No News Might Be Bad News: An Analysis of Under-reported Hearing Aid Problems with Bec Bennett, PhD

Brian Taylor 0:10
Hi, everybody, and welcome back to another edition of This Week in Hearing. I’m Brian Taylor. And today we’re going to be talking about some subjects that sometimes I think kind of fly under the radar, especially at this Week in Hearing where we focus an awful lot on hearing aid technology. And you know, rightfully so there’s a lot of really fascinating new products and features coming to market, self fitting, hearing aids, automated testing, and I think my colleagues, Bob Traynor, Amyn Amlani, and others have done a fantastic job of, of summarizing some of those things that have been coming to market. And you can see those on our This Week in Hearing channel. But today, we’re gonna focus and shift gears a little bit and focus on unreported hearing aid problems. And also, I think we’re probably touched on a little bit social and emotional, social and emotional impact that hearing loss can have on adults. And with me today to talk about that our guest is one of the most prolific researchers in the profession right now. I mean, I have a file of probably a dozen peer reviewed papers that she and her colleagues have published over the last just a couple of years. And we’re going to touch on just a few of those papers today, I think. And my guest is Dr. Bec Bennett, who’s a researcher at the Ear Science Institute in Western Australia, Perth to be exact, although she’ll tell us she’s not dialing in from Perth, but the other side of the continent. So welcome, Dr. Bennett.

Bec Bennett 1:45
Thanks, Brian. Thanks for having me today.

Brian Taylor 1:47
It’s great to have you on our episode of This Week in Hearing where we can talk about something other than just technology, maybe contextualize a little bit. And I thought a good place to start would be for you to kind of tell us about yourself, the institution where you’ve done a lot of great research and also what those research interests might be.

Bec Bennett 2:10
Yeah, so I’m an audiologist. I’ve been a clinical audiologist for about 17 years now. And I’ve been a researcher for a while, I started my PhD in 2013, and finished it in 2018, having three babies in between. And all at the University of Western Australia while working at the Ear Science Institute in Perth, in Western Australia, I’m very fortunate to be living in an era where I don’t have to physically be in the same place as all of my wonderful colleagues. So I was physically in Perth for the first sort of 11 years that I worked with Ear Science. But the last three years I’ve been over here in glorious Queensland and the Sunshine Coast, enjoying the beautiful sunshine that we have out there this morning. And yeah, my to my PhD, I focused on hearing aids, hearing aid problems and hearing aid handling and management issues. And but my more recent sort of postdoctoral research, I’m really interested in those psychosocial and emotional impacts of hearing loss, predominantly how that impacts on the person with hearing loss, but more so what we as audiologists are doing about it and how we’re supporting our clients with managing and how we’re supporting them with those psychosocial impacts of hearing loss.

Brian Taylor 3:30
Well, I thought a good place a good starting point with starting your research would be to talk about unreported hearing aid problems. And I believe was about a year ago in the hearing journal, which is we call it a trade publication. There was a really excellent summary of some of the work you’ve done in that area. I think that I just I’ve used in my own talks, citing some of the statistics and some of the findings from from that work. So maybe you can kind of give us a flavor for your work in the area of unreported hearing aid problems.

