When a patient is diagnosed with hearing loss, his or her common response is disbelief. Audiologists work to counsel patients to help them understand test results and their hearing in a broader context: How might this hearing loss affect their life? How do these test results explain what the patients have already noticed? Will their condition get worse? Can it get better? What are the next steps and their options? A wide range of techniques and tools can be used to counsel patients regarding their hearing loss and communication needs. There is perhaps no more common tool in every audiology clinic—from private practice to government-run facilities—than the audiogram, likely due to its long and storied history as the record of a patient's pure-tone thresholds.1 However, its utility as a counseling tool has received surprisingly little attention.
From its inception, the audiogram has been used both as a record of a patient's hearing sensitivity and as a means for the tester to communicate the results to the patient. In Fowler and Wegel's initial report of the audiogram to the American Laryngological, Rhinological, and Otological Society, they discussed the diverse audience of the new tool and the issues encountered when sharing the graph.2 They noted: “Considerable difficulty seems to be encountered in the interpretation of audiograms.”2 While others have described the development of the audiogram into its current state,1 so little has changed that any modern clinician can quickly recognize these earliest graphs as audiograms and would even have little-to-no-difficulty interpreting the results. However, it is vital to remember that the audiogram has long served roles beyond recording one clinician's tests of a patient.
ONE CHART, MANY PURPOSES
In today's hearing health care practices, the audiogram commonly functions in three broad domains:
1. specialist-to-specialist and clinical record,
2. specialist-to-non specialist health care professional (such as the primary care doctor), and
3. specialist-to-non specialist layperson (such as the patient).
For the first domain, like many other records, the audiogram likely functions well for the individual who created it. The audiogram would not have survived the past century if it did not adequately serve the first purpose. Moreover, experienced clinicians can interpret modestly different audiograms from other clinicians with only a brief period of acclimation. We should note that one clinician describing an audiogram to another can be more problematic. For this reason, audiology teams at Mayo Clinics have instituted a policy that requires a simple description of the overall magnitude of the hearing loss based on the pure-tone average and type (conductive/sensorineural/mixed) using standardized mathematical formulae. More detailed descriptions of audiometric configuration are allowed after the required classifications are documented on the report if they are thought to be necessary.3 This difficulty between expert clinicians is a prelude to difficulties we believe exist in the other two domains.
The second domain of audiogram function is to serve as a communication tool between the hearing health specialist and non-specialist clinicians in health care, for example, the patient's primary care provider. Scant evidence exists on the use of the audiogram as an interprofessional communication tool, but anecdotally we can attest that some audiologists send the audiogram to referring physicians as part—or all—of their report. We were unable to find any published literature on the effectiveness of the audiogram in communicating audiological test results to a physician. An informal survey of curricula from medical schools in the United States yielded no sections dedicated to hearing sensitivity or interpreting audiological test results. Furthermore, we know that even among the highly educated, graphical literacy can vary substantially.4 As such, we believe the audiogram is not ideally suited for communicating important test results to non-specialist clinicians, and we'll soon publish results from a study documenting the difficulties of primary care physicians in correctly interpreting audiograms.
The third category, and in our minds the most problematic, is the use of the audiogram to help patients understand their hearing. One published study has investigated the ability of adult patients to remember their first counseling session with an audiologist.5 The authors found that many patients (43.4%) could not remember whether the audiologist had even discussed their degree of hearing loss. It seems likely that the stress and newness of the situation may reduce a patient's ability to follow and retain information from their appointment.
KEY TAKEAWAYS FROM SURVEYS
From an informal online survey conducted by the Ida Institute, we found that patients rated their overall ability to understand their hearing test results as six out of 10 (N=67), and rated their ability to explain the results to family and friends as five out of 10 (N=67). The unfortunate reality of these low ratings indicates a clear disconnect between what we as audiology professionals would hope for our patients (i.e., an informed patient who is able to clearly relate his or her results back to his or her family6). The audiology-specific results are bolstered by evidence from other health care domains. For example, only 41.9 percent of patients were able to recall their diagnosis at the time of their discharge from the hospital.7
In another survey among hearing care professionals (N = 71), 83 percent revealed that they always or almost always showed the patient the audiogram in a consultation. The top three reasons included: (1) to help the clinician understand the results, (2) to program hearing instruments, and (3) to explain the results to the patient and communication partner. About 99 percent of the respondents indicated that they would like new tools, resources, and methods for better communicating with patients about their hearing loss and its functional impact on their daily lives. These survey results mirrored the qualitative data from focus groups with audiologists in the Chicago area. The audiologists’ (N = 28) practice fell into three broad categories: (1) showing the audiogram to every patient and use it to explain the patient's hearing; (2) showing the audiogram regularly, but do not use it as a primary counseling tool; and (3) only showing the audiogram if asked. When patients were asked in the focus groups and interviews about how clinicians explained their audiology test results, some of the comments illuminated where communication breakdowns occurred:
- “Enough for them, but not for me.”
- “They really didn't explain or describe, and I didn't know what I should ask. I learned more from support groups than professionals. I often feel like just another ear to them.”
- “It was not really explained in a way I could understand. More like ‘we can fit you with this product… by the time I qualified for a CI, more complete information was supplied.’”
There is no one-size-fits-all tool for counseling, and hearing health care professionals will always use their best clinical judgement to tailor their conversations with patients. However, because of the inherent complexity of the audiogram and the low rates of patients’ health and graphical literacy,4,8 we believe that new tools would help clinicians discuss hearing with their patients. Rather than serving multiple purposes, these tools should be specifically designed to help patients understand their hearing and make decisions about hearing health care.
