Trust in Audiology: An Interview with Dr. Jill Preminger



Author: Brian Taylor, Au.D.

This issue of Audiology Practices is devoted to communication and trust, two of the cornerstones of a thriving clinical practice. Who better to get things started than Jill Preminger, Ph.D. She has a distinguished career as a prolific researcher. Prior to her academic appointments, she managed audiology clinics in a variety of settings. Dr. Preminger has an active clinical research program at the University of Louisville, which focuses on adult audiologic rehabilitation. Her current research focuses on the impact of hearing loss on significant others. Dr. Preminger has over 60 peer-reviewed publications and presentations. In her interview with AP, she outlines some of her recent research on trust.

AP: What prompted your interest in doing research focused on trust?

Dr. Preminger: In 2010 I started to work with a group of researchers from several countries; we were conducting interviews with adults who had different levels of experience with hearing healthcare (i.e. those who never had a hearing test, those that did have a hearing test but did not pursue a hearing aid, those that obtained hearing aids but stopped wearing them, those who wore hearing aids but reported poor satisfaction, and those who wore hearing aids and reported good satisfaction.) The purpose of this study was to describe perspectives of adults with hearing impairment on hearing help-seeking and rehabilitation (Laplante-Lévesque et al, 2012). I completed the 9 interviews conducted in the US. We had no questions in our interview guide specifically related to trust, yet most of the participants spontaneously brought up trust when describing their expectations or experiences with the hearing healthcare system.

Trust was brought up repeatedly by the very first participant that I interviewed. The participant was an 80 year old woman who lived alone and had an active social life. She had a flat bilateral sensorineural hearing loss with pure tone averages of 45 dB HL left and 53 dB HL right. She had purchased one set of hearing aids at her ENT office and returned those while in her trial period: “He fitted me with a hearing aid that completely blocked the ear channel. And I’ll tell you I put ‘em in one afternoon in his office, then went to a meeting out here, had em in until like 10:30 that night and oh when I got home I just thought, I couldn’t wait to get them out.”1

About 9 months later, the participant decided to try hearing aids again, and this is when her concerns about trust emerged. She went about finding a hearing healthcare2 professional by asking friends who used hearing aids for their recommendations. She made an appointment for an evaluation and unexpectedly purchased a set of open fit hearing aids. “I went to him to talk to him and I walked out with hearing aids. I just wanted to see what it was about and I walked in his office and I walked out with them.” The problem, however, was that she noticed little benefit from the hearing aids. Part of the reason why this must have been the case is that she lived alone. Shortly after purchasing the second pair of hearing aids she received a phone call from a different hearing healthcare provider who got her name from one of her friends. “I thought this wasn’t very business-like. The woman called me one day and said, well now do you want to set up an appointment and come up here? And I said, well I’m sorry but I have bought some. And, and she said, where did you buy’em? and I told her and she said, well I bet you paid a whole lot more for ‘em there than you would have paid us. And I thought that just sounds so unprofessional!” In the meantime, she was still in the trial period and she was still unsure that they were beneficial. She noted that the date of her hearing aid recheck was after the conclusion of the 6 week trial period so she went back earlier to discuss her concerns. For the purpose of convenience, she visited a different office from the same practice. She told the hearing healthcare clinician that she was unhappy with the hearing aids and she wanted to return them. She also told him that she was unhappy with the level of service that she received from the first clinician that she had seen at that practice. The second clinician recommended that she return the hearing aids and then see him directly to purchase a new pair of hearing aids, but she shouldn’t tell the first clinician about this. She returned the HAs and did not go back to see them. She summed up this experience by saying: “See, I told this friend, I said I feel like I’m buying storm windows or a used car.”

AP: Why is trust so important?

Dr. Preminger: There is really no research in the field of audiology to answer this question. However, research in medicine has consistently shown that high levels of trust in physicians and nurses are associated with better patient outcomes. High trust levels have been associated with improved patient satisfaction, greater treatment adherence, and better health status (Farin et al, 2013; Safran et al, 1998; Thom et al, 1999; Trachtenberg et al, 2005). I expect that outcomes in the field of hearing healthcare would be very similar.

AP: Can you tell us about the research design and methodology in your recently published article in International Journal of Audiology (IJA)?

Dr. Preminger: As I mentioned previously, the article on trust in IJA (Preminger et al, 2015) was based on interviews conducted for a previous study (Laplante-Lévesque et al, 2012). In the earlier study we interviewed 34 adults with hearing impairment from four developed countries (Australia, Denmark, United Kingdom, and the United States). In that study we asked people to describe their experiences with the hearing healthcare system, and to explain the actions that they took, or to clarify why they chose not to take action. Twenty nine of the 34 participants spontaneously discussed trust during their interviews. We reread all of the transcripts looking for any discussion related to trust and found 100 different excerpts. These excerpts were “coded”: a description of the excerpt meant to reflect the participant’s perceptions and intent. These codes were organized into themes and subthemes (Braun & Clarke, 2006; Knudsen et al, 2012; Smith & Osborn, 2008). In this way we could construct an understanding of trust which was described by these 29 individuals.

