Patient Management | September 2017 Hearing Review
12 questions that can help bring the patient to the solutions they need.
As a national trainer for three of the largest hearing aid dispensing companies in the United States, I have observed hundreds of patient evaluations. Many clinicians are highly adept at interacting with and counseling patients. Yet, in my heart and mind, something was always missing every time a patient with a severe hearing loss would say upon receiving the recommendation, “I don’t think my hearing is that bad,” or “I want to think it over.” In these cases, it’s hard not to admit that the hearing care field is failing to communicate with the patient and (when present) their significant others in a way that makes the hearing difficulties of the patient unavoidably clear and makes the need for hearing help undeniable and evident—even to the most reluctant patient.
So the question becomes, “What am I capable of doing as a hearing professional to impact the patient in a way that makes lifestyle changes palpable and desirable?”
Ideas and Paradigm Shifts
At one time, one could make a very good argument that the advent of digital hearing aid technology was not as important as the switch to wide dynamic range compression (WDRC) hearing aids. Today, with the advanced wireless features, feedback and occlusion reduction algorithms, a host of digital hearing-in-noise solutions, and rap- idly expanding telecare options, I think few people would argue that digital aids represent a new paradigm in hearing healthcare.
The heart of all invention is the thinking that creates a new paradigm for thought. For example, think of all of the ramifications new self-driving cars create for you—without really knowing anything about the myriad of problems and benefits we will all be experiencing in 20 years. There is no such space in our culture to critically think about the subject.
This article explores a new way of thinking about the hearing evaluation and counseling. But one of the overarching premises of the article is this: One of the biggest favors you can do for a patient (and for yourself) is to make sure he/she is accompanied by a spouse, close friend, or family member during their first appointment. In particular, your patient care coordinator or receptionist must be aware that, when scheduling patient visits, one of the most important tasks they have is to get a third-party person to attend the initial consultation with the patient.
What Exactly Is Counseling?
Seek first to understand then seek to be understood. Beyond a shadow of a doubt, the word “counseling” is the most misunderstood word in the hearing industry. Most think it means to tell or educate your patient. It does not!
Counseling is the keen ability to ask perceptive questions and listen closely to the patient’s answers so that the hearing care professional (HCP) can gain profound insights into the patient’s world—as told by the patient. Far too often the HCP becomes intoxicated with the sound of their voice and drones on about what they know, thinking their duty is to share their hard-earned knowledge. However, the answers to acceptance of a patient’s hearing impairment and the decision to purchase hearing aids resides within the patient. They cannot be “told” into these decisions. The key to changing this well-accepted paradigm in the hearing industry is new thinking, which does not live in our old case history forms.
I read an article recently which said that the HCP should make a studied effort to get to know the patient. I agree. However, there is a greater goal that the HCP should keep in mind, and this is the heart of the matter in the counseling approach.
People go to counselors and healthcare professionals because some aspect of their life is not working. When it becomes clear, due to the focused efforts of the counselor, the patient then comes to grips with their role in the part of their life that is not working. At this point, the patient realizes and has the ability to change their self-sabotaging behavior.
Once a hearing-impaired patient becomes aware of how they limit themselves by dismissing their auditory difficulties, with the artful help of the hearing professional, they can become open to professional recommendations—and the process of helping themselves.
We are often blind to important dimensions of ourselves. Why do you think patients with obvious hearing loss deny the facts pre- sented to them by people they normally love and trust? We humans do not want to admit or be faced with our personal deficiencies. Wearing hearing aids that others may see is a critical admission of one’s shortcomings. The patient with a broken leg needs no encouragement to go to the emergency room, for the gravity of the situation is painfully clear.
Where does the pain live for the hearing-impaired patient? The pain lives in the listening environments in which they cannot function effectively, and the emotional pain that occurs as they lose contact with spouses, family, and in important social circumstances (the ones they most value). Once the patient becomes clear about all of this with the help of the hearing professional, they will become far more open to acceptance of their hearing impairment and more likely to take action by accepting their HCP’s recommendations.
What Might Work Better than Talking and Telling?
