Teamwork is essential in the management of patients with hearing and balance concerns. As the director of the Balance Center within the large academic medical center of Keck Medicine at the University of Southern California (Keck Medicine of USC), I am often coordinating care for patients with dizziness among the Department of Physical Therapy, Department of Occupational Therapy, and Department of Neurology.
To develop these relationships, I reached out to providers and delivered educational sessions to review the role audiologists can play for their patient populations. My goal with this outreach was to foster a strong multidisciplinary network to manage patient care. Within my own department, I implement the same strategies to strengthen the interdisciplinary relationship between audiologists and otolaryngologists.
The audiology and otolaryngology relationship is symbiotic, as both professions are operating in the ecosystem of hearing and balance health care. Our desire to provide the highest quality of hearing and balance health care to the patient populations we serve requires acknowledgment of the specific roles each profession plays in patient care.
To assure that this relationship is mutually beneficial, I wanted to explore the key components that encourage a strong interdisciplinary bond. I met with our four neurotologists and our otology physician assistant to explore our interdisciplinary relationship. During the conversation, we identified three key topics that facilitate a healthy working relationship between audiologists and otolaryngologists. These include the following:
- Establish effective communication between providers,
- Critically think to optimize workflow, and
- Integrate educational opportunities for professionals and trainees.
Effective communication between providers is integral to advancing patient care. The need for effective communication is highlighted with the physical-distancing protocols and clinical-scheduling adjustments required while combating the spread of COVID-19.
As many of you may have experienced, our clinic underwent a sudden closure of non-urgent, in-person services. This shift required a pivot of our clinic service provision and our communication modalities.
The closure of the clinic resulted in a reliance on phone calls, e-mail, video communication, and electronic medical records to share information. Although all these modalities play a critical role in relaying information for patient care, one key piece of the puzzle was eliminated, our ability to physically see each other during the workday.
In our separation, we recognized that physical proximity is also important to generate informal conversation among providers. In our hospital clinic, the audiology division is next door to the otolaryngology office. This location fosters informal encounters that are just as critical as the structured or guided conversations that occur within meetings.
Opportunities to ask questions regarding patient care, discuss cases, or address clinical concerns in real-time benefit all parties. The ability to connect with the audiology department during the workday increased the otolaryngologist’s confidence when counseling patients on complicated test results or on expected outcomes for hearing or balance rehabilitation.
The frequent opportunity to interact among professionals informally minimized any intimidation of being “judged” for asking questions about audiology concepts. Discussion of the medical/surgical perspective, in addition to the audiological care, allows both parties to learn from each other and to enhance patient outcomes.
Beyond the initial physician encounter, the audiologist often serves as the bridge between the patient and the otolaryngologist when communicating care plans. In completing pre-and post-operative visits or frequent encounters for hearing-health care, the audiologist can continue to strengthen the bond between the patient and the care team.
For surgical cases, such as the evaluation of cochlear implant candidacy, the audiologist directs the auditory evaluation by helping the patient navigate the required health-care steps and connect with the surgeon when needed.
It was noted within our meeting that, often, patients with concerns of hearing loss do not require surgical intervention or medical management. Zapala and colleagues (2010) support this and identified that, within one year of evaluating Medicare beneficiaries, a neurotologist determined that 78 percent of reviewed cases only required audiologist services.
However, in many cases, the otolaryngologist continues to serve as the gateway to additional audiology services. Therefore, it is important to inform physicians and physician assistants about the audiology services offered within the clinic beyond hearing aids. This can help the physician inform the patient of expectations before arriving in the audiology clinic for additional services such as a tinnitus evaluation or vestibular assessment.
Optimizing workflow is a constant discussion within our large academic medical center. Conversations among otolaryngologists and audiologists about workflow provide an opportunity for generating ideas for improving our schedules and enable each profession to work at the top of their license.
Within our conversations of optimizing workflow, the key factor was trust among providers. Our otolaryngologists often counsel their patients that the audiologist will decide if the patient needs to return for care. The physicians are comfortable with this plan, as audiologists are aware of the red flags that require the patient to return to the otolaryngologist. This system allows for each group to maximize their clinic time.
Our traditional clinical workflow was altered with the expansion of telemedicine services required by COVID-19 physical-distancing protocols. For most new patient cases, the otolaryngologist first would meet with patients via telemedicine.
If an audiometric assessment or balance assessment was ordered, the audiologist was required to complete the initial in-person physical exam of the patient. Additional red flags that may not have been apparent due to the limitations of telemedicine were then identified by the audiologist. The audiologist’s physical assessment, in combination with the diagnostic test results, would then help to triage patients for an urgent, in-person assessment.
Even with the added challenges of COVID-19, our workflow needed to adjust for expansion of clinical locations and added faculty members. Clear communication among providers helps determine staffing at each location. This communication extends beyond the audiologist and otolaryngologist and involves scheduling assistants, medical assistants, office staff members, and clinic managers.
The coordination required to schedule an adult patient for an evaluation of sensorineural hearing loss demonstrates the choreography required by the multiple stakeholders in the patient-care process. When the patient calls for an appointment, the scheduler will find a day where the patient can be seen by both the audiologist and otolaryngologist. When they arrive at the clinic, they will be seen for a diagnostic audiogram and a follow-up appointment with the otolaryngologist.
Following the assessment, the patient will then be scheduled for a hearing aid evaluation at a location near their home address. The patient is managed by the audiologist for hearing-health care and annual audiograms. If otological concerns arise, the patient will be asked by the audiologist to return to the otolaryngologist.
Within our department, opportunities for interdisciplinary education are offered weekly. The chance to attend these meetings has expanded with the integration of video telecommunications. Providers are no longer hindered by the physical location of these meetings as a barrier to access.
The integration of video conferencing has broadened the ability for providers within our department to connect with each other, many of whom had never physically crossed paths. The weekly lateral skull base conference is an occasion for neurotologists, neurologists, audiologists, physician assistants, and radiologists to review cases where imaging is requested. This review of imaging allows for the attending group to discuss case management and discuss possible surgical plans.
Case-management discussions also occur within our monthly audiology meeting, where a neurotologist meets with the pediatric audiology team, educational specialist, and speech-language pathologist of the USC Caruso Family Center for Childhood Communication to discuss the status of pending surgical cases and report the progress of post-surgical cases.
These meetings help the program initiate strategies of interdisciplinary patient management aimed to address the patient’s hearing-health-care needs from birth to adulthood. Audiology externs and otolaryngology residents attend these meetings as well. This early integration of both training groups in meetings helps foster an understanding of each other’s specialty.
Our role within the academic medical center is to offer opportunities for interdisciplinary relationships among otolaryngologists and audiologists through residency and fellowship programs. Within our center, residents rotate through the adult and pediatric audiology clinic to observe diagnostic hearing and balance evaluations and hearing health care.
The work to develop relationships among audiologists and future otolaryngologists extends beyond the clinic, as many audiologists are involved in lecturing to residents about hearing and balance-related concerns. Also, the audiologists are available to the residents and fellows to answer questions and provide explanations on patient results or next steps.
The underpinnings of a successful symbiotic relationship among audiologists and otolaryngologists relies on the realization that we are two clinicians working on the same team. The respect between the two professions is fostered in the way in which we communicate with each other, how we strive to elevate each profession to operate at the top of its license, and how we continue to inform each other and the future generation of providers.