John Greer Clark, PhD

Professor, University of Cincinnati, OH

Audiologists must always be prepared to view their patients in a context wider than the immediate condition for which they may be seen. One of the seven primary components of person-centered care in audiologic practice is that of a holistic outlook for patients which dictates “a continued vigil for the safety and well-being of those served both within the clinic and within the patient’s broader life context” (Clark & English, 2019, p. 5).  Both hearing loss and dementia can have negative impacts on patients’ emotional well-being, psychological status, and societal and family interactions.  The incidence of dementia increases with advancing age, as does presbycusis, presenting significant challenges to the audiologist when these conditions coexist (Cacace, 2007).

Hearing loss is one of the noted modifiable risk factors for dementia (Livingston et al., 2017), and if identified and treated early, its impact on dementia may be lessened (Beck et al., 2018).  Similarly, early detection of dementia has the potential to lessen the negative impact of hearing loss on one’s quality of life.

Broaching the Subject

One means of broaching the subject of possible cognitive decline with patients is to include inquiry of concern within the case history (Amero et al., 2017).  The following scenario depicts how to segue into a discussion about screening.

While reviewing case history information with Mr. Baxter and his wife, Dr. Collier says, “I see that you answered ‘Yes’ to the question ‘Do you or any members of your family have any concerns about memory challenges or confusion that you appear to have?’ Can you tell me a bit about your concerns?”

Mr. Baxter looks over at his wife hoping that she might respond to this topic that he tries his best not to think about.  After a brief pause, Mrs. Baxter responds, “Well we aren’t sure if it is anything really, but we have noticed that Jim seems to lose things a lot.  His glasses… keys… his watch the other day.  We all lose things, but this just seems to be so much more frequent than before. And last week he called me from the grocery parking lot.  He said he wasn’t sure if home was to the left or the right from the store.  We downsized four years ago and it used to be a right turn out of the lot, but now it’s a left turn.  We haven’t really talked to anyone about this.  Not yet, anyway.”

“Well, you are correct,”Dr. Collier says.  “We all do forget things and lose things, even lose our direction sometimes.  But what you are saying does seem to make one pause.” Turning to Mr. Baxter, she continues,“Would you be willing to have me give you a brief screening to see if we should be concerned?  If the results of the screening suggest that further exploration on this would be in order, I know a wonderful doctor I could recommend for you.”

(From: Clark & English, 2019, with permission)

 

And Then What?

Continue reading →

Kris English, PhD

The University of Akron/NOAC

In Part 1 of this series, we considered empathy as an act of “sharing space” with another’s experience and emotional state. In Part 2, we highlighted the importance of actively checking our impressions of another’s experience and state, to avoid the disconnect of “rejected empathy.”

Taking this learning process to its logical conclusion, as educators we are charged to evaluate the development of these interpersonal skills. However, to date very little has been written in audiology as to how to go about it.  Fortunately, there are several valid and reliable assessment tools (Batt-Rawden et al., 2013), including the Four Habits Coding Scheme, described and referenced below.  Before testing out the Four Habits, though, let’s consider one habit not included on this rubric, a habit that we may need to break: a tendency to try to “make things better” by saying “at least.”

“At least” … Creating Distance, Not Sharing Space

Such a seemingly innocuous phrase! And yet, consider the following comments and their impact on empathy:

• At least we can improve your hearing problems with modern technology.
• At least we identified your child’s hearing loss early.
• Lots of people have hearing loss far worse than you do (“at least” is not spoken but implied).

On the surface, our intention is commendable: to help a patient or parent feel better (Lundberg & Lundberg, 1997). However, ironically, to say or imply “at least” only makes the speaker feel better, and at the same time diminishes the patient’s experience. By offering impersonal reassurances, we inadvertently distance ourselves from our patient.  We convey access to some special knowledge, that we know more about the situation than the person experiencing it. Such distance-creating signals are inconsistent with what Carl Rogers (1979) called “the subordination of self.” Discuss!

Applications to Audiology

Continue reading →

Kris English, PhD

The University of Akron/NOAC

In Part 1, a vignette depicts a patient informing her physician that her spouse had recently passed away. Unfortunately, the physician assumed too much about the patient’s life and experience, and expressed empathy for a situation that didn’t exist. The patient decided to correct the physician’s assumptions, an awkward counter-response that Frankel (2017) calls “rejected empathy.” Although hypothetical, we should spend a moment imagining the rest of this scenario: once the first exchange went off the rails, the physician would hopefully apologize, clarify, and try again — still appreciated by the patient but not an optimal outcome (Derksen et al., 2017).