Getting the patient’s emotional cards on the table. In each evaluation I’ve witnessed, the starting point seems to be an authentic attempt by the HCP to establish rapport with the patient in pursuit of creating trust and friendship which calms the patient and creates an atmosphere of comfort.
Once the ice is broken, let the insightful questions begin. Once you are confident that proper rapport has been established, smile and ask, “What are your expectations of me?”
A common (and truthful) answer may be, “We are expecting you to try and sell me hearing aids.” The HCP should not be surprised by this answer. Frequently, there is a adversarial attitude on the part of the patient, and it is expressed as reluctance, denial, and/or guarded skepticism. However, the patient’s answer in these cases leaves the door open for the HCP to respond in a manner that will put the patient and third party at ease, and dis- charge any hidden agenda hanging over the evaluation. The HCP and the patient often find that the “expectation question” is a relief valve for all involved in the evaluation, and sets a tone of honesty and intimacy for the rest of the evaluation.
“If you can’t close you can’t sell.” Closing a sale—or more appropriately phrased, convincing a patient to take action—is important. However, this short error-filled axiom misses the point; if the patient is not open to the process the HCP is about to recommend, there can be no “close” or help for them. It is impossible to help someone who is not open to the emotional process of accepting a hearing impairment and seeking help through some kind of amplification device (usually a hearing aid). Helping the patient to see their situation honestly is the critical step.
Throughout this article we will be work- ing with Bob and Mary Jones, a hypothetical patient and spouse of the patient, respectively.
Examples of Utilizing Third-party and Experiential Counseling
HCP Question #1: It’s important that I understand your world of communication so I have a clear sense of what is going on for you on a daily basis. Bob, who encouraged you to come see a hearing care professional?
Reluctance and denial start to go out the window when the third party is present. If the patient says, “It was my idea,” you know you’re in a pretty good position; it shows the patient already has at least some ownership of the problem. In that case, the HCP should follow up with, “Please tell me about that.” At this point, the patient is almost required to speak to his/her concerns about a hearing loss.
If the patient says, “It was my wife’s idea,” in an attempt to move beyond personal accountability, we take this in another direction. In either case, the counseling protocol should shed light on the patient’s truth.
One strong suggestion is to use the word “communication” in place of “your hearing.” The primary reason to use “communication” is because the patient can be sensitive to and defensive about conversations addressing his personal deficiencies. In fact, he/she may be a master at fending off suggestions of a hearing problem. Second, most people view communication as a two-way street for which they are not totally accountable. Third, in most cases, we really are more interested in communication ability as opposed to hearing or audibility (remember, a lot of patients say they hear fine, they just can’t understand people).
HCP Question #2a: What sorts of things has Mary been saying about the communication between the two of you?
Bob: “She says I don’t listen to her and she feels that she has to repeat too much. However, it’s impossible to hear her sometimes with all the background noise, and Mary mumbles sometimes or is turning away from me when she speaks.” At this point the patient thinks he has absolved himself from responsibility for the breakdown in communication with his spouse.
HCP Question #2b: Mary, what have you noticed about the communication between you and your husband, Bob? Though we have heard the husband tell us what his wife has said, we want to hear it straight from her mouth, so that she has a sense of involvement and ownership in this process.
Mary: “He doesn’t listen to me—or at least he can’t hear me. It is very hard to have an important conversation with him because he doesn’t hear the most important details or points. Plus I feel like I’ll scream if I have to repeat myself one more time!”
HCP Question #3a: Mary, how long has communication been difficult between you and Bob?
Mary: “Oh, it has been at least 3 years.”
HCP Question #3b: Bob how long would you say communication has been difficult between you and your wife?
Bob: “I don’t think it has been any 3 years—maybe a few months at the most.”
HCP Question #4a: Mary, how do these communication difficulties with your husband concern you? It’s important to get a complete and full answer; let the third-party person (Mary) express themselves. This often represents a turning point in the counseling protocol. The conversation may take an unexpected turn and even become emotional. The point is that the patient is now presented with some of the consequences of untreated hearing loss from someone he/she cares about and respects. For example…
Mary: “I am not only put off by the fact that I have to repeat; I have come to think that safety is a real issue.”
