Kris English, PhD

The University of Akron/NOAC

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

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

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

It Might Look Like Denial

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

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

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

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

Do We Inadvertently Impede the Sensemaking Process?

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

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

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

Sensemaking as a Social Process Continue reading →

Devon Weist, AuD

Audiology Clinical Instructor, Externship Coordinator

The University of South Florida

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

The Best-Laid Plans

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

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

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

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

Suddenly a Solution

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

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

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

This Year and Every Year

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

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

References

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

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

Kris English, PhD

The University of Akron/NOAC

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

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

Source: National Assessment of Adult Literacy

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

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

Definitions of Health Literacy are Evolving

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

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

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

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

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

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

Applications for Audiologists Continue reading →

Kris English, PhD

The University of Akron/NOAC

Scenario: Today an audiologist will meet a new patient, Mr. Jones. She asks about his concerns and obtains a comprehensive case history. When the testing is completed, she confirms the patient’s suspicions about his hearing problems. She begins to discuss treatment options, but then realizes her patient has stopped listening.  She pauses, and soon the patient breaks his reverie. He shakes his head, makes eye contact again and says:

The thing is … years ago, I was so impatient with my dad’s hearing problems.  I didn’t even try to understand and just stopped talking to him.  I was pretty awful about the situation. Then after he died, I started to realize how stubborn and selfish I had been.  This man I had loved so much – we had been become strangers.  And now it’s me – and maybe the whole cycle will start again with my kids! That would just … it would just break my heart.”   His voice breaks and he looks away again, sighing deeply.

In less than 30 seconds, several emotions have tumbled out: guilt, regret, self-blame, worry.  The audiologist was mindful of the change in demeanor, and gave the patient the opportunity to express these concerns.  But now that we know what the patient is experiencing, what do we do?  Do we assure the patient that everything will work out and then “get back to the point” of the appointment?  Are we defining “the point” only from our own perspective? And if so, are we ourselves missing an important point?

Portrait of an apprehensive senior man.

What Exactly Is The Point?

In a recent conversation, Tim Cook (webmaster at the Ida Institute) mentioned a concern shared by many Ida seminar participants: When patients get emotional, how do we redirect them back to hearing solutions – that is, get them “back to the point”?   This concern assumes that patient emotions will inherently impede progress — not to imply that the emotions are irrelevant to the patient, just irrelevant to the appointment goals. Emotions are perceived as a problem, a “noisy byproduct” that we need to manage, control, suppress (Stone et al., 2010, p. 13). Continue reading →

John Greer Clark, PhD

The University of Cincinnati & Clark Audiology, LLC

An enemy generally says and believes what he wishes.

Thomas Jefferson

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? Continue reading →

Kris English, PhD

The University of Akron/NOAC

Even the most family-centric audiologists can find themselves on a different page than parents on the topic of consistent amplification. One reason may be our training: we have been taught to emphasize the relationship between amplification and the development of speech and language. While true, it is also possible that families are not following our logic. In fact, logic may not be part of their reactions at all. At the moment, families’ uppermost concern may be centered around their child’s emotional development: Will our baby be happy? Feel safe? Will she know we love her?

Families intuitively want to nurture and bond with their baby, and hearing actually supports that process. But even as hearing is taken for granted, so are the effects of hearing on parent-child bonding. Our challenge is to align our communication with what families value, and be comfortable talking to parents about the importance of their child hearing “the love in their voice.”

Following are two topics: A brief summary of selected research describing listening skills in infants with no hearing loss, and then a suggestion on how help families use amplification for the express purpose of bonding with their baby. We can think of this process as “auditory imprinting.”

Babies are Born Listening

Babies hear their mother’s voice for many weeks before they are born, and after birth are ready to listen for mom at surprisingly sophisticated levels. For instance, Querleu et al. (1984) tested 25 newborns, all less than 2 hours old, by presenting recordings of five women speaking the babies’ names. One voice was the baby’s mother, and four voices were unknown to the baby. Three observers independently rated each baby’s reaction to each voice as nonexistent, weak, or strong. They found that when the babies heard their mother’s voice, they had strong reactions almost half the time. Not a robust finding, but remember, the babies were only 2 hours old but already telling us that mom’s voice is meaningful to them.

A classic study by DiCasper and Fifer (1980) found that not only does baby recognize mother’s voice, but actively prefers it to others. The researchers recruited 10 mothers to record reading from Dr. Seuss immediately after they delivered their babies (agreed, that alone is amazing). Their newborns were later placed under headphones before they were 24 hours old. After obtaining baseline sucking rates (using nonnutritive nipples and computer software to calculate rates per minute), the researchers presented recordings of mother and other women reading. Babies quickly learned they could control the input: when they sucked on the nipple at a rate lower than their baseline, that action would deliver an unfamiliar female voice. When they increased their sucking rate, they would hear their mother’s voice.  Once they learned the relationship between sucking rates and voice input, they consistently “chose” mother using an increased rate. Think about it: a 1-day old baby is capable of mastering an elementary lesson in cause-and-effect based on what he or she heard, and it is mom’s voice that facilitates that learning. Continue reading →

Kris English, PhD

The University of Akron/NOAC

Here is a thought-provoking experiment. Ask audiology students to visualize the first moments of a typical appointment with a new patient.  The patient sits down, and the audiologist says, “So what brings you here today?”  Got the image? Now freeze that frame! And then ask, “In this scenario, who has power: the patient or the audiologist?”

Interestingly, students tend to say, “the patient.”  When asked why, the explanations tend to recognize the patient’s power of autonomy: ultimately, a patient can and will decide whether to follow to our recommendations (Calman, 2004). A reassuring answer! But remember, I was referring to the beginning of the appointment, not the end.  It seems possible that we could overlook a new patient’s vulnerability, and be unaware of an initial state of powerlessness. If we are blind to it, we are not likely to take active steps to start shifting the balance of power in the patient’s direction (Goodyear-Smith & Buetow, 2001).

Empathy 101 and Power.  To understand what powerlessness feels like from a patient’s point of view, let’s put ourselves in their shoes. Before and during our first appointment, we would have many questions, and experience some anxiety, worry and doubts. We would have absolutely no idea what to expect. We would see unfamiliar technology, framed diplomas and licenses hanging on the wall, and models of strange anatomy sitting on shelves. We would see brochures and posters about new hearing aid technology – something we have been avoided thinking about, and now it’s “in our face.” At this moment, we have little going for us – except for our unique story. This is a type of latent power: our story is valuable but it will have no impact if we are not given an opportunity to share it.  Is anyone interested?

Across from us is the audiologist, Dr. Somebody, with a white coat and specialized training and expertise. Dr. Somebody will determine how we start the appointment, what steps we take along the way, and how we conclude the appointment. It is reassuring to have an expert take the lead; it’s why we made this appointment in the first place. But it does means that we are still relatively powerless.  Will it always be that way?

Initially, there is an inescapable power inequity in the patient-clinician relationship, a situation not unique to audiology. Palmer (1998) notes that “Virtually all professionals have been deformed by the myth that we serve our clients best by taking up all the space (i.e, holding all the power) with our hard-won omniscience…” (p. 132). Continue reading →