Audiology in the Past
The very beginning of the audiology profession had its roots in counseling. Until June of 1978, the American Speech-Language-Hearing Association (ASHA) banned hearing aid dispensing. Therefore, most audiologists did not dispense hearing aids in the early years of our profession. Instead, they worked with veterans suffering otologic complaints alongside physicians, speech pathologists, psychologists, and other professionals.
Hearing aids during the early years had relatively few adjustments that could be made, consisting of potentiometers that adjusted gain and output. Physical modifications were commonplace, such as adjusting tone hooks or venting to achieve the optimal sound quality. Beyond these basic adjustments, patients needed to be counseled on adjusting to their hearing aid settings. Expertise in counseling and communication strategies, the art of hearing aid dispensing, was a defining element of our great profession.
Audiology in the Present
Hearing aid technology has become infinitely smarter. Our current generation of audiologists have a standardized education that provides competency on the science of hearing aid dispensing. We have doctoral level professionals who are exiting our programs well versed in concepts such as real-ear coupler differences, directional microphones, and frequency transposition. But what about the art? Today, blending the science of hearing aid dispensing with the art of hearing aid dispensing is often what differentiates one practice from the next. Most educational programs have at least one class dedicated to patient counseling. The additional length of the doctoral education also affords more opportunities to observe other clinicians and to practice counseling skills. In other words, the educational foundation and clinical experience of audiologists allows for unique insights into how to maximize the benefits of amplification. Despite the exposure to these skills, the challenge of counseling is largely in learning how to adopt a style that resonates with your patients, covers the necessary material, and feels both natural and ethical to deliver.
Patient and Family Engagement
The process by which patients and their family members take an active role in their own health care has gained attention in the broader context of health care. This concept is particularly salient in today’s health-care environment, as reimbursement becomes related more closely to patient satisfaction. The process has been called patient engagement, patient activation, shared decision making, patient self-management, choice architecture, and patient-centered care. Ultimately, each of these concepts involves the process of providing the knowledge and confidence for patients and their families to co-manage their health-care decisions.
When we diagnose pediatric hearing loss, we rely on the parents to play a critical role in the management process. Yet when we diagnose adult hearing loss, we tend to forget that participation is critical from both the patient and family. Clearly defining the roles and responsibility of patients gives them a higher likelihood of successful engagement. The process requires education and communication with patients. They should wear their hearing aids as recommended, give us feedback regarding their experience, and participate in brain training and compensation strategies.
We also must teach family members how to communicate with a hearing-impaired loved one. Family members often do not understand the limitations of amplification, and they can become frustrated when communication continues to be impaired following amplification. Family members of patients with hearing loss might require direct education on how to be an effective communication partner, and they are often valuable in repeating and reinforcing the patient’s role. We ask our patients to include family members throughout the amplification process to improve the experience for family members as well as our patients.
We have a responsibility to give patients all of the available resources to maximize their potential, and patients have a responsibility to use those resources. Patient engagement is said to lead to improved outcomes and reduced health-care costs (Veroff et al, 2013).
Differentiating Your Practice
Patients today have increasingly more options for purchasing amplification, and over-the-counter hearing products are sometimes said to threaten the very existence of our profession. Audiologists are therefore faced with the challenge of differentiating themselves from the competition and showcasing the added value of comprehensive, audiological care. Many patients are unaware that hearing aids that look identical can have different features and benefits. They are also unaware that professionals who look identical can offer different levels of experience and expertise. Almost every professional who plays a role in hearing health care wants their patient to succeed. These professionals dispense similar products for similar prices with similar goals. A goal of marketing is to differentiate yourself from the competition and to convince your audience that you are able to meet their defined needs.
Regardless of how superior you believe your product or service to be, the key is that the patient shares this belief. In audiology, we primarily achieve this goal through input from the person served and then through targeted counseling. There are many differences across practices and clinicians as to how these goals are achieved. At JFK Johnson Rehabilitation Institute in Edison, New Jersey, part of Hackensack Meridian Health, we have introduced a “complete aural rehabilitation program,” one that emphasizes our commitment to evidence and research while remaining mindful of patient preferences. The following outlines the framework of this approach with an emphasis on what we have coined the “ABCs of Hearing Rehabilitation”—Audibility, Brain Training, and Compensation Strategies (see Figure 1).
Audibility is arguably the most important factor in improving speech intelligibility (Moore, 2006). The American Academy of Audiology (Valente et al, 2007) and American Speech-Hearing-Association (ASHA, 2006) advocate real-ear verification as a standard of practice for hearing aid dispensing. We rely on real-ear measurements as a critical step in ensuring audibility. Research suggests that manufacturer “first-fit” algorithms can deviate by more than 20 dB from prescription formulas such as NAL-NL2 (Sanders, et al, 2015) and that the large majority of manufacturer first fittings are not within 10 dB of the prescriptive formula (Aazh, 2012).
