Patient-Provider Communication in the Context of Hearing Loss

Psychosocial Impact

The number of individuals with hearing loss who do not seek help is staggering. Loss of hearing sensitivity affects more than just detection of sound. Hearing loss impacts how people interact with others and has been linked to depression and isolation. Despite being the third most common chronic health condition in the elderly population, many older people do not seek diagnosis [3] and even fewer seek treatment. The absence of treatment can affect the quality of interactions with family, friends, and within the workplace [4]. Recent data from Johns Hopkins University have established a correlation between hearing loss and dementia [5].

Signs of Hearing Loss

There are many signs that might indicate an individual is having trouble hearing. Asking for frequent clarification is a key indicator that an individual may need to be referred for audiometric evaluation [6]. Often, adults presenting to an audiology clinic will comment that they “hear people talking, but the speech is not always clear.” They may also note that they need others to repeat themselves more frequently. Generally, the accompanying spouse or family member will comment that the patient repeats himself or herself often or that the person is having trouble hearing particularly when there is background noise. A person with hearing loss will watch facial expressions and lip movement more intently.

For children, signs of hearing loss may be more subtle. For example, parents may note that their child is not developing language at a normal rate or that his or her speech seems unclear. The child may also ask for the volume on the television to be raised or not respond when called. Virtually all newborns are now screened for congenital hearing loss at birth; however, children can develop late onset hearing loss due to medical conditions or inherent abnormalities at birth [7]. Referral to a qualified pediatric audiologist for a hearing evaluation is key if there are questions regarding a child's detection of environmental noise and discrimination of speech.

A Typical Office Visit

Long before the actual visit, there are encounters that could be potentially challenging for people with hearing loss. For example, when scheduling an appointment, most people use the phone rather than email or another modality. When scheduling an appointment on the phone without the ability to rely on visual cues, the patient may have difficulty understanding the scheduler. Patients with hearing loss have varying levels of speech discrimination, even with appropriately-fit devices. If a patient understands only 20% of the conversation in the absence of visual cues, he or she is likely to misunderstand the date, time, or even the purpose of the appointment. This can lead to frustration not only in scheduling; both the provider and the patient may be upset if the patient arrives at the wrong date or time. Fortunately, many clinics now offer the ability to communicate via email or patient portals. These options allow patients to read the appointment information, reducing frustration on the part of both the patient and the provider.

After scheduling, many people receive reminder calls, which are a great service, but once again, these calls rely on an auditory signal. Depending on the degree of hearing loss and speech discrimination ability, the patient may or may not comprehend the reminder call. In our own clinic, for example, our system provides the option to cancel an appointment through the reminder system by pressing a number on the phone. There have been many instances in which individuals did not adequately hear the instructions and inadvertently cancelled the appointment. Text options, web portal systems, or other mediums that will allow patients to read messages are a good alternative to an auditory only system.

Arriving at the clinic, a patient usually sits in a waiting room, perhaps with a number, so that the receptionist can call the next patient by number instead of by name. It is quite probable that some patients are unable to hear the announcement. Not only is this embarrassing, but it can potentially result in missed or late appointments. Screens which display the number being called facilitate improved communication. Diligent office staff can monitor the waiting room for patients who have been in the lobby longer than expected to prevent unnecessary waiting or confusion.

During a visit, health care practitioners provide critical, often sensitive, information. The Joint Commission has acknowledged that what a patient actually takes away from a conversation is affected by many factors [8]. Hearing loss is definitely a confounding factor. For an individual who may not be able to hear or discriminate words, critical information regarding medications and when to take them, as well as the importance of a diagnosis, may be lost. While some patients or family members act as good self-advocates and tell the provider when they do not understand, many are not comfortable asking for clarification. Some individuals may nod or shake their heads to indicate understanding in order to avoid a conversation about their difficulty hearing. By simply asking the person to repeat what has been said, the provider can judge the degree of understanding. Additionally, the use of after visit summaries ensures that patients have written information in the event that they have missed key pieces of information during the visit.

Communication Strategies

When speaking with patients who have hearing loss, it is critical to face the individual. This may seem like common sense; however, in a digital age, we often write or enter data into the computer at the same time we talk with patients. In that case, the face or mouth may be obscured by the computer. Speechreading can be a helpful tool to aid in overall understanding. However, it is important to note that only approximately 40% of English sounds can be seen on the lips [9]. Rate of speech is also important [10]. We know that individuals with hearing loss have more difficulty understanding when others are speaking quickly.

There are some individuals who, even when wearing appropriate amplification, may still not be able to understand speech well. They may bring family members with them to facilitate conversation. While the family member may be helpful in conveying information, it can be tempting to exclude the hard-of-hearing individual. For someone with hearing loss, exclusion is both isolating and frustrating. For improved communication with hard-of-hearing individuals, typing or writing important information may be helpful. There are some excellent speech-to-text applications, including Dragon Dictation [10]. When speaking with potential cochlear implant patients who are often unable to understand open set speech information, our clinic often utilizes this application with either computers or cell phones, and it has enabled us to communicate more easily with some individuals.

Thankfully, there are many assistive devices and strategies that make communicating with hard-of-hearing patients easier in a digital age, beginning with the initial point of contact.

Assistive Devices

Health care providers are in the position to urge patients to have their hearing checked by an audiologist who can then recommend appropriate amplification or additional assistive devices. There are several major hearing aid manufacturers in this country, as well as several smaller manufacturers, who create personal amplification devices. Literature shows that the method in which the device is fitted is critical [11]. Kochkin has stated that the number one predictor in satisfaction with a hearing aid is the fit of the product. Therefore, it is critical that verification measures are used when a patient is fitted with a hearing aid. While the hearing aid itself may be appropriate, additional characteristics such as ear canal resonance can dramatically change how well a person perceives speech. Qualified audiologists will provide evidence-based practice during a hearing aid fitting to improve speech recognition. In some cases, these adjustments can result in significant improvements in speech understanding.

As insurance coverage for hearing aids changes, and some insurance providers mail hearing aids to their beneficiaries, health care providers may need to refer a patient to an audiologist if the patient seems to be having difficulty hearing even when wearing a device. In fact, if you are noticing that patients struggle with understanding despite wearing hearing aids, there may be additional options such as cochlear implants or bone-anchored devices that could improve their overall functionality. Referring the patient to a qualified audiologist may result in improved communication at your next visit.