Bec Bennett 4:03
Yeah, well, this, this work really was some of the first work I did when I moved into research. So as a clinician, I would say that majority of our clients would have these wonderful experiences with their hearing devices, wonderful outcomes, they love their devices, they use them often. But then there was this proportion. And the research sort of suggests it’s anywhere between sort of 15% or up to 30% in some studies in some countries, so 15 to 30% of people are not using their hearing aids or don’t feel like they’re getting any benefit. And it’s a bit of an anomaly because we can see that majority people really do get a lot of benefit. And so I wanted to drill down and better understand why there was this proportion of people that weren’t benefiting or weren’t really getting much out of their hearing aids, weren’t using them. And so I did a focus group, a sort of a qualitative study, where we interviewed a whole lot of people who are hearing aids, and that included people who use them, and some people who own them, but didn’t use them, as well as a whole lot of audiologists and audiometrists. Yes, I’m not sure if that terminology translates to the US. But here we have clinicians with different types of qualification. So clinicians, and we interviewed them to ask them about the kinds of problems that arise with hearing aid ownership. And so we had these different groups, and we asked them went through this process and asked them to list all the different problems that arise. And that we had this long list hundreds and hundreds of hundreds of problems, we sort of grouped all the information and removed the duplicates, and kind of edited it down to a shortlist of about 100 or so core sort of individual problems that can arise with hearing aids, which is kind of huge, like 100 different problems that can arise. It is a long list. So thinking as clinicians, we need to be aware of these 100 things that can go wrong. And at some point, we kind of need to make our clients aware that there are these 100 things that can go wrong. And so if it goes wrong, don’t feel like you’re alone, and don’t feel like you failed or we failed or it’s failed, it can happen. And we can fix it together, we can get through these problems. So the fact that there was sort of 100 or so problems was a huge finding in the first instance. But what we then did is we asked the adults with hearing aids as well as the clinicians to then group this list of 100 in a way that made sense to them. And it’s just we call it this sort of thematic analysis where they identify core themes. And through this process, four key themes arised. And so it was hearing aid management was one group of problems, hearing aid, sound quality and performance with another group of problems, thoughts, feelings, and behaviors, which is this kind of how we sort of feel and respond to hearing aid problems as they arise, whether we feel it’s our fault, or the clinicians fold for this sort of thing. And then information and training, so knowledge about problems training about how to overcome problems.

Brian Taylor 7:15
I see. So one of the things that was really interesting about it was the high, this the number of the percentage of people that actually had problems with their hearing aids, and the number that didn’t get reported to the clinicians. Could you talk a little bit about that?

Bec Bennett 7:30
Yeah, so the second study we did then is we developed a survey based on the individual problems that were from the hearing aid management category, and the hearing aid, sound quality and performance category. We turned that into a survey. So there was about, from memory, there was about 25 problems that were from those two categories. And we emailed that survey out to about 500. Well, we emailed it out to many more, but we received a response from about 500 hearing aid owners from across Australia. So we were very fortunate to partner with seven different hearing clinics from all over Australia. Some in metropolitan areas, rural areas, we had young adults, all the adults, all different mix of people, 500 hearing aid owners, and we asked them to tell us whether they had at some point experienced these problems or not, whether they were currently experiencing any of these problems, and whether they had sought help from their clinician to overcome any of these problems. Now, the range of problems. So there were some people who I think there was there was about 2% of people who had never experienced any of those problems. And 98% of Hearing Aid owners had experienced at least one of these problems. Some of these people, it was only one or two problems, and then overcome them, and we’re fine. But I think it was about 50% of people around that sort of mark had, were experiencing about 50% of the problems. And some, it was sort of this bell curve, and so some there was this sort of small group who had or were experiencing almost all of the problems. And so they’re just so many problems that they’re experiencing with to do with hearing aid handling and management. So they couldn’t insert it, they couldn’t clean it. They couldn’t change the filter or change the battery. Or they weren’t happy with the sound quality. It was too sharp or tinny or it hurt them or those sorts of things. They couldn’t hear a noise, those sorts of problems that they would encounter.

Brian Taylor 9:45
Well, that’s really interesting. I guess I’m wondering if you could share your take on this for the clinician that’s out there seeing these patients. I mean, it’s just speak to the importance of telecare to maybe offload some of the interpersonal in some of the interactions into smaller chunks that are more convenient for both the patient and the provider. I mean, what is I guess what I’m asking back is, what does this research mean to the clinicians out there?

Bec Bennett 10:11
Yeah, well, what it means to clinicians is that there are a lot of problems and the problems are real and that patients are experiencing them. And so if you can imagine the person that has a couple of problems, is probably doing okay, and can just put up with those problems or maybe address them themselves. But the person with lots of problems is more likely to give up. And in fact, we looked at a an association between hearing aid benefit and hearing aid success. So whether they self reported their hearing aids were beneficial and successful and worthwhile. And there was an association. So people who had more problems, felt that their hearing aids were not beneficial and weren’t worthy, and so we’re less likely to use them. And we’re less likely to refer their friends and family on to get more hearing aids and these sorts of things. But an important part of that study was also that element about whether they had reported the problem to their clinician or not. And for me, this was the big clincher. So about 50% of problems had not been reported to their clinician. And when we delve into that a subsequent study, we’ve delved into that a little bit deeper, and tried to identify what people do when they experience hearing aid problems. And they talked about these were adults with hearing loss, and they talk about, sometimes they would go to their clinician. And as we saw from this paper, about 50% of problems are reported to clinicians, but 50% are not. And in these instances, this might be where the person will just put up with it, or give up with a hearing aid, or ask a friend or go online to find information and seek, seek help and support elsewhere. And as we all know, the internet is full of wonderful, wonderful resources. But it’s also full of some perhaps be great and not very helpful resources and support. So I think there’s a really important role for the audio for the clinician to play in supporting clients to first of all realize that hearing aid problems can and probably will occur, but to let them know that we’re here, and we’re here to help. And these are the different ways we can help and to focus on that partnership, and that long term relationship.

