Kris English, PhD, The University of Akron/NOAC

We are working through a discussion on Patient-Centered Care per Stewart et al.’s (2014) model. Part 1/5 provides an introduction; Part 2/5 (Exploring) and Part 3/5 (Active Understanding) apply the first two interactive components of their model to audiology. In this entry, we will consider the 3rd component, Finding Common Ground.

It’s Time to Focus

Finding common ground is an intentional move toward a mutual “meeting of minds,” with the goal of matching our patients’ goals with our expertise and recommendations. Gone are the days of “paternalism” in health care, when clinicians authoritatively informed patients of the treatment plan and expected unquestioning compliance (Emanual & Emanuel, 1992). An alternative approach, called the “informative model,” involves providing all options but with no attempt to motivate or inspire patients toward a particular direction. Needless to say, neither of these approaches supports the process of finding common ground. Patient-centered care requires what the Emanuels called an “interpretive model,” wherein the clinician not only explains all options but also works with the patient’s goals and values to ensure they co-develop a shared understanding of the plan moving forward. Gawande (2014) explains:

[As patients] we want information and control, but we also want guidance. The Emanuels described a third type of doctor-patient relationship, which they called “interpretive.” Here the doctor’s role is to help patients determine what they want. Interpretive doctors ask, “What is most important to you? What are your worries?” Then, when they know your answers, they tell you about the red pill and the blue pill and which one would most help you achieve your priorities. (p. 201)

In other words, we seek to combine our knowledge and experience with patient needs to help us agree on a plan for preferred outcomes, land on the same page. We are in no way a neutral bystander; in a very real sense, we are the “most important instrument” in the room.

Moving Toward Common Ground

Finding common ground in health care is a 2-step process: (1) agreeing on “what is wrong” and (2) agreeing on “what to do about it.”

We readily learn “what is wrong” from the patient’s point of view as we explore and actively understand a patient’s concerns and needs. We may be inclined to begin our formal assessments at this point to determine “what is wrong” from an audiologic perspective, but that step could interrupt the “finding common ground” process. It can be a challenge to disrupt what Stewart et al. (2014) call the “canonical organization” (p. 112) of an audiology appointment, but let’s give it some thought.

It’s true that without test results, it’s too soon to “agree on what to do” about hearing help, but we can lay some preliminary groundwork to that conversation by seeking input regarding “what to do about it” from the patient’s point of view. We are fully aware that hearing help recommendations are often met with resistance, objections, distress. A first-time patient is surely harboring many questions about amplification, and it can help to open up those questions before confirming a hearing loss. Once we collect our patient’s ideas on “what to do about it,” we can pick up on the testing process.

Some “Common Ground” Tools

Until we ask, we do not know how hearing loss affects what matters most in our patients’ lives, and what they want to do about it. To understand these concerns, audiologists can use some simple tools to elicit and document patient input. Following are screen shots of 3 readily-available tools:

1. The Client Oriented Scale of Improvement. The COSI is a classic patient-centered tool that helps the patient articulate desired changes.  As mentioned above, when patients effectively write their own treatment plan, they are more likely to adhere to it.

2. Ida Institute Scales. The two scales below ask the patient to rate importance and also self-efficacy (“how much do you believe in your ability…”). When the ratings are low, we are once again reminded we cannot assume anything. A follow-up on our part should include the queries: what would it take to move your answer higher on the scale?  What is on your mind that holds you back?  To access these tools, first create an account here: 

3. The Characteristics of Amplification Tool (COAT). Developed by Sandridge and Newman in 2006, this is one of the first tools to ask about motivation and also expectations (“how well do you think HA will improve your hearing?”). Their original article explains how to use the tool; a recently modified version is available to download here.

