“Can I Just Give You a Hug?”

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Anna Hollingdale, MSc, is an Audiologist in West Sussex, England. She recently touched base after an audiologic counseling course at the Ear Foundation in Nottingham with the following patient encounter:

Recently, a 73-year old female came to see me for a fine tune. The patient’s initial complaints were ones, as Audiologists, we hear often: “I cannot hear in noise” or “I am struggling to communicate with others.” It would have been so easy for me to quickly do a fine tune, or respond with the ‘limitations of hearing aids’ script but instead, I listened…

meSoon I learned she has a busy social life and takes part in many activities, but having the hearing loss had started to affect all this. This patient has been coming to our clinic for over a year and had never had the chance to really speak about how the hearing loss was affecting her.

Once she had finished talking, I responded by reflecting what I heard, without adding any solutions: “It seems you are having a really hard time with this, it must be really tough for you.” This “invitation” then enabled the patient to open up even more, and share that she had been avoiding social events and was always looking for ways to cover up her difficulties. The hearing loss was significantly affecting her life and relationships with others. Notably, she did not ask for any answers. All this patient needed was for someone to listen and empathise with her.

At the end of the appointment the patient stood up and said, “Can I just give you a hug?”

I think this says a lot more than any words could!

long road

Another Dimension to Patient Journey: Traveling Together, We Go Farther

The Ida Institute encourages audiologists to consider a “journey” metaphor to better understand the patient experience. A patient’s entry into audiologic care is not an abrupt event, but rather is preceded by several influential experiences. We are charged to sort out those experiences, usually with a question such as “What brings you here today?”

The patient will relay salient facts, an important part of the journey — but not the only part. To date, the journey has also likely been lonely, stressful, confusing. If we fail to inquire about these concerns, the patient may fairly wonder if we even care. Without an indication that the audiologist is personally invested, the prospect of moving forward with no apparent  emotional support may seem daunting and unappealing. Consider, for example, a recent study that found a low degree of adherence to hearing aid recommendations when audiologists dominated the conversation discussing technology (Grenness et al., 2015). Our challenge is to convey with our counseling skills that we are not just watching from the curb as patients travel past, left to their own devices. Rathr, we are committed to travel this journey with them.

The Ultimate Confirmation

It seems safe to say that being asked to give a hug is the ultimate confirmation of patient trust. Patients may initially resist hearing help, and therefore resist us, but if we can mindfully travel with them, help them drop their guard, consider change, and know we care, the subsequent relief can be tremendous! When a patient feels words alone will not convey that relief, and instead asks for permission to enter our personal space, trusting that  our answer will be YES, she has made an important break-though.

Most patients don’t ask for a hug, but they all ask, somehow or other, for our attention and support.

Reference

Grenness, C., Hickson, L., Laplante-Levesque, A., Meyer, C., & Davidson, B. (2015). The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations.  Journal of American Academy of Audiology, 26, 36-50.

 

Patient Care 365 Days a Year

Screen Shot 2016-05-10 at 10.07.36 AMDevon Weist, AuD

Audiology Clinical Instructor, Externship Coordinator

The University of South Florida

As 2014 comes to a close, I find myself a little overwhelmed with the holiday bustle and those pesky year-end tasks we tend to put off until the last moment.  This past week, I woke up one morning with the intention of getting to my office early to finish grading exams and papers from my third year AuD students. I was anxious to get this task completed because I knew I had a full clinic schedule the following day. As I just finished grading my first couple exams, another clinical instructor popped into my office holding a very sad looking ITE aid.

The Best-Laid Plans

She explained that an older gentleman had just shown up at the front desk. He mentioned coming to our clinic in the past and appeared to not only be having difficulty hearing, but also seeing.  He thankfully was with his teenage grandson, but was clearly struggling with both senses we often take for granted.  He told my colleague he had broken off the switch and couldn’t turn the hearing aid on.

My colleague normally works with cochlear implants, so she wanted to make sure she wasn’t missing anything during her troubleshooting.  She and I checked the aid and discovered it was an old analog, trim pot hearing aid.  The brand and serial number were not legible, likely from years of use.

We also discovered this gentleman had not been into the clinic since 2000, so we no longer had his records.  We both grumbled to each other about the patient waiting until a few days before the Christmas holiday to seek help.  She then met with the older man and told him that due to the age of the hearing aid, it was unlikely it could be repaired and if it could, the cost would be significant due to the age.

