Kris English, PhD

The University of Akron/NOAC

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

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

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

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

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

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

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

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

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

The Ultimate Confirmation

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

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

Reference

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

Kris English, PhD

The University of Akron/NOAC

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

Matt White, BSc (Hons) Aud

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

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

All I did was listen.

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

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

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

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

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

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

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

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

References

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

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

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

Jane Seaton

Seaton Consultants, Athens GA

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

What Was Said / What Was Heard

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

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

Reducing Misunderstandings

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

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

Audiologists as Reflective Practitioners

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

References

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

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

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

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

Simon Howe, Clinical Scientist (Audiology), BSc (Hons), MSc

Audiology Department
Manchester Royal Infirmary

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

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

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

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

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

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

The Missing Piece

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

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

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

Understanding Continue reading →

Eileen Rall, AuD

Children’s Hospital of Philadelphia

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

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

Assumption: All Swans Are White

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

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

We Can’t Assume Readiness

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

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

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

References:

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

Ida Institute. (n.d.)

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

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