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This article explores the questions HCPs can ask early within every hearing aid consultation to increase patient adherence to recommendations and reduce returns, thereby saving valuable clinical time and improving a clinic’s bottom line. By John Greer Clark, PhD, and Michael A. Harvey, PhD Hearing aids that are returned to the manufacturer for credit result in more than lost income for clinics. These returns represent lost opportunities to be of assistance to patients and their families struggling with communication as well as a substantial clinical time investment that cannot be recovered. Equally vexing is the fact that patients who return hearing aids during their adjustment period and choose not to pursue amplification return to their communities with their own reports that they tried hearing aids but did not find them beneficial. Bad news spreads fast. There are a variety of reasons hearing aids may be returned to the manufacturer, and many patients who return hearing aids continue with the fitting process and become successful hearing aid users. But even a small fraction of the hearing aid returns that represent lost fittings, or patients who chose not to accept the recommendation for hearing aids, can adversely impact a clinic’s bottom line. Two questions, asked early in the consultation, can lead to greater numbers of successful hearing aid fittings. These questions take virtually no clinical time for the majority of patients but are paramount in opening requisite dialogues for those who are not yet prepared to pursue amplification. Not All Patients Are Ready for Help A fatal flaw in any patient encounter is assuming patients want the help that they are requesting and that a professional is ready to offer. The majority of adult patients who make an initial audiology appointment with a complaint of hearing loss appear to be ready to obtain hearing help, which most often includes the purchase of hearing aids. But this is not always the case. A systematic review and meta-analysis recently found that as many as 38% of those who purchase hearing aids do not continue with their use.1 This is consistent with the fact that audiologists frequently see patients who are in denial of the impact of hearing loss or are not yet ready to use hearing aids based upon attitudes, perceived stigma, or a lack of internal motivation. More than 50% of those who schedule a hearing test or purchase hearing aids have reported that family members were key influencers in their action.2 This suggests that the consultation may not have been the patient’s idea and readiness for amplification may be lacking. If the audiologist proceeds with recommendations for treatment when readiness is not present, we might see one of three outcomes. 1. A patient who challenges our findings, fails to acknowledge a perceived impact of the hearing loss, resists professional recommendations, and ends the appointment with a stated intention to talk it over with a significant other or a comment that the intent of the appointment was only to obtain a first opinion and that decisions are not to be made at this time. Famous last words: “I’ll be in touch.” 2. A patient who appears more compliant, but who is in reality not fully on board. This may be characterized by the following psychological dynamics: From the patient: People tell me I need help, but I disagree. Therefore, I will ask for help, but not accept it. The doctor explains how treatment will help. This makes me angry, but I cannot show it because that will make the doctor talk more. So I’ll nod my head and plan my escape. From the audiologist: It’s clear that this patient needs help. If I explain this thoroughly enough and convey my expertise, then the patient will trust me and accept my help. I know I’m succeeding at this because the patient is nodding in agreement. 3. A patient who recognizes there is a hearing loss and moves forward with recommendations but is not psychologically prepared to use hearing aids. Patients falling within this third potential outcome often join the ranks of those who have “tried” hearing aids only to later return them or who leave their purchased hearing aids in the dresser drawer. The solution to these scenarios is simply to check on the patient’s readiness for help before proceeding with recommendations. You can determine a patient’s readiness by their perceived importance of treatment recommendations and their comfort level. A Question of Importance Using responses from a previously completed self-assessment questionnaire (or statements the patient has made earlier in the consultation), a readiness check is as simple as asking, “How important is it to you to have fewer arguments about the hearing loss others believe you have?” (from a positive response on the Hearing Handicap Inventory for Adults). Or, “You said earlier that you often will miss key lines when watching movies on TV. How important is it to you to hear as well as possible in as many situations as you can?” (a possible importance question based on a pre-evaluation conversation). Checking on the importance of making a change takes little time, as most patients will say in response to such questions that importance is high. Note that the question was not, “How important is it to you to use hearing aids?” Answering the importance question empowers patients to reduce the intimidation inherent in many audiology appointments. As an example, one patient, after entering the audiologist’s office with, as he put it, “My tail between my legs,” responded to the audiologist’s question with, “If I didn’t believe it was important to hear better, why would I be in your office?” Then he felt in charge. If no difficulties are noted on the self-assessment, asking the importance question is not needed. When this is the case, or when an importance is stated to be low, the door is open for discussion before you spend too much time that cannot be recouped discussing amplification options with someone who is not interested. A Question of Comfort If audiologists are to practice effectively and efficiently, it is paramount that they learn about the patient’s comfort level for using hearing aids before getting too far into their recommendations. There is no need to inquire about a patient’s comfort