The field of audiology swings on a pendulum that began in rehabilitation and swung heavily toward diagnostics as we developed increasingly sophisticated means of identifying the locus of pathology within the auditory system. The profession’s diagnostic services through the years have become indispensable to the otolaryngologist’s treatment of oto-pathology, yet it seems clear that the profession of audiology can never find its autonomy fulfilling that role. Audiology can only gain autonomy through rehabilitation.
Diagnostics, by necessity, will always remain an important aspect of audiological care; it is upon our diagnostic endeavors that we base our treatment recommendations. Nevertheless, audiology will always have its greatest impact in its ability to assist those with hearing loss to become more active and more successful through improved hearing.
Twenty-five years ago, audiologists clamored for the right to dispense hearing instruments. While the American Speech and Hearing Association (as it was known at the time) maintained that the linking of diagnostics and dispensing by the same professional was unethical, many of its members felt differently. In the end, audiology practitioners and the patients they serve won out, and the irrational ban on dispensing was lifted. The opportunity was granted to us all to show that we could indeed fulfill the visions of the founders of the profession: a vision for truly meeting the comprehensive rehabilitative needs of those with hearing loss.
Unfortunately, somewhere along the way we lost sight of our mission, and we, along with our patients, have been the poorer for it. We created a promise that we have not fulfilled. The unforeseen travesty is that we routinely stop treating our patients before we finish.
There have been claims that audiologists could do a better job than the more traditional means of dispensing hearing instruments. But if we look at the instrument return rate for hearing instrument dispensers and audiologists, as shown in the accompanying table, we might question how much better we are doing. Before audiologists began “ethically” dispensing hearing instruments, the standard dispensing practice was to set an initial appointment with those with hearing loss to evaluate their hearing, to explore their needs, and to make an impression of their ear(s). This was followed by a fitting appointment, typically 2 weeks later, which in turn was followed by a post-fit check usually in another 2 weeks. Things haven’t changed much with the fitting process reaching completion in three to five visits regardless of the background of the dispenser.1
I believe the founders of the audiology profession had envisioned more from the dispensing process. I believe they were (and are) disappointed when they see that the accepted protocol for hearing instrument dispensing has not changed significantly from what it was years ago.
Our Goals for Our Patients
Our goals in the dispensing process are simple and straightforward. We want to provide a valid reduction in the psychosocial and communicative impact of hearing loss for patients. A worthy goal, indeed. And one I am sure all hearing care professionals would ascribe to. We want to help our patients to maximize—not just improve on—their communication efficiency. This is another worthy goal that we would hope to fulfill. And, finally, we want to ensure a lasting satisfaction with the intervention we have provided to our patients. This, too, is a worthy goal. Unfortunately, we cannot achieve these goals in three to five visits. Our return rates attest to this. And the currently low reported levels of satisfaction with hearing instruments2 attest to this as well.
We have largely abandoned the rehabilitative aspects of the dispensing process. In particular, the human aspects of audiology have fallen to the technical/diagnostic aspects of dispensing hearing instruments—to the detriment of our goals with our patients and, I believe, to the embarrassment of the profession.
We need to instruct patients in much more than the use, care and maintenance of their hearing instruments. If we are to meet the above goals, patients and their families need instruction in the identification of sources of communication breakdown, how to identify obstructive responses to the problems they encounter, and how to master more effective communication behaviors. These are not things that can be realistically accomplished, one-on-one, within three to five visits in the typical dispensing protocol.
Group Intervention: An Impracticality within Routine Practice?
The idea of group audiologic rehabilitation (AR) is hardly new. It is out of such group therapy that the profession of audiology grew within the early military aural rehabilitation programs established following World War II. Unfortunately, outside of VA and university clinics, group intervention is most often viewed as impractical for a variety of reasons.
It is true that most practitioners have recognized that group intervention can be financially beneficial to a practice in spite of the problems that may be encountered in obtaining direct reimbursement for the services rendered. Although compensation may not be as direct, as it is with diagnostic testing or hearing instrument dispensing, the indirect profit advantages that these services bring to a dispensing practice can easily justify their inclusion. These can include a reduced return rate for dispensed hearing instruments; a decrease in the time-intensive trouble-shooting visits with patients who have not been fully versed in hearing loss management; increased word-of-mouth referrals from more highly satisfied patients; enhanced community relationships; and the marketing niche provided when offering fully comprehensive hearing care services.
However, in spite of these benefits gleaned from group AR, audiologists often point out that there is not time within the workweek to provide these services on top of all the other requisite duties within their practices. Most who advocate group AR classes state that the ideal number in a class would be six to twelve people. However, the success of any group AR class is based upon the participation of both the individual with the hearing loss and one or more important communication partners. Within a class of 12, at best we can only include six hearing instrument users.