An Avoidable Misstep

We would never intentionally cause hurt or harm by offering empathy that a patient will need to reject, but we may find ourselves taking similar missteps. Perhaps we still think of empathy as Barrett-Lennard (1981) did when he described an “empathy cycle” consisting of three phases:

• Phase 1: the inner process of empathetic listening to another who is personally expressive in some way
• Phase 2: the attempt to convey empathetic understanding of the other person’s experience
• Phase 3: the other person’s reception or awareness of this communication

In light of Frankel’s vignette, it seems fair to say that this “empathy cycle” is incomplete. All three phases were involved, and yet the outcome was ineffective. Perhaps Barret-Lennard suspected as much, since he does point out, “There is room for considerable slippage” (p. 91).

Teaching “Checking”

When we take on the task of teaching empathy skills, we should base our instruction on the most complete definition possible.  Like Frankel, Mercer and Reynolds (2002) include the aspect of “checking for accuracy”:

1. Understand the patient’s situation, perspective, and feelings (and their attached meanings)
2. Communicate that understanding and check its accuracy (emphasis added)
3. Act on that understanding with the patient in a helpful (therapeutic) way (p. S9)

In other words, regarding #2 above, “If you don’t get that confirmation, you aren’t done” (Coulehan et al, 2001, p. 225).

Applications to Audiology

Continue reading →

Kris English, PhD

The University of Akron/NOAC

The concept of empathy is a foundational aspect of audiologic care – foundational but elusive. Students and instructors generally know how to define it, for example, “the ability to understand the patient’s situation, perspective and feelings, and to communicate that understanding to the patient” (emphasis added) (Coulehan et al., 2001, p. 221).

However, as is often said in counseling texts, “knowing is not enough.” Knowing a definition does not mean a skill has been acquired. How can instructors bring the concept of empathy to life, and actively support the develop of empathy through course content and clinical training?

Guidance is available in related fields. For instance, Batt-Rawden et al. (2013) provide a systematic review of methods designed to teach empathy to medical students. These methods include a range of educational interventions that effectively maintain and enhance students’ personal capacity for empathy, such as:

• Patient narratives
• Reflective essays
• Communication skills training
• Problem-based learning
• Interpersonal skills training (role-playing, standardized patients)

Applications to Audiology

For our purposes, we can start with two simple exercises on the process of “sharing space” with another. Here is a combination of reflective essay and communication skills training, for both students and instructors:

Learning objective #1: Develop “empathic understanding” (Mercer & Reynolds, 2002), or more specifically, “the passive emotional response of one individual to the emotions of another” (Batt-Rawden et al, 2013, p. 1171).

Learning activity: View this popular 4-minute video developed by the Cleveland Clinic: Empathy: The Human Connection to Patient Care.   Then, write down at least four specific scenarios that made an impact on you, and describe what the persons in those scenarios were experiencing. Include adjectives that describe emotional states. Repeat the exercise one month later; do any scenarios have a different impact than before? Again, write down your perceptions of patient and family experiences.

Learning objective #2: Demonstrate “empathetic communication” (Mercer & Reynolds, 2002); described as “an active skill that can be acquired and is amenable to nurturing” (Batt-Rawden et al.,2013, p. 1171) and “a visible communication behavior that is enacted when a clinician recognizes and responds to another person’s suffering” (emphasis added) ( Frankel, 2017, p. 2129).

Learning activity: Ask a friend or family member to view the same video, then ask for their reactions and listen carefully. Listen but do not insert your own reactions into the dialogue. Find ways to express that you are trying to understand. Provide some prompts: what else caught your attention?  Other scenarios you’d describe as important or memorable? Later, evaluate your skills: did you refrain from interrupting? Was it difficult or comfortable to “just listen”? Did you understand the other’s experiences and actively communicate that understanding at least once?

Caution: “Empathic Communication” Could Go Awry

Continue reading →

Kris English, PhD

The University of Akron/NOAC

Recently, a panel of pediatric audiologists asked parents for guidance in developing a Childhood Hearing Loss Question Prompt List (CHL QPL). QPLs are used in many specialties in health care to help patients and families remember the questions they want ask, suggest questions they may not have thought about asking, and broach questions they’d like to ask but don’t know how. As a counseling tool, QPLs are very effective for patient education as well as for the open invitation to discuss important or difficult topics, and to equalize the power dynamic in a health care appointment.

One Question Stands Out

The CHL Question Prompt List underwent several stages of review, and the final version can be found here.  The report on this QPL does not include a breakdown of each question and degree of support, but one result is a stand-out and is worth highlighting here: of all the questions reviewed to keep or reject, the only question that was approved by 100% of parent reviewers (N = 122) was this one:

Any unanimous response is rare, but this one really should come as no surprise: research has long reported parents’ desire to connect with other parents for support. Parents in Mueller et al.’s (2009) study valued access to other parents as a source of information and emotional support, and a sense of being in a larger family. Other benefits include gaining new skills to deal with day-to-day issues, increasing a sense of power and belonging (Law et al. 2009), and reducing stress (Hastings & Beck, 2004). Parents of children with hearing loss have specifically identified their “predominant need” as meeting other parents (Luterman & Kurtzer-White, 1999), and the provision of these support services is described as a “state-of-the-art practice in family counseling” (Jerger, Roeser, & Tobey, 2001).