Brian Taylor 12:27
Yeah, it’s kind of scary when you think about it, when I put my clinical hat on to think that about 50% of patients that have hearing aids, are not letting us know that they’re having difficulty or problems with that. And how do we close that gap? Is it more visits? Is it more? Do we need to be more proactive? And what do you think, how do we close that gap? Yeah, well,

Bec Bennett 12:47
here in Australia, our model is that we will generally do a hearing assessment and followed by hearing aid fitting, and then there’ll be this sort of six month period where we’ll see the clients perhaps a few times within that six months to fine tune and get it right. And then we generally have an annual review appointment. So we are recalling our clients on an annual basis to check in and see if they’re having any difficulties. And if they need any support fine tune and maybe they need extra devices, you know, those sorts of things. But we get some okay here, similar in the US are fantastic. So we, just a couple of months ago, I think it was we’ve published a paper that looked at that we call it an annual review appointment. And the first paper we looked at what are people coming to their annual review appointment? And if so, who’s coming? Why are they coming? And then what are they getting out of it? And so we offer in Australia if the services funded by the government, so there’s no cost to come to that annual review appointment. But even still, it was only about 30% of people are actually coming in for that review appointment, and intended to not be people in remote locations. So as you say, this is an opportunity for tele then how we support people in remote. And by remote. I don’t mean rural kind of Australia remote. I just mean people that weren’t living within a suburb of the clinic.

Brian Taylor 14:13
Hour drive or half hour. Yeah,

Bec Bennett 14:16
definitely, definitely. So. So tele is something to consider to help us overcome that distance barrier. And also just a time barrier, you know. But we also found it was people who valued the relationship with their clinician, we’re more likely to come and get that support and have that annual appointment. And so that personal relationship with your clients, I think is of utmost importance to make sure that they know that you’re there and that you’re going to support them. At any point throughout the ongoing it’s not just about a hearing aid sale. It’s about an ongoing relationship over the decades as they’re going to need multiple hearing aids over the decades of their lives.

Brian Taylor 15:00
I think that’s a challenge here in the US is we have a business model that’s based on selling more products, once, one with this bundled model, it’s, I think it discourages clinicians from following up sometimes maybe the way that they should, because the all of the revenue is kind of front loaded into this into the, into the transaction. But that’s changing somewhat, I think it may change even more rapidly now that OTC and Medicare, our government funded health care system for seniors, may pay for hearing aids starting in a few years, and that could change some things in a big way. Maybe it’ll be a service component, as part of that, that will encourage people to come back in more often. Tell me a little bit more about this relationship aspect to people’s willingness to come in what way? What can clinicians do to foster a stronger bond with your patients? Yeah, so