He then began to tell her he would have to save up little by little to make the repair costs, and it would likely take him a great deal of time to save for a new hearing aid. As the conversation progressed my instincts and looming paperwork made me think at this point we couldn’t do anything further and could schedule him for an appointment after the holidays to discuss financing and options.

Suddenly a Solutionaha

Just as it looked like he would be returning after the holidays, our audiology assistant reminded us of a donated hearing aid we had in the cabinet.   A few weeks back, the family of a patient who had recently passed away sent us the aid and a note asking to please donate the aid to someone in need.  My grinch-like tendencies quickly remembered the reason and responsibility we have to those who seek our services.

In short, we were able to fit the patient with a much newer, higher quality working hearing aid.  We also learned during the time we spent testing his hearing that his wife had passed away several months ago, his daughter and grandson recently began living with him, and he was battling the effects of diabetes which include the deterioration of his vision.  He was able to set up a payment plan for a new earmold and office visit fees, but more importantly left the clinic hearing, smiling, and for the first time in a long while able to carry on a conversation with his grandson.

While this unexpected patient didn’t allow me to finish those grades like I had planned, he fortuitously reminded me of the value we serve to patients each and every day.  We each take an oath when we receive our white coats that states, “I will act to the benefit of those needing care, striving to see that none go untreated.” (Steiger, Saccone, & Freeman, 2002).  If we had told the patient to come back after the holidays, we wouldn’t really have honored this oath.

This Year and Every Year2015 happy new year

Our profession has long realized that the patient’s encounter is the centerpiece for patient-centered care (American Academy of Audiology, 2004). Patient-centered care is not about making a sale or fitting patients into a neat and tidy schedule.  It means making a commitment to serving your patients’ needs even when they don’t have a “scheduled” appointment.

Experiencing the emotional joy that occurs when a patient is given the ability to hear is one of the main reasons we as audiologists love our profession.  It is also equally fulfilling to see family members’ emotional joy when they are able to re-connect with a loved one who can now hear.  Seeing this gentleman and his grandson have a conversation together and the smile on both their faces more than makes up for spending an extra hour in my office grading papers.  It is important to remember that every patient has a story and a journey in regards to their hearing loss, and we as audiologists have a responsibility to provide them care that is patient-centered, no matter what day of the year it is!

References

American Academy of Audiology.  (2004).  Audiology: Scope of practice.  Available at  www.audiology.org/resources/documentlibrary/Pages/ScopeofPractice.aspx

Steiger J., Saccone P., & Freeman B. (2002).  A proposed doctoral oath for audiologists.  Audiology Today, 12(5), 12-14.

 

The “Real” Tinnitus Story: Lessons Learned About True Patient-Centered Care

IMG_3261Peter Huchinson, Class of 2016

The University of South Florida

 

When I hear the word tinnitus, my eyes widen and endorphins race to my brain. Ringing in the ears—one of the most common issues associated with any type of hearing loss— is the topic of research for my doctoral project. When I hear the words ringing, buzzing, whooshing, or pulsing my hyper focus kicks in and I say to myself “this is my thing”. I have read article after article discussing statistics about who tinnitus affects, what might be the cause of this debilitating ringing, how it is measured in humans and animals, and the general lack of understanding in this subject. So when I found myself face to face with a patient who was so deeply disturbed by her tinnitus, that she was willing to request a nerve section, I realized that I did not know that much at all. What I realized that I lacked, was personal connection, empathy, and the counseling ability that I knew was going to be crucial to this case. Additionally, I realized how much I did not know regarding tinnitus and management in a clinical population. I learned two important lessons with this patient; the first being serving the patient and not just the condition. The second being that sometimes there are things that are simply out of my control and my scope of knowledge.

tinnitusProviding patient-centered care is something that sounds appealing and makes logical sense, but often I find difficult to practice. When I see a moderate, sloping, high frequency hearing loss, I think about the hearing aid I will recommend at the end of the appointment. When a patient complains of dizziness upon getting out of bed, I consider BPPV. These initial thoughts are natural, and there is nothing wrong to start thinking about the issue at hand and the recommendation that I will make. The problem is that I often find myself stopping there. I forget to consider the needs and desires of that particular patient. I forget to consider the patient’s activity limitations, participation restrictions, and perceived or experienced stigma. I forget to consider the emotional journey that the patient has been on for much longer than the last 30 minutes that they have been in my sound booth.

