Communicating with Primary Care Providers



Author: David A. Zapala, Ph.D.

Collaborative healthcare requires efficient and effective communication. Audiology can contribute to the management of a broad range of health conditions with co-managing physician and non-physician providers. How well such collaborations work depends in large part on how well the audiologist communicates and integrates clinical information. What information is important to share, and how it should be organized depends on the nature of the condition to be co-managed, and requires an understanding of body systems beyond the special sense of hearing. This issue of Audiology Practices will highlight some of conditions and body systems that commonly interact with vestibulocochlear system. Before focusing on these conditions, this article will focus on the basic organization of the audiological evaluation as might be collected in an adult audiological evaluation and shared with a primary care provider in the medical home. That is, we will focus on the kind of audiological evaluation often completed for individuals seeking hearing aids, with the audiologist serving as the entry point to hearing healthcare. The intent is that this type of evaluation would always be shared with the PCP in the medical home.

To complete an adult audiological evaluation, the audiologist must answer two fundamental questions. The first question is: “Is there evidence for a disease requiring medical referral or co-management?” If yes, the audiologist must have in mind where to refer the patient, and what specific audiological information the receiving provider will need to effectively initiate a care plan. The second question is: “Is there evidence for a functionally significant hearing difficulty that can be mitigated by audiological care?” If the answer is yes, the audiologist should have in mind treatment options to offer the patient. To the experienced private practitioner, these questions may seem intuitively obvious. However, it is important to report the answer to both questions to the healthcare team in a collaborative care model.

In terms of disease management, Kleindienst et al., (2016) listed a set of over 100 diseases and conditions that could conceivably be encountered during an adult audiological evaluation. The diseases and conditions1 were categorized along several dimensions, two which are particularly relevant to this discussion. These dimensions are: 1) the likelihood that disease-related signs and symptoms would only manifest as an otologic problem, or present with signs and symptoms affecting other body systems first; and 2) the likelihood of subsequent morbidity or mortality if the disease was missed during an audiological evaluation. In diseases where the signs and symptoms develop in the otologic sphere, the audiologist has a special responsibility to screen for the condition and initiate referrals as needed. When signs and symptoms are present in other body systems, the audiologists will not likely detect the initial disease process, but will provide information that may help stage the progression of the disease. Understanding this helps to organize what information needs to be communicated in the report. Naturally, diseases that are associated with morbidity or mortality are more important to detect than trivial conditions.

For example, uterine cancer metastasis to the posterior fossa, which can present as a progressive unilateral or asymmetrical retro-cochlear hearing loss, would have a very significant risk of mortality (dimension two). The initial signs and symptoms of the disease would involve body systems other than the auditory system (dimension one), and the diagnosis will be made by other health care providers. However, finding a hearing asymmetry in a woman with a prior history of uterine cancer should raise the possibility of metastasis. The referring physician, the patient’s oncologist, and otolaryngologist should receive a report that clearly notes the presence of an unexplained hearing asymmetry in the setting of prior uterine cancer. This is what is meant by co-management. Information developed by other providers is integrated into the decision-making of the audiologist, and vice versa. Together, they form a system whereby disease detection and progression can be monitored effectively.

In contrast, an acoustic neuroma or vestibular schwannoma may sit quietly for many years without observable signs or symptoms beyond an insidiously progressive unilateral hearing loss. In an otherwise asymptomatic adult seeking hearing aids, it falls upon the audiologist to recognize the risk for underlying disease and refer appropriate (Zapala, et al, 2008). There is no one else positioned to perform this vital service.

The handshake between audiology and otolaryngology is well worn. Audiologists and otolaryngologists are familiar with each other’s terminology. Otolaryngologists are trained to be able to evaluate audiological test data and understand our classification systems (e.g. Type “C” tympanogram, air-bone gap, mixed hearing loss). Importantly, they know how to integrate audiological test data into their evaluation process and come to their own conclusions about the nature of the underlying problem (e.g. Eustachian tube dysfunction).

The average physician will not be as capable as our otolaryngology colleagues, nor will they always have the interest to delve into the intricacies of the audiological evaluation. We will inevitably interact with physicians who have varying familiarity with our disipline. Moreover, when physicians have a complex patient to manage, they are required to digest a great deal of information from many sources to understand the patient’s current state of health. Their time and effort is best directed towards the needs of the patient. Poor report writing results in ineffective information exchange. It increases reading time, comprehension effort, and, importantly, increases the risk of misunderstanding. If we are to contribute to the co-management of disease, we must present our impressions clearly and succinctly. “Clearly” means that the assessment and plan sections are easily found in the report. “Succinctly” means that the impression statements use the minimum number of words necessary to communicate. But what is necessary?
Figure 1. Example ECG.


