Twentieth century American psychiatrist and internist George Engle observed that, in addition to biophysical and psycho-emotional concerns, patients also exist within a social context encompassing family, friends, and community. Dr. Engel's (1977) biopsychosocial model of health-care engagement underpins what we recognize today as person-centered care. 

Many health-care providers, including audiologists, fail to engage in person-centered clinical behaviors that recognize the biopsychosocial interactions of health, even though patients prefer this dynamic (Grenness et al, 2015; Roter and Hall, 2006). Among the seven characteristics of person-centered care (see Table 1), the sixth characteristic—a holistic outlook for those we serve—draws attention to our need to confront the uncomfortable with patients. Two such uncomfortable topics include childhood bullying and encroaching dementia.

Childhood Bullying 

Bullying consultation.Childhood bullying is nothing new. Recent research has raised heightened concerns about the long-term effects of bullying: i.e., children with a history of being bullied are more likely to experience overall mental and physical health problems, anxiety, depression, and self-harm throughout their adult years (Lereya et al, 2015). To stress the importance of this concern, childhood bullying is now considered a form of child abuse (Takizawa et al, 2014). 

Children who are being bullied hesitate to ask for help. Rather than wait for a child to mention the problem, the American Academy of Pediatrics (2009) adopted screening for bullying concerns as a standard of care. Squires and colleagues (2013) have since advocated for audiologists to assume the same responsibility, for instance, screening for concerns after routine assessments are completed. 

We recommend that audiologists prepare for this kind of conversation by (1) reviewing the website StopBullying.gov for important information on red flags, cyberbullying, bullying concerns outside of school, and a child's legal rights to a safe educational environment; (2) staying up-to-date about local laws and policies regarding anti-bullying programs; and (3) communicating with school administration whenever possible. 

A Sample Conversation about Childhood Bullying

Audiologist: We're done with testing, Janie, and no changes. All is well. Before you head out, I want to talk to you and your mom about something kind of serious—it's about bullying. I know your school has some anti-bullying programs. Could you tell me about that?

Janie:  Sure. We have a safety officer. She talks to us about bullying at assemblies and stuff. She's okay.

Mom: The school offers flyers, posters, and programs and they have a zero-tolerance policy about bullying. They have it covered.

Audiologist: Good to know! The school and your teachers really care. But, Janie, even with all that support—do you ever notice any bullying?

Mom: Not with a zero-tolerance policy! Kids wouldn't do that.

Janie: Well, actually, Mom, it does happen. Like my friend Tori—there are a couple kids who are really mean to her all the time.

Mom: That's terrible! How can the teachers let that happen?

Audiologist: Janie, you were saying it happens all the time—to you, too? Do you get bullied?  

Mom: Of course not! I would know if that were happening.

Janie: No, no problems. 

Mom: Yes, exactly, because I would know. 

Audiologist:  For lots of reasons, we are learning that kids tend not to tell. Does that make sense, Janie, that a kid may not want to tell?

Janie: A kid probably wouldn't talk about it. It could make things worse.

Mom: Janie, honey, you would tell me, though, right?

Janie: (starts to cry) I'm not sure! Maybe it's not bullying.


(From: English, 2018 and Clark and English, 2019, used with permission)

Encroaching Dementia 

Demenita consultation.At the other end of the lifespan continuum are adult patients who might be developing dementia as well as hearing loss. The incidence of both dementia and hearing loss increases with age, a coexistence that presents significant challenges for the patient, the individual, the family, and the audiologist (Cacace, 2007).  

Hearing loss is one of the identified modifiable risk factors for dementia (Lin et al, 2011, 2013; Livingston et al, 2017; Nirmalasari et al, 2017). Treating hearing loss can lessen the impact of co-occurring dementia (Beck et al, 2018). Identifying early dementia can assist in hearing-care planning. 

Given the high incidence of dementia and the low rate of self-reporting of memory loss and confusion, adult patients would be well served if audiologists and other health-care providers performed screenings of mental status (Armero et al, 2017; Beck et al, 2018). One means of broaching the subject of possible cognitive decline with patients is to include an inquiry of concern within the case history (Armero et al, 2017).

When screening patients for dementia, a useful tool is the Mini-Cog Screener (Borson et al, 2003). Beck and colleagues (2018) have cautioned that the very act of screening for dementia can present a post-traumatic trigger for the memories of the many unwanted life changes that frequently accompany aging. To offset this risk, these authors suggest empowering patients following a screening by relinquishing the lead and asking if they would like information on how the results of the screening may be beneficial.

We suggest that the ensuing conversations should include discussions of the nature of screenings, and that results (not implying failure) can be related to many factors, including prescription medications, vitamin deficiencies, or depression. Our role should be noted as one that hopes to ensure patients remain as socially active as possible and that further evaluation is recommended to help achieve that goal. When a patient performs well on a cognitive screening, discussions should still include mention of the imperfect nature of screenings. The patient and family should be encouraged to discuss their concerns with the patient's family physician if current concerns continue or increase.