I realized that I needed to practice better patient-centered care the day I first met the patient with the debilitating tinnitus. Tears poured from her eyes the entire appointment. I tried to offer knowledge, suggestions, and recommendations, but the tears would not stop. Upon reflecting on this appointment, I realized that I tried to provide informational counseling, when what she needed was emotional counseling. I tried to suggest technology and rehabilitation programs without developing a common ground with the patient.

“At the end of the day, patients are autonomous beings, and they decide whether to follow our recommendations. Those decisions depend heavily on the partnerships we develop via counseling. And this approach is an evidence-based practice. Finding common ground has been shown to be a key to a successful clinical outcome. (Brown, Weston, & Stewart, 2003)” (Clark & English, 2014)

It did not matter what I suggested at the moment. At the moment, my patient wanted support counseling. She wanted to know that we haven’t reached the end of the road. She wanted to know that the people she was looking to for help understood what she was going through, and that we weren’t going to just give up. She wanted to start a relationship of complete care and trust, instead of a regiment.

A different issue that I encountered was including and counseling this patient’s husband. Counseling loved ones is something that my (lack of) experience has not afforded me yet. The husband, while being caring and defensive for his wife, tried time and time again to get information out of me that I was not confident to or capable of answering. “What is causing this? What is the likelihood of it getting better? Why are you passing us off to the physician? Why won’t you give us answers?” This reminded me that counseling the communication partners, as well as the patient, is an equally important activity. I had not appropriately devoted time to helping the husband understand my role in the process. He heard my suggestions for technology and other options, but he had not heard me validate his or his wife’s personal journeys.

The other lesson that I learned was that sometimes there will be cases that are out of my ability to handle or out of my scope of knowledge. When the husband pressured me for medical advice I had to be careful regarding what information I could offer. It was a situation that I had never been presented with before, and it made me realize that I need to be prepared to refer a patient when their issues are beyond my ability to help. I think that much of this tension could have been avoided by developing a more trusting relationship through better patient centered care.insight

Regardless of what happened during the appointment, I am thankful for the learning opportunity that this patient and her husband offered me, as a growing clinician. I learned the importance of listening to the patient’s journey and experience, and I learned that I need to know when I am no longer capable of providing adequate care and when to refer. I hope that every student and young clinician has an experience where they feel uncomfortable, unprepared, and less than qualified. These are the experiences which transform us from mere button-pushers and technology experts into the exceptional clinicians that our patients deserve.

Reference

Clark, J. G., & English, K. M. (2014). Counseling-infused audiologic care. Upper Saddle River, NJ: Pearson Education, Inc.

 

 

“All I Did Was Listen”

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Matt White is an audiologist in the UK National Health System, and works in Doncaster in South Yorkshire, England. He recently participated in a counseling course at the Ear Foundation in Nottingham, wherein he described the following patient encounter:

photo

Matt White, BSc (Hons) Aud

My patient was a man in his late 70′s who has had a rubbish time over recent years. Multiple organs are in failure, one kidney has also been removed for cancer treatment and he’s had other cancer issues too as well as issues like pancreatitis. His mobility is greatly compromised and he carries a “do not resuscitate” order with him as his physicians have told him that the efforts required to resuscitate him are likely to kill him, but in a much more horrible way than just going. He told me that his family is already grieving him in advance and he just can’t wait to be with his wife again, who passed away a few years ago.

I wasn’t sure at first what type of person he was going to be, some elderly people that I see in this condition have given up and just want to die. Others, like this gent are very positive and just want to get what they can out of the time they have left. This chap, for example, was off to get his cataracts done under local anaesthetic so he can see better. He talked about seeing the faces of his great-grandchildren more clearly. He talked about all this while explaining that he just wanted to hear as well as he could, which I was able to improve for him in the appt. Explaining all the non-hearing related parts of his life this seemed to help him.

All I did was listen.

listen-guitar-island

“All I Did” … But It’s Actually a Lot!

Audiologists almost inevitably downplay their supportive role as listeners, not from false modesty but because little has been said about the skills involved. These skills come easily to a few, but can be a genuine challenge to many others. Happily, they can be learned. As with any skill, it helps to break it down into steps. Consider the following steps that might occur as an audiologist meets a patient:

  • As we prepare our own work, we keep alert for expressions of patient troubles, sometimes only indicated nonverbally or “between the lines.”
  • When we perceive our patient is a “troubled sender” (Pollack et al., 2007), we consciously decide to “stop all the clocks” (W.H.Auden, 1937), re-prioritize, and put our agenda to the side.
  • In doing so, we put the patient’s needs before our own tasks. Needless to say, easier said than done! It takes an act of selflessness to suspend our natural self-absorption (Nichols, 1995).
  • We create an emotionally safe place and time for the patient to express those concerns and offer our support.
  • We sustain undivided attention and focus. We do not day dream and wait it out.
  • We consider whether follow up is warranted (referrals, e.g.), or whether the patient just needed to make a human connection.
  • We willingly choose to open ourselves to another’s distress and share pain for a brief time.
  • And then, when it seems appropriate, we find a way to transition the conversation back to the appointment, and manipulate the remaining time available to complete the “business” portion of the appointment and keep everyone on schedule.