Consider the electrocardiogram (ECG) in Figure #1. ECGs are relatively simple to interpret. They have a complexity about on par with an evoked potential study. There are defined waveforms that vary with electrode position. The waveforms are listed alphabetically from P through T. Heart rate, inter-wave intervals and amplitudes relate to the function of the various regions of the heart muscle and their neuro-electrical drivers. Waveshape, variations in rhythm, and dipole changes can all be interpreted in terms of normal versus abnormal, and have implications for likely site of lesion. Is this important to you, a non-cardiologist looking at this record? You can see the raw ECG waveforms (data) and a few measurements (heart rate, QR interval, etc...). You could learn to interpret these waveforms and understand the implications of those measurements if you wanted to do so. Normal values are easily obtained on the web. But if you saw this in a patient’s chart, would you take the time to do this? No. You have other things to do. Your interest should be focused on the impression statement of the cardiologist – the specialist who is qualified to interpret the data and explain what they may mean. In this case, the cardiologist felt there was evidence for a myocardial infarction in the posterior wall of my heart. Yes, this is my ECG study. It looked like somewhere down the line I had suffered a silent heart attack. (Fortunately, it turned out not to be true.) Now if this were you or your patient, how important is it for you to know how to interpret the raw waveforms in this report? If you had a second study, where would you look first to get the information you seek? You would look at the impression statement.

There are several parallels between the ECG and the basic comprehensive audiological examination. Just like the ECG, the audiological evaluation containers several types of data and classification systems that require a specific technical background to understand. You might be tempted to present these test results and review the meaning of each test. Don’t do this. Other healthcare providers will look to you to present your assessment succinctly in a series of easily understood impression statements. They tell everyone reading the report what you have learned that guides you to propose what should be done. That is, each impression statement is actionable. Each one leads to a subsequent proposed action in the treatment plan. There is no time or space to review the results of specific tests. No one has time for that.

In the case of my ECG, it was the impression of myocardial infarction that triggered a cascade of tests to evaluate the truth of that clinical hypothesis. So what does the analogues statement look like on an audiological report? When answering the first question, “Is there evidence for a disease requiring medical referral or co-management?” use the following format:

<magnitude>,<type>, <likely etiology>

Where magnitude is the common severity classification (such as “mild”, “moderate”, “severe”, “profound”); type is the common site of lesion classification (“conductive”, “mixed”, “sensorineural”, etc…), and likely etiology can be “consistent with age-related hearing loss/prior noise exposure/idiopathic hearing loss etc...) I typically do not go into great detail about audiometric configuration as this is most often used to establish etiology. Rather than force the reader to remember what is implied with various audiogram shapes, make it easy for them: explicitly tell them what is implied. When the etiology is likely age-related or noise -related, there is no need for subsequent medical evaluation. If the hearing loss is idiopathic, or from some other cause, referral would be implied, and this becomes part of the treatment plan. Non-otolaryngologists will appreciate the simplicity of this approach.

If there is an additional reason for medical referral not captured in the above impression statement format, and additional statement can be added. For example:
  1. Right Ear: mild sensorineural hearing loss, likely age related.
  2. Left Ear: moderate sensorineural hearing loss, idiopathic.
  3. Unexplained hearing asymmetry.
These impression statements lead to the first item on the audiological treatment plan:
  1. Recommend otologic evaluation of idiopathic left sensorineural hearing loss.
From the primary care providers perspective, this statement has the effect of saying “referring provider, you have more work to do to arrange for an otologic evaluation.”

In contrast, if the first impression statement addressing the need for medical referral were: “bilaterally symmetrical, mild to moderate sensorineural hearing loss, in keeping with age-related hearing changes”, it would follow that there was no identified need for additional medical evaluation and no such plan would be proposed. The ,, format is an unambiguous way to communicate to primary care providers the medical implications of audiological evaluation results. There is no need to be overly specific with the etiology statement. If it looks like mastoid disease, let the specialist make that diagnosis. It is sufficient to simply state: “idiopathic conductive hearing loss.” This is enough to establish the need for further evaluation on the part of the referring provider.

