COMMUNICATION WITH ADULT CLIENTS IN AUDIOLOGY: PART ONE
Introduction
This series is designed to provide a day-to-day context to audiology counseling principles. Adults are emphasized however general applicability to paediatric audiology will be obvious. Another focus is the subtleties of (apparently) ordinary interaction, rather than the traditional themes of “breaking the news”, grief work; or interpretation that counseling is only about giving information. Examples were drawn from over 20 years of personal observation, then evaluated by a pool of clients, experienced Audiologists and Clinical Psychologists who specialize in hearing impairment. Optimal communication from a client point of view is stressed. This is not to downplay outstanding communication in audiology but to suggest a risk management approach to every day pitfalls, for both parties. By analogy, when we visit our own doctors, lecturers, advertisers etc we are usually keenly aware of communication we liked and would like to see improved.
Of Course I’ve got Good Communication Skills – I’m an Audiologist
One of the potential downsides to repetitive casework is an unchecked confidence in our communication style e.g. “I’ve been around a long time – I pride myself on my ability to tell what the client’s problems are in the first 5-10 minutes, so why talk and talk about it?”. Alternatively – “the touchy feely stuff is fine but get real – it won’t make much difference to our sales figures!”.
Behind at least some of these views is a trend identified by Tibita (2008) - a characteristic interest by many audiologists in details, objective measurements and "going by the book". This at worst may act – unwittingly or otherwise - as a kind of defense against those client needs which require a non-technological, global or alternative clinical approach to that of our winning formula. A local trial in which (non audiologist) assistants were trained in hearing aid management showed several variations on this theme e.g. one client commented to an assistant "you're not an audiologist are you, you're really listening to me" (ouch!). Parent responses in a New Jersey survey on perceptions about audiologists included: "they don't listen,", "too much jargon" and "they make decisions for us". They also felt - I hasten to add - that we’re "supportive, instructive" and "connect us with other organizations" (WAIDE, 1999).
In addition to the bias towards details and measurements suggested above is the question of which yardstick of professionalism is guiding us (there are many). Consider for example, the mix of perspectives in our seminars and publications. To what extent do the implied notions of “need” and “help” reflect the current views of the hearing impaired/deaf community vs that of the professional community? In theory at least there is a strong overlap in the focus of our clients and ourselves i.e. we share a common definition of “professional”. If this remains an unchallenged presumption though, mismatches are a risk in interaction with clients e.g.
Audiologist (thinks): “I hope Mrs Gray is reassured by the thoroughness of assessments at this appointment. My friends will be impressed that I’ve just done the new Z3Z Test. The info is useful, and I can mention it in my Performance Review next week…”
Mrs Gray: (thinks) “It really hurts when Terri and the kids say “ah never mind”. I just want to hear about what’s going on in their lives, their ups and downs. The audiologist, Sally, is very pleasant. I’ll keep an open mind but so far she hasn’t wanted to discuss the isolation and sadness I feel, and which lead me here – well, maybe later. I hope these tests help me find a way to join in the family like I used to”.
It doesn’t always follow that a high regard by our peers and mentors will be shared by our clients, likewise many professionals with a low profile career are widely respected by the public.
A common criticism of the western health care system is that consumers feel rushed and not listened to, as in the above example. Certainly, one of the cited reasons for the lesser counseling of adult audiology clients vs parents and children is insufficient time. In response to this, an Australian clinic manager offered extended appointments to deal with the psychosocial aspects of hearing loss. This wasn’t taken up by the 5 or so audiologists; the main reason given being limited training in counseling adults. It would be interesting to learn what changes in training and appointment scheduling have taken place since then, the mid 1990’s.