Knowing that the majority of hearing aid fittings may be underamplified or overamplified without real-ear verification, we rely heavily on objective verification to ensure that the patient’s hearing aids are maximizing access to speech while maintaining comfort. We recently completed a quality improvement initiative to ensure our practitioners are performing real ear verification consistently and appropriately (Kader, 2015). When appropriate, such as with bone anchored or implantable devices, we perform aided soundfield measurements to ensure audibility.
Verification is our starting point, and for many patients we are able to acclimate them to 100 percent of target gain at the initial fitting. Yet we cannot and do not ignore patient preferences. We are mindful that in the field of health care, no one prescription is appropriate for all patients. Our primary goal is to educate patients on the consequences of their choices when they deviate from “best practice” recommendations. Anecdotally, about 10 percent of our hearing aid fittings request significant reduction or increase in gain as compared to prescription targets.
We do not shy away from asking our patients and ourselves the difficult questions. For example, is wearing a hearing aid significantly under target gain better than wearing none at all? Neither science nor art offer all of the answers. Both the patient and the professional must be motivated to achieve the best outcome in a way that is educated and ethical. Ultimately, we strive to improve the quality of life for our patients. We use evidence-based validation measures such as the Client Oriented Scale of Improvement (COSI) (Dillon et al, 1997) or the Parents’ Evaluation of Aural/Oral Performance of Children (PEACH) (Quar et al, 2012) to reinforce that a clinician successfully addressed the unique concerns of each patient. We typically administer these questionnaires at the first follow-up, before patients have completed the aural rehabilitation program. Therefore, we are able to determine how well audibility improvements alone contribute to the patient’s hearing goals. Some patients achieve their goals with a hearing aid fitting alone and elect not to pursue further services. Other patients are motivated to make additional progress through brain training and compensation strategies.
Brain training refers to a specific form of aural rehabilitation that focuses on higher level auditory processing skills, such as hearing in noise. We know that age-related declines are expected in areas such as sentence (Gordon-Salant and Fitzgibbons, 1997) and word recall (McCoy et al, 2005). In addition, deficits in processing ability for listeners with cochlear hearing loss might contribute to reduced performance in certain conditions (Moore, 2007). Evidence suggests that cortical plasticity is possible into late adulthood (Erickson et al, 2007). In fact, hearing aid use alone has been shown to induce central auditory changes for older listeners, such as improvements in speech identification in noise and dichotic listening (Lavie et al, 2015).
The goal of brain training is to maximize patient performance after audibility has been restored. At our clinic, we have chosen the Listening and Communication Enhancement (LACE) program to provide individualized auditory training. The LACE program is a formal auditory rehabilitation program that allows listeners to practice in the areas of speech in noise, rapid speech, competing speech, and working memory. In some research, the LACE program showed improved listener performance across training sessions (Sweetow and Sabes, 2007).
In other research, participation in the LACE program did not improve patient outcomes over amplification alone (Saunders et al, 2016). In general, there is not strong evidence supporting computer-based auditory training (Henshaw and Ferguson, 2013); however, there are individuals in each study who demonstrate benefit from such training. We hope future research will help to identify which patients are most likely to benefit so that we are able to better customize our plan of care to the individual patient.
The primary reasons for hearing aid abandonment and return for credit are “poor benefit” (Kochkin, 2000) and “difficulty in background noise” (Kochkin, 2007). Bridging the gap between a patient’s pre-fitting expectations and post-fitting outcomes is a complex process, and we know it may be useful to focus your counseling on a patient’s specific concerns and listening environments (Cox and Alexander, 2000). Hearing aids alone may not be enough. Unfortunately, research on the efficacy of “brain training” tasks is in its relative infancy. Brain training does not necessarily improve performance over long periods of time or even necessarily generalize to everyday listening (Owen et al, 2010).
To combat the potentially limited impact of brain training programs, we encourage our patients to be lifelong learners and to practice aural rehabilitation in their daily lives. We’ve often struggled with how to acknowledge and incorporate the limitations of evidence-based research regarding brain training with our strong belief in the theory of brain training and the importance of patient's taking some accountability for their own outcomes. The LACE program offers us a tool to achieving this goal. We are able to use the program to illustrate to patients that they are not alone in their struggles, and that hearing involves a complex process beyond audibility that involves attention, working memory, and other skills.
When counseling on the LACE program, we often compare the process to physical therapy. We remind patients of the amount of work required for rehabilitation following medical procedures such as knee or hip replacements. We often borrow the words of audiologist Steve Sederholm when describing the LACE program: “[Hearing aids are] only part of the rehabilitation process. It’s the physical therapy that makes the patient strong again” (2007).
