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 →