The second question to be answered by the audiologist is: “Is there evidence for functionally significant hearing difficulties that can be mitigated by audiological care?” I strongly propose that this question be answered in a separate impression statement from the ,, statement. It is unfortunate that the current classification system for describing hearing loss magnitude (i.e., “mild,” “moderate” etc…) has been conceptually anchored to a decibel range, communication difficult descriptors, and average overall hearing loss severity (Clark, 1981, Manchaiah & Freeman, 2011). This co-mingling of constructs can leave the mistaken impression that the audiogram links all of these constructs together. Do all people with mild to severe steeply sloping sensorineural hearing loss have communication difficulties? No.

Separating impression statements of hearing loss magnitude (<magnitude>,<type>, <likely etiology>) from impression statements about hearing difficulty and subsequent need for audiological intervention avoids the ambiguities inherent in using a confounded classification system. It also clearly states to the referring provider that the audiologist will take over care of the patient’s communicative needs. In most cases, this is welcomed news for the referring provider – one less problem on the problem list.

As we have moved to interoperable electronic health records (EHRs), the industry has adapted SOAP structured to document clinical encounters. Reports generated from audiology encounters should follow the structure as well. The alternative structure, APSO (assessment, plan, subjective, objective) may also be acceptable so long as the assessment and plan portions of the report are clearly and succinctly presented (Zapala , 2007).

The treatment plan, at minimum, should address the need for further medical evaluation if such a need is established in the <magnitude>,<type>, <likely etiology> statements. It should also explicitly state that the audiologist will take over care for any hearing difficulties or communication impairments. Additionally, if there is a risk or question about hearing loss progression, a follow-up evaluation at an appropriate time interval should be recommended.

Audiology is rapidly evolving. Not only is hearing aid technology becoming more sophisticated, but our role in co-managing patients with otologic as well as systemic disease is likely to broaden. Against that backdrop, it is vitally important that audiological reports be digestible to specialists and generalists in other healthcare disiplines. Using the <magnitude>,<type>, <likely etiology> structure to describe the pathophysiology, and separating this from the patient’s need for audiological management will greatly facilitate information transfer across disciplines.    

1 In the interest of making this text more readable, we will use the word “disease” to mean both disease and non-disease conditions that should be identified and referred for medical evaluation.
David Zapala earned his BA from California State University at Fullerton, MS from Utah State University, and PhD from the University of Memphis. Early in his career he developed the Infant Hearing Center and Hearing and Balance Center at Methodist Healthcare in Memphis and served as a clinical professor in Otolaryngology at the University of Tennessee. He is currently a Senior Consultant and Chair of the Audiology Section at the Mayo Clinic in Florida and an Associate Professor of Audiology in the Mayo School of Medicine. Dr. Zapala has published and taught in the areas of vestibular assessment and diagnostic audiology. He has served on the American Board of Audiology, the Board of the American Academy of Audiology, the American Balance Society and the Institute of Medicine’s Committee on the Accessibility and Affordability of Hearing Healthcare. He is currently an NIH funded clinical researcher, investigating how well consumers and audiologists assess ear disease risk.
References
Clark, John. (1981). Uses and abuses of hearing loss classification. ASHA. 23. 493-500.

Kleindienst SJ, Dhar S, Nielsen DW, Griffith JW, Lundy LB, Driscoll C, Neff B, Beatty C, Barrs D, Zapala DA. (2016). Identifying and Prioritizing Diseases Important for Detection in Adult Hearing Health Care. Am J Audiol. 25 (3):224-31. PMID: 27679840 PMCID: 5333525 DOI: 10.1044/2016_AJA-15-0079

Manchaiah VKC, Freeman B. (2011) Audiogram: Is there a need for change in the approach to categorize the degree/severity of hearing loss? International Journal of Audiology 50:9, pages 638-640.

Zapala D. Documentation In Clinical Audiology- An Information Management Perspective. In: Holly Dunn, Ross Roser, Michael Valente (eds). Audiology: Practice Management Second ed. Vol. Three. New York: Thieme; 2007.

Zapala DA, Shaughnessy K, Buckingham J, Hawkins DB. (2008). The importance of audiologic red flags in patient management decisions. J Am Acad Audiol. 19(7):564-70. PMID: 19248733