False Smiles and “Elderspeak”
It’s a tired old cliché but worth repeating – first impressions are often the longest lasting. The physical appearance of ourselves and our clinics are obvious priorities, however a lasting confidence in us as health professionals usually hinges upon more subtle signs:
An earnest and friendly demeanour can quickly be undermined by contradictory behaviour. Kargas and Doyle (1996) for example, found that when audiologists were more than 15 minutes late, the client’s irritation was likely to persist throughout the appointment – despite the audiologist’s best efforts. Overly enthusiastic efforts to be “nice” can be off-putting, as well; especially if our tone drops noticeably at the hint of extra work required to help the client. Scripted spiels can meanwhile be useful tools in appointments. Unless the wording and intent are our own though, the message left may unwittingly include “this audiologist is fresh out of a communication/marketing workshop”.
Very obvious to our clients but less so to ourselves is how well our words match our body language – in cases such as the above, the tension of muscles around our mouths and the width of our pupils. Our intonation is the other big clue, and can be tracked and modified more easily than facial expressions. For the very clearest insights into what we do and don’t mean to say nothing beats candid feedback from clients and viewing our taped interactions.
Research on “elderspeak” offers a poignant view on the importance of personal greetings in the health care system. Of the 660 elderly people in Levy’s (2008) study, those exposed to descriptors like “forgetful” and “shaky” performed worse on memory and balance tests. Those commonly greeted with “how are we today?” and “dear” were more aggressive and less cooperative.
Careful Explanations …Quickly Forgotten
Another challenge to health services focused increasingly on an ageing population is the reality of adult learning and memory. Margolis (2004) comments that 50% of information given to patients is quickly forgotten, 25% is misinterpreted and only 25% is retained. As information increases, recall decreases, she noted. Martin (1990) surveyed client‘s recall of the reported degree of their hearing loss one week after their appointments. He found a 46% recall accuracy. Intelligence and severity of diagnosis were of less relevance than familiarity with concepts and emotional state, in consolidating recall. No wonder relatively simple procedures like cleaning a hearing aid are often forgotten! Consider in turn the cost to businesses of phone and counter queries plus aftercare appointments for (easily fixed) wax blockages.
A key reason why we may overestimate a client’s memory lies in our own familiarity/over- familiarity with the subject being discussed – teachers are thought to recall over 95% of a session’s content while students only recall around 20% (Chi, Bassok, Lewis, Reimann & Glaser, 1989). How often have you heard or said "...I told him so clearly last time, why can't he just remember it...?"
Promotion of client recall includes: written materials proof-read by end users before circulation, frequent checks on comprehension, limited new information per session, attendance of communication partners, consideration of local market research and staff training based on key issues obvious in outcomes measures. There are also many options available to clients themselves e.g. note taking, audio recording, clarification on written information at subsequent appointments and memory training.
Part One Summary
“Good” professional communication will at times be viewed differently by ourselves and our clients. This is often explained (above) by an overemphasis on details in audiology, insufficient training in counseling and limited discussion time in appointments. Client perceptions may initially be shaped by how they are greeted and how well our actions match our intentions. How the rapport evolves after that may be influenced by attention to client factors such as memory and learning style. The next part of this series deals with targeted choices of words, phrases and analogies for “driving the message home”.
It’s not the case that all audiologists have poor people skills. We can all identify contrary examples in ourselves and colleagues to the weaknesses listed above. The question “how am I coming across?“ will nonetheless apply right across our careers. Upsides to this and addressing communication “blind spots” include the capacity to gain more detailed information upon which to tailor clinical strategies and the building of long term relationships –being cornerstones of both rehabilitation and commercial models.
If you have any tips, comments or anecdotes on this topic please post them on the ASA online Members Forum. Alternatively email: ian.henderson@westnet.com.au
Ian Henderson
REFERENCES
Chi, M. T. H., Bassok, M., Lewis, M. W., Reimann, P., & Glaser, R. (1989). Self-explanations: How students study and use examples in learning to solve problems. Cognitive Science, 13, 145-182.
Kargas, S & Doyle, J Patient satisfaction with time use in Audiological consultations. British Journal of Audiology 1996, Vol. 30, No. 6, Pages 355-361
Levy, B In “Sweetie and Dear: A Hurt for the Elderly. New York Times October 7 2008.
To be published in The American Journal of Alzheimer’s Disease and Other Dementia’s.
