Stumbling into Success: The Lived Experience & Occasional Stress of Audiologists

Brian Taylor 0:10
Welcome back, everyone to another episode of This Week in Hearing. I’m Brian Taylor. And I think most of us that are clinicians out there know that there’s a lot of stress in the world today, we have been dealing with COVID for a long time, up and down, it seems like every few months, inside the clinic, we have some stressors around over the counter hearing aids, uncertainty with that. We have uncertainty around legislation around with Medicare and how possibly down the road it may pay for hearing aids. There’s really no shortage of stress for everybody these days. And with us today to talk about stress inside of a clinic and provide some insight on that topic is Professor Diana Emanuel. But I get your name, right. Diana Emanuel. Diana is a professor at Towson University, which is in Towson, Maryland. And she’s actually written some really interesting papers recently on occupational stress in audiology. So, Diana, Professor Emanuel, I thought I’d maybe have you tell us a little bit about yourself.

Diana Emanuel 1:20
Thank you. It’s nice to be invited. My professional background is I got a master’s PhD and did a postdoc at Penn State. I started as a professor at Towson in 1994. So as of this August, I’ll have been there for 28 years. And my interest in professional issues and leadership within the profession started very early. So two years after I started at Towson, I was the director of audiology, two years after that, I created the Doctor of Audiology program – well, I wrote the proposal, there were a lot of people that were involved in actually getting it passed, but it was the first doctorate in Towson University’s 150 year history. So it was it was a pretty difficult accomplishment. And at the time, there were only 10 AuD programs in the US. So I was part of that group of audiologists that helped get the AuD really rolling in terms of numbers. I also I served as a as a Program Director for 16 years, then I’m now acting director, because our directors on sabbatical, and then almost eight years as department chair, I’ve been doing professional issues type research for about 21 years. And I’ve had a lot of leadership positions that have exposed me to various professional issues. So I was the president of our state association for a little while. I served on the CAE accreditation board for four years, including a year on the Executive Council, president of the Council of 80 program directors for a year. So professional issues are kind of have been part of my my professional lived experience for most of my career.

Brian Taylor 3:10
Well, I guess this would fall under the umbrella of professional issues. And I know that as I mentioned previously, you had two papers published, I think it was an American Journal of Audiology, talking about the lived experiences of audiologist, and you provided some insights on occupational stress within the profession. And I was hoping that you could maybe elaborate on the motivations for that line of research.

Diana Emanuel 3:32
So yes, there were those two recent papers, we also have another paper with the principal author is Maddie Zimmer, who has worked on her project as a student, and just wins another project. So basically, I have four out of my lived experience project, four completed projects. And there are about um, eight or nine that are currently in progress. And so I’ll tell you the impetus and it was some of it was serendipity. A number of years ago, and then I started my lived experience paper with discussing that I started to feel really uneasy about the huge number of changes that have impacted the profession. And I started to sort of fear like, where are we going, you know, are we you know, there’s lots of different kinds of changes very, there’s changes that can cause beautiful, robust changes in a profession and changes that can can destroy parts of the profession. And I’ve loved this profession for many years. So so I was sort of uneasy and afraid. And in the back of my head, I’m like, I wonder if other people feel this way. And so so that was the initial thought process, but I was the chairperson at the time. So I was doing no self study and accreditation and mission and strategic all this stuff that gets in your way of really being able to focus on a research project. But um, as it would happen like my husband and I became empty nesters. We moved to Baltimore City, and we decided to do some Airbnb. Okay, and our first guest was Dr. Ashley Duggan. And she came in with the poster, you know, the ubiquitous poster. And you know, there’s a researcher who’s going to be presenting at a conference and putting the poster up. And so she’s from Boston College, and she’s a communications professor. And the paper she was presenting was called it was came out in 2017, on the on the inner life of physicians. And so she and I sat down and talked about it. And I was absolutely fascinated by what she had done. And she taken these physicians and had them journal for a year, on their experience, their lived experience, and and how they deal with patient death and how they deal with being responsible for patient lives and so forth, was absolutely delightful to read. And I thought, I wonder if I could do that with audiologists, it has to have a different flavor, though. Because audiologists just, you know, audiologists don’t, aren’t responsible for patient death. I mean, it certainly could be but we, you know, we are not performing surgeries, were not providing medication that could be the wrong medication, and so forth. So it’s, it has to have a different flavor. But I tucked it away in the back of my head, like I’m gonna do that someday. Well, a couple of months later, a colleague, a friend of mine from from college, reached out and said, you know, my mother is a researcher, and she wants to interview academic leaders. And you’ve posted a lot about being a department chair. So could you, you know, participate in Sure. So and that was Dr. Donna Jorgensen from Delaware Valley University. And she said, I’ll drive down interview and I said, I want you to spend a couple of extra hours here because I have a project idea that I want to discuss with you. And so I picked her brain, and she helped me create the beginning of the lived experience project, because I’ve had three decades of experience with qualitative research and survey research, excuse me with quantitative research and survey research. But I haven’t done a lot of qualitative research. In fact, this was my first designed, conducted an analyzed qualitative study. Before that, I’ve only done you know, thematic analysis from open set questions from surveys. So she really helped me and one of the interesting parts was that she said, Well, what do you want to know? What is? What is your research question? And I said, Really, at the heart of it, it’s, I want to know if other audiologists are afraid about what’s happening, and what’s going to happen to the profession. And she said, Okay, well, to approach that, qualitatively, you can’t ask people if they’re afraid. And of course, that sort of blows the mind of someone infuses survey researcher because you say, Well, are you afraid? Yes. No. what are you afraid of, and you list all the things and then you have an open comment box and say, Please provide anything. So as I started this interview study, I had to do a significant amount of self study and seek out mentors to to get this interview, right. And it started out asking, you know, audiologists, but one of the positive things about your work environment with a negative things like trying to get people to give me how they’re feeling.

