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.

Violating Patient-Centered Care? Seriously?

This statement is not as radical as it sounds, and in fact is very basic. Consider the Institute of Medicine’s (2001) definition of patient-centered care:

care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. (p. 3)

As minor as it may seem, being “respectful of and responsive to” a patient’s nonverbal request for a pause may be the essence of patient-centeredness. With the simple act of breaking eye contact, the patient indicates she needs a moment, and may want to take the conversation in another direction. Moving forward as if that preference had not been communicated is, at the least, inconsistent with patient-centeredness.

When a Patient Looks Away … How to Respond?

count to ten!

  1. Slowly, silently count to 10 as the patient gathers her thoughts and reactions. When she re-establishes eye contact, she may decide to share her concerns. Pauses often precede disclosures which would not have been expressed otherwise (Eide et al., 2004).
  2. If the patient or parent does not regroup after counting to 10, we can interrupt the reverie with an invitation:
    • Were you reminded of something?
    • Your thoughts?
    • Is there something I missed?
  3. If the patient declines to elaborate, we should move forward but be vigilant re: potential issues later.

Final Question: “Waiting” sounds easy enough – Why point it out?

Easy doesn’t mean comfortable. Stivers et al. (2009) report that the gap between speaking turns averages around 250 ms, and that silences longer than 2 seconds are relatively rare. We may have been socialized to perceive pauses as uncomfortable silence, and when we are uncomfortable, we tend to choose avoidance. However, Bartels et al. (2016) can help us reframe this learned response by viewing pauses as connectional or invitational silences, a natural part of the “musicality of language” (p. 1584). A pause of 10 seconds could cause us genuine distress, but it also actively focuses us on the patient as the center of our care. And with practice, distress lessens/confidence increases as we experience the value of waiting.

Patient-Centered Audiologic Practices

We currently lack a definitive application of patient-centeredness in audiologic care. As with all changes, small steps are more likely to be successful, and “learning to wait” for patients as they look away is perhaps the smallest step possible. At the end of the day, we have to ask ourselves if “waiting is worth doing,” and the answer is yes. Unlike a social conversation or an informal chat, our interactions with patients (including silences) should be at least as therapeutic as our assessments and technological treatments.

References

Bartels, F., Rodenback, R., Cieskinski, K., Gramling, R., Kiscella, K., & Epstein, R. (2016). Eloquent silences: A musical and lexical analysis of conversation between oncologists and their patients. Patient Education and Counseling, 99, 1584-1594.

Eide, H., Quera, V., & Finset, A. (2004). Sequential patterns of physician-patient dialogue surrounding cancer patients’ expressions of concern and worry. Social Science & Medicine, 59, 145-155.

Finset, A. (2016). Silence is golden. Patient Education and Counseling, 99, 1545-1546.

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

Kajimura, S., & Nomura, M. (2016). When we cannot speak: Eye contact disrupts resources available to cognitive control processes during verb generation. Cognition, 157, 352–357.

Stivers, T. et al. (2009). Universals and cultural variation in turn-taking in conversation. PNAS, 106(26), 10587-10592.

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

Ear to the Ground: The Value of a Patient’s Story

sundarGirija_audGiri Sundar, MPhil/PhD

Osborne College of Audiology Director, Distance Education

Salus University

As a clinical audiologist for over 25 years, I have encountered numerous people with hearing loss, only to conclude that this is not a homogeneous group. What differentiates each patient is his or her unique story; fortunately for us, if we allow the story to unfold, we will learn how to help. Here is an example:

One of my patients described a get-together in the family. He has three children and five grandchildren. They had all arrived from different parts of the northeast, and he had not seen them together in some time. Once the entire clan was in the dining room, everything (chairs, cutlery, plates, people, mouths) was in constant motion. The dining table was the only thing that did not move.

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My patient’s eyes could not quite keep up with the pace of activity; dependent on the visible word, his social encounters were manageable when limited to roomful of one or two people, and he’d developed his own strategies to cope with his hearing loss in simple listening conditions. But too many people in one room with the scattered sources of sounds left him unnerved.

Sounds blended together in a din and he retreated into the sanctuary of his study, leaving his dinner unfinished. He could not tolerate the blurring of words; he could not participate or even spectate. The very people he loved seemed insufferable and tiresome. His retreat, however, was misconstrued by his grown children and created quite a bit of tension in the following days. His wife’s observation of the possibility of hearing loss being at the root of this behavior allowed the rest of the family member to somewhat understand this gentleman, and upon his daughter’s insistence he decided to seek some help.

He was quite forthright when I asked him what made him see an audiologist at this particular time. Although in the beginning he only wanted a hearing test, routine questions regarding his communication difficulties brought his real story: he felt an alienation from his family.

He often had to imagine what they might be saying. “No one wants to listen or take the time to listen. Going out with people you comfortably socialized with has become something of an ordeal…it is claustrophobic; when you are in the middle of a group of people and cannot participate in the conversation, it is as though the people around you suffocate you. You know what I mean?”

