Patient-Centered Care and the Therapeutic Relationship



Author: Jay R. Lucker, Ed.D., CCC-A/SLP, FAAA

As the healthcare system slowly moves toward the use of internet and mobile interventions for improving health and wellness, there are certain chronic conditions that are likely to benefit from the personal, face-to-face interaction between a patient and a provider. The services provided by audiologists are one of them, but today these professional services are undifferentiated. That is, we use essentially the same counseling approach with every patient: orient them to hearing aids and temper their expectations of hearing aids. Much of what we call patient-centered care today revolves around the devices we dispense. In a world of rapidly changing technology, including self-fitting hearing aids, this product-centric approach must change.

Adults coping with the effects of gradual sensory neural hearing loss, especially when it coincides with other conditions of the aging process, like cognitive & physical decline, are likely to need personalized care and attention for extended periods of time. Audiologists who focus on the emotional and social needs of their aging patients are likely to offer a differentiated service, a service that is in high demand – even as lower costs and more direct-to-consumer hearing aid technology continues to evolve.

Over the next few years, the profession may even see the development and use of novel approaches to patient and family centered care. In order to fully appreciate the human element of modern audiological care, it is helpful to be reminded of what true patient- centered is and why it is so critically important, not only to our patients but also to our profession. Last year in an issue of Audiology Practices (vol.7, no. 4), Caitlin Grenness, an Australian research audiologist, shared some of the findings from her research on patient-centered care. Dr. Grenness’s work reveals some important insights about what our patients find valuable about our profession:

“When participants described what patient-centered hearing care meant to them, a common theme across all participants was the need to individualize hearing care. Moreover, participants were able to describe what it was that they wanted individualized. A central dimension of hearing care that required individualization was the therapeutic relationship. That is, the audiologist needs to take the time to get to know the patient, make them feel comfortable and develop trust.”

Another valuable insight from Dr. Grenness’s work is that the quality of the therapeutic relationship rests with the audiologist’s ability to recognize the very basic humanity of each person, as she writes in her article:

“What constitutes a therapeutic relationship was different for any given participant and thus, audiologists’ skills in deciding what is needed are paramount. It is worth noting that when the audiologist’s skills and attributes were described, participants sought more than friendliness and kindness – participants valued genuine care, flexibility and interest in their person and context.”

The type of patient-centered care described by Dr. Grenness requires a time commitment from the audiologist, as the ability to demonstrate genuine care, flexibility and interest in each patient cannot be squeezed into a 15 minute appointment. Perhaps the one thing that is valued the most by many patients is our ability to allow enough time for them to feel they are being heard. Exactly how we fill our time with each patient is important, and again, Dr. Grenness’s research provides some guidance.

“First, audiologists should always value relationship development; second, seek and invest in bilateral exchange of information. Specifically, take the time (particularly in the history phase) to learn about the patient; ask questions that are psychosocial in nature and relate to their lifestyle and be comfortable with letting the patient take the lead. When it comes to offering your expert advice, do so in a way that is accessible from a health literacy perspective, and provide all the genuine treatment and remediation options (not just a hearing aid).”

As audiologists begin to think about how they can develop deeper relationships with their patients - the types of relationships that cannot be duplicated by other professionals or technology, we offer you another perspective on patient-centered care. Dr. Jay Lucker from Howard University provides us with his insights on family centered care and how he uses it to differentiate his practice from other professionals. Over the next few years, in the face of commoditization of technology and mobile health, Dr. Lucker offers a glimpse into how time spent with patients is our most critical asset. It’s up to all of us to develop new uses of this time to truly master patient-centered care.

How Should I Approach Working with My Population? A Family-Centered Approach

Background
A patient visits your practice. The patient has a hearing loss and is interested in finding out about hearing aids. He is an adult who lives with a family that includes the patient, spouse, one child still living at home, and one child (and family) living away but visiting often as well as communicating by telephone. As an audiologist, you want to help this patient, so you speak with the person, find out the person’s concerns, and identify that the person is finding greater and greater difficulties communicating with family, friends, and people at work.

