John Greer Clark, PhD
The University of Cincinnati & Clark Audiology, LLC
An enemy generally says and believes what he wishes.
While our patients are not the enemy, we most certainly at times can be viewed as theirs. Adult patients arrive at our office doors at a set stage within their hearing loss journey. This journey does not begin with the appointment with the audiologist (Gregory, 2012). It often follows a long and circuitous path that may have only reached a point of suspicion of hearing loss at the time of consultation. Along the way, patients who have not yet reached a stage of readiness to embrace our recommended hearing solutions may have categorized persons into one of two camps – the ally camp and the enemy camp.
The enemy camp is filled with those who want the patient to address the very situation he or she has been trying to deny. Friends and family who have been noticing communication failures, and who are becoming increasingly frustrated living with someone else’s untreated hearing loss, have likely suggested scheduling a hearing test on numerous occasions. As part of many patients’ pre-appointment journey, those with hearing loss may have progressed from scanning hearing aid advertisements in magazines and newspapers to reading these advertisements in detail. They may have completed Google searches on hearing loss, hearing loss treatment and hearing aids. And they may have asked friends and acquaintances who wear hearing aids (or who have tried hearing aids) what they think – with responses that sometimes are less positive toward the potential help available than audiologists might hope. And of course, as the journey becomes more protracted the patient and the patient’s communication partners frequently become more frustrated.
Prior to making an appointment with the audiologist, most persons with hearing loss gradually come to the realization that the communication frustrations are the result of, or at least aggravated by, their own existing hearing loss. They come to the realization within their journey that much of the problem lies with them and that they do indeed need to take action. Those family members who may earlier have been viewed as soldiers within the enemy camp, may gradually be viewed as having the persona of a supportive comrade. And these comrades frequently come to the initial hearing consultation appointment with the patient to lend their aid as together they embark on a new leg of the hearing loss journey.
But not all patients who come through our doors have reconciled themselves with their hearing loss. Some still harbor varying degrees of denial, continuing to place much of the blame for communication failures on the speaking habits of others. And these others continue to be viewed as residing in the enemy camp, pushing for actions that are not wanted or that are not perceived as needed.
How Do You Want to be Viewed?
If we want to make positive inroads during an initial hearing loss consultation with patients who have yet to reconcile their view of themselves with hearing loss, we are best off if we can avoid joining the enemy camp. Yet, it is within the enemy camp that we firmly place ourselves when a patient has not yet reached a stage of readiness for rehabilitation solutions and we move forward with confirmation of the hearing loss and the provision of recommendations. How do we avoid this? We must speak to the patients’ reality, not our perceptions of the patients’ reality.
Our perceptions of the impact of hearing loss are ingrained within us from academic training and clinical experiences. We know the impact of varying degrees of hearing loss on speech perception, the effects of background noise on speech understanding and the negative life impact that may have been reported by previous patients with hearing loss similar to that of the patient in front of us. Our perceptions of impact, and our projections based on what we have seen with other patients, serve to erode the empathy we may be trying to portray to our patients (Clark & English, 2014). Until we elicit and listen to the patient’s perceived impact of hearing loss, we have little place to go but the enemy camp. When we formulate discussion around the patient’s reported impact of hearing loss we can become the patient’s ally: Not one who is pushing toward unwanted action, but a partner in a discovery process and an exploration of alternatives.
As Thomas Jefferson noted, the enemy may say what he wants to achieve a goal. Patients who perceive our recommendations as a means toward achieving our goal (another sale) and not their own, may not take the positive actions required for their own success. Patients who do take action, but who do not perceive the true need for assistance as arising from their own hearing difficulties, are typically the patients who return their hearing aids during the customary adjustment period. At this juncture they may justifiably believe they have appeased their enemies at home. I gave it a try. Hearing aids just don’t work for me. And we, as the patient’s audiologist, encourage them to consider the difficulties that may be confronted (keep a diary) and return in 6 months or a year to see if things have changed: truly a scenario that depicts a missed opportunity for the patient, the patient’s family and ourselves. We usually fail to recognize our own role in the lack of sale or hearing aid return. We never realize that we set up camp with the enemy. Was this how we wanted to be viewed?
Is There a Better Approach?
Pietrzyk (2009) reported that less than 10% of audiologists use self-assessment measures on a routine basis. Yet it is use of these readily available tools that allow us to break free of our pre-conceptions and explore along with patients how hearing loss is impacting their lives from their perspective. How much more successful might we be if we approached each patient in the following manner?
- Step 1: Review the patient’s case history and hearing loss impact questionnaire (aka: self-assessment). “You noted on this questionnaire that you… That must be difficult for you. (Review several points with the patient.) I’m not sure if you have a hearing loss. As you said, others seem to mumble, and perhaps they do. Let’s do a quick hearing test to get a better picture of what’s going on.” This step sets the stage that the audiologist is not jumping to conclusions and landing right in the middle of the wrong camp. Instead, the audiologist is positioning him/herself as an ally in the exploration of the problem and the discovery of a potential solution.
- Step 2: Present your findings. Well, I suspect you’re correct that others have bad speaking habits. (Strengthen that ally position.) But it does appear you have some hearing loss as well. Do you want the details of what I’ve found or just the bottom line and what I would recommend? (Most often patients do not want our details at this juncture (Martin, 1994), nor are their mind in a good space to digest the information (i.e.: Anderson et al., 1979; Kessles, 2003).
- Step 3: Check on the importance of change, starting with a recap of results from the hearing loss impact questionnaire. Given what we have discussed about the difficulties you are having which seem to probably be from a combination of other’s speaking habits and your hearing loss, how important is it to you to make things better, say on a scale of 1 to 10 with 10 being very important. If importance for change is low, exploration is needed by weighing the pros and cons of inaction vs. action. It is best not to court failure if importance is below about 7.
- Step 4. Assess the patient’s belief in abilities to succeed (self-efficacy) only when importance for change is high. Well, it sounds as if it is fairly important for you to have more successful communication and to decrease some of your frustrations. How likely do you believe you can follow my recommendations if they include the use of hearing aids? It is certainly best to know of the pending impediments at this juncture than to leave them unexplored.
Following these four simple steps in the hearing aid consultation process can position you as an ally and clearly outside of the enemy camp. And thus is the essence of motivational engagement. For further step-by-step discussion of the audiologist’s use of motivational engagement, see Clark and English (2014). Free CEUs on the use of motivational engagement tools are available through the Ida Institute.
Anderson, J.L., Dodman, S., Kopelman, M., & Fleming, A. (1979). Patient information recall in a rheumatology clinic. British Journal of Rheumatology, 18,18-22.
Gregory, M. (2012). “A possible patient journey:” A tool to facilitate patient-centered care. Seminars in Hearing, 33(1), 9-16.
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.
Pietrzyk, P. (2009). Counseling comfort levels of audiologists. University of Cincinnati, Unpublished capstone.