“We are drowning in information, while starving for wisdom. The world henceforth will be run by synthesizers, people able to put together the right information at the right time, think critically about it, and make important choices wisely.”

—E.O. Wilson

Sitting across from you is a new patient whom you have just diagnosed with hearing loss. After discussing the results with your patient what do you do next? Do you gauge their level of acceptance and willingness to discuss treatment options? What are their options? How many manufacturers do you work with? How many levels of technology per manufacturer are there? How many styles of devices, per technology level are offered? What features are available? What are the accessories that work with each device? Do the hearing aids have rechargeable or traditional batteries? What color casing does your patient want? What about assistive devices like captioned phones, alarms, devices for the televisions, or pocket talkers? What services does your office offer? If they visited another office or retail store, would their options significantly change? 

Feeling overwhelmed yet? Chances are your patients do. The array of treatment options a patient must consider are more numerous than the variations of drinks available at your local coffee shop—and growing every day. No wonder some choose not to decide. Does the abundance of options factor into the rates for returns, dissatisfaction, and failure to commit (i.e., purchase or use)? Are patients more content when given a limited set of choices? 

The Excessive Choice Effect or Choice Overload

In the early 2000s, an influential book, The Paradox of Choice (Schwartz, 2004) brought these and more issues to light. Through several studies, Schwartz exposed some evidence that the more choices a person is given the less confident and the less satisfied he or she is with the ultimate choice. An example is choosing between two ice cream stores. The first offers three flavors to choose from and the second offers 30. Not surprisingly most participants initially choose the store with more flavors; however, when asked to rate their satisfaction with their choice in ice cream flavor (out of 30), participants were less satisfied than those who were only given three options. So, while we as consumers want more choices, some of us may be less satisfied, regret our decision, or simply decide not to choose when faced with too many choices. This problem is termed the “excessive choice effect” (ECE) or “choice overload.”

Are your patients the type who want to maximize their choices by ensuring that they have purchased the best they can? Or, do they simply want something that will meet their needs. “Maximizers” may be more influenced by ECE than “satisfiers” (Mittal, 2016). In fact, Schwartz found that maximizers, for all of their work, are less happy than those who were content once they found something that met their needs. A third factor that influences decision-making and outcomes is how knowledgeable a person is about a product or service. The less a person knows about a product the less likely he or she will feel confident that the choice is in his or her best interest. When faced with numerous options that one has limited exposure/knowledge to, are there strategies that can influence decision-making? 

Take a moment to think about your patients and I bet you can identify a few who fall into each category. Would you have changed your counseling style if you knew their general consumer habits? Can you sometimes identify those traits through your interview and case history? What can we do to ensure that we are meeting the needs of those who seek our expertise? While it may sound funny or a bit uncomfortable at first, our patients are also health-care consumers. Their approach to seeking treatment will most likely stem from their behaviors in other areas of consumerism. 

While much of this discussion lends itself to the device, it is also important to point out that service and quality of care should also be a large part of the conversation. A new hearing aid user will likely highly value counseling and technology assistance in the beginning, more so than an experienced hearing aid user who is more comfortable and versed in care and maintenance. 

But Are There Positives to Choice Overload?

Perhaps not surprisingly, some have argued that while the ECE or choice overload phenomenon might exist, its exact nature and contributing factors do vary. Chernev et al (2015) completed a conceptual review and meta-analysis of choice overload. First, in full disclosure, the authors found a disproportionate number of studies investigating the negative effects of large set choices, presumably due to its novelty and counterintuitive nature. While the lopsided argument supporting the existence of the negative side of too many choices, the authors do mention some positive outcomes that merit attention. In our current culture, it is difficult to imagine having no choice with regards to purchasing virtually any product, whether that “product” is in the grocery store or pharmacy, or is a health-care provider. Having options can help a person define value and creates a “freedom of choice.” Having more than one option can also help someone determine that they are not missing out on a potential alternative. The more choices you have does come with the downside, however, namely the mental effort required to sift through the information. 