Mastering each of these steps requires training, practice and feedback.

Learning to Mask is Hard. Learning to Listen? Much Harder!

Brownell (1996) once posed the question, Does listening require conscious effort? He answered his own question with a resounding YES.

Although individuals can hear when they are passive, effective listening is active and mindful” (p. 55).

Someday we will find a more meaningful way to say, “All I did was listen.”   When our listening is exactly what the patient needed, and when it was a conscious decision on our part, and when the patient leaves feeling better than when he arrived, “just listening” isn’t “just” anything but in fact becomes the epitome of patient-centered care. Listening is an advanced clinical skill, always worth developing and considered by many to be a life-long learning process. When students modestly describe a successful “listening moment” as accidental, let’s be sure to articulate the sophisticated skills they employed, and the value of these skills.

References

Brownell, J. (1996). Listening: Attitudes, principles and skills. Needham Heights, MA: Allyn & Bacon.

Nichols, M. (1995). The lost art of listening. NY: Guildford Press.

Pollak, K.I., Arnold, R.M., Jeffreys, A.S., Alexander, S.C., Olsen, M.K., Abernethy, S.P., et. al. (2007). Oncologist communication about emotion during visits with patients with advanced cancer. Journal of Clinical Oncology, 25(36), 5748-5752.

 

Counseling Thyself: “Did I Really Say That?”

Jane FLJane Seaton

Seaton Consultants, Athens GA

 

A few years into my career as an educational audiologist, I was shocked to hear a mother whose child I had seen at 10 months of age tell a parent group how devastated she was to hear the audiologist say that her daughter would never talk. Assuming (incorrectly as it turned out) I was that audiologist, I was appalled to think I would have said anything that could possibly be interpreted this way. Reflecting back on my reaction then, I now realize how often our comments can be taken out of context or misinterpreted in stressful situations such as when parents first learn of their child’s hearing loss.

What Was Said / What Was Heard

Margolis (2004) reported approximately half of new information is forgotten immediately, and half of unfamiliar information is remembered incorrectly. Add in the increasing cultural diversity and non-native English speakers being seeing in all audiologic practice settings, and we have the perfect recipe for miscommunication.

It has been well documented that most children with congenital hearing loss are born to parents with typical hearing, and the vast majority of these parents have little or no prior exposure to or experience with deafness. To say that identification of hearing loss through the universal newborn hearing screening process is often unexpected, shocking and stressful for new parents is a huge understatement. In our eagerness to help families access state-of-the-art technology and services as quickly as possible, we may unintentionally compound parent confusion and stress by providing lots of new information in a short period of time at the end of a diagnostic appointment. Too frequently little time is left for questions or feedback concerning what parents have heard from the audiologist.

Reducing Misunderstandings

Parents report they need for us to take time to listen to them and encourage them to ask questions (Luterman and Kurtzer-White, 1999). However, when the diagnosis of hearing loss is unexpected, some parents may not feel emotionally ready or knowledgeable enough to ask questions until they’ve had time to process what has been heard. It can be helpful to encourage parents and caregivers to let you know how they are feeling prior to, during and after their initial diagnostic appointment. Asking a parent what they will tell a spouse or other family member about our results and recommendations is a strategy that can help us know what has been heard and what information needs repeating or re-explaining in nontechnical terms. Use of an interpreter for non-native English speakers can be helpful, but this also adds another link in the communication process where misunderstandings can occur (Alberg, 2003).