Margolis, RH (2004) Informational Counseling in Health Professions: What Do Patients Remember? Retrieved from www.audiologyincorporated.com , reported in
Urban, B (2009) What do Patients Remember? American Academy of Audiology “Audiology Now” Convention, Dallas, April 1-4
Martin, E., Kreuger, S., & Bernstein, M (1990) Diagnostic information transfer to hearing impaired adults. Texas Journal of Audiology and Speech Pathology, 16(2), 29-32.
Tibita, L. (2008) “Why Don’t More Audiologists & Patients Engage in True Aural Rehabilitation? ” (Panel) American Academy of Audiology “Audiology Now” Convention, Charlotte, April 2-5
Western Australian Institute for Deafness Education (1999) Early Intervention Professional Development Seminar. Date and presenter name not available at time of publication.
COMMUNICATION WITH ADULT CLIENTS IN AUDIOLOGY: PART TWO
The second in a series designed to provide a day-to-day context to audiology counseling principles
Introduction
The first part of this series dealt with common audiologist’s “blind spots” in communication e.g. overemphasis on technical details and measurement, presumption about client’s reasons for consulting and lack of strategies to account for adult memory. This chapter suggests how apparently ordinary clinical discussions can significantly affect rapport building and client outcomes.
Skills from Practice, not Listening
Tell me and I may forget
Show me and I may remember
Involve me and I will understand
Chinese Proverb
An example of clinician frustration in Part 1 went as follows: “I told him so clearly, why doesn’t he remember!”. In addition to the known limitations of processing new concepts is the question of “where” information is best stored by clients i.e. as “declarative (knowing) or procedural (autonomous action) memory (REFERENCE) Comparison of learning styles in traditional cultures vs western cultures is a useful analogy in this regard – traditional learning is often whole-task and trial and error based while the western style is more literary and talk based. The latter doesn’t always produce best results for client recall e.g. how to clean slim tubing in 5-20 weeks time, apply communication repair strategies in background noise or use a T switch.
A“tickabox” approach to appointment can help our own memories, though sometimes only adds to the above weakness when it comes to galvanizing concepts with clients. Without client practice, our assessment of his/her competency and plans to redress if necessary, a column of ticks may only mean “I told her about X and Y, gave her something to read about Z…I’ve done my job Ô. Client hands on experience is the obvious recommendation here, as in the above proverb. Most would agree, however there are still suggestions we’re not “getting through” e.g. when longstanding clients say “nobody told me about that (button, cleaning tool etc)” it often means they really were told, but client competencies were not “signed off” at appointment.
If you’re feeling really confident about this, ask your clients to demonstrate or say back to you tasks and concepts you’ve taught them. It can show the difference between what you said and what you actually communicated. Findings on a high prevalence of auditory processing difficultes amongst people with presbycusis provides a further clue as to why training and practice are so important (REFERENCE)
Beautifully Said, Poorly Communicated
Just ask an OT - laying foundations in procedural memory as above will yield long term benefits. Most of what we communicate in audiology though, is by the spoken word. As such we’re told that at worst, we use too much jargon, are paternalistic and don’t listen.
How many people share our notions of “frequency”,“mid range”, “moderate”, “ear pressure” and “channels” for example? What is your understanding of “the pivot points use a nut-sert”? This is solar panel installation terminology and may mean as much to you as do audiology terms do to a client. Some clients will indicate uncertainty, though are likely to be in the minority e.g. “that’s gubldigook to me…”, “excuse me, can you please return to speaking plain English” (client comments).
One likely reason for the research finding on client’s poor recall of audiograms (Part 1) is the challenge of relating lines, crosses and circles on a graph to the subjectivities of hearing in daily life. One effective solution to this is to link the client’s daily communication and/or speech test results to the audiogram with concepts like bass/treble (not “frequency”), loud/soft (not “intensity”) and vowels/consonants. Pointing out small peaks and troughs and a gentle slope may have little or nil meaning. These are usually best left out unless critical to explaining client difficulties or a rehab plan; likewise air-bone gaps, unless explained with a diagram of the hearing system.
