The Four Agreements in the Clinic

Author: Erin Wright, Au.D.

Anyone in the field of Audiology can relate to those days where people test your patience. How could it be otherwise when we are a profession of helpers, trying to the best of our abilities to make the right recommendations and provide solutions? Most of us have had the experience in the clinic where someone explains a problem, you offer a solution, and they continue to explain the problem. You then reply, “Understood. I understand what you are saying, and my suggestion is this.” Then, as though you never spoke, they recount another example of the same problem. When times like these arise, I breathe deep and remember the posters I have memorized in my clinic labs from a book I read years ago. The book, by Don Miguel Ruiz, is called “The Four Agreements,” and it has been widely read and published. I considered his agreements often in my personal life, but somehow it took a lightbulb to go off to realize how valuable these agreements are in my clinic.

According to Don Miguel Ruiz, the four agreements are:

Be Impeccable with Your Word
Impeccable means without sin. And sin is doing anything that goes against yourself. For example, if I know of a hearing aid that might suit someone’s needs, or may solve a potential problem, then I will always suggest we try it. We all have been in the situation where someone has a complaint; it may be at the end of their trial, and in the backs of our minds, there may be a different hearing aid that just may solve their problem, or, in some way, be slightly better for them. You could say nothing and save yourself the work, or you could be impeccable with your word and take on the extra time and expense to do a return for this customer.

When we are impeccable with our word, it also means to not speak disparagingly about ourselves or blame or criticize others. This negativity in the clinic is easy to slide into when placing blame on the manufacturer, or speaking poorly of a competing clinic. Keep your comments and commentary positive, being careful not to lay blame or judgement on others.

In my clinic, the most important component in this agreement is to honor your commitments (your word). This translates for me as being careful not to overpromise what a hearing aid will be able to deliver. If I say I am going to do something, I will follow through, even if it means that I incur a cost. If I tell someone they are going to be able to easily stream their TV through their hearing aids, but they can’t get it connected at home, then I will go to their home to ensure that what I promised is the experience that they get.

Don’t Take Anything Personally
Ruiz says “Nothing other people do is because of you.” Imagine you see someone for their first hearing aid follow up. They had a poor night’s sleep, got a parking ticket, haven’t eaten all day, and are feeling a mistake they made at work is going to cost them their job. Now, imagine how that person might interact with you at their appointment (likely not very positively). Imagine seeing them the day they win the lottery, have a great visit with an old friend, and were treated to an amazing lunch. This person will likely interact differently with you. The important part in these scenarios is that we as clinicians are the same. We have not changed in either scenario.

What people say, the opinion they have of you, either good or bad, has nothing directly to do with you. It is a projection of their own selves. I find this agreement critical to remember when someone is upset and complaining of how he hates his hearing aids. The battery is too small, the volume control is too fiddly, the wax guards need to be changed every day. It is easy, especially when we are feeling tired and overworked, to be short with people in our exchanges, and interpret these comments as somehow our fault.

It is easy to become defensive as though patients complaining about their hearing is a direct attack on you. If they imply that you are bad at your job do you believe them? Instead, watch their words from a distance. Don’t take them in. Listen empathically to their message and try to hear what their needs are, without somehow taking it as a personal attack. Maybe they just want to vent because they are frustrated. Maybe not every situation is horrible, but they are exaggerating to get their needs of being heard met. Realize they are attempting to communicate a need; you just have to listen skillfully in order to hear it. And remember, it is not about you.

Don’t Make Assumptions
The problem with making assumptions is that we believe the assumption is the truth. As clinicians, we need to skillfully ask questions and not assume that, for example, just because someone is 85 years old, they are not employed or do not use a smartphone. Don’t assume that because someone comes in well dressed, that they can afford high end hearing aids. If we operate on “assumed beliefs,” we are ultimately to blame when we make decisions in haste. (Example: she is 95 years old and will do fine with basic hearing aids). Learn to clearly ask questions until you understand lifestyle needs, prior to considering a product to recommend.

Always Do Your Best
There is just one more agreement, but it’s the one that allows the other three to become deeply ingrained habits. The fourth agreement is about the action of the first three: Always do your best.

Ruiz continues: “Under any circumstance, always do your best, no more and no less. But keep in mind that your best is never going to be the same from one moment to the next. Everything is alive and changing all the time, so your best will sometimes be high quality, and other times it will not be as good.”

What this means to each of us may be different. To me, as an independent clinic owner, doing my best is committing to being knowledgeable and up-to-date on all hearing aids from all major hearing aid manufacturers. This is how I know that I am doing my best-- I listen carefully to patients explain their needs, I don’t make assumptions and I thoughtfully make the recommendation for the product that will best suit their needs and budget.

I promise to not “give up” on keeping up with the fast pace of change in our industry and profession, so that I am always the expert that they expect to see and trust. This is not easy, and every year that I get older I think how much easier it would be to use only one hearing aid manufacturer. But I am not in this for easy, I am in this to do my best. These four agreements can have the power to radically change your life. In relationship with family, colleagues and clients, the agreements you make to yourself can result in both financial and personal reward. For a free downloadable poster to hang in your clinic visit:    
Dr. Erin Wright is an Audiologist and private practice clinic owner in Victoria, British Columbia, Canada. She can be contacted at