A Sample Conversation about Encroaching Dementia

While reviewing case history information with Mr. Baxter and his wife, Dr. Collier says: "I see that you answered 'Yes' to the question 'Do you or any members of your family have any concerns about memory challenges or confusion that you appear to have?' Can you tell me a bit about your concerns?"

Mr. Baxter looks over at his wife, hoping that she might respond to this topic that he tries his best not to think about.  

After a brief pause, Mrs. Baxter responds: "Well, we aren't sure if it is anything really, but we have noticed that Jim seems to lose things a lot. His glasses… keys… his watch the other day. We all lose things, but this just seems to be so much more frequent than before. And, last week, he called me from the grocery parking lot. He said he wasn't sure if home was to the left or the right from the store. We downsized four years ago and it used to be a right turn out of the lot, but now it's a left turn. We haven't really talked to anyone about this. Not yet, anyway."

"Well, you are correct." Dr. Collier says: "We all do forget things and lose things, even lose our direction sometimes. But what you are saying does seem to make one pause." 

Turning to Mr. Baxter, she continues: "Would you be willing to have me give you a brief screening to see if we should be concerned? If the results of the screening suggest that further exploration on this would be in order, I know a wonderful doctor I could recommend for you."


(From: Clark, 2018 and Clark and English, 2019, used with permission)

TABLE 1. Proposed Components of Person-Centered Care in Audiologic Practice from a Biopsychosocial Perspective. (Clark and English, 2019, used with permission.)
DIVERSITY RECOGNITION A respect for differences in cultural background, beliefs, values, and opinions aimed toward a recognized common ground
THERAPUETIC LISTENING A demonstrated attempt toward empathic understanding of the patient/family perspective of hearing loss impact underpinned by an unconditional positive regard and non-judgmental relationship
INFORMATION SHARING Discussion of findings in the context of expressed patient and family concerns seeking to match provided details to patient readiness 
SHARED DECISION MAKING Recommendations based upon research, expert opinion, and the expressed experiences, needs, and concerns of the patient and family; shared goal rendering encourages active participation from all parties and, as needed, negotiated compromise
ASSESSED OUTCOMES Functional capabilities and satisfaction of delivered care assessed through measured outcomes
HOLISTIC OUTLOOK A continued vigil for the safety and well-being of those served, both within the clinic and within the patient's broader life context
FOLLOW-THROUGH Timely and accessible service provision in an established ongoing framework to ensure continued satisfaction and success

A Possible Roadblock to Holistic Practice

Audiologists may feel hampered in providing meaningful screenings, such as those for childhood bullying and encroaching dementia, or other such screenings that may help to ensure proper patient care. The Academy Code of Ethics (American Academy of Audiology, 2018) clearly states that we are ethically bound to "…use available resources, including referrals to other specialists…" Yet, our scope of practice (American Academy of Audiology, 2004) may limit our ability to identify referral needs. Specifically, under Identification, the Academy Scope of Practice states, "Audiologists may perform speech or language screening, or other screening measures, for the purpose of initial identification and referral of persons with other communication disorders."  

We recommend the following change to the current language: "Audiologists may perform speech or language screening, or other screening measures, for the purpose of initial identification and referral of persons with suspected disorders or circumstances that may impact treatment plans or patient welfare." 

We are already screening beyond what our scope of practice allows. If we suspect child or elder abuse, state law dictates this concern be reported. To do so, we are providing a visual or situational screening to make a judgment on the need for reporting. To add value as a member of the health-care team, audiologists often screen for depression, caregiver stress, and falls risk.  

It is our opinion that the Audiology scope of practice needs to be modified to more broadly define audiologists' screening responsibilities when we see the need.  

Our Responsibility

Our professional responsibility calls us to ensure that we strive to guide our patients to their greatest communication potential and success in life. To achieve this goal, the need may arise to enlist the assistance of other professionals. We should watch for factors in our patients' lives that may impede their success, screen for potential concerns, and refer as needed.

Readers interested in exploring additional aspects of difficult communications can receive Tier 1 continuing education hours on this counseling topic  and others through the Academy's Web Seminar platform: www.eAudiology.org.

We must each examine our comfort with engaging with our patients in difficult conversations. If we find ourselves uncomfortable with these difficult conversations, we are ethically bound to engage in introspective reflection, discuss our concerns with colleagues, and prepare ourselves to provide the best patient care possible.

Audiologists should be familiar with local resources for psychological and social intervention. When counselors who are familiar with hearing impairment are not readily available in our employment settings or communities, it becomes our responsibility to develop relationships with area mental health professionals and provide relevant training on effective communication strategies when counseling those with diminished hearing (Clark and English, 2019).