That’s not all, misunderstanding can work both ways, such as the audiologist interpreting lay-speak without clarification e.g. “high pitch” is used by some clients for “loud” while others use it for “tinny”; “echoey” may mean occlusion or excessive low frequency/overall gain; “beeping” may mean intermittent feedback, or flat battery/program signal; “inner ear infection” usually means otitis media rather than labrinthitis (though, check!)
You’ll Feel Better When You See Things My Way
Dr Thomas Gordon is known for coining the term “communication roadblocks” (REFERENCE) – common phrases which when used frequently or at the wrong moment can significantly undermine a helping relationship e.g. “it’s not so bad”(client thinks: “he/she doesn’t understand me, isn’t comfortable with my distress”), “it would be best for you if you would…” (client thinks: “He/she feels superior to me and that I can’t work things out for myself…”), “you need to understand that…” etc. The counselling principles of empathy and active listening give us obvious alternatives to these e.g. instead of “you should treat your tinnitus like this…” – “options for the intrusive tinnitus you’ve told me about include XZY, X being a good starting point because…”
Roadblocks peculiar to hearing aid audiology include:
“is that better?” - a leading question with social pressure towards a “yes” response. “Is that different?” opens the way to a more authentic response as the client is free to describe what is actually happening without a sense of what the “right answer” may be. If only “yes” is the answer you can probe with “in what way?” for more details.
“that should be better now”, at the conclusion of an appointment. Some client who then finds things are no better or are actually worse in the real world, may feel reluctant to return and/or say so. Three common reasons for this, according to clients themselves(REF), are that i) they’ll disappoint/trouble the audiologist who was so helpful and optimistic; ii) further disappointment following attention by the expert only confirms the “I’m just hopeless” theory; and iii) audiology and hearing technology can’t deal with “my sort of problem”. The reverse is also true – when an aid or mould is adjusted and a client says “that’s better!” it often transpires that they really meant “it’s a real relief to get away from that last setting” i.e. a relative improvement which may or may not stand the test of experience.
Fortune Teller or Health Professional?
The way we forecast clinical outcomes can impact greatly on our credibility. If we are frequently “black and white”, those words can return with a sting or “lose” a client if they mismatch his/her experience e.g. “when the GP gets my report she will probably refer you to an ENT to sort this out”, “the way I’ve changed your aids should help you to hear much better at the bowls club”. Just as an experienced VROA observer is aware of his/her degrees of certainty about a child’s response, it makes sense to express clinical predictions within a continuum of likelihood i.e.
---Very Likely---Likely---Probably---Possibly---Unlikely---Very Unlikely---
Unfortunately, many people will still process “grey area” statements as absolutes, and others will make a glass half empty/full interpretation depending on their world view. The risk of this is greatest when information is filtered through hope or fear. Some of this is within our control, some isn’t. A good rapport increases the likelihood of us being able to identify and work with a client’s mindset on the day.
“I don’t know” is often our most honest response and can come across in either of two ways – professional (action plan to gain more information explained) or unprofessional (no further comment, implying disinterest). One of the most important factors to determine which way this will swing is our network of allied professionals and community resources to draw on and refer to.
Part Two Summary
Achieving long term outcomes, especially with an ageing clientele, usually means changing the clinical context. For example, we usually associate learning with “chalk ‘n talk”, however better results often arise from embedding the memories in a client’s fingers and hands. The transition from tertiary education to a clinical load may or may not include learning a whole new language – the words and analogies best recognized by the public to explain audiology concepts. It’s easy to forget that most of these and the jargon we’re so comfortable with now were once new and alien to us, too. Taking that empathy a step further includes a partnership in tackling problems, rather than the usual “you need to…”s. Finally, audiology is full of ambiguities and emerging details. Saying so won’t blow your credibility, it may even strengthen it if done the right way.
The final part of this series deals with challenging clients and the ingredients of a long term professional relationships.