HCP Question #4b: Please help me understand why you think safety is an issue. Conversation leads you to natural follow-up questions; these are the impetuses behind getting at the patient’s truth.
Mary: “When he is driving, he doesn’t hear horns or sirens. Once I came home and something on the stove was burning and the smoke alarm was ringing, and he did not hear that either.”
Let’s assume for the sake of seeing all sides in this dilemma that the patient said he is only in your office because his wife made him come to the appointment. What we must have is the patient’s ownership of this appointment. Returning to Mary’s concerns about safety: if the patient has told you he only came into your office because his wife persisted, he is not taking any accountability for being there. This is, of course, a form of standard denial and is relatively easy to overcome.
HCP Question #5: Mr Jones, do your wife’s concerns about your ability to communicate effectively as a couple concern you? This is a pretty hard question to answer “no.”
Bob: “Of course they do or I wouldn’t be here.”
HCP Question #6: Then, Mr Jones, given your concern, would it be fair to say that you are not only here for your wife, but you are also here for yourself? Again, the patient has no choice but to say yes, thus admitting ownership of the visit to your office—and a personal investment in the outcome of the evaluation. This is quiet a departure from his original statement that he was only in your office to appease his wife.
So where are we, five minutes into this new case history?
- The patient has told his story about his hearing.
- The third party has told hers.
- The third party has expressed legitimate concern about her spouse’s hearing, and (in this case) his safety.
- They have both admitted that communication difficulties have been going on for some time.
- The patient has told us that he shares his wife’s concerns and, in essence, he owns the visit to your office.
Not bad for such a short time. These are the consequences of insightful questions that are designed to lead the patient to a deeper understanding of the cost of hearing impairment.
HCP Question #7a: Mrs Jones, you said that you have been aware of these communication difficulties for 3 years…Do I have that right? All parties must realize that you have heard them accurately and that you are paying close attention to this entire conversation.
HCP Question #7b: Mr Jones, you said you have been aware of communication difficulties for only [this minimizes his time frame] a few months. Do I have that right?
HCP Question #8: However, Mr Jones, you did not come in one week ago, or one month ago, or even a few months ago. What was it about now that you decided to come in? Once again, the patient will provide a more revealing answer than before, due to your follow-up question.
Bob: “Well there just isn’t much peace at home, and I got tired of fighting over this subject.” This is critical. When you want to get at emotion you should ask what is the impact, effect, or result when you are unable to communicate effectively in a specific listening environment.
Understanding Difficult and Critical Listening Situations for the Patient
HCP Question #9a: Mr Jones, besides at home with your wife, what is another difficult listening environment for you?
Bob: “Well, when I go to a restaurant with my wife or friends, it is impossible to hear what is being said.”
HCP Question #9b: What is the effect of that on you?
Bob: “I find myself feeling excluded.”
Always try to collect several specific and meaningful listening situations in which the patient is experiencing communication difficulties, and then ask about the impact, effect, or result of that hearing difficulty. You may ultimately get to the emotion(s) that leave the patient feeling frustrated, angry, and disconnected. These emotions will be used when the HCP summarizes what he/she has learned during this counseling protocol.
On the other hand, do not ask, “How does that make you feel?” This question does not have any power, and leaves the patient searching for emotions that he/she is often unwilling to express. It’s recommended to try to get at least 2-3 listening situations in which the patient struggles (similar to a Client Oriented Scale of Improvement [COSI], which can also supplement this protocol):
HCP: What is another difficult listening environment for you Mr Jones?
Bob: “Sometimes I get things wrong on the phone at work and that creates problems.”
HCP: What sort of problems Mr Jones?
Bob: “I am a lumber broker and make my living selling plywood by the carload. If I get an order wrong, it can cost my company thousands of dollars.”
HCP: When you get an order wrong, what is the result of that for you Mr Jones?
Bob: “Well, it’s embarrassing and unprofessional and I feel incompetent—and it can cost us money.”
HCP: Are there any other difficult listening environments that come to your mind Mr Jones?
Bob: “I really enjoy my grandchildren and often I don’t hear exactly what they are saying, and my daughter tells me that they sometimes think I don’t care what they say. That breaks my heart!”