You complete a hearing test and sit with the patient to present the results of the hearing test. Hearing aids would be appropriate, based on the patient’s hearing loss. You ask yourself, “How do I interest this patient in trying hearing aids?”

You ask the patient, “Have you considered trying hearing aids? As you can see, the hearing testing revealed you have a hearing loss, and the new, modern hearing aids could help you hear better while reducing background noise, so you could communicate better with your family, friends and colleagues at work. You said you came here to see whether you might need hearing aids, and your hearing test shows you do need hearing aids?”

The patient indicates that he would like to learn more. So, you show the patient sample hearing aids that would be appropriate for the hearing loss identified, and ask, “Would you like to try these on and listen and see how they improve your hearing?” The patient agrees and you fit an earpiece to the hearing aid and hook the hearing aids to your computer and start the programming process. In the course of programming, the patient says, “Wow, I can hear you so much better,” while a big smile comes across the patient’s face.

Eventually, you get to the cost of the hearing aids, and the patient does not seem negative about the cost once you explain the payment system you have available. You also inform the patient about the 30-day trial period and the patient agrees to leave a deposit and come back in 20 days to re-evaluate the programming and complete the sale. The patient takes the hearing aids and leaves your office with a positive attitude.

Two days later, the patient returns and says, “I think I am doing well without the hearing aids and would like to return them and get my refund back.” You are very surprised, but you speak with the patient. You ask the patient, what was done over the two-day period, and the patient says the hearing aids were worn at home, with a group of friends, and at work. When you ask if the patient felt that hearing and communication were better during the two days, the patient merely responds, “I just want to return the hearing aids and get my money back.” You then try to explain that it might take more than two days to adjust to the new hearing aids, and encourage the patient to try them for another week and then come back. But, the patient insists, “Just take them back and give me my refund.” Eventually, you take the hearing aids back and provide the patient with the refund.

In looking back at this situation, you ask yourself, “What went wrong? Was I too pushy?” Then you come to the conclusion that the patient really was not interested in getting the hearing aids, or the patient thought they were too expensive so that is why the hearing aids were returned. There is another possible reason. This reason has to do with the term “patient” used throughout the above discussion. Just who is your patient? Have you been too professional-centered? Did you really take a patient-centered approach?

In a previous issue of Audiology Practices (volume 7, no. 4), Caitlin Grenness discussed the patient-centered approach in aural rehabilitation counseling. She argued that audiologists often think we are patient-centered, while we really are not. Largely the reason is that we truly do not understand the patient or patient-centered approach to counseling and do not know how to apply it in our audiological work. However, what Dr. Grenness missed is the identification of our patient, or better said, patients.

When a person walks into your office, store, or clinic, that person may not be your patient or at least not your only patient. Most of the people with whom we work are involved with families which may consist of their true families or close friends who function like family. These “family” members may be the ones who got the patient to come to you in the first place, and it may be that the patient coming in with the hearing concern is not your only patient. Thus, a question arises whether the best approach to take is a patient/patient-centered approach or a family-centered approach. The remainder of this discussion focuses on the differences between a professional-centered approach, a client/patient-centered approach and a family-centered approach. The main features will be what are the differences and why is the family-centered approach often the most important approach to take as an audiologist.

The Professional-Centered vs. Patient-Centered Approach
The most common approach the author has seen taken by audiologists is a professional centered approach. As Dr. Grenness indicated in her article, audiologists often think they are taking a patient-centered approach when they are really taking a professional-centered approach but focusing on their patient. For example, in the example presented originally in this article, the audiologist completed the hearing test and then explained the hearing test findings to the patient. However, the question arises whether the patient (a) asked to have the test results explained, (b) which test results the patient wanted explained, and (c) did the patient understand what the audiologist explained so that the patient could re-explain the findings to anyone in the “family” who asked, “So, what did the doctor find?”