Helping parents clarify their “next step” (e.g. scheduling another appointment, talking with pediatrician, contacting their early intervention service coordinator) facilitates parent empowerment and should be automatic each time a family is seen. Providing names, job descriptions and reasons why other professionals in the EHDI and/or education systems may be contacting parents can lessen some of the confusion felt by families when starting their journey with hearing loss. I’ve often found that parents appreciate a brief phone call 2-3 days after we’ve met to find out how they’re doing and answer any questions, even when we have a follow-up appointment scheduled later.

reflectionsAudiologists as Reflective Practitioners

I admit I was relieved to find out that I wasn’t the audiologist being referred to in the situation described above, but I often wonder how many times misunderstandings have occurred without my realizing it. Donald Schöen described the need for reflective practice more than 30 years ago, and it is probably more valuable than ever today (Scaife, 2010). Now that a wealth of information is available instantly from a variety of sources, the value of taking time to listen to ourselves as well as our clients and their caregivers is immeasurable.

References

Alberg, J. (2003). BEGINNINGS serves families with diverse needs. Volta Voices, 1, 15-17.

Luterman, D. & Kurtzer-White, E. (1999). Identifying hearing loss: Parents’ needs. American Journal of Audiology, 8, 13-18.

Margolis, R. (2004). Audiology information counseling: What do patients remember? Audiology Today, 16, 14-15.

Scaife, J. (2010). Supervising the reflective practitioner: An essential guide to theory and practice. London: Routledge.

When 1 on 1 Just Isn’t Enough …

photoChelsea Twyman, Class of 2016

Kent State University/NOAC

When audiologists and patients discuss amplification, the topic of realistic expectations must be carefully discussed. This discussion lets the patient know that adjusting to amplification will take time, patience and effort, and that struggles might occur along the way.  Some patients have minor challenges that we can readily solve with programming adjustments.  Most patients can also acquire new communication and coping strategies, especially if we remember to provide that support.  However, how can we help patients who still struggle with the following challenges after their month-long hearing aid trial?

  • Not advancing to appropriate amplification target/not obtaining enough benefit;
  • Not tolerating high frequency input/not improving speech clarity;
  • Daily HA maintenance and/or using hearing assistive technology (HAT);
  • Psychosocial distress (perceived HA benefit but burdened by cosmetics, stigma, etc.);
  • The hard work of adjustment outweighing perceived benefit.

Patients struggling with these challenges could benefit from group support, defined by Katz and Bender (1976) as “voluntary small group structures for mutual aid in the accomplishment of a specific purpose…usually formed by peers who have come together for mutual assistance in satisfying a common need, overcoming a common handicap or life disrupting problem, and bringing about desired social and/or personal change” (cited by Solomon, 2004, p. 393).

Support groups can help not only patients but also their communication partners, since they too are directly affected:

Brooks et al (2001) described frequent misunderstandings and resulting frustrations in couples in whom one member had a hearing loss. Piercy and Piercy (2002) reported that limited communication can negatively affect a couple’s intimate relationship. Most recently, Scarinci et al (2008) noted a broad range of effects that hearing loss had on the SPs [spouses] in their everyday lives. They noted difficulties in carrying out normal conversations, effects on the SPs’ emotions such as frustration or embarrassment, limitations in their social lives, and increased tensions in their marital relationships. (Preminger & Meeks, 2010, p. 316)

These studies highlight the importance of including both patients and their communication partners in a support group, specifically a group aural rehabilitation program.

10872735_sRecently, I attended a support group for patients with cochlear implants (CI) and their significant others.  The patients at this support group all had difficulty with two or more of the categories discussed above.  Usually, this support group splits into two subgroups — one for CI users and one for their communication partners, to chat separately before coming together near the end of the session.  On the day I visited, attendance was small due to the weather, so the group stayed together the entire meeting. Continue reading

Trust, Catharsis, Change

PicsArt_1397486111881Chanel Rogers, Class of 2017

Kent State University/NOAC

This past February I had the opportunity to be involved in a hearing screening at a senior health center. I never imagined a hearing screening would provide me with as great of a life lesson as it did. I had the pleasure of meeting and screening a woman (“Ms. B”) who was around 65 years old. She reported interest in our screening program because she had been experiencing difficulties in many areas of life that require hearing, such as not following what was being said in one-on-one conversations, contributing to conversations in a group setting, and understanding song lyrics while attending church.

With all of the many listening challenges that Ms. B had described, I expected her results from the hearing screen to show that she had at least a moderate hearing loss, but that was not the case. The results that I collected showed a mild hearing loss with no frequency tested being greater than 35 dB, but it affected her greatly on an everyday basis.

Earning Trust

My preceptor and I summarized our brief test, relating the results to the troubles that she had mentioned.  She seemed to feel safe with us, because she then began to recount not just other hearing problems and her family’s frustrations, but other health and safety concerns and their impact on the quality of her life.  The more she shared (“This is the first time I’ve said this out loud”), the more she seemed to understand her resistance to help (“As they say, denial is not just a river in Egypt”). I believe Ms. B started to trust us (English & Kasewurm, 2012) and her trust showed through the emotions that she shared.