until the importance to proceed is stated to be high. Once importance has been established, a patient must feel comfortable and committed enough to follow through with treatment. As an analogy, how many of us acknowledge the obvious importance of exercise but, for one reason or another, don’t actually make ourselves do it? To address perceived comfort, the audiologist may ask, “Given that you’ve told me you know it is important for things to be better, how comfortable are you following my recommendations even if that might include the use of hearing aids?” Response to this comfort question directs the patient to reflect on concerns or beliefs that might impede success. When comfort is noted to be low, while acknowledging how daunting the prospect of using hearing aids may be, the audiologist can directly ask what specific concerns the patient may have. Knowing and discussing these concerns before the hearing aids are fit can help avoid hearing aid returns during the post-fitting adjustment period. Again, to return to the exercising analogy, after assuring a physician that the patient knows exercise will be beneficial, the doctor may ask, “How comfortable are you making a commitment to walk more …?” How Do We Open the Door for Discussions? The purpose of this article is to highlight the importance of eliciting patients’ perceived importance for and comfort with following professional recommendations for hearing assistance. When an audiologist knows where a patient stands, it becomes possible to practice more effectively. If importance or comfort is noted to be low, audiologists can either recommend a return visit at a later date or, more preferably, explore patients’ reluctance or ambivalence to better ensure success for their patients. Other sources provide greater detail about how to more fully engage in discussions when patients’ perceived importance to receive hearing help is felt to be low, or when a patient does not feel comfortable with all aspects of recommendations for improved hearing.3,4 Addressing these issues through motivational interviewing techniques is within the audiologist’s scope of practice and can significantly improve a clinic’s bottom line. as well as improve hearing success for more recalcitrant patients.5 The objective of time-efficiency warrants elaboration. There is a perception that exploration of reasons behind low importance, or discomfort with recommendations is that these “tell me more” discussions take too much time. As we have discussed, proceeding with discussions of hearing aids and possibly even continuing through the fitting of hearing aids when patients are not ready, often results in the loss of valuable clinical time. This expenditure of time would be better spent checking on perceived importance and comfort up front to better ensure adherence to recommendations and successful use of hearing instrumentation. It is important to emphasize that the time expenditure required to check on importance and comfort is typically minutes. There is a plethora of literature outlining protocols focused on agenda-setting and time management in the medical interview; how physicians can incorporate so-called “micro-interventions”during normal medical visits .6,7 One article is aptly entitled The Three‑Minute Mental Makeover (“3MMM”) to emphasize that many psycho-social interventions can be brief - less than three minutes – and can be used within the constraints of a busy clinical practice.8 Questioning patients about how important it is to improve their hearing and their comfort level certainly requires less than a few minutes. These two fundamental questions lie at the heart of motivational interviewing. Conclusion Audiologists cannot assume that every patient is prepared to move forward with audiologic recommendations. Two simple questions to assess patients’ perceived importance to make a change and their comfort to move forward with recommendations are foundational to time-efficient hearing aid consultations. When importance is low, the door is open for a cost-benefit discussion of accepting recommendations vs. maintaining the status quo. When the comfort level for required actions to improve hearing is low, exploration of concerns is possible before proceeding. About the Authors: John Greer Clark, PhD, is a professor emeritus at University of Cincinnati, co-author of Counseling Infused Audiologic Care and Introduction to Audiology, and author of the consumer guide Hearing to the Max.Michael A. Harvey, PhD, provides training and consultation on mental health issues having to do with hearing loss. As a clinical psychologist, he has a private practice in Framingham, Mass. He has published over 60 articles, and his latest books are Listen with the Heart: Relationships and Hearing Loss and The Odyssey of Hearing Loss: Tales of Triumph. References 1.Marcos-Alonso S, Almeida-Ayerve CN, Monopoli-Roca C, et al. Factors Impacting the Use or Rejection of Hearing Aids-A Systematic Review and Meta-Analysis. J Clin Med. 2023;12(12):4030. Published 2023 Jun 13. doi:10.3390/jcm12124030. 2.The Hearing Review. BHI survey finds family members play critical role in addressing loved one’s hearing loss. 2009. Available at: https://hearingreview.com/hearing-loss/bhi-survey-finds-family-members-play-critical-role-in-addressing-loved-ones-hearing-loss 3.Beck DL, Harvey MA. Motivational interviewing. Hearing Professional. 2018;58-65. 4.Clark JG, English KM. Counseling-Infused Audiologic Care. Cincinnati, Ohio: Inkus Press/Amazon.com; 2025. 5.Harvey MA, Citron D. The Tevye Phenomenon: Why one may be ambivalent about using motivational engagement tools. Hearing Review. 2020;27(1):14-15, 18-19. 6.Frankel RM, Quill TE, McDaniel SH (eds.).* The Biopsychosocial Approach: Past, Present, Future.*Rochester, NY: University of Rochester Press; 2003. 7.Mauksch LB, Hillenburg L, Robins L. (2001). The Establishing Focus protocol: Training for collaborative agenda setting and time management in the medical interview. Families, Systems & Health. 2001;19(2):147–157. 8.Thoele DG, Gunalp C, Baran D, et al. Health Care Practitioners and Families Writing Together: The Three-Minute Mental Makeover. Perm J. 2020;24:19.056. doi:10.7812/TPP/19.056 Featured image: ID 218275362 © Fizkes | Dreamstime.com

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