How I Manage Patient Expectations: The Benefit/Comfort Scale

Author: Adam Bostock, B.Sc.

Hearing instrument technology is constantly evolving. However, unlike eye glasses, there is little in the way of instant gratification. For a first time user, it is commonly known that hearing aids can sound tinny or metallic, and often amplification can be too loud, as the brain becomes accustomed to hearing missing sounds. For this very reason, hearing instruments have been designed with acclimatisation features, and it is common practice to use the first few follow up appointments to reach the desired prescriptive target.

Since I have been in the audiology profession, both working as an audiologist and while working for hearing instrument manufacturers, I have found that even if this process is explained to the patient thoroughly, some patients will still return less than satisfied. The reasons can vary, but when people are spending a lot of money on devices to improve their hearing, they have high expectations – and so do their family members. It is vital that these expectations are managed, so the patient and their significant others can receive the full benefit that we know, as audiologists, the instruments have to offer.

I have tried several different ways of managing patient expectations effectively, and have found the visual method of drawing a simple graph, while talking it through, has had the most success.

Below is an example of how I explain this graph to patients.

There are two things that everybody wants from a hearing aid fitting. Benefit and comfort. (Write Benefit and Comfort at top of page). If I were to give you full benefit and full comfort we would score these 10 out of 10 (Write the number 10 under Benefit and Comfort).

Zero would be no benefit, and no comfort at all (Write down zero at the bottom under each word).

With a hearing instrument fitting, you will obviously want 10 out of 10 benefit, and 10 out of 10 comfort. However, it doesn’t quite work like this.

If I were to give you 100% benefit straight away i.e. 10 benefit, you would receive 0 comfort (Draw arrow from 10 benefit to zero comfort). This is due to your brain making you overly aware of the sounds you are not used to. It would sound horribly tinny, and your own voice wouldn’t sound nice.

Likewise, if I were to give you 10 out of 10 comfort (Draw line from 10 comfort to 0 benefit), you would get 0 benefit. As to make it completely comfortable, I would have to turn the hearing aids down in gain.

Therefore, when we first fit hearing instruments, we start somewhere around 5 (draw number 5 in the middle of each line). This means that the hearing aid is going to be giving you some benefit to begin with, but it is also going to be more comfortable than at full benefit.

As you wear the hearing instruments, and teach your brain that the sounds you are hearing are normal, we can work our way up from 5, to 10 on both sides. (Draw lines on each side simulating climbing up the ladder). This can vary with each person, and it requires you to wear the hearing instruments as often as you can.

It is first used at the initial assessment, usually when demonstrating technology to the patient as a precursor to turning the instruments on, so the patient understands why the hearing instruments sound tinny and metallic. It also prepares them for the fitting appointment, where it is used again.

At the fitting appointment, it can be used twice – initially to work through and explain where the intended acclimatisation level is likely to be set and why. It can then be reinforced at the end of the fitting appointment, during which the benefit/comfort level may have changed, for example if the customer is able to accept the instrument closer to the prescription target than initially intended.

Follow-up appointments are where the comfort/benefit scale is most useful. Rather than arriving at the appointments frustrated, or even apprehensive about approaching the fact they aren’t satisfied, they arrive with a goal in mind. That goal is to move up the benefit scale.

I believe the Benefit/Comfort Scale works because:
  • It is simple to understand and relatively quick to go through. At a hearing instrument fitting for a first time user, there is a lot of information to take in.
  • It satisfies patients who prefer either visual or auditory learning styles.
  • It gives two numerical values to work from, and something to work towards. These can be used to set objectives and monitor progress.
  • It encourages patients to wear the hearing instruments, with an understanding that higher comfort cannot be achieved without use.
A criticism of using this method, is that by suggesting ten out of ten benefit is achievable, could be setting the patients' expectations unrealistically high. This is a valid concern, but avoidable with a good explanation explaining that ten out of ten benefit is “potential benefit”. Some may even prefer to substitute the word ‘benefit’ for something they feel more comfortable with, such as ‘gain’ or ‘level’. It is worth mentioning here, that the Benefit/Comfort Scale isn’t a substitute for listening to the patients, and personalizing their journey to meet their own complex needs.

An implication of using the Benefit/Comfort scale, and something that may need further consideration, is rethinking the way remote controls are approached with patients. I tend not to fit remote controls on initial fit unless a patient is insistent, with the reasoning being that remote controls encourage the patient to move more towards comfort than benefit. It does however give me the opportunity, when the patient is at the desired target, to approach the subject of remote controls in order to give them more comfort when needed.

As a tool, the Benefit/Comfort Scale can be used to help manage patients’ expectations effectively. It gives a simple and clear goal, encourages hearing instrument use, and reduces the risk of patients and their families being unnecessarily dissatisfied with such an important purchase.    
Adam Bostock, B.Sc., is Branch Manager and Audiologist at Amplifon UK. Adam can be contacted at