Ms. B began to cry and as more information came out, a revelation occurred to her. We silently marveled as Ms. B moved herself out of the state of denial, into acceptance. By the end of the screening, she was ready to make an appointment to discuss the options available to her for amplification and other assistive technologies.

Catharsis and Change

When she felt ready to leave, Ms. B put on her coat and while tying her belt, she said with some surprise and relief, “I feel better!”  Later, we reflected on that comment, indicative of catharsis.  When given the opportunity (i.e., given time, respect, compassion), patients may feel ready to unburden themselves of worries and fears. Once these are shared with a receptive listener, the speaker does not feel alone and defensive, but instead feels understood and supported (Stone et al., 2010).  The subsequent emotional relief changes how we view change: perceived barriers are no longer insurmountable, and options can be considered.

In this experience, I learned a very important lesson that I will carry with me throughout all of my future years of practice. That lesson is that, no matter what the hearing loss looks like on paper, it can affect each individual differently. Before this day, I did not think a mild hearing loss would have such a great impact on someone’s everyday life as it did with Ms. B. She helped me see firsthand that being in the healthcare field requires us to be compassionate and empathetic to the issues that the patient faces and also that just because the patients are in to see for a particular reason, there may be something deep down that has been suppressed that may come to light with their time with us.

This day made me realize that it is true that we must treat the whole patient and not just the hearing loss, which is an essential mental note I will carry with me forever.

References

English, K., & Kasewurm, G. (2012). Audiology and patient trust. Audiology Today, 24(2), 33-38.

Stone, D., Patton, B., & Heen, S. (2010). Difficult conversations: How to discuss what matters most. NY: Viking.

Supporting the Unsteady: Counseling in Vestibular Rehabilitation

Thumbnail picSimon Howe, Clinical Scientist (Audiology)BSc (Hons), MSc

Audiology Department
Manchester Royal Infirmary

 

Rehabilitate (v): To restore to good health or useful life

As an Audiologist working for the National Health Service in the UK, it is my job to rehabilitate both patients with hearing loss and those with vestibular deficits. Whilst full recovery from vestibular deficits is likely, up to 2/3rds can become chronic, disabling conditions (Yardley & Luxon, 1994). As General Practitioners (GPs) tend only to refer those cases of dizziness persisting for months for a specialist opinion, the majority of patients seen in our Vestibular Rehabilitation Clinic at the Manchester Royal Infirmary have developed chronic dizziness, present for many months or years.

Many patients experiencing an acquired loss of vestibular function will recover fully without the need for any therapeutic intervention. So what causes some patients’ vestibular deficit to become a chronic balance problem? Firstly, the long-term prescription of vestibular sedatives by GPs is commonplace, and inhibits the natural process of recovery, and secondly, the natural behaviour for motion-provoked or situation-specific dizziness is to avoid the movements or environments which elicit the symptoms, again hampering recovery. Often these avoidance strategies can result in almost phobic thoughts related to these triggers of the dizziness.

Exercise-based vestibular rehabilitation is the primary therapeutic approach for such patients, focusing on promoting central compensation for the acquired vestibular deficit. The application and benefits of vestibular rehabilitation are well documented (Hillier & McDonnell, 2011). However the more I work with patients with chronic balance problems, the more I find myself increasingly perplexed by their unpredictable prognosis. Three things strike me as unexplained:

  1. Some patients struggle to make any meaningful progress with vestibular rehabilitation, despite apparently adhering to their exercise programme.
  2. The time taken for patients to recover seems to be completely independent of the degree of vestibular deficit.
  3. Attendance at rehabilitation appointments and adherence to exercise programmes is inconsistent, even if the patient’s difficulties would appear to act as sufficient motivation.

Reassuringly, it appears I am not alone in seeing this variability (Herdman et al, 2012), therefore there are clearly other factors at play which are influencing recovery. But there is a piece missing from the puzzle; something still unaccounted for in all the research thus far.

The Missing Piece

Chronic balance disorders can be functionally limiting conditions because of our reliance on balance to fulfil the most basic of personal, household, and occupational responsibilities. Difficulties in performing these tasks can increase dependence on family and friends, and can place strain on relationships. Where such a support network is not readily available, the resulting social isolation can have profound emotional effects. Reduced activity levels can also lead to an increased incidence of co-morbid conditions which can in turn exacerbate the psychological impact. Some chronic balance disorders can also be unpredictable in the frequency and severity of their presentation and this can further increase emotional stress.

