The Patient’s Role in Developing a Treatment Plan

With Peter Stelmacovich, MCl Sc

As most of the readers of Canadian Audiologist know, I am a man of many hats: father, husband, audiologist, amateur musician, dabbler in photography, and lousy archer. I also have a significant hearing loss, which has a profound impact on my work and life on a daily basis.

And, as readers may also know, I am a strong advocate of developing patient treatment plans in audiology.  Treatment plans are of particular importance to patients with more significant hearing loss, greater challenges with hearing in noise, or those with complex hearing needs.

Engaging the patient as part of the treatment planning process is critical to the success of the plan. Patients will simply not follow the recommendations of equipment and behavioural modifications needed to successfully communicate if they have not played a significant role in its development.

But what exactly is the role of the patient in the treatment planning process?  Well, as an audiologist with hearing loss, I have walked in both sets of shoes, so I would like to offer some suggestions.

First, here is a list of things where the person with hearing loss knows best:

1.Ask and find out all the different situations in which the person with hearing loss is having difficulty.  List them all and seriously look at how we are going to help overcome those challenges.

2. The patient knows and can tell you how it feels to be in a given situation.  Don’t be afraid to ask about this.  When a patient says ‘I could not hear at my daughter’s wedding” find out how they felt about that.  It is good to just let the patient explore their feelings and frustrations.

3. Discuss past experiences both good and bad to see what you are up against.  For example, find out if the client ever tried a wireless microphone system or ever used directional microphones in the past.  Likely if something was a failure in the past, find out how much coaching the patient had in how to use the equipment.

In short the patient knows, better than you the clinician, the situations they are having the most difficulty in, and what it feels like to have a hearing loss.

But here is what the patient does not necessarily know and where the expertise of the professional is required.

1. The electroacoustic characteristics, features, programs that are needed in the hearing instrument.

2. The style of hearing instrument is most appropriate. A patient can wish all they want for a tiny hearing aid, but if the loss is too severe, it can’t be done. Yes, many patients have lots of choices of the form factor, but some do not.

3. What technology for managing noise is needed?  For example, if a client has a moderate severe loss and a speech in noise test such as the LiSN-S PGA indicates that a wireless microphone system is needed, the hearing health professional NEEDS to communicate this to the client.  The client does not know what technology is required.  They just know the situations they find challenging.

4. How to effectively use the equipment.  You cannot simply toss the equipment at the client and hope they figure out how to use it in the difficult listening situations that were identified.  Patients need our counseling and coaching here.

Let’s consider a working adult with hearing loss who has difficulty communicating at work. The specific situations at work need to be fully explored. Ideally, you can do this formally with the COSI.  Again, the patient understands this so much better and he needs to tell us as much as he can about his challenges if we are going to have any chance of finding appropriate solutions.  Next we need ask the patient how he or she felt in these challenging situations.  We really need to explore the emotional impact the hearing loss has on the patient.

By doing so we can now focus on the solutions that will work. I have seen in my 20+ years of professional experience numerous patients who are wearing “dirty little secret” tiny aids and are not getting the correct amplification.  They came in asking for the smallest (or cheapest) hearing aid there is.  If we can dip into their emotions we can then focus on solutions that actually work.  We need to provide leadership here and work the client towards more appropriate amplification.

Similarly, we must always consider not just the amplification needs but also the hearing in noise needs as they relate to the client’s own personal situation.  Will the client need directional microphone technology?  Should it be fixed or adaptive directional microphones? Will directional microphone technology be enough or will wireless microphones be needed?  Most patients with moderate severe loss and greater will likely find themselves in situations in which a hearing aid or cochlear implant is not enough.

I agree that we cannot force anyone to take our professional advice.  But patients do have a right to make an informed decision. In my opinion, we are obligated as hearing health care professionals to give the patient all the facts.  Too often, when I give talks about directional microphones, wireless microphone systems, and other assistive devices, a patient will ask me “How come this is the first time I am hearing about this stuff?”