I have observed students of audiology in their clinical practice “explain” to their patients (the person whose hearing they tested) the results of the audiogram and audiological testing. Think about when you first learned about the audiogram. When the teacher was explaining it in class, did you really understand everything that was said? Could you tell your undergraduate college roommate all about the lesson on the audiogram so that your roommate understood? Did your roommate really care about the low, middle and high frequency hearing for each individual ear and whether the audiogram showed a sensorineural or conductive hearing loss? I doubt it, unless your roommate was also a communication sciences and disorders undergraduate major.

Have you ever ended your audiological testing and said to your patient, “What would you like to know?” Or, do you go right into an explanation of the hearing test findings. What if all your patient wants to know is if a hearing loss was found? The patient did not ask which ear, what degree of hearing loss, what type of hearing loss, but that may be what you are telling your patient. The real question is why are you explaining the hearing loss? For the author, a patient-centered approach means that the patient is at the center. Thus, it is our job to explain, in terms the patient requests, what the audiological test findings really show. The patient might then ask the question, “What can I do to hear better?” The audiologist’s job is to educate the patient as to what might help so that the patient can determine whether hearing aids should be tried. In essence, our job is to educate and guide our patients, so that they can make informed decisions. In doing so, the patients will be more likely to invest in the idea of purchasing and using hearing aids, before they try them.

The Family-Centered Approach
The question then should be asked, “Who is our patient?” Is the patient the person whose hearing you have tested and to whom you want to fit with hearing aids? Maybe or maybe not. Or, maybe there is more than one patient?

The people who come to see audiologists typically have families, particularly if we define family in the standard sense and to include extended family such as close relatives and friends whom the person might consider “family” members. In the example presented above, we never identified what brought the patient in for the audiological evaluation in the first place. It is true that the audiologist identified that the patient came in to find out about a hearing aid, but notice that the audiologist never identified what brought the patient to come in to find out about hearing aids. It is possible that the patient really did not care much whether hearing aids were or were not used, but the patient’s spouse, children, or some very close friend “bugged” the patient until the patient said, “Okay, I’ll go try a hearing aid.”

Then, when the patient came home with the two new hearing aids on trial, the person who “made” the patient come in for the hearing test and to try the hearing aids may have been outraged. Perhaps, the “family” member who encouraged the patient come in for the evaluation and hearing aids felt the hearing aids were too expensive, the patient did not understand or was not able to explain the identified hearing loss and how the hearing aids would help. Thus, your patient was not merely the person you tested but also the person who sent your “patient” to you in the first place. However, without taking a family-centered approach, your time and work led to an unsuccessful ending regarding helping that person hear and communicate more effectively.

Basic Elements of a Family-Centered Approach
In a family centered approach, there are a number of basic elements. First, you must identify all appropriate family (and extended family) members who are concerned about the hearing problems, and identify their concerns. Your job is to educate all family members so that questions that might arise when the person with the hearing loss is not with you, can be answered by other family members, and that all family members support the fitting and use of the hearing aids.

Another element of a family-centered approach relates to attitudes. In the case presented above, the “patient” was positive about trying the hearing aids and gave the deposit accepting the payment system for the aids. However, were all critical family members supportive of trying the hearing aids and putting down a deposit and paying off the final costs for the hearing aids? We have no idea because we never met with any other family members. Thus, it is possible that the attitude of a critical family member led the “patient” to return the hearing aids.

One of the advantages to a family-centered approach is that what one member of the family does not “get” during the sessions with the audiologist, another member of the family might understand. In such a case, our job as audiologists is to identify the family member who understands how to explain things, and have that family member present the explanations to those who do not understand. This approach allows the family member doing the explanation to fully comprehend the situation (such as understanding how the hearing loss is affecting the person with the loss and how hearing aids might help that person). In the end, the family becomes the focus of discussions. You might actually find that you are speaking very little while family members are doing most of the talking amongst each other. They are “buying into” the process and helping the process succeed. Eventually, when problems or questions arise at home where you are not present, there can be a family member who can provide answers.