What to Do With This Information?

This web forum focuses on audiology counseling, but we must recognize our limitations. We cannot help parents the same way other parents can. In addition to providing every professional support possible, we can also:

• Support a parent group in our community (provide space, communication mechanisms [newsletter, website], etc.)
• Provide parents contact information about existing groups in our community and online (e.g., Hands&Voices)
• Maintain and share a list of “veteran parents” who generously volunteer to provide one-on-one support, especially to those new to “the journey.”

Conclusion

Once again, parents have spoken. Will we act as well as listen? What can we do in our communities to meet this full-throated request for support?

References

Hastings, R., & Beck, A. (2004). Practitioner review: Stress intervention for parents of children with intellectual disabilities. Journal of Child Psychology and Psychiatry, 45(8), 1338-1349.

Jerger, S., Roeser, R., & Tobey, E. (2001). Management of hearing loss in infants: The UTD/Callier Center Position Statement. Journal of the American Academy of Audiology, 12(7), 329-336.

Law, M., King, S., Stewart, D., & King, G. (2002). The perceived effects of parent-led support groups for parents of children with disabilities. Physical and Occupational Therapy in Pediatrics, 22(2/3), 29-48

Luterman, D., & Kurtzer-White, E. (1999). Identifying hearing loss: Parents’ needs. American Journal of Audiology, 8(1), 13-18.

Mueller, T.G., Milian, M., & Lopez, M.I. (2009). Latina mothers’ views of a parent-to-parent support group in the special education system. Research and Practices for Persons with Severe Disabilities, 34(3/4), 113-122.

Kris English, PhD

The University of Akron/NOAC

This entry concludes a discussion on Patient-Centered Care with several applications to audiology practices. The first four entries are:

• Introduction (Part 1/5 )
• Exploring (Part 2/5)
• Active Understanding (Part 3/5)
• Finding Common Ground (Part 4/5)

As mentioned in Part 4, finding common ground is often assumed to be our final step, since we’ve agreed on next steps and are ready to conclude the appointment. But the difference between a transaction and patient-centered care includes one more component: our skill in enhancing patient relationships.

Stewart et al. (2014) described these four components as interactive, and here is where we see it most clearly: forward-moving steps to an ultimate goal. We don’t explore for exploring’s sake, but to understand (and actively indicate that we understand) our patient’s needs as prerequisites to finding common ground.

However, the linearity of this model doesn’t do justice to the interactive impact of each component. Perhaps we can envision a set of cogs, each one vital to the process and each one affecting the others. Regardless, we are ready to consider some aspects of our last component:

Enhancing Patient Relationships

Stewart et al. (2014) list several characteristics associated with each interactive component of patient-centered care. Among those related to “Enhancing Patient Relationships,” we will focus on two that could be considered two sides of the same coin: empathy and self-awareness.

A piano sounding board

§ Empathy: Gallese et al. (2007) describe empathy as “intentional attunement” to another person’s experience, bringing to mind the metaphor of a sounding board. As clinicians dedicated to sound, we might especially “resonate” to Josselman’s (1996) definition: the ability to “put aside our own experience, at least momentarily, and reverberate to the feelings of another” (p. 203).

Interestingly, recent fMRI studies confirm that humans do in fact need to “put aside” other thinking as we empathize. Jack et al.’s 2013 report on fMRI studies indicate that humans seem to have a built-in neural constraint that prevents us from thinking empathically and analytically at the same time. The need to “toggle” from one mental state to another requires mindfulness, i.e. “a constant awareness of the encounter at multiple levels” (Scott et al., 2008, p. 319). We don’t give ourselves enough credit when we say “All I did was listen” – since “just listening” means an intentional decision about where we direct our attention.

§ Self-awareness: Epstein (1999) identified five types of self-awareness:

1. Intrapersonal awareness of our own strengths and limitations
2. Interpersonal awareness of how we are seen by others
3. Learning awareness of our knowledge and skill levels, and the means to achieve learning goals
4. Ethical awareness of our values and how they shape treatment decisions
5. Technical awareness of our need to correct procedures in process, including communication

Readers will likely agree that, except for ethics, these types of self-awareness are not discussed much in audiology.  However, it has been observed time and again, including by McWhinney (1989), that “We cannot begin to know others until we know ourselves” (p. 82).