Bec Bennett 15:59
there is a bit of research out there about this patient and clinician relationship. And I think a lot of it comes down to that sort of building rapport. I mean, if you think about your own experiences, have you ever been to a health professional, and thought, Okay, this doctor, this health professional, really hears me really sees me really knows what I need and and you have this relationship and you want to return to them? Or have you ever had that experience where you sit there and you think they are just trying to push me out the door and move on to the next client, and they just, it just feels like a conveyor belt kind of thing. You know, we’ve all had positive and negative experiences ourselves. And so it can be really as simple as just pause for a moment, and reflect on those experiences, what made the good experience good, and what made the bad experience bad. And in most cases, the good experience is where you don’t feel rushed, and you truly feel heard and listened to. And the bad experience is where everything’s rushed and flustered. And you kind of you’re not not really seen and heard in your entirety. And so I think what happens a lot with clinicians and you know, guilty myself in my earlier years as well, is we kind of get in the habit of thinking, ‘I’m the clinician, I’m driving’ this appointment. And what I need is I need to do a hearing assessment, I need to do REMs, I need to change the tubes, I need to do this, I need to do that. And then I need to get them out the door cuz I need to get the next one. And we get in this mindset of, ‘I can’t do it all in an hour’. So I’ve got a rush, rush, rush, rush. But sometimes the client comes in and they need something different to what we’re offering them. In fact, if I can sidetrack for a second, my husband is a clinician as well. And so he works in actually, he works for Bloom, which is one of the Widex owned companies here in Australia. And he had a client not so long ago that he was working with. And the client came in and said, “You know, I’ve been putting it off for years. I’m ready for hearing aids. So here I am. Let’s just do it.” And my husband said, okay, no worries, we’re going to start with the hearing assessment went through. And there was a significant asymmetry. My husband said, you know, let’s talk a bit more about the case history. And the client said, “I’ve noticed this is been deteriorating, and things are just fuzzy on that side”. And there was terrible speech on the lower side. My husband said, Look, I really think we shouldn’t jump into hearing aids. Yeah. And I really think you need to go and see an ENT. And it turned out there was an acoustic neuroma. And so went through surgery and all of this. And then a couple of months later, the client came back in and said, “Look, I came in for hearing aids, and I didn’t get them, yes, you probably saved my life. Thank you. But I came in for hearing aids. So let’s just get the hearing aids” and tongue in cheek was a bit of a giggle moment. But still, my husband was so focused on what he needed to do. Whereas perhaps he could have still fit a hearing aid to the other side or, you know, thought about what the client needed in entirety. So I think sometimes we’re so focused on our own agenda and what we need to do, whereas a really good starting point is “Hi, how are you going? And what can I help you with today? What’s brought you in here today? Where would you like to start with today’s appointment?”

Right. I think it’s easy when you’re in a helping profession to kind of get ahead of where the patient is. And we have to always find ways to kind of walk alongside the patient, guide them through the process and not tell them what to do. And I find myself in my 15 or 20 years as a clinician, it’s really hard to avoid that righting reflex where you’re always trying to tell somebody, this is what you need to do when they’re maybe not ready to hear that yet. So that’s a good example of what you said of how that happens.

Yeah. I think it can happen at both ends. So it can be people who have hearing aids and perhaps aren’t using them optimally. So you know those people perhaps sometimes you’ll have clients that come in and say I only wear it when I’m watching TV, or I only wear it when I’m going to certain situations and, and we sit here and think, “no, you have to wear it all day every day”. But if we’re going into that with a kind of pushing them, rather than hearing their needs, then it’s going to be more difficult to kind of convince them. But if we if we help them understand what they’re trying to get out of it, and if it is holistic hearing health, then we can talk about the cognitive benefits of hearing 24 hours or 12 hours a day and wearing the hearing aid all day in that case. And so thinking about what their needs are, we can still come to that same sort of solution at the end, I guess, but helping to understand what what their needs are first, which will then help how we deliver that, that health care and advice and information.

Brian Taylor 20:55
I think the irony here is that as hearing aid technology becomes more automated and more advanced, the need for person centered, client centered communication is more important than ever before. Yeah, that really needs to be a focus, in my opinion, what audiologists, that’s what we need, that’s the value that we add, in a world where people can potentially self-fit, at least some people themself with their own devices. I wanted to ask you one more question about the unreported hearing loss work that you’ve done. If I remember, right, and I think you mentioned this, some of the the unreported problems were like could, would maybe warrant an adjustment to the hearing aid from the software, and others probably wanted more of counseling. can you kind of unpack those findings and what what you found?