PRINCIPLES FOR EFFECTIVE AUDIOLOGY COUNSELING
The Centers for Disease Control and Prevention (CDC) suggested five principles for effective counseling:9
1. Establish and maintain rapport with the client.
2. Assess the client's needs and personalize discussions accordingly.
3. Work with the client interactively to establish a plan.
4. Provide information that can be understood and retained by the client.
5. Confirm client understanding.
These principles are well aligned with and an integral part of delivering person-centered health care. Clinicians can build rapport by focusing on the patient's needs and preferences through active and open communication techniques. Clinicians can involve patients—as well as their family and friends where possible—in the decision-making process, thereby recognizing patients as equal partners in their hearing care. Information-sharing is an important part of counseling that equips patients to be more active and empowered in making health care decisions. How many of us, in the daily hustle-and-bustle at the clinic, have stopped for a minute to reflect on whether our standard way of using the audiogram to convey information and help the patient make decisions actually works? Have we ever thought of the audiogram and its ability to help or hinder us from providing person-centered care?
CONSIDERATIONS IN HEALTH LITERACY
Another important area to consider is patients’ literacy and health literacy levels. The World Health Organization defines health literacy as “the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions.”10 The results of a European health literacy survey showed that 12 percent of individuals demonstrated insufficient health literacy, while 47 percent demonstrated limited health literacy.11 In addition, the report highlighted great variance from country to country, and noted that factors like financial deprivation, old age, low social status, and low education were associated with limited health literacy. In general, poor health literacy is associated with poorer outcomes where individuals tend to make less healthy choices, engage in riskier behavior, display poorer health, engage in less self-management, and require more hospitalization.12 Patients with poor health literacy are good at masking their status. As such, clinicians are encouraged to employ recommended strategies13 to ensure clear health communication with patients, including explaining a patient's hearing test results:
1. Explain the purpose of the document: Define the purpose and benefit from the patient's perspective.
2. Involve the learner: Focus on desired patient behaviors, and describe useful and realistic actions for the learner to take.
3. Make the material easy to read: Use common words and active voice as if talking to someone; use headings/subheadings to draw attention to the key messages.
4. Make the material look easy to read: Include a lot of white space, use sharp contrast with at least a 12-point font size, and add cues to direct attention to key points.
5. Select visuals that clarify the material and motivate the learner: Use realistic visuals, graphics appropriate to the learner, and captions that clarify the point of the visual and describe the recommended actions.
Effective counseling tools should be designed using the preceding guidelines and cover what is most important to the patient. While the current audiogram provides answers for clinicians, it may not do so for the untrained patient. As long as pure-tone audiometry is the gold standard of clinical audiological practice, the audiogram will have a place in clinics around the world. However, we believe that new tools, designed specifically to help clinicians and patients discuss the results of a hearing test and the functional impact of hearing loss, will improve patient outcomes and reduce clinician burden. In the coming year, the teams at Northwestern University and the Ida Institute will release new tools designed to aid clinicians and patients with making sense of common hearing test results.
1. Jerger, J. (2013). Why the audiogram is upside-down. International Journal of Audiology
, 52(3), 146-150.
2. Fowler E & Wegel R. 1922. Audiometric methods and their applications. In: Transactions of the Twenty-Eighth Annual Meeting of the American Laryngological, Rhinological, and Otological Society, Washington, DC, May 4–6, 1922, American Laryngological, Rhinological, and Otological Society
, pp. 98-132.
3. Zapala, David (2019) personal communication.
4. Nayak, J. G., Hartzler, A. L., Macleod, L. C., Izard, J. P., Dalkin, B. M., & Gore, J. L. (2016). Relevance of graph literacy in the development of patient-centered communication tools. Patient Education and Counseling, 99(3), 448–454. https://doi.org/10.1016/j.pec.2015.09.009
5. Martin, E., Krueger, S., & Bernstein, M. (1990). Diagnostic information transfer to hearing-impaired adults. Texas Journal of Audiology and Speech Pathology
, 16(2), 29-32.
6. Margolis, R. H. (2004). What do your patients remember?: The Hearing Journal, 57(6), 10. https://doi.org/10.1097/01.HJ.0000292451.91879.a8
7. Makaryus, A. N., & Friedman, E. A. (2005). Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge. Mayo Clinic Proceedings
, 80(8), 991–994. https://doi.org/10.4065/80.8.991
8. Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. NCES
2006-483. National Center for Education Statistics.
9. Centers for Disease Control and Prevention (2014). Appendix C: Principles for Providing Quality Counseling, April 25, 2014 63(RR)4);45-46. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a4.htm
11. Sørensen, K., Pelikan, J. M., Röthlin, F., Ganahl, K., Slonska, Z., Doyle, G., … Brand, H. (2015). Health literacy in Europe: Comparative results of the European health literacy survey (HLS-EU). European Journal of Public Health
, 25(6), 1053–1058. https://doi.org/10.1093/eurpub/ckv043
12. Kickbusch, I., Pelikan, J. M., Apfel, F., Tsouros, A. D., & World Health Organization (Eds.). (2013). Health literacy: The solid facts. Copenhagen: World Health Organization Regional Office for Europe.
13. Pfizer Clear Health Communication Initiative. (2006). Help your patients succeed: Tips for improving communication with your patients.