So here is the paradox, the missing piece: this inter-relationship between dizziness and emotion is well recognised and documented (Yardley, 1994), and yet there is a very poor correlation between patient and clinician ratings of dizziness severity (Honrubia et al, 1996).

In many ways this poor correlation is not unlike the mismatch we might see in Aural Rehabilitation between the hearing difficulties the clinician might predict from a patient’s audiogram and their self-perceived disability. In fact hearing loss and loss of vestibular function are not dissimilar. Difficulties are often specific to certain activities or situations and can therefore cause a change in self-concept; the functional capabilities of the patient have changed and this can have a profound effect on their feeling of self-worth.

Understanding Continue reading

Mistakes I’ve Made: Assumptions

eileen-rallEileen Rall, AuD

Children’s Hospital of Philadelphia

So why am I sharing with you some of the mistakes I’ve made along the way? Usually when I am sharing “life lessons” with my daughters or my students, I am trying to give them the opportunity to learn from my stumbles so they don’t have to experience them on their own. One of the most important skills we can have as professionals (and as human beings) is the ability to recognize when we can do something better or even more importantly, when we do something wrong. Maya Angelou’s quote, “When you know better, you do better” is something I try to live by every day.  This philosophy is one of the reasons why I love where I work. At CHOP, we are constantly re-evaluating our clinical practice to identify areas where we can be better – what a humbling and yet exciting place to be. To do that well, you have to practice reflectively (Schön, 1983; Thompson, 2008) and be ready to say that the things we do every day can be better.

One of the areas that I feel I have grown the most in is my avoidance of making assumptions. When you first start out in this field, you are (as I was) unconsciously incompetent – you don’t know what you don’t know. I remember trying to soothe a parent’s anxiety when scheduling her child’s surgical procedure by telling her, “Don’t worry, it is a really simple procedure, they’ve done it thousands of times.”  I assumed that if she understood the routine nature of the surgery, her anxiety would vanish.  It did not; instead, she very sternly said to me “Don’t ever tell a parent that their child’s surgery is simple and ‘nothing to worry about.’ You clearly don’t know what it is like to be a parent.”  She was right, I didn’t know. I assumed that I could put myself in her place and comfort her; instead, I ended up offending her. Flash forward 8 years to me anxiously sitting outside the OR when my youngest was having this same “simple” procedure – it was the longest 14 minutes of my life and I would have bitten off anyone’s head who dared to tell how I should feel.

Assumption: All Swans Are White

Assumption: All Swans Are White

Sometimes we assume we know how someone will feel about information they receive. I was leading a lab in amplification.  We brought in a friend of mine who had clearly been suffering with hearing loss for a few years.  She was even evaluated by an audiologist the year before and hearing aids were recommended but not fit.  The students were responsible for doing a complete evaluation and then develop a treatment plan that would include amplification.  She did indeed have a hearing loss so the students launched into what hearing aid that they were going to get her instead of reviewing her test results. They assumed that, because she reported that she had been previously diagnosed with hearing loss and hearing aids were recommended, she understood her diagnosis. She did not. I watched her eyes glaze over as the students enthusiastically described the advanced-feature hearing aid they were going to order.

I interrupted their plan and asked the patient – do you have any questions? – and she responded, “Are they saying that I have a hearing loss?”  As smart and as previously well-counseled as she was, she thought that if she took enough allergy medicine before the test, her hearing loss would have gone away.  We assumed she knew – we didn’t realize what her truth was. Simply put, she was not ready for this conversation.

We Can’t Assume Readiness

Since “readiness” is a process involving stages of awareness, acceptance and adjustment, it is quite possible our patient is not yet ready, but “in process,” or as the Ida Institute describes it, in the midst of a patient journey.  We are not mind-readers; we need to ask “readiness” questions with the 0-10 scale or other tools to meet patients where they are – not where we think they are. Once the students developed the requisite common ground (Brown et al., 2003), my friend felt comfortable with their plan and is now a champion for using amplification, sharing her positive experience with anyone who will listen. That would have never happened if we continued with our assumptions and didn’t address her questions.