I asked him if he wanted hearing aids. He did not: he only wanted to know if he had bad hearing loss. The answer told me my patient did not yet realize himself that the issue was his hearing problem (unique to him and his life), not his hearing loss. Because I understood his story, I could help him make the connection between his hearing loss and the alienation that had been hurting him so much.

 

The Most Important Instrument in Audiology

Kris English, Ph.D.Kris English, PhD

The University of Akron

From 1999-2009, I had the opportunity to teach an online course in counseling for audiologists earning an AuD through the Central Michigan University/Bill Wilkerson Center Vanderbilt University distance education program. It will seem hard to believe now, but when the AuD program started, many enrollees had little experience with email, so to get the ball rolling, the first assignment was to complete the Keirsey temperament questionnaire and email me the results (Rational, Artisan, Idealist, or Guardian).  My two goals were to jump-start the “know thyself” process and to help students become familiar with my email address.  I wasn’t looking for any trends, but … take a look (updated September 2016):

graphTen years and 25 semesters later, with results from 390 audiologists (all with MA degrees and an average of 15 years experience), the summative data show a very strong tendency toward Guardian temperaments (82% in the middle bar, compared to 40% in the general population on the left). Since then, I have posed the same assignment to AuD graduate students (from 2008 to 2016, right hand bar), and have also frequently asked attendees at workshops to spend 10 minutes on this exercise, with very similar results. For instance, among 27 practitioners in a recent workshop, our results were 0% Rationals, 18% Artisans, 15% Idealists, and 67% Guardians.

“Knowing Thyself” Stimulated Change   Continue reading

Gradual Hearing Loss and Sensemaking

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Recently, a friend described how her grown son currently chooses to be homeless. She doesn’t know how to find him, and doesn’t know how he manages. Needless to say, she is worried sick. Looking back, she now recognizes the early signs of mental health problems during his teen years, but at the time, she didn’t recognize them as such. After all, it’s not unusual for teens to be rebellious, non-communicative, disorganized, or moody. As any parent would, she applied what she knew in general about adolescence to make sense of her son’s decisions and actions; only when her explanations no longer made sense (this is not how teens typically act) did she feel ready to consider broader, more complicated explanations and seek help. The diagnosis of mental health problems was a first step toward making sense of a profoundly unfamiliar situation.

Most adults approach life’s uncertainties in the same way: we experience something we don’t fully understand and start by working through “what we know.” Our car makes a funny noise so we look under the hood. We notice a new ache or pain, and make changes in our diet or environment (maybe more exercise?). Our computer freezes so we turn it off, count to ten, and turn it back on. In doing so, we are applying the sensemaking process, which helps us understand a change or shift in our world. If that process fails us, we consider taking the next step of asking someone for help.

Although much of audiologic counseling focuses on emotional and psychological reactions to hearing loss, our patients of course are also decision-making individuals whose minds seek logic, facts, and answers that make sense. Here we will consider how the sensemaking process applies to our patients as they ask for our help.

It Might Look Like Denial

Sensemaking in health literature is often applied to the diagnosis of a life-altering disease or disability (e.g., Pakenham, 2008), as in “why is this happening to me?” and “what will become of me?” Acquired hearing loss is certainly a life-altering condition, and both patients and audiologists attempt to make sense of it. We understand our role: in our initial encounter with a new patient, we begin with the query, “What brings you here today?” to help us understand the patient’s concerns, and then we test. However, we may not understand that the patient is also striving to make sense of this appointment. For many patients, a gradual hearing loss does not yet make sense, as reflected in these remarks:

  • My family says I can’t hear them – but that can’t be true because I definitely hear them complain!
  • People speak too fast these days.
  • It’s not my hearing, it’s the background music on TV that’s the problem.
  • How can anyone be expected to hear in such noisy restaurants? They used to be quieter.

Gill et al. (2010) describe these types of comments as “candidate explanations,” offered to convey a patient’s efforts to make sense of the situation. However, we may be inclined to interpret these comments as denial (or stubborness, embarrassment, suspicion) instead of reasonable efforts to understand a problem based on what the patient currently knows: that one’s hearing seems to be generally adequate.

What patients don’t yet know is their actual hearing status. How we go about informing them can support the sensemaking process.

Do We Inadvertently Impede the Sensemaking Process?

 Knowing that many patients are trying to make sense of our time together, we have to ask ourselves if we help or hinder that process. Consider the information that we collect but do not share with patients until our testing is done:

  • During pure tone tests, patients have no idea of the intensity required to define their thresholds. Whether it was 20 or 70dB, as far as they know, it was soft and therefore assumed to be “good” hearing.skeptical copy
  • During word recognition tests, patients receive no feedback about the words they misheard, and are often shocked to be told they missed any at all.
  • During speech-in-noise tests, patients recognize at some point that the noise is a problem, but they don’t know that their abilities may be far from normal.

Their hearing concerns now make sense to us, but so far the patient has been kept in the dark. When we do convey test results, we must understand why some patients will still be skeptical, challenging, or confused. Our summary can be quite inconsistent with what makes sense to them (that they can hear fairly well). Can we do better?

Sensemaking as a Social Process Continue reading