Compounding the numbers problem is the fact that patients fit with amplification for the first time are not the only prime candidates for AR classes. Those who decline hearing aid recommendations can benefit greatly through inclusion in a class with their peers who have taken the plunge they themselves may still fear to take. Getting these individuals within a group of their peers who are acclimating well to new amplification may be just what is needed to help them to move along the “readiness continuum” that stretches from denial of the problem to a desire to take action to correct the problem. In addition, there are patients who have worn hearing instruments successfully for many years yet would benefit from the communication enhancement training provided in AR classes.
A sizable practice can quickly lead to a string of small AR classes further making the inclusion of such classes within the standard hearing instrument dispensing protocol more problematic. Yet, how do we say we do not have time to do the most important part of what we should be doing?
Even when hearing care professionals recognize the benefits of AR classes, and feel they can invest the time to conduct the multiple classes that may ensue, they can be quickly stymied by the lack of space within their practices to offer group classes. Typically, university and VA settings advocate group AR classes. However, as Stika and Ross3 point out, most hearing instruments dispensed in this country are dispensed in private practice settings and physician’s offices. These non-university/non-VA-dispensing practices typically do not have the requisite space to hold even a small AR class. A class with only three new hearing aid users with a significant other in tow comprises a pretty cramped group within most practices.
Hearing Instrument Return Rates
Source: MD Skafte, The Hearing Review, June 20001
Making the Impractical Practical
The greatest impediment to conducting AR classes within most clinical practices is the space constraints within the office. When space is a constraining factor, consideration toward moving AR classes outside of the confines of the office can present a number of advantages. The obvious is the ability to move into a larger space. Additional important advantages are the alliances we can forge with other groups, the greater visibility we gain within the community, and the opportunity to market our classes to potential future customers who have either purchased their first hearing instruments elsewhere or who are still gathering information prior to taking action. There are a number of agencies willing to host repeated non-commercial “Hearing Help Workshops” including hospital-based community education programs, church groups, and senior citizen centers.
It is unfortunate that advocates of AR classes typically present this vital adjunct to the dispensing process as one conducted within small groups much to the exclusion of other approaches. If hearing health care is ever to tap into the large population of people with hearing loss who have not sought corrective services, its professionals will need to increase the benefits derived from services rendered and thereby increase the satisfaction levels of those who purchase and use hearing instruments. Toward this end, larger numbers of audiologists need to be converted into active participation within the rehabilitative final step of the dispensing process.
Conducting AR classes held in facilities that are separate from the dispensing practice to accommodate larger groups of hearing instrument users and their significant others is a viable means of attaining practical AR instruction. Through increased satisfaction with hearing instruments, large-group AR classes can become a key to facilitating action among the population of those with hearing loss who have not sought corrective services.
It can be argued that small AR classes of six to twelve people enhance the interactions between the facilitator and members of the group, and among the members themselves. Trychin4 rightly points out that learning is best facilitated when a concept is presented followed by an opportunity to practice that concept within a real-life or simulated context. Such interactions never reach the same level of familiarity and openness in large groups.
This fact, however, does not preclude the occurrence of significant learning. It simply means that a different dynamic is in place. An elementary classroom with a teacher-pupil ratio of one to 12 has a different dynamic than one that has a ratio of one to 24. That doesn’t make the learning in the larger class insignificant; useful information is still learned. This is true with large group AR classes as well. Group intervention need not be an impracticality within routine practice.
Where To Begin?
Many professionals shy away from audiologic rehabilitation beyond the mechanics of hearing instrument dispensing. They do this not because they do not think AR is a primary aspect of the services that hearing care professionals should provide, but rather because of personal insecurities in the provision of AR services stemming from a lack of exposure in the area and the lack of a practical means of providing the services. While the good news is that large group hearing therapy classes provide the means, this news is sweetened when it is realized that the methods for conducting group classes are clearly delineated for them. It is not necessary to reinvent the wheel in order to present the follow-through care required to meet the needs of patients and the future of the profession’s growth. A number of resources are available that provide outlines, materials, and guidelines for AR classes.5-7 The hard work has already been done for us.
The primary theme for the workshops should be better communication and, as such, all discussion should tie into communication, what impedes it, and what can improve it. While we might start with the usual overview of the ear and audiogram, discussion should be related directly to things with which the class participants can identify. Those with the hearing loss, and their significant others in attendance, should clearly understand why speech may sound mumbled to the person with hearing loss and why this person may seem to understand sometimes but other times miss what is said. Knowledge of the sources of communication breakdown related to the listener, the speaker and the environment can go along way in learning to circumvent or minimize breakdowns. Discussions on repair strategies, methods of clear speech, and the importance of not bluffing are important to all who are trying to communicate successfully in the presence of hearing loss. Discussions on hearing instruments, proper expectations and limitations, as well as the many advantages of assistive listening devices, are also integral to the class presentation.