It is well documented that hearing loss can have a negative effect on health-related quality of life (Dalton et al, 2003). Compensation strategies are taught both formally and informally throughout the rehabilitation process. During the hearing aid fitting, realistic expectations are reviewed as they apply to the patient’s specific listening goals. Also, all patients and their families are invited to a two-part aural rehabilitation class offered each month within our department. Classes are taught by an audiologist and the material covered is often tailored to the specific questions and concerns of the class members. However, general topics include the types of hearing loss, understanding the audiogram, word recognition, auditory deprivation, the emotional impact of hearing loss and hearing aids, and communication strategies.
A handout of communication strategies is also available for our patients, highlighting the importance of visual cues and environment modifications. Much like brain training, the long-term benefits of these efforts are not well documented. Fortunately, a review of the existing evidence on formal aural rehabilitation (AR) classes led researcher David Hawkins to conclude “there is reasonably good evidence that participation in an adult AR program provides short-term reduction in self-perception of hearing handicap and potentially better use of communication strategies and hearing aids” (2005).
Patients are counseled that even with the best amplification and brain training efforts, there will be scenarios that require compensation strategies. These situations are explored during the class, with the opportunity for participants to give examples of situations where they have experienced hearing difficulty. These classes offer the opportunity to discuss hearing aid adoption with a professional as well as their peers. Audiologists are often more comfortable with the technical aspects of hearing loss rather than the emotional. Our goal is to provide a safe, guided discussion of hearing loss among individuals who can relate to both the benefits and limitations of amplification.
Time constraints and reimbursement are frequent explanations as to why counseling is not a larger part of audiological care. But a “complete aural rehabilitation program” changes the approach to amplification in such a way that counseling becomes integral to all stages of the journey. The goal is not to increase the time spent with each patient, but only the quality. In fact, we believe that sharing the responsibility of successful hearing aid use with our patients might ultimately reduce the overall number of visits required per patient.
Natural scientists are not necessarily natural artists, and vice versa. In other words, we cannot rely on audiologists to be proficient in both technology and counseling without training. We have found that the majority of audiologists have far more direct education related to diagnostics than counseling. Even associated skill sets such as business and marketing are not a priority for most doctoral programs.
Some students are able to absorb these skills from talented preceptors and colleagues, but many require direct instruction. At our facility, we have prioritized direct education on these types of extraprofessional skills, using sources such as manufacturer representatives, online training, and cross discipline models where appropriate. We have a weekly in-service to discuss, using evidence-based support, the most salient questions and concerns within our practice.
Many patients decline aural rehabilitation classes or computer-based training. Some patients are not appropriate candidates for the LACE program for reasons such as limited English or limited computer proficiency. For those patients we offer a series of “auditory activities,” such as gradually increasing the signal to noise ratio while they converse with family members in the comfort of their homes. Though the science is lacking for some types of home auditory exercises, the sentiment is resounding.
The patient has a responsibility to assist with achieving their goals. Patients who have completed brain-training exercises tend to self-report an increase in communication confidence. Patients who have declined brain training tend to report that they are satisfied enough with their performance that they are not motivated to complete the training exercises. Even among patients who chose not to participate in “brain training,” the introduction of brain training has served as a powerful counseling tool and a logical sequitur regarding realistic expectations. Our patients appear to better accept the limitations of amplification and recognize their own role and responsibility in the rehabilitation process.
Audiology in the Future
In our future practice, we plan to monitor patient outcomes by administering questionnaires throughout each stage of the rehabilitation process. When we consider the future of audiology at large, we can only imagine how far research and technology will advance. Our current glimpse suggests that over-the-counter and smartphone-based devices will continue to grow, and telehealth technology might eliminate the need for many routine office visits. There are professionals in other disciplines that seek to share our scope of practice in many aspects of audiology, including hearing aid dispensing. We see growing candidacy for devices such as cochlear implants, and the horizon of medical research offers fascinating potential in domains such as hair cell regeneration and stem cell therapy.
Considering the future, it is reasonable to feel like the profession of audiology is at a crossroad. We might even fear that the profession of audiology will become obsolete. These concerns are almost as old as the profession itself, but what endures is our ability to adapt to the changing landscape. With concern comes opportunity. Our willingness to adapt is what will continue to elevate the profession in the years to come. We must educate our patients on the difference between selling hearing aids and providing hearing health care. We must remind ourselves that the patient's experience should never be lost in our growing list of priorities. In clinical practice, we implement both evidence and theory. We strive to validate theories by analyzing data, and we are receptive to changing our approach if evidence leads us in a different direction. But for now, for today, we embrace the art and the science of the patient journey. Using the three-tiered frame of audibility, brain training, and compensation strategies allows patients to share responsibility for successful hearing health care outcomes and helps to differentiate one practice from the next. Not least of all, the approach provides audiologists the greatest opportunity to play a continued role in the hearing health care of tomorrow.