Intrapersonal awareness would include knowing our strengths as helpers, dedicated to hearing and balance health. If we are consistent with the general population, we are probably extroverts, but about one-fourth of us, as introverts, may not be fully aware of experiencing a greater energy drain from daily patient care compared to our extroverted colleagues. Our energy levels can affect patient care, but the toll is rarely acknowledged (although colleagues half-jokingly suggest a support group for “Introverted Auds” — as long as it doesn’t involve meeting and talking).

It seems we may not be like the general population when it comes to temperament. Informal data suggest we are twice as likely to be Guardians as classified by the Keirsey Temperament Sorter, which provides food for thought when we consider typical characteristics. Might Guardians sometimes struggle with patient-centeredness? An AuD student  recently gave himself the opportunity to transcend this tendency.

As for interpersonal awareness: what is our reaction to potentially difficult patient/family conversations? Are we inclined to avoid them altogether, rather than risk opening a “can of worms” (English et al., 2016)?  And do we recognize that we signal that reluctance? Or do we convey a willingness to work with them, as this audiologist reported during a workshop:

“A female patient felt her old hearing aids needed replacing. She had had three sets over the past 13 years. At today’s appointment, she posed many questions about her audiogram, wanting a ‘thorough explanation’ of her long-standing HL.”

Here is where the audiologist stepped “into the breach.” He did not have to ask any follow-up questions, but he did: “When I asked her how she was feeling, she got very emotional and left the room to compose herself. When she returned, she explained that she now realized for the first time that her hearing loss was not going to get better.”

Was this conversation uncomfortable for the audiologist? Yes — but he approached it anyway. What it therapeutic for the patient? She indicated it was: she felt grief but also relief, after all those years of holding on to false hope. We will find ourselves occasionally challenged to decide between our discomfort and potential patient catharsis and clarity. Those who are comfortable with difficult conversations could serve as mentors to those who are not. Avoidance helps no one, and is the antithesis of patient-centeredness.

Enhancing Relationship Tip #1: Empathy is Teachable

If empathy is not an innate skill, or was not nurtured (or even crushed!) in graduate school, clinicians can still evolve as empathizers, especially with self-evaluations or feedback from colleagues. Lundeby et al. (2015) provide a “teachable consultation model” that could serve as a study-group project with like-minded audiologists. (Contact the author [[email protected]] to request a copy.)

Enhancing Relationship Tip #2: Know Your Temperament

Are you a Guardian like most audiologists? Or an Artisan, Realist, Idealist?  And how does your temperament align with your clinical goals? Find out at the Keirsey Temperament website. (Tip #3: after setting up an account, answer 71 questions; your results will follow in a Mini Report. Paying for additional information is not necessary!)

The Ultimate Question: Are “Enhancing Patient Relationships” an Evidence-Based Practice?

In addition to research and our own clinical expertise, EBP also considers patient values. For one patient’s (and her readers’) perspective, see “Are Audiologists from Mars?”  We must ask ourselves: if she had enhanced relationships with her audiologists, would she need to create a wish list?

And finally, some food for thought: ever wondered about the consequences of putting other priorities ahead of patient-centered care? Consider this essay.

1. I am aware of the attention required to toggle between empathy and problem-solving.

Yes            Working on it          Not sure what this means

2. I can explain how a “Guardian” temperament might be at odds with patient-centered practices.

Yes        I haven’t given this much thought

3. I am generally comfortable engaging with difficult conversations in clinical settings.

Yes            Working on it          Would rather avoid them

4. I can explain how all four components to patient-centered care interact with each other.

Yes            Working on it          Not sure what this means

References

English, K., Jennings, M.B, Lind, C., Montano, J., Preminger, J., Saunders, G., Singh, G., & Thompson, E. (2016). Family-centered audiology care: Working with difficult conversations. Hearing Review, 23(6), 14-17.

Epstein, R. (1999). Mindful practice. JAMA, 282(9), 833-839.

Gallese, V., Eagle, M., & Migone, P. (2007). Intentional attunement: Mirror neurons and the neural underpinnings of interpersonal relationships. Journal of the American Psychoanalytic Association, 55(1), 131-175.

Jack, A., et. (2013). fMRI reveals reciprocal inhibition between social and physical cognitive domains. NeuroImage, 66, 385-401.

Josselman, R. (1996). The space between us: Exploring the dimensions of human relationships. Thousand Oaks, CA: Sage Publications.

Lundeby, T. Gulbrandsen, P., & Finset, A. (2015). The expanded Four Habits Model: A teachable consultation model for encounters with patient in emotional distress. Patient Education and Counseling, 98, 598-603.

McWhinney, I. (1989). A textbook of family medicine. NY: Oxford University Press.

Scott, J., et al. (2008). Understanding healing relationships in primary care. Annals of Family Medicine, 6(4), 315-322.

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

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

[email protected]

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.