I recently had to share some difficult information AND generate ideas for a new opportunity at a team meeting. My assumption, and how I ended up making an ass out of me (not U), was that everyone at the meeting came with the same information. BIG MISTAKE.  The result of the meeting was elevated negative emotions, hurt feelings, significant anger with me and hardly any enthusiasm for the opportunity I hoped to move forward on. As a team leader, I needed to take a step back and support each team member to get them to the same place before we could move forward. Now, instead of working on the opportunity, I am doing damage control.

So what am I hoping you take away from this? Try to not make assumptions – instead take the time and acquire the skills to learn the truth. The definition of assume is “to suppose to be the case, without proof.”  Try to remember to seek out the “proof” and, if you are successful, in the end you will stumble a whole lot less.

References:

Brown, J. Weston, W., & Stewart, M. (2003). The third component [to patient-centered care}: Finding common ground.  In M. Stewart et al. (Eds.), Patient-centered medicine: Transforming the clinical method (2nd ed.), pp. 83-99.  Abingdon, UK: Radcliffe Medical Press.

Ida Institute. (n.d.)

Schön, D. (1983). The reflective practitioner: How professionals think in action. NY: Basic Books.

Thompson, S. (2008). The critically reflective practitioner. NY: Palgrave Macmillan.

Counseling and Health Literacy

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

 

Audiologic counseling has many facets, including patient education (Clark & English, 2014). Patient education is not inherently easy: every audiologist has had those moments when we realize our patient doesn’t understand us.  Sometimes the patient is emotionally distraught and cannot concentrate, and sometimes we unintentionally provide more information than the patient-as-learner can process.

Another variable to consider is the patient’s health literacy. In addition to reading abilities, health literacy as measured by the National Assessment of Adult Literacy (NAAL)(2006) includes the ability to interpret graphs, do basic calculations (numeracy skills), and use a computer.  We cannot take any patient’s health literacy for granted; in fact, the NAAL reports that more than 1/3 of adults in the United States (77 million) have limited (basic and below basic) health literacy skills (see figure below).  Persons at basic/below basic literacy levels are not able to read or fully understand a newspaper article, fill out forms for Social Security, Medicaid or Medicare, or follow a bus schedule or calendar (Weiss, 2007).  Relatedly, low health literacy is linked to more mistakes in medication usage, more emergency room visits and hospitalizations, and a higher risk of death. Relevant to audiology, it could mean misunderstanding instructions for hearing aid use, misinterpreting Internet sites about cochlear implant candidacy or auditory processing problems, or an inability to complete scales/questionnaires or provide a medical history.

Source: National Assessment of Adult Literacy

HealthLit_Overall

Health literacy skills are affected by age, education, income, health insurance status, and first language acquisition.  But as Weiss (2007) warns us, “You can’t tell by looking” (p. 16).

Health literacy is a topic of high interest these days because health-related information continues to grow in complexity. This article has two parts: defining health literacy, and suggestions for audiologists on how to address health literacy concerns in their patient care.

Definitions of Health Literacy are Evolving

The definitions of health literacy have evolved rather quickly, from the static “snapshot” described in the figure above, to a dynamic process of growth and empowerment (Nutbeam, 2008).  For instance, rather than pinning down health literacy as an unchangeable state as the NAAL data might imply, Zarcadoolas et al. (2005) prefer to define health literacy as “the wide range of skills, and competencies that people develop to seek out, comprehend, evaluate and use health information” (emphasis added)(p. 196). Such development can occur independently on the patient’s end, but it also can occur as a result of effective communication with health care providers. In other words, if we counsel and educate effectively, a patient’s health literacy level should increase over time.

Berkman et al. (2010) list several definitions of health literacy, but their own refinement is most suitable for our purposes:

Health literacy is the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions (p. 16)

They added the phrase “communicate about” to the Institute of Medicine’s 2004 definition because they considered oral communication skills (listening and speaking) to be a critical part of health care – as do audiologists and others.  For instance, Ishikawa and Yabo (2008) point out that, in addition to NAAL’s consideration of functional skills (reading, interpreting graphs, computation, computer use), communication skills are also essential, including the ability to:

  • Articulate health concerns
  • Describe symptoms accurately
  • Ask pertinent questions
  • Understand verbal information accurately

Another dimension to health literacy is media literacy, or the ability to critically evaluate media messages in all formats.  Additionally, health literacy is affected by context: patients may be proficient in managing medications and appointments for other health conditions, but with no prior experience with hearing loss, they may not immediately be ready to apply what they know to the novel context of audiologic care. And although not mentioned in the health literacy literature, audiologists might want to add understanding/use of technology (apart from computers) as a health literacy skill.

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