Based on the thematic analysis, we organized the data (the transcript excerpts related to trust) into four dimensions of trust as shown in Table 1. The participants spoke quite a bit about what made them trust their hearing healthcare professional. These thoughts are organized into the four components (and subcomponents) of trust. Table 1 also shows quotes from the transcripts. Some of the quotes show behaviors or systems that promote trust while others show the opposite.
Table 1. The four dimensions of trust that emerged from the data. Transcript excerpts (examples) are in italics
Dimension 1. Components (and subcomponents) of Trust
Relational Competence
  • Communication Style “She talks serious business but she also jokes.”
  • Empathy “They listened carefully at what I experienced and how I was.”
  • Instruction for Self-Management “They’re more interested in selling hearing aids and not the maintenance of hearing aids.”
  • Promotion of Shared Decision Making “He was quite curt and abrupt....well there was nothing I could say, he was the one who decided everything.”
Technical Competence
  • Based on Services Received “She didn’t close the door completely. I could see her reflection on the glass so I knew when she was pushing buttons!”
  • Based on Reputation or Education “I suppose they’re like opticians. They haven’t got a proper medical degree or anything like that, but they are expert in their field.”
Commercialized Approach
  • Solicitation “I notice they’re offering free hearing tests. I rather imagine it is so they can flog them a very expensive hearing aid.”
  • Focus on Service versus Focus on Sales “Some people in some professions …they’re just money-grabbing.”
  • Cost of Hearing Aid “I trusted his advice, because he said ‘No need to go for the gold. Just go for one the middle of the road.’”
  • Public versus Private Healthcare System “I never thought for a minute that National Health would be as good. I thought they’d be just basic hearing aids.”
Clinical Environment
  • Clinic Setting “When I walked in I thought to myself, what have I gotten myself into? Because it was not very professional at all... He wasn’t professional looking himself.”
  • Clinical Services “Well they (hearing clinic) don’t care whether you use them or not, once you have bought them there is no follow-up unless you go in and ask for it."
  • Public versus Private Hearing Healthcare “I think they (private hearing center) must have a bias towards a hearing aid or a firm who’s supplying them, so I would have thought the other (public) would give you a wider range or a more independent view of them."
Dimension 2. Assignment of Trust
  • Interpersonal Trust
  • Institutional Trust
Dimension 3. Level of Trust
  • Varies from Low to High
Dimension 4. Time Course of Trust
  • The Level of Trust prior to receiving Hearing Healthcare Services
  • The Level of Trust after receiving Hearing Healthcare Services
Note: Table 1 is adapted from Preminger J.E., Oxenbøll M., Barnett M.B., Jensen L.D. & Laplante-Levesque A. 2015. Perceptions of adults with hearing impairment regarding the promotion of trust in hearing healthcare service delivery. Int. J. Audiol., 54, 20-28. Transcript excerpts have been added to the original Table.


AP: How can the patient’s perception of trust change over time?

Dr. Preminger: In Table 1 on page 14, we can see that the level of trust can vary from low to high; additionally, this level of trust can vary over time (Dimension 3 and Dimension 4). Individuals who entered their first hearing healthcare appointment with a high level of trust were typically referred by a physician or friend who endorsed these services. Individuals with a predetermined lower level of trust may have heard negative hearing healthcare experiences from friends or family members, or noticed advertisements “commercializing” hearing healthcare services. Depending on the actions and communication of the hearing healthcare clinician (or institution) at the time of service delivery trust levels could rise or fall.

AP: In your IJA paper you talk about institutional and individual trust, can you tell us a little more about the differences between them?

Dr. Preminger: Individual trust refers to trust in the hearing healthcare provider and this trust is typically based on the experience during a hearing healthcare appointment; whereas institutional trust refers to trust in the hearing healthcare office or system. What I mean by “system” varied by the participant; some referred to the hearing aid industry, others to hearing aid providers, and some considered the public or private healthcare system. One participant from the U.S. described his hearing healthcare experiences with the Veterans Administration (VA) system versus the Army healthcare system: “The VA seemed more friendly like they cared about you. Whereas Army doctors, it’s like McDonalds you know: Get the bag out the window and next car.” Some of the participants appeared to be ambivalent in terms of their level of trust. That is, they had low trust in the hearing healthcare system (based on hearing negative stories from others) but they had high trust in their hearing healthcare provider (based on the actual services received.)

AP: You also mention in that paper how trust differs from satisfaction. They seem fairly interconnected, could you elaborate on the similarities and differences between trust and satisfaction?