Also: Simple “Readiness Scales”

Palmer et al. (2009) found an important correlation between hearing aid decisions and a patient’s answer to the question,”On a scale from 1 to 10, 1 being the worst and 10 being the best, how would you rate your overall hearing ability?’’  Most patients are familiar with the 1-10 scale concept; a simple way to determine readiness is pose the question, On a scale of 1-10, how ready are you to:

“The readiness is all” (Hamlet V, ii)

• hear better?
• try amplification?
• try an assistive device?
• advocate for yourself at work?

Shakespeare had it right: we don’t make any changes or decisions until we are ready — a psychological state that is hard to explain but easy to quantify. Asking patients to think about and rate their state of readiness helps them organize their priorities, acknowledge their doubts, and hopefully clear away misgivings.

Finding Common Ground = Intentionally Sharing Power

Please note: finding common ground means “mutually influencing each other, each potentially ending up in a place different from where they began, with different understandings than either would have reached alone. It is not a matter of who has power and who does not.” (Stewart et al., 2014, p. 138).  (More on “sharing power” here.)

Closing Thought

Finding common ground is often mistakenly assumed to be a final step, occurring after all the information about the patient’s problem is obtained and sorted out by the clinician. But patient-centered care includes one more component, to be explained in Part 5/5 of this series.

The Ultimate Question: Is “Finding Common Ground” an Evidence-Based Practice?

See Stewart et al. (2000) to learn more.

NEXT: Patient-Centered Care, Part 5/5: Patient Relationships

1. I can explain the difference between “informative” and “interpretive” models in patient care.

Yes            Still working on it

2. I am willing to disrupt the “canonical organization” of an audiology appointment in order to learn what a patient “wants to do” re: hearing help before I begin testing.

Yes              Not sure

3. I already use at least one of the “common ground tools” described above.

Yes              No

4. I actively strive to “share power” with patients and families.

Almost always       Sometimes         I haven’t given this much thought

5. I can explain why “finding common ground” is an evidence-based practice.

Yes            Still working on it

 References

Emanuel, EJ & Emanuel, LL. (1992). Four models of the physician-patient relationship. JAMA, 267(16), 2221-2226.

Gawande, A. (2014). Being Mortal: Medicine and what matters most in the end. NY: Henry Holt.

Palmer C. et al. (2009) Self-perception of hearing ability as a strong predictor of hearing aid purchase. JAAA, 20, 341-347.

Sandridge S, & Newman C. (2006). Improving the efficiency and accountability of the hearing aid selection process – Use of the COAT. 

Sandridge S, & Newman C. (2014). Characteristics Of Amplification Tool, v2. 

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.

Kris English, PhD

The University of Akron/NOAC

As mentioned in Part 1/5 and Part 2/5 of this 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.

Fig. 1. Physician responses to patients’ expressions of emotion: immediate effect on communication and associated patterns of further communication. (Adams et al,, 2012, p. 47)

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 Understanding 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 4/5 and 5/5

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

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

NEXT: Audiology Counseling and Patient-Centered Care, Part 4/5: Common Ground

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

Almost always         Sometimes        I tend to skip this step

2. 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

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

Yes              Not sure

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

Almost always       Sometimes         I often skip this step

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

Yes            Still working on it

References

Adams K et al. (2012). Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotions in hospital admission encounters. Patient Education and Counseling, 89, 44-50.

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.

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.

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.

Kris English, PhD

The University of Akron/NOAC

As mentioned in Part 1/5 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.

NEXT: Audiology Counseling and Patient-Centered Care, Part 3/5: Understanding

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

Almost always         Sometimes        Not Sure

2. 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

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

Almost always         Sometimes               Not usually

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

Almost always         Sometimes               Not usually

5. 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.

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:

2/5: 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)

3/5: 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)

4/5: Finding Common Ground

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

5/5: Enhancing the Patient-Clinician Relationship

• 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.

NEXT: Audiology Counseling and Patient-Centered Care, Part 2/5: Exploring

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 21^st 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 (3^rd ed.). London: Radcliff Publishing.

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 →

John 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 →

Karen 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 Given

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, 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