If you have any tips, comments or anecdotes on this topic please post them on the ASA online Members Forum. Alternatively email: ian.henderson@westnet.com.au
Ian Henderson
REFERENCES
Photos of Sonic Hearing clients by Ian Henderson, published with permission
Background paintings by Mr Barry Evans
COMMUNICATION WITH ADULT CLIENTS IN AUDIOLOGY: PART THREE
Introduction
The key points of Part 1 and 2 of this series were as follows:
* an overemphasis on details, tests and admin may be at odds with a client's interest and needs
* ignoring research on adult memory and learning can result in clients who either don't return or return repetitively
* few clients understand our jargon or have the same idea as us about "frequencies", "channels", "sloping audiogram", etc
* likewise, many client's use of "echoey", "low pitch", "static" etc may differ from ours
* phrases such as "you need...", "you should...", "don't worry about it..." are "roadblocks" and can work against rapport and trust.
* "is that different...how?" will return a more authentic response than "is that better?" (less social pressure to say "yes")
* practice and opportunistic checking on hearing aid skills have more enduring value than information counselling
* it's ok to say "I don't know", when client’s concern is acknowledged and a plan for gaining further key info is made
* it's often more appropriate to use "possibly"/"probably" than a definitive statement, when forecasting clinical outcomes
This final part of the series focuses on conflict management, respectful ways of discussing a client’s challenges and advocacy for people with hearing loss.
Up Close, Nothing Personal
Conflict avoidance and management is a reality for anyone working with the public; equally so when we ourselves are the patient or customer. A primer on this theme deserves detailed discussion elsewhere, however one point is worth considering - our own role in determining whether or not a challenge turns into conflict.
While the other party may be unreasonable, illogical or rude, tension may only creep into the dialogue when we are stirred up, and show it. Audiologist Glenn Johnson takes this a step further "sometimes you will clash with someone. Consider how you can alter your own behaviour to lessen the reaction. With experience, today's frustrations may well evolve in tomorrow's triumphs. However there may come a point where it is better to refer your client to a colleague, rather than persist with irritation and frustration. You don't have to be a "perfect match" for all clients…". *
Sometimes, the way we deal with simple issues can lead to tension. This is an even greater risk when the issue is one we face on a weekly basis, and have become blasé . To the client however it may be a first time, and concerning point e.g.
Client: "I want to talk with my GP before considering hearing aids"
Audiologist: "But GP's don't know anything about hearing aids …" (this undermines the GP and your rapport. Focusing on evidence based options and allowing client to follow their familiar pattern is likely to help retain them).
Client: "the other audiologist said I wouldn't have to do these tests again"
Audiologist: "He was wrong; our protocols say we always do it like this…" (Undiplomatic and officious. It's easier to suggest that your colleague was acting in good faith, then explain why an update or more details will help with diagnosis/referral/rehab).
Client: “the aid is good for TV, but hurts my ear”
Audiologist “it looks like you haven’t put it in properly” (“Properly” implies judgement of client responsibility or ability . “Snugly” or “securely” is more neutral).
* The ASA Code of Ethics offers useful guidelines on managing disagreement with both clients and colleagues.
My Needs Are Defined by Me, Not You
Early Twentieth Century Psychoanalyst Karen Horney coined the term “the tyranny of the should’s” to describe projection of one’s values onto others (Paris, 1994). Decades of liberal thought later, the term still points to a weakness in the health industry, audiology included. Feedback from University of WA Masters students attending lectures on this series’ theme included "ok, I can see why "you should/you need to…" is a roadblock, but just what are we supposed to say?". Depending on the context, options include:
Facilitating client choice: “If you want to do that (reach a stated goal), then option X would help because…”
Advice on a better option than the one nominated by client: “that would partly achieve/not achieve what you’ve sought help for as it’s limited by X. This option however will do a better job, because…”
Suggestion as to why client behaviour is one of the barriers to resolving a stated need: “you mentioned X earlier/ in your History – if you changed it like this/scaled it down it would help overcome XYZ. I can support you in this by…”
Client chooses clinically inappropriate option: “ I can’t do X as it is potentially harmful to you/against my code of ethics, however how would you feel about Y & Z?”