Bec Bennett 21:46
Yeah, so the study we did about the annual review appointment. The second part to that study is we wanted to see whether annual review appointments were actually successful in improving hearing aid problems. So we surveyed a whole group of adults with hearing loss before their annual review appointment, to see which of these hearing aid problems they were having, as well as some other surveys to look at hearing aid use and satisfaction and benefit and outcomes and those sorts of things. And then we let them go ahead and have their annual review appointment separate to us. So we don’t know what their clinician did, their clinician didn’t even know they were in the study. So it was totally separate to the research. And then a month later, we surveyed them again to ask them what hearing aid problems, they were having the same surveys, so we could see if there was a change. So if they had more problems or less problems, which problems were improved that sort of thing. And what we found is that overall, people had fewer problems. So problems to do with hearing aid handling and management, improved problems to do with sound quality, and performance improved. And so it shows that where the individual was aware of the problems and reported their problems to the clinician, the clinician had the skills to actually improve and address those problems. And and also those people who had reduction in problems, also then had an improvement in their perception of their hearing aid, use and benefit and satisfaction and that sort of thing. So for us, it showed that the clinician is a really important piece of that puzzle and can help their clients overcome those hearing aid problems, and can help improve that hearing aid benefit. But part of the the breakdown of that was the tuning as you say a lot of those problems were to do with fine tuning the device and you know, changing the plumbing, improving comfort and fit and that sort of thing. But a lot of the cause for some of these problems are a lack of understanding and lack of training and education. And so that’s where it’s really important that the clinician has the skills to train their clients in a kind of safe and comforting environment. So I’ll always remember this beautiful lady who was one of the participants in one of our focus groups, who, during our conversation, have these hearing aid problems. She came and she said, So she’d lost her hearing aid in the garden, gardening at one of them. And so she came in and saw her audiologist and the audiologist said, ‘Oh, no worries, no worries,’ we’ll change it. We’ll get you a new you know, we’ll get to a new one for that side ordered a new one not a problem. And then one month later, she lost it again. And so she came back in and said oh no worries audiologist said no worries, no worries, we’ll get a new one not a problem under insurance. Totally fine. No problem. She said she lost it a third time. And she came in and again oh not a problem that happens to everyone. Don’t worry, not a problem. And she said she felt wonderful and safe in the hands of this clinician that she could tell them even though she knew it was her fault she was losing If it was a safe environment, they could work together. One of the other participants in the same group piped up and said, I lost my hearing aid and told my audiologist and the audiologist reprimanded me and said, Do you know how much these things are worth, you shouldn’t have lost it. So they got a new one. But then when they lost the new one, they were too ashamed to go back and tell them again, that they just now don’t have that hearing. They’re just using the one and don’t use the one that they lost, because they were so confronted by the first experience. And yeah, couldn’t go back in. So that

Brian Taylor 25:36
shows you the value of compassion, yeah, and, you know, taking care of patients that you’re seeing, that reminds people, sometimes it’s not how much you know, it’s, you know, how you get the information, how you treat people,

Bec Bennett 25:52
yeah, how you treat people, how you provide that kind of support, and there’s the, the providing the education in a supportive way. So it’s not, you know, we don’t want to make people feel belittled, or we don’t want to patronize them in how we’re showing them how to change the tubes and things. But it always needs to be appropriate. So some older adults will have the cognitive function, that we can just describe it in the same way we would a 20 year old client, and some perhaps don’t have the same cognitive function. And so do need us to break it down and talk a bit slower and describe things in a simpler with some more simple language. But we need to make sure we’re doing that in a way that it’s not then patronizing, that it’s still in this sort of safe and comfort and yeah, comfortable relationship.

Brian Taylor 26:41
What’s your opinion about using the internet, maybe YouTube videos to kind of supplement the direct patient or client to provider. And I think about like some of these some of these skills that patients or wears need to be a good hearing aid user or, you know, fairly routine, they just may need to hear it a couple of times. Do you think that it’s good to put them on on a video or maybe having a system that helps out? What’s your what’s your opinion about that?