Without asking them- are you afraid? Are you… Those didn’t work for the first couple interviews, and I chose a grounded theory approach. And one of the nice things is the research questions can evolve during the project and soak in the interview questions. And that’s kind of part of the approach. And so at that point, I stopped and I said, How can I go somewhere between this vague What are your positive and negative experiences at work? And is really specific? Are you afraid? And so that’s when the stress question sort of became part of the interview. So that’s when I started saying, Well, tell me what brings you joy at work? Tell me what causes you frustration? What kind of stress is there at work? And how do you react to it. And so once all of a sudden 30 interviews, so each one was about an hour, so hundreds and hundreds of pages of transcripts. And it was too much for one article. And so the lived experience is the theoretical framework on how various things are connected. And then the second paper, which was the stress paper, was pulling the information about stressors out of it and making that into a second paper. And then there’s a third paper, like it says, coming in JAAA, probably in a month or so. And a student of mine had looked at burnout and stress at the same time via survey. And it’s remarkable that my stress paper and hers actually completely different people different methodology came up with very similar results in terms of stressors that audiologists face.

Brian Taylor 9:24
well that’s interesting, let’s maybe that’s talking about the first paper, the lived experiences, if you could maybe share with us what you found, how you studied it, I mean, kind of talked about that already, but basically what you found in that lived experiences research

Diana Emanuel 9:42
okay. So when I started out, I took a look at what were the types of things that I could basically get at how audiologists are feeling and so I have questions that are associated with things like – you know, how long have you been an audiologist? How did you become an audiologist so that gave me their origin stories. And in the interview, people just love to talk about where they came from, and the origin stories and so forth. And then, you know, what do your patients value about you? What do other healthcare professionals value about you? And how are you reacting to change? What do you see as the future and so forth. So lots of different areas in which they could possibly totally what, what they were doing. And one of the interesting things is I found coming up with the themes. You know, from this and grounded theory, you’re basically you’re taking the words and ideas from the participants, and through a series of systematic, you know, coding strategies, you develop these these themes. Well, that was, you know, extraordinarily time consuming, but rather straightforward. So, you know, like the majority of audiologists mentioned, hearing aid dispensers during the interview. It was not associated with any of the interview questions, but it emerged from their thought processes, processes relative to value and changing whatever. And so I knew that was a theme. But the problem was, I wasn’t quite sure how everything connected initially, because we have such a broad perspective on hearing aid dispensers, some people said, Oh, they’re, they’re great, because they increase access to hearing health care. Other people are like, well, they’re like, used car salesman and if I could wave a magic wand, I’d make them go away. So this is really this huge continuum of perspectives. What everybody wanted to talk about them. People were like, you know, I’m confused with a hearing aid dispenser, so I don’t feel my degree is valued kind of thing. And so I went through this stage where I’m like, Okay, I know what the themes are. They’re very clear. But how are they connected? And with hearing aid dispensers it eventually ended up becoming connected with professional identity. And so how do we as audiologists uniquely identify ourselves in hearing healthcare as separate from hearing aid dispensers, because they’re trying to increase their scope of practice, and we’re trying to, you know, portray our value and how we’re unique and so forth. And so I went through this stuff to be perfectly honest, at a stage of cognitive dissonance, where I’m like, how do these connect?

