Audiologist as Incrementalist

Barbara Weinstein PhD

by Barbara E. Weinstein, Ph.D.

Today’s post is an opinion piece contributed by Dr. Weinstein, who usually writes “Downstream Consequences” at Hearing Economics.

I recently completed an excellent piece in the New Yorker titled “The Heroism of Incremental Medicine,” by Atul Gawande a noted surgeon and author. It was inspirational and timely, leading me to conclude how audiologists should consider pivoting so the profession can continue to thrive and survive.


Why Pivot Now? 


We must pivot now because the increasing number of persons with hearing loss require our expertise.  A chronic condition, the effects of which develop over time, hearing loss management requires a partnership between the professional and the person with the condition. The recent findings of Kiely et al. (2016) underscore that hearing loss is long-lasting and persistent; a condition with which people must learn to live:

  • Adults 65 years of age and older will likely live more than half of their remaining years with at least mild hearing loss.
  • Adults over 75 years of age can expect to live more than half of their remaining life with moderate levels of hearing impairment.

We must pivot now because the new models of hearing aid delivery, which include self-contained, self-fitting hearing aid (SFHA) and over the counter (OTC) hearing aids, remove audiology from the hearing health care equation. Proponents of self-fitting hearing aids and OTC hearing aids argue that accessibility, and affordability of hearing health care will be realized with these innovations.

In reality, the potential benefits of internet based delivery of hearing aids namely, lower cost, convenience or physical accessibility, may not outweigh the value added from working with a trusted and experienced hearing health care professional who will maximize skills essential to self management of hearing loss and its ramifications (Chandra & Searchfield, 2016).


How to Pivot – Shift the Focus 


We must reach people with hearing loss earlier, perhaps at the juncture between the preclinical and clinical phase, when symptoms first begin to appear and before the progression and onset of the devastating consequences of untreated hearing loss.  By adopting an incremental approach to hearing loss, we could help persons with mild or moderate hearing loss benefit from earlier uptake of a tailored situation specific hearing health care intervention/solution when cognitive resources and functional abilities are optimal (Kiely et al, 2016).  

Consider the principles underlying incremental medicine as described by Gawande, namely that the relationships and trust that are built through the provision of incremental care or the commitment to seeing people over time, makes all of the difference in the lives of persons with chronic conditions.  Incrementalists, according to Gawande, produce value by improving the lives of the people they treat over extended periods of time; great value is placed on care that takes time to pay off. At the heart of incremental medicine are the four kinds of information, listed in Table 1, which matter to health and well-being of persons with hearing loss.


Table 1. Four Factors that Matter When it Comes to Hearing Health and Well-Being (Modified from Gawande, 2017)

  • The state of one’s internal systems (audiologic test results)
  • The state of one’s living conditions (housing, community, economic, environmental circumstances-public health approach)
  • The state of the care one receives (what the hearing health care professional has done, treatments provided)
  • The state of one’s behavior and that of family members (e.g. stress levels, adherence to treatments)


Focus on our Long Game 


Familiarity and trust built over time, incrementalists argue, influence willingness to seek out medical attention when there is a change in one’s health that is impacting quality of life. Gawande points out that to make a difference, health professionals must understand what is normal for their patients and identify barriers to change for individuals (i.e. what is getting in the way of taking the steps that will reduce stress and improve quality of life)?

Figure 1.  Technology adoption cycle. (Wikipedia)

According to the diffusion of innovations theory as described by Rogers (2003), long term relations with our patients will help us learn about and influence their propensity to adopt a specific innovation which will be driven by social influences as much as our expertise.  In fact, the technology adoption cycle (Fig 1), a sociological model that describes acceptance of a new product, holds that the decision to adopt an innovation takes place over time in five stages which conform to the normal bell shaped curve.

We should be present at the first stage to help influence the rate of adoption of a targeted intervention and we must recognize that a powerful influence on the decision to adopt is peer pressure and how widespread or accepted actions are by others (Rogers, 1962). Once eyeglasses became a fashion statement, an entire industry blossomed.


Let’s Do This!


So how can we reach the 80% (i.e. persons with mild to moderate hearing loss) so that we are the professional to whom persons with hearing loss can turn when the need arises?  To begin,

  • We must accept that along with other health professionals we are poorly prepared to deal with hearing loss as the chronic condition it is. We must be viewed as the main source of care for people with hearing loss be it children, adolescents, adults or older adults. It is the relationship and familiarity with what we do as professionals which can turn the tide. 
  • We must work hard to erase the stigma of an audiologist as being a hearing aid sales person, much like someone who sells cars.  We should work to become the go-to professional to help persons self manage hearing loss when environmental and social barriers preclude participation in daily activities, impact job performance, enjoyment of concerts, etc.

Let’s begin to customize our care to match patients needs and behaviors.

Let’s lower the entry cost, guarantee performance in challenging situations.

Let’s inspire persons with milder hearing loss to turn to hearing care experts to expose them to the latest innovations, as knowledge is power and we should be the go to resource.

Let’s take a vow to focus on a person’s hearing health over time, customize our care to match the needs and behaviors of the persons with whom we work.


Pivot To the 80%


There are many explanations for failed diffusion, but I would argue that in hearing health care, low adoption rates of hearing health care interventions are attributable to our failure to be incrementalists, to bring people in to our offices early, to start small and slowly. We have little to lose– and the 80% have much to gain–if we pivot now.




Chandra, N. & Searchfield, G. (2016). Perceptions Toward Internet-Based Delivery of  Hearing Aids among Older Hearing-Impaired AdultsJournal of the American Academy of Audiology. 27:441-457.

Gawande, A. (2017). The Heroism of Incremental Care. The New Yorker. Jan. 23. Accessed online 30 January 2017 at

Kiely, K., Mitchell, P., Gopinath, B., et al., (2016). Estimating the Years Lived With and Without Age-Related Sensory Impairment. J Gerontol A Biol Sci Med Sci. 71: 637–642.

Rogers, E. (2003). Diffusion of Innovations, Fifth Edition. New York: Free Press.

Rogers, E. (1962). Diffusion of Innovations, Glencoe:  Free Press.


Barbara E. Weinstein, Ph.D. earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly.  Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.

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1 Comment

  1. Barbara
    Great article. In addition to lowering our costs we need to get to primary care physicians and get them to value what we do and to start referring patients before their hearing loss is moderate or worse. If we just got them to do a hearing loss check list like yours we could change the practice.

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