Consider the following example: A patient goes home and a few days later forgets how to change the battery of the hearing aid. The patient would normally have to wait until you are available to come into your office and have a re-explanation of how to change the battery. However, if that patient came to you originally with the spouse and, maybe, an adult child, the spouse or child might remember how to change the battery and show the patient (at home) how to do it. In this case, both the person with the hearing aids and the family member(s) helping to change the battery are “buying into” the person’s use of the hearing aids. Also, the person with the hearing loss sees that family members are supporting the use of the hearing aids rather than fighting their use. This example can be applied to many other situations that can occur when a person is fit with new hearing aids.

One important element of a family-centered approach is that the audiologist’s job is no longer to focus on the person with the hearing loss. The job is to focus on all family members. Additionally, it is the audiologist’s job to identify who the other critical family members are who need to be involved in the counseling, fitting, and aural rehabilitation services. For example, a patient and spouse may come in for the hearing testing and initial hearing aid fitting. What if there is a family member living with them (as in the original example)? Imagine if that family member thinks the whole idea of that member’s parent being “old” and needing to wear hearing aids is negative. That child could sabotage the successful fitting of the hearing aid if the parents (together) are not strong enough to ignore what the child says.

However, if the audiologist asks the patient and spouse something like, “How do you think your son will feel when he sees you with your new hearing aids?” The two parents may admit that this could be a problem. The audiologist might suggest that the family try to get the son to come into the office the next day and then fit the hearing aids while the son is present so that the son sees the positive changes the hearing aids make comparing communication without the hearing aids vs. communication with the hearing aids. The audiologist could also speak with the son to determine his attitude and work to educate him to support the parent using the hearing aids.

One of the most important aspects of a family-centered approach is that there are many patients. The ideal is that there is one patient called the family all working together to support the use of the hearing aids. However, this is not always the case. Additionally, in many cases, the original family coming in for the hearing test and hearing aid fitting and trial might be the immediate family who live with the person having the hearing loss. Extended family members may not support the hearing aid fitting and use. The audiologist should provide an “open door” policy explaining to the original family members that, should a problem ever arise regarding the person’s use of hearing aids, feel free to come in with the family members (or friends) who have questions so that these issues can be discussed and the person can be better educated. This can bridge the family to you as an important resource whenever a problem occurs. In essence, you become sort of a member of the family.

Advantages and Disadvantages of the Family-Centered Approach
Hopefully, you can see the advantages of the family-centered approach vs. the professional-centered approach and the client/patient-centered approach. The greatest change is that the family should be doing most of the talking, and it is the family members who should be sharing with each other. The advantage is that there is support for the person with the hearing loss outside the audiologist’s practice.

One disadvantage is that it can be a challenge to identify family members who have concerns and to help the family resolve these concerns. Most of the other disadvantages involve family dynamics. Not all families are easy to work with—it takes practice for the audiologist to become adept at working with entire families, especially those with negative group dynamics.

Just remember, our job is to help people who have hearing loss and not to get involved in family quarrels. An audiologist needs to engage the supportive members of the family and try to minimize involvement with the negative members whose attitudes cannot be changed. Initially, it is good to try to change the attitudes of those negative family members who do not support the audiological evaluation and hearing aid fitting, but this cannot always be achieved.

However, audiologists applying a family-centered approach should see the following positive outcomes:

First, less need for the audiologist to repeat things because family members are encouraged to communicate and provide explanations. Second, the person with the hearing loss can sense the support of the family and knows to that they are there to provide support when a problem arises so that it is not always necessary to return to the audiologist to resolve minor issues. Third, because there is a stronger support system in place, the hearing aid fitting has a better chance of success.

There are other positive factors we can consider, but the present discussion focused on the most important ones. The greatest advantage the author has seen, in employing a family-centered approach, is fewer hearing aid returns, greater success, and easier handling of problems when they occur—in part because, in many cases, the family members have already done the initial troubleshooting.

Audiologists are here to help people with hearing loss lead more successful lives through improved communicating and hearing. Families are often the most successful helpers. Thus, consider a family-centered approach in your audiological practice.    
Jay R. Lucker, Ed.D., is a Professor in the Dept. of Communication Sciences & Disorders at Howard University in Washington, DC. Dr. Lucker specializes in auditory processing disorders and language processing disorders. He can be reached at apddrj@gmail.com.<./i>