At this point we have received what we need from Mr Jones regarding difficult listening environments without pushing. I recommend that you do not push, because you may alienate the patient.
At this point in the counseling protocol, it is a good opportunity to explain the audiogram, because the patient is coming to some realizations about his hearing and is likely to pay closer attention to your findings about his hearing loss.
HCP: Mr Jones, everything you have told me makes perfect sense. Let me show you why…The HCP explains the patient’s audiogram, and ties it in to his difficult listening environments.
HCP Question #10: Mr Jones, you have given me four difficult listening environments:
- There is at home with your wife Mary,
- There is out in restaurants with your friends and Mary,
- On the phone at work, and
- Time spent with your grandchildren.
So that I better understand what is really important to you, could you please prioritize these environments in order of importance to you?
Bob: “Well, my wife would be the most important, then the phone at work, my grandchildren, and out in public at restaurants.” Though it may not flow off his tongue this easily, gently stay with the patient so that they are able to prioritize the order of importance to them. Then repeat the environments along with the attendant emotions, starting with the least important environment and ending with the most important environment:
HCP Question #11: So, Mr Jones, if I could:
A) Help you communicate with your grandchildren better, so they knew you cared and you didn’t get upset due to communication difficulties with them;
B) If I could help you hear more clearly on the phone at work so you did not feel embarrassed or unprofessional, and perhaps be at risk of losing your company’s money;
C) If I could help you communicate better in restaurants so that you did not feel left out and disconnected when you are with your friends and Mary, and
D) Perhaps most importantly, if I could help you and Mary communicate better at home, and that prevents her from getting annoyed about repeating herself all the time…
Would these be the results that you are looking for, provided I could fit this into your budget? How can Mr Jones say anything but “Yes,” as you are only repeating what he has told you?
Bob: “Yes, that would be great, and I would like to take a closer look at it. But, of course, this means money…”
Demonstration and Recommendations
At this point, you’ve entered a distinctly different part of the initial consultation. However, the “heavy lifting” portion—convincing the patient and third-party there is an important and solvable problem—has been accomplished. They are on board. You can now begin demonstrating the solution by programming a pair of hearing aids and placing the devices on the patient.
Similar to the previous counseling protocol, the primary objective of the demonstration is to allow the patient and third party to convince themselves about the benefit of accepting the HCP’s recommendation. Allow the third party to have plenty of interaction in this endeavor, reading word lists, sentences, etc. The last questions allow them to confirm their mutual need for the amplification:
HCP Question #12a: Mrs Jones, what will be the daily impact on your life if your husband could hear you like this around the house and in restaurants?
Mary: “Oh, this would be a game changer. We wouldn’t fight (well, not as much!), and I could be heard without having to repeat myself constantly.” Mr Jones still has his hearing aids on and heard every word that his wife just said.
HCP Question #12b: Mr Jones, what will be the daily impact on your life if you were able to hear your wife at home with ease, your grandkids, on the phone at work, and in restaurants as well as what you just heard when I put these hearing devices on you?
Bob: “Mary is right. This would help me quite a bit. However, I am still not sure how we’re going to pay for them.” Money is a common issue for hearing professionals, and at this point you must present your best professional answer—possibly including different technology options. Financing options should also be mentioned and, if they’re interested, most financing companies provide fast approval processes. Sit down with your patient and come up with the best possible plan to address the money question.
Of course, these questions and answers do not always unfold as easily as in the text above. The truth is that listening and the formulation of insightful questions are skills that need to be honed and developed to better assist your patients. However, arguably, counseling is the most important skill you can have as a hearing professional—and you will also find many other areas of your life where these principles translate effectively.
If this strikes you as difficult, it is—until you decide to throw your heart into it. We live in a culture that likes to talk and give advice. In truth, the key to an effective counseling protocol is listening and asking insight- ful and caring questions of those who come into contact with you.
Correspondence can be addressed to Von Hansen at: [email protected]
More details about the counseling protocol are also offered by the author upon request.
Original citation for this article: Hansen V. Developing a persuasive counseling protocol that works for you and your patients. Hearing Review. 2017;24(9):32-37.