Classes are most effective as two- or three-part workshops lasting 60-90 minutes per session, although some may favor more (or even fewer) sessions. A good approach is to announce AR classes as “Better Hearing Workshops,” as many potential participants may be reluctant to sign up for a class labeled as “therapy.”
Pulling it Together
It is unfortunate that it is a minority who will attend any form of group AR class, as most families with hearing loss in their midst will benefit significantly from the lessons learned. In spite of the fact that most reports indicate only 20% sign up for AR classes when offered, it is important, from the standpoint of meeting our implicit responsibility to the goals of the fitting process, that these classes are made available. Several means of increasing attendance in AR classes can be employed. Some hearing care professionals, recognizing the fewer return visits made by those who attend AR classes, offer an incentive such as a year’s supply of free batteries for those who attend. However, the numbers attending may be most closely related to the ability to convey the importance of the material to be learned to potential attendees. At a minimum, a brief discussion of the Better Hearing Workshop—presented with a printed announcement of purpose, dates, and times—should be given to every patient: new patients, long-time patients and prospective hearing instrument users.
If a large-group approach is selected for AR classes, a facility to hold the workshop can most often be easily found among local hospitals, community centers or churches. Perusal of the community newspaper for the locations of various self-help group meetings can also reveal potential workshop locations. The facility selected may even have its own newsletter permitting announcement of workshops to persons outside of one’s own practice.
Local newspapers will often place an announcement of workshops in their self-help column if the listing is worded to mention the non-profit host site and not one’s for-profit practice. And, of course, fliers with a good cover letter should be sent to all patient referral sources and potential referral sources. Certainly one advantage of large group AR is the ability to disseminate better hearing and communication guidelines to a larger segment of the general population of persons with hearing loss.
When the full gamut of the treatment provided is defined almost exclusively by the hearing instrument dispensing process, we are short-changing our patients, our profession and ourselves. Truncating rehabilitation services with the delivery, verification and validation procedures entailed in the dispensing process is not fulfilling the full mission that the founders of audiology envisioned for the role of audiologists. The American Academy of Audiology mission statement, for example, calls on audiologists to provide “efficacious hearing health care that optimally meets the nonmedical needs of persons with impaired hearing.”
If dispensing professionals do not provide patients with an opportunity to learn strategies to effectively manage their communication environments and the communication breakdowns that are routinely encountered, can we truly say we have optimally met their needs? If we do not provide our patients with these opportunities, who will?
We have the potential for a win-win-win prospect. If those in aural rehabilitation can broaden the vision of AR classes to include a large-group format, they have the potential to win, as the dream of enlisting more hearing care professionals into the provision of these services may begin to flourish. If larger numbers of audiologists in the mainstream dispensing environments of private practice and physician’s offices begin to embrace the provision of AR services, they too will have won as they begin to make a greater impact than previously possible with the patients they serve. And finally, if AR classes do at long last become the normally anticipated capstone of the dispensing process, then the larger public with hearing loss and their families and friends will have truly won.
|John Greer Clark, PhD, is director of clinical services for HearUSA/Helix Hearing Care of America, Cincinnati, Ohio.|
Correspondence can be addressed to HR or John Greer Clark, PhD, HEAR USA and Helix of Hearing Care of America, 5963 Glenway Ave., Cincinnati, OH 45238; email: [email protected] If you would like to obtain a copy of the conference proceedings, or find out more about the next conference (to be held in May 2003), contact: Geoff Plant, The Hearing Rehabilitation Foundation, 35 Medford Street, Somerville, MA 02143; email: [email protected]; Web site: www.hearf.org.
1. Skafte, M.D. The 1999 hearing instrument market—the dispensers’ perspective. The Hearing Review. 2000;7(6): 8-40.
2. Kochkin, S. The VA and direct mail sales spark growth in hearing aid market. The Hearing Review. 2001;8(12), 16-24,63.
3. Stika, C. & Ross, M. Consumer responses to a hearing aid services and satisfaction questionnaire. Adult Aural Rehabilitation Conference. Portland, Me. 2001.
4. Trychin, S. 2001. Living with hearing loss: What people who are hard of hearing and their significant others should know and do. Adult Aural Rehabilitation Conference. Portland, Me. 2001.
5. Clark, J.G. & Martin, F.N. (Eds.) Effective Counseling in Audiology: Perspectives and Practice. Boston: Allyn & Bacon. 1994.
6. Matonak, K. A rehabilitative program for long-term success. In R. Sweetow (Ed.), Counseling for Hearing Aid Fittings. San Diego: Singular Publishing. 1999;205-259.
7. Wayner, D. S. & Abrahamson, J. E. Learning to Hear Again: An Audiologic Rehabilitation Curriculum Guide. Austin, Tex: Hear Again Publishing. 2001.