by Jill Preminger, PhD
I became aware of the importance of trust in audiology care while participating in an international research study in which we interviewed people and discussed their experience with and perceptions of hearing healthcare. All participants had some degree of hearing loss and varying degrees of experience with hearing healthcare; for example, some had never had a hearing evaluation, some were happy hearing aid users, and some had stopped using their hearing aids.
Participants were from four different countries (the United States, United Kingdom, Denmark and Australia) that all had both private and public healthcare systems (in the US we included some individuals who had access to services at the VA). Individuals were asked to tell the story of their hearing loss and why they did, or did not, get a hearing evaluation and a hearing aid. Trust was a topic that came up repeatedly; my colleagues and I were intrigued that trust was discussed similarly across these countries with such different health care systems.1
Patient Perceptions in Hearing Healthcare
In our work, we found that lack of trust was closely tied to a commercialized approach in hearing healthcare. This occurred when the patient felt that the audiologist (or dispenser) was more interested in selling hearing aids than in addressing their hearing related problems.
Two different women from the US noted this in different ways. A 77-year old woman with no hearing healthcare experience noted: “I’m a little bit leery of the actual hearing-aid places that advertise the free hearing things. I’d rather hear it from a doctor.” An 80-year old woman who was a dissatisfied hearing aid user said: “I feel like I’m buying storm windows or a used car. That’s just the feeling that I get. They didn’t explain what they do or how they work… they were just more interested in giving me hearing aids.”
These comments demonstrate that many potential or existing hearing aid users have a lack of trust in audiology care that is tied closely to viewing audiologists as individuals who primarily sell hearing aids.
The quotes in the previous paragraph were collected in 2009, today’s potential hearing aid buyers face more decisions than ever:
- Should I see an audiologist or find a hearing device on-line?
- Are these devices I see on-line as good as hearing aids; are hearing aids really worth the extra cost?
- Is the “premium” hearing aid really better than the “advanced” hearing aid?
On the surface, all of these decisions appear to be about cost, however, if a patient had a trusted advisor to explain the answers, the cost concerns would likely diminish.
Over the past two years, colleagues and I have been developing an internet-based decision coaching guide to promote audiology care. In the process we have held focus groups with a variety of adults with hearing loss, both treated and untreated, in order to learn what motivated them (or would motivate them) to seek audiology care. Some common themes emerged. For example, satisfied hearing aid users appear to trust their audiologists, whereas those hesitant to visit an audiologist appeared to lack trust. In addition, those that knew unhappy hearing aid users, didn’t trust that hearing aids would be beneficial, and thus they didn’t trust audiologists as they assumed that the audiologist would sell them an inadequate product. Finally, some of those who did see an audiologist were concerned that the audiologist’s primary goal was to sell hearing aids or to “upsell” unnecessarily expensive products.
Trust and Patient Adoption of Services and Technology
We believe that a lack of trust in hearing aids and audiologists is keeping potential patients out of our offices. That is why we are working on the internet-based decision coaching guide, as a method to promote trust and get people into audiology offices. But – it is also important to promote trust when a patient is in your office.
The medical literature shows that patients who trust their clinicians typically demonstrate improved satisfaction, treatment adherence, and clinical outcomes in comparison with patients who possess low trust.2 This means that patients who trust their audiologist are more likely to purchase a hearing aid, wear the hearing aid, and be more satisfied with their hearing aid.
How can you promote trust during your appointments? We can look back to our 2015 study for some suggestions. The most important factor in promoting trust is what we call “relational competence”; adults want an audiologist who:
- Is a good communicator: “She [the audiologist] talks serious business but she also jokes”
- Expresses empathy – Individuals want an audiologist who cares and listens to the patient’s story and who makes recommendations about their individual needs: “Of course there is also empathy, that they [audiologists] are there simply with the aim, with the primary aim to help me. They don’t have some medical approach as to how severe or how mild (the hearing loss) is. They’re there simply to find precisely the best and most optimal solution to the problem being presented to them.”
- Practices shared-decision making: “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… 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.”
- Gives instruction for self-management: “I don’t think there was enough explanation given on how to care for the hearing aids and things.”
A 2017 paper by Ekberg and colleagues is a wonderful example of promoting trust by practicing shared-decision making.3 They recorded 49 audiology appointments in which an audiologist recommended hearing aids to adults over the age of 54. Most of the time the audiologist recommended a particular hearing aid at a specified price and waited for the patient to either accept or reject the option.
When the patient expressed concerned about the high price the audiologist, more often than not, ignored the patient concern; in these cases the patient was typically not interested in further discussion and the appointment ended. However, when the audiologist practiced shared-decision making, by offering a range of hearing aids with a range of cost options, the patient was more willing to continue the conversation and consider purchasing a hearing aid. This is an example of being a trusted advisor while practicing shared-decision making. The audiologist presents the options, including the benefits and drawbacks of each, while guiding the patient to a decision that makes sense for their individual situation.
Promoting trust in your appointments is more important now than ever. Patients now have many options to purchase hearing technologies on their own, and the options will continue to increase when OTC hearing aids become available. Why not unbundle your prices and “sell” your trustworthy expertise rather than a product?
As we make our way through the COVID-19 pandemic our patients need healthcare providers who can keep them safe and give them accurate information. In this way patients have an opportunity to select an appropriate product for their needs at a price they can afford. In addition, the audiologist should provide instruction for self-management so the patient can learn to take control of his/her hearing problems. In these uncertain times, we all need a little bit of control over our lives.
- Preminger JE, Oxenboll M, Barnett MB, Jensen LD, Laplante-Lévesque A. Perceptions of adults with hearing impairment regarding the promotion of trust in hearing healthcare service delivery. Int J Audiol. 2015;54(1):20-8. Epub 2014/09/30. doi: 10.3109/14992027.2014.939776. PubMed PMID: 25262671.
- Wrede-Sach J, Voigt I, Diederichs-Egidi H, Hummers-Pradier E, Dierks ML, Junius-Walker U. Decision-making of older patients in context of the doctor-patient relationship: a typology ranging from “self-determined” to “doctor-trusting” patients. Int J Family Med. 2013;2013:478498. Epub 2013/05/22. doi: 10.1155/2013/478498. PubMed PMID: 23691317; PMCID: PMC3652207.
- Ekberg K, Barr C, Hickson L. Difficult conversations: talking about cost in audiology consultations with older adults. Int J Audiol. 2017;56(11):854-61. Epub 2017/06/24. doi: 10.1080/14992027.2017.1339128. PubMed PMID: 28643531.
About the author
Jill Preminger, PhD, is a professor and director of the Doctor of Audiology Program at the University of Louisville. She investigates the auditory rehabilitation process from the point of view of adults with hearing loss, their spouses, and their adult children. Currently, she is evaluating a decision coaching guide in improving the uptake of audiology services in adults with unaddressed hearing impairment.