates with a history and a future” (Ransom & Vandervoort, 1973). Biological and legal ties are traditional but not required. It is likely all readers know of someone who was “adopted” as a cousin or aunt or brother because of long-standing involvement and support that transcended simple friendship. To be “considered family” when not actually related is usually accepted as a high honor.

How Families Function Continue reading