Dr. Preminger:b> This is something we wrestled with when analyzing the data: separating trust from satisfaction. We looked to the literature for help. Some authors have postulated a temporal relationship between trust and satisfaction. It has been proposed that satisfaction is based on past healthcare experiences, whereas trust is an expectation about the future. Alternatively, satisfaction may be based on the experience during an individual office visit and trust develops over repeated visits (Thom & Campbell, 1997; Thom et al, 2004). We based our data analysis on the work of Hall and colleagues (2001) and our audiology colleagues Drs. Kris English and Gyl Kasewurm (2012) who posit that satisfaction with services received promotes trust.

AP: How does the level of trust in the hearing care industry compare to other health care professions?

Dr. Preminger: In our recent paper (Preminger et al, 2015) we reviewed the literature and found seven components of the physician-patient relationship that promote trust: 1) communication ability, 2) demonstrating caring behaviors, 3) building relationships, 4) fidelity (acting in the best interests of the patient), 5) demonstrating competency, 6) honesty, and 7) confidentiality. All of these components (except for confidentiality) were seen in the transcripts from our research and are shown in the four components of trust in Table 1. However, one of the components that we found: The commercialized approach, was not seen in the literature describing trust in physicians. This is particularly interesting as physicians do “sell” medical devices such as artificial hips and cochlear implants. If we try to discover why the commercialized approach is not an important factor in building trust in physicians, we may begin to understand how to promote trust in audiologists.

I cannot answer your specific question about how the level of trust in audiologists compares to that in other professions, as we did not collect data to answer that specific question. But I am hopeful that our discussion about trust will inspire other researchers. In a 2004 phone survey, 2000 adults in the U.S. reported “a lot of trust” in nurses (65%), doctors (61%) and dentists (56%) (Harrisinteractive, 2004). It is interesting to consider how these percentages may have changed over the past 10 years as our healthcare system continues to go through upheaval; it is also interesting to consider how trust in audiologists stacks up against trust in other healthcare professionals.

AP: I think you do a great job summarizing how being perceived as “too commercialized” diminishes trust. Given the basic fact that audiologists need to “sell” hearing aids generate revenue, what can audiologists do to bridge the gap between being perceived as overly commercial and generating revenue to stay in business?

Dr. Preminger: Several of our participants reported trust in their hearing healthcare providers despite the fact that they felt that the field of hearing healthcare was too commercialized. They trusted clinicians who:
  1. Practice good communication
  2. Display empathy
  3. Enable shared-decision making
  4. Promote self-management (Several participants reported low trust in providers who did not teach them how to take care of their hearing aids.)
  5. Display technical competence
AP: What can the private practice audiologist do to promote trust?

Dr. Preminger: I believe that following the 5 steps above are important. I will let one of our participants explain this further. This is how a 47-year-old woman from Australia explained what she wanted from her audiologist:

The audiologist needs to be engaged I think, so there is that touch of compassion. There needs to be a sense of engagement that is, “I’m interested in your position and the way you deal with things,” just exactly what you are doing now; being interested in the position that hearing-impaired people have in society. That’s a story I have always wanted to tell people just so that they understand what it is like.

The same participant described hearing healthcare professionals that she trusted:

They realize that I have spent my whole life with this hearing loss. That I probably know better than them what I need from my hearing and I know better than them if there is something wrong. Whereas for them all they know is really the technology behind it, they know how to test the hearing, they can do it very well, but they realize there’s a compromise that you have to make between the hearing impaired person and the audiologist. You cannot just tell the hearing-impaired person, “This is what you need,” you have to agree with the hearing-impaired person and say, “Yes you’re right, that’s probably better for you than another product.”    
Dr. Preminger is a professor at the University of Louisville, Department of Surgery, Program in Audiology. She can be contacted at jill.preminger@ louisville.edu.

Acknowledgements:
I would like to thank my co-authors from the 2015 IJA article: Ariane Laplante-Lévesque, Maria Oxenbøll, Lisbeth Jensen, and Margaret Barnett. I also thank want to acknowledge Ariane Laplante-Lévesque, Louise Hickson, Lesley Jones, Line Vestergaard Knudsen, Sophia Kramer, Thomas Lunner, Graham Naylor, Claus Nielsen, and Marie Öberg for their valuable contributions to the 2012 IJA article. This work was funded by the Oticon Foundation.
Endnotes
1 Transcript excerpts are in italics.

2 It is important to note that I do not refer to the individuals who provided hearing healthcare services as audiologists. This is because this subject did not refer to them as audiologists. I believe that some of the individuals she saw were hearing aid dispensers and others were audiologists, but to this patient, and for most of the 34 individuals that we interviewed, they were unaware of these distinctions.
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