Client unhappy about multiple appointments with little apparent progress: “You’re right, we’ve been trying to resolve this for some time; and you’ve been patient throughout. Sometimes, when the standard approach doesn’t give the usual result, we have to explore other strategies. Most often, this pays off and we get a good outcome. I believe the best option now is to do XYZ then review the whole situation/refer/trial new strategy or technology…”
The point made in Part 1 is worth repeating here – delivery of these phrases in a rote, mechanical way is very offputting e.g. the sound of someone fresh out of a counseling workshop or overdosed on political correctness. The “right words” and conviction will flow once we’re focused on the best possible outcome, and have begun to understand the client’s stance. As Glenn Johnson suggests above, this gets easier with experience.
Client Advocacy
Audiologists are uniquely placed to foster understanding between clients and the public. Mythbusting in a family context is a powerful means of achieving this e.g.
“He’s got selective hearing”: Usually the result of real hearing loss, even a risk with 20 db HL (3FA). The reason why “he” may hear very clearly sometimes and not others depends on varying acoustics, competing sounds and familiarity with the context.
“She doesn’t concentrate, she’s lazy”. Most people’s hearing diminishes with time, however we may continue to “listen” in the same way we did when we were 20. We don’t always notice that more concentration and favourable acoustics and positioning in the room is now needed. Even with good communication strategies, the effort required can be tiring; like learning a second language. A well fitted hearing aid can help a lot, though in difficult times it still won’t be as easy as when “she” was 20.
“My hearing’s ok, they just mumble, especially the young ones”. The number of mumblers and people with soft voices and accents probably hasn’t changed; but as your hearing goes down you become more and more aware of who they are!
Another context for advocacy is that of the clinic, including differentiation between clients with complex needs and those with issues secondary to deafness. Stereotypes include “she’s just one of those people who like to come in for something to do”, “he’s just a whinger”, “she’ll never be happy, no matter what we do”, “it’s not fair, the Government don’t pay us for these extra appointments”. At this point, it can help to explain to support staff and other audiologists the reason for repeat appointments e.g. chronic feedback related to unusual canal geometry, collation of information for case management involving multiple professionals, repackaging of rehab to meet cognitive and skill challenges, measured client profile requiring more exploration. Yes, it’s also true that a client’s approach can contribute to the overall level of challenge in casework and the relationship. Comments above on self insight as an antidote to conflict provide a beginning to management of this ; training courses on dealing with difficult can clients take this further e.g (Author, 2006)
Part Three Summary
In short, the blame game is tempting but doesn’t work. Conflict management isn’t about political correctness; the broader context includes our careers, businesses and services. Parallel to this is maintainance of rapport, including effective alternatives to the paternalistic “you should”s and “you need”s. Finally, a well timed reality check on how deafness “works” can make life easier for ourselves, clients, their family and clinic support staff.
Communication with Adults in Audiology: Series Conclusions
This series has aimed to show how the subtleties of our everyday transactions can impact on client outcomes and our overall efficacy as audiologists. Professional communication guidelines tend to have an academic tone until given personal meaning in our own lives eg the highs and lows of casework, caring for a sick or disabled loved one, accessing the system during personal crisis. We seek help from people with good reputations or who project competence and humanity. In the end though it’s the apparently small things which can leave the most enduring impression e.g. our tone of voice when discussing a routine issue which is nonetheless a cliff-hanger to the client, a quick response or no reply to emails and phone calls, our information and referral resources on deafness in addition to those arising in the course of commercial activity , the way we respond to judgements made of our clients by family members and other staff.
There is no one “best way” of dealing with communication challenges, only the goal of improving and reviewing our own style throughout our careers. As one Audiology student put it: "I am someone who likes solid, structured answers, however it’s good to see that with client communication - one response can't and won't fit all…" (UWA student, 2009)
REFERENCES
Johnson, Glenn (2010) Personal communication
Paris, Bernard (1994) J. Karen Horney: A Psychoanalyst's Search for Self-understanding, Yale University Press, New Haven
University of WA Masters of Audiology Students (2009) Personal communication and evaluation sheets
