Avoiding Clinical Blind Spots with Good Audiology

by Brian Taylor, AuD

“Signal & Noise” is a bimonthly column by Brian Taylor, AuD.

Over the past two years, since the now infamous PCAST report calling for the creation of a category of products sold directly to consumers, there has been seemingly non-stop chatter and deliberation about the roles and responsibilities of audiologists in the changing clinical landscape. Most of the kerfuffle – observed on professional listservs, convention floors and more than a few barrooms – has been a debate about the pros and cons of allowing patients to buy their own hearing aids without the guidance of a licensed professional.

While the debate rages about how hearing aids are sold, let’s turn our attention to another critical issue: the proper identification and referral of possible cases of retrocochlear involvement.

Audiologists’ Duty of Care

It’s helpful to remember that the primary responsibility of an audiologist is to identify patients who are likely to have nonbenign forms of hearing loss and make the proper referral to a physician for further evaluation and treatment. We do this, of course, through a carefully constructed decision-making process based on pure-tone asymmetries, acoustic reflex threshold patterns, speech recognition scores and the results of other important tests.

I fear that in our rush to provide care and service to the millions of adults with benign forms of hearing loss through the provision of hearing aids, assistive listening devices and auditory rehabilitation, some clinicians have lost sight of this primary responsibility.

Needles in the Haystack

Nonbenign hearing problems are exceedingly rare relative to benign cases of age-related hearing loss in older adults. Consider, for example, the 20-plus million Americans over the age of 65, more than half have age-related hearing loss, while in that same group of older adults, there are just a few thousand combined cases of nonbenign ear-related conditions, like vestibular schwannoma, cholesteatoma, and other assorted pathologies affecting the auditory system. In other words, identifying patients with nonbenign hearing problems is like finding a needle in a haystack.

Given the low probability of an older patient having one of these medical conditions relative to the garden variety age-related hearing loss, there might be a natural inclination on the part of the experienced professional, who long ago moved from conscious incompetence to unconscious competence, to cut some corners on the comprehensive test battery. Or, to automatically decide that he’s seen this pattern of test results and place the patient with some vague symptoms or equivocal test results into the hearing aid queue, instead of making that referral to otolaryngology.

We can roll the dice and probably guess right that the patient has benign age-related hearing loss, but it’s our ability to find those rare cases –the needles in the haystack — that benefit from early identification and treatment from a physician that make audiology an incredibly valuable, cost-effective player in the healthcare system.

Reasoning, Blind Spots and Silver Linings in Clinical Practice

Audiologists are not the only healthcare professionals grappling with diagnostic errors. According to recent reports^1,2 diagnostic errors in medicine occur at an appreciable rate. It is estimated that somewhere between 10% to 15% of medical diagnoses are in error. These diagnostic errors reflect breakdowns in both our healthcare system and clinical reasoning.

When it comes to the practice of “good audiology” the one area where audiologists have control is in their clinical reasoning or decision making. This starts with conducting a thorough case history and the careful use of assessment procedures supported by clinical evidence. For experienced clinicians, this is easier said than done.

With experience comes the ability to rely on pattern recognition to quickly and efficiently make decisions, but the dirty underbelly of experience is that one might become prone to clinical blind spots that get in the way of proper identification and referral of patients suspected on nonbenign forms of hearing loss. Relying on swift judgments (over confidence) or pattern recognition from incomplete audiometric information (anchoring effect) are cognitive biases that audiologists best avoid. (See recent posts at Hearing Economics for a more thorough analysis of cognitive bias)

Perhaps the silver lining of a deregulated hearing aid market is that greater emphasis will be placed on the diagnostic skills of audiologists. If that is the case, then all of us in the profession need to make a concerted effort to avoid cognitive biases, use less reflexive rush to judgment (Type 1 thinking) and rely more on deliberative executive override (Type 2 thinking) to ensure we are not missing those rare, yet consequential cases requiring further medical attention.

For rank and file audiologists the use of executive override means doing the following to avoid clinical blind spots:

Conducting a thorough case history and comprehensive audiological assessment (AC, BC, Speech testing to find PB Max, tymps, reflexes and OAES)
Relying on checklists to ensure every step of the evaluation has been conducted
Conducting all tests in a manner that reflects current best practices
Taking a diagnostic “time out” to review your work and ensure you are not missing an obscure detail
Reporting all findings to with referring physicians, including when your findings indicate a possible nonbenign condition
Conducting grand rounds with staff to discuss challenging or unusual cases
Using Big Data to build your own set of normative data for each test you conduct

References

Ely, J. et al (2011) Checklists to reduce diagnostic errors. Academic Medicine. 86, 3, 307-312.

Saposnokk, G. et al (2016) Cognitive biases associated with medical decisions: a systematic review. BMC Medical Informatics and Decision Making. 16, 138.

Brian Taylor, AuD

Brian Taylor, AuD, is audiology advisor for the Fuel Medical Group. He continues to serve as Editor of Audiology Practices, the quarterly publication of the Academy of Doctors of Audiology. During the first fifteen years of his career, he practiced clinical audiology in both medical and retail settings. Since 2005, Dr. Taylor has held a variety of leadership & management positions within the hearing aid industry in both the United States and Europe. He has published over 50 articles and book chapters on topics related to hearing aids, diagnostic audiology and business management. Brian has authored three text books: Fitting and Dispensing Hearing Aids(co-authored with Gus Mueller), Consultative Selling Skills for Audiologists, and Quality in Audiology: Design & Implementation of the Patient Experience. His latest book, Marketing in an Audiology Practice, was published in March, 2015. Brian lives in Golden Valley, MN with his wife and three sons. He can be reached at [email protected] or [email protected].