The authors were able to generalize the antecedents as well as the consequences of choice overload across 53 studies (Chernev et al, 2015). The antecedents refer to the extrinsic (objective) factors such as choice set complexity and decision difficulty as well as the intrinsic (subjective) factors like preference uncertainty and decision goals. 

In terms of hearing health care, we cannot necessarily control the extrinsic factors. Our patients are inundated with information regarding product and services outside of our office through many different channels. Are we further “muddying the waters” when they make the decision to come to our office? Or are we facilitating clear, outcomes-based discussions while acknowledging our patients’ experiences? 

Could your patients identify the “major” hearing aid companies? Do you think they are knowledgeable about the high-end versus basic technology products? Do you think that lack of knowledge helps decision-making or hinders it? These factors interplay to create choice overload situations for our patients. 

Chernev et al (2015) further divided the consequences of choice overload into two categories; subjective state and behavioral outcome. Subjective state consequences included metrics such as satisfaction, regret, and confidence while behavioral outcomes included deferral, switching, assortment choice, and option selection. Examples of subjective effects of choice overload include reduced confidence in their choice and feelings of regret. Behavioral consequences include deferring choice or reversing their decision. How many times has a patient made the decision to be fit with hearing aids only to come in nearing the end of their trial period with the devices in the box stating that they were just not ready? What does that “not ready” mean? Were they not ready to hear sounds better, or more likely were they not ready to make a decision? 

How many different hearing aids do you allow your patient to try and how do you facilitate honoring the patients’ wishes to make an informed choice? How do you structure your trials or demos? Can these provide enough information for your patient to make an appropriate choice?

One intriguing study investigated ECE and how presentation and inclusion of certain information positively influenced consumers who were given various options in an unfamiliar field (Malone and Lusk, 2017). Over the last decade, craft beer has become a thriving industry. Seemingly endless rotating lists of IPAs, porters, ales, lagers, and stouts are commonly seen in restaurants. But how does the consumer know which to choose, if any, particularly if they are unfamiliar? 

Malone and Lusk (2017) implemented two strategies to see if the ECE effect was mitigated simply by modifying how information was presented. They chose to conduct their “2×3 quasi-experiment” at a wine bar, where people may not be as knowledgeable in craft beer. They varied their beer menu to have either six or 12 choices and investigated whether listing a “special” on the menu or providing Beer Advocate scores increased the sale of beer at the establishment. They found that while including specials increased beer sales with the smaller set, the Beer Advocate scores increased in both six and 12 beer lists when compared to their control list. The results suggest that adding “informational nudges” may help to mitigate ECE in this particular arena.

Conclusion

How do you present the information without overwhelming your patient? Are you delivering most of the information verbally or do you use a chart or brochures? Have you placed ads with “special pricing” for a limited time to invoke an immediate call to action? Do you include patient testimonials, or some sort of ranking of devices and services? 

In most counseling toward amplification sessions, we speak of particular features and how they might translate to specific benefits. Often, we are the translators, simplifying and equalizing professional jargon so that patients can make somewhat informed choices based upon their lifestyle and communication needs. However, it is easy to slip into a monotonous soliloquy exalting the merits of one device/feature over another, thinking we are helping our patients make an informed decision. But, are we providing too much information? What is the right amount of information for our patients? Are our conversations being led by us or by what our patients are asking us?

In the end, these questions have no easy or “one-size-fits-all” answers. As the field of products and services continues to expand in hearing health care, it is more important than ever to assist our patients as they navigate through the quagmire of choices and make the most appropriate decisions for themselves.   


References

Chernev A, Böckenholt U, Goodman J. (2015) Research Review—Choice overload: A conceptual review and meta-analysis. Jour Cons Psych [serial online]. April 1, 25:333–358. 

Malone T, Lusk J. (2017) The excessive choice effect meets the market: A field experiment on craft beer choice. Jour Behav Exper Econ [serial online]. April 1, 67:8–13. 

Mittal B. (2016) The maximizing consumer wants even more choices: How consumers cope with the marketplace of overchoice. Jour Retail Cons Svcs [serial online]. July 1, 31:361–370. 

Schwartz B. (2004) The Paradox of Choice. Why More Is Less.New York, NY: Harper & Collins.

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