All of us have taken shortcuts on the calculated risk that the odds are on our and the patient’s side. Short cuts are just that — they save time and eliminate sidetracks. In the case of hearing loss, shortcuts allow the clinician to cut to the chase and fit hearing aids so the person can hear better. The patients are probably going to end up with hearing aids anyway, or at least a recommendation for fitting, so why not skip the full audiometric battery, forego referrals to other specialists, and reduce time and money spent on tests and imaging examinations? And, keeping the patient within the practice guarantees that the patient will not be lost to fitting and follow-up if they are referred out.
All of that shortcutting works if the patient’s main complaint is communication difficulty due to hearing loss and if the hearing loss is the result of noise trauma/exposure and not an occult medical condition. That last big IF requires adequate testing by the audiologist to rule out middle ear disorders and watch for red flags indicative of diseases of the inner ear and central auditory system, before sending the results with a referral to an ear specialist (Otologist). The purpose of that referral is to rule out rare conditions affecting cranial nerves (acoustic neuroma, aka vestibular schwannoma, Ramsay Hunt Syndrome and other inflammatory events) and auditory pathways (e.g., multiple sclerosis, space occupying lesions, hemorrhage).
Even proper referral does not guarantee comprehensive evaluation, because it’s not just audiologists who take shortcuts. Ear-Nose-Throat (ENT) doctors do the same thing, relying on clinical judgement rather than test results because they’re reasonably certain that the test results would do nothing more than confirm their judgement. In such cases, the patient who presents to the ENT with a hearing problem is sent for an audiogram and hearing aids are recommended. And that can be a problem for all the reasons enumerated above.
One case study of a patient seen had a significant between-ear hearing asymmetry, accompanied by noise exposure history. This particular individual also had communication complaints and was fitted with hearing aids previously. Almost in passing, the patient mentioned a recent history of two weeks of severe, unexplained vertigo which his primary physician treated with Meclizine.
This patient did everything right: he self-referred to a well known, respected ENT practice in another state three years before; he was compliant in following the recommendation to purchase binaural amplification from the ENT practice; he went to his physician recently when the vertigo commenced and followed instructions to take medication. Yet, neither the hearing asymmetry or the subsequent vertigo prompted a referral for complete audiological evaluation, imaging or work-up by a vestibular specialist. The patient did it right, the medical/audiological community let him down twice. With all of these pieces, he was finally sent to imaging. The original diagnosis from the ENT was confirmed, but that isn’t always the case.
What happens when the results aren’t in line with the clinical judgement? Click on the following link for a case where a patient is suing his ENT for failure to diagnose a tumor on the hearing nerve despite a “series” of audiograms. You can take it to the bank — as this patient probably will — that the audiometric work-ups were incomplete. The only reasons the audiologist isn’t included in the lawsuit (an assumption we’re making) is that the audiologist:
- Works for the physician and was “just following orders.”
- Doesn’t have as much money as the physician.
Are those good reasons? Yes and No in our opinion. Yes, the audiologist probably doesn’t have the deep pockets to make it worth suing him or her. No, audiologists’ training– regardless of employment situation– makes us complicit if we do less testing than is indicated by the symptoms and basic results, even if that’s all that was ordered. Why is that? It is because we have graduate degrees, state licensing, and sometimes certification that distinguishes us as experts who know or should have known what audiologic tests are required to arrive at a differential diagnoses for individual patients.
We as clinicians always have to ask ourselves, “What am I missing?” In fact, this ongoing process will prompt other posts on short cuts. Clinical protocols should always be reviewed and updated to make sure we, as audiologists, do not miss anything by cutting corners.
Feature Image courtesy of wersm