Bec Bennett 27:13
Yeah, look, I don’t know what the answer is. I’ve been thinking about this for a long time. And I’m really interested in this area and in a, in fact, I put a grant application even this space last year, and I’m really interested in this sort of area. And I don’t know what the answer is. So there are some great resources out there already. So Mel Ferguson and her colleagues in the UK, produced that See to Hear or m2hear, CDs, and they’re all online. And I know there are some other groups in the US I forget his name, but there’s that fellow that the audiologist that has the YouTube channel that a lot of a lot of clients here in Australia, Dr. on what’s his name, anyway? Cliff? Yeah, that’s a lot of our clients here in Australia, watch his stuff as well. So there are some great resources out there, and a lot of clients love them and use them. But a lot of clients don’t as well. And then we know that there are some issues with the hearing aid user manuals, not having ideal readability and font size and that sort of thing. But then if you look at what proportion of clients actually open them to read them, well, not many anyway. And so I do think a lot of our current clients prefer that human contact and a human showing them. And so in the the group that I work for at Ear Science, we have the clinician, actually, as we have a clinical arm, and the clinicians do the training, but we also have admin support, who can then do extra additional support and training. And all of our front admin staff are fully trained in how to, you know, clean and change batteries. And so we do a lot of over the counter support and over the phone support and that sort of thing. And so I think the model that we that a lot of clinics in Australia try and use is that the the whole team is a sort of a family and we all have the skills to support clients at any stage. And some of our clients have a really close relationship with the admin and they’ll call them to say the tube stuck again, remind me how do I do this. And some of them prefer to come in and see their actual the actual audiologist. So I think that’s the essence of this patient centered care and family centered care is to set up a clinic that allows you to deliver a service that is modifiable to the needs of the individual patient as each one comes in.

Brian Taylor 29:34
Well I’m excited to know what direction you take that with your research because it sounds like that’s a fertile area to learn more about, you know, I think maybe you could tailor the skills based on the personality and the style and social style, the patient, you know, and then you just kind of plug in what’s gonna work best for them. And you’re also I think, go ahead No, go ahead.

Bec Bennett 29:55
I was gonna say the thing I’m most interested in. I always like to start, maybe It sounds a bit pessimistic, but I always like to start with, ‘why didn’t it work the first time?’, you know, so my PhD research was Okay, let’s stop. And let’s look at the problem. And now let’s build a solution kind of thing. And so I can see the the manufacturers have these amazing apps. And there’s wonderful YouTube channels. And there’s these DVDs. And there’s, there’s so many incredible resources out there to help our clients learn hearing aid management skills. But there’s low uptake, and there are still huge amounts of skill deficiencies. And so my first thought is, what’s the problem here? What’s not working? What is it that as clinicians, we’re not telling our clients about these resources? Is that the gap? In which case, yeah, do we need something simple, a brochure that lists all the different options that we can then give every client with every hearing aid sale? Or is the problem that the things have been designed with a certain client in mind, maybe a younger or more tech tech savvy client in mind, and that they haven’t been designed really with the whole range of your average client in mind? And so yeah, I think my my starting point is, there’s amazing stuff out there, why isn’t it being used? Why isn’t it working? Let’s focus on the problem first, and then start to build the solution?

Brian Taylor 31:22
Well, I hope you can find a solution for us, because that’s a problem that many of us here in the States and Canada, other parts of the world are experiencing as well. There’s a gap between I know, many, many audiologists out there that talk about this stuff, and then the patients just don’t for whatever reason, don’t take advantage of some of the things that are available. It’s hard to know why that would be. Well, anyway, we I think we’ve been chatting out for well over 30 minutes. And we definitely want to have you back because we haven’t even talked about the social and emotional impact of hearing loss on adults. And that’s definitely something that I want to pick your brain about. Talk about your research in another episode. So can we have you back somewhere in the next few months? Maybe after the summer is over down there?

Bec Bennett 32:09
Yeah, yeah. I’d love to Yeah, we’re about to enter our glorious summer period, 40 degree Celsius days, weeks and weeks at the beach. I’ll come back a whole nother darker shade of I’ll see you on the other side.

Brian Taylor 32:21
Because there’s about 5pm here and it’s almost dark. But, anyway, Dr. Bennett, where can people contact you? Do you have an email or website that you’d love to share?

Bec Bennett 32:36
Yeah, yeah. So my email address is [email protected]. And so you can Google me at Ear Science in Perth, or send me an email and yeah, please reach out. I’m always always keen to meet other clinicians around the world and answer any questions or hear your stories, please. Yeah, reach out to me. I’d love to hear from you.

Brian Taylor 33:00
That’s great to know. Thanks again. Dr. Bennett, Bec Bennett, researcher at Ear Science Institute in Perth, Australia. And we’ll see you in a few months. Thanks for your time.

Bec Bennett 33:12
Thanks Brian.

Brian Taylor 33:14
Bye bye.