And it’s the most difficult part of qualitative research and the quality of researchers I’ve talked about are like, yeah, because you always assume that there is, in fact, a theoretical construct you’re going to be able to create. But the reality is, you know, you interact with the data in order to create it, but I just didn’t see it. And my problem was that I was completely ignoring the origin story. So origin stories are such that the majority of audiologists across the entire I mean, I interviewed audiologists, 40 some years of experience and two years of experience. The origin stories are the same, the majority stumbled into audiology. And this is something that’s been pointed out before Doyle and Freeman pointed out Denae is pointed out in some of his research, and and so I’m like, well, it’s not original. But the thing is, I’ve never seen it connected to anything. And I finally went back and looked at it. And I’m like, wow, this is, this is the linchpin. So here’s here’s how it goes. 60% of my participants have an origin story that I call the ‘undergraduate stumbled pathway’. And some research by Denae, he used the stumbler methodology to kind of grab that, obviously undergraduates stumbles. And so most of the students are coming into audiology, because they go to the undergraduate program with an idea that they’re going to do X, usually speech pathology, they generally will come into audiology via speech pathology, but not always. But then they hit something. And then as either they realize they don’t like speech pathology, or they don’t like their current program, and they’re searching around for something and they somehow stumble in audiology. A lot of times it’s funny is, there’s a lot of stories where they’re like, well, he’s gonna do pre med, pre Dental, PT, whatever, whatever. But then I got to this one class. And this was a story where he’s like, a goddess is one class, I knew I couldn’t go there. And I did a presentation at ASHA a couple of months ago, and I said, you know, what, the classes and everybody called it out. And I’m like, yep, that’s the class and it was organic chemistry. So the story came up. For me, I was I’m also an undergraduate stumbler. But for me, it was calculus too, uh, like, I just don’t really enjoy that. No, this I don’t want to be a math and computer science major anymore. But so they hit a stumbling block, or they decided, I don’t like what I’m doing. I’m gonna reach around and I’m gonna stumble into this. So they shadow an audiologist to take one audiology class, or a friend of theirs says, Hey, consider speech pathology and then they go into they don’t. So that’s that stumble path is 60%. And that’s a low number. If you look at some of the other origin stories research, they find it a greater percent of audiologist into that same regardless of what generation they’re in, and then 40% fall into one of two camps, ‘early-purposeful’, which are the people who I knew I wanted to be an audiologist. from junior high high school, whatever, and it’s usually because either they or someone in their family had hearing loss, or they were exposed to American Sign Language very early on in Deaf culture. And then they’re the ‘later-purposeful’ where they get a degree in education or engineering or something like that. And they go into the workforce and like, I don’t like this. So they start really systematically exploring what do I like? What is my personality like and looking at so. So those are the purposeful, and they are quite similar in, in how they view audiology, and very dissimilar from the stumblers. So the lynchpin for the theoretical framework is that origin story has a huge impact on your perception of the profession, and the future of the profession. And I’ll and I’ll give you some numbers, I just didn’t have these in the original paper, but I just wrote them up for the police for a recent editorial. So I asked the question, “Have you considered leaving audiology?” So when you look at the Undergraduate Stumblers, 87% of them said, ‘yes, I’ve considered leaving’. When you look at the Purposeful only 36% said, ‘yes’. So a third of the early purposefules said ‘yeah, I considered leaving’, 87%. And then I said, “Would you choose to be an audiologist again”, if you were picking a career today and you could sort of do it over? Okay. When you look at the undergraduate Stumblers, 47% of them said, ‘yes’, so about half. But when you look at the Purposeful 90% said, Yes, so 90% of them would do audiology again. And then the one question, and this was was of particular interest to me as an academic, because I’m worried about recruiting future audiologists, you said, if, “if you had friends or family looking at career choices, would you recommend audiology?” This is really important, because we know word of mouth is very important for recruitment with audiology, because people haven’t heard of it in high school. Very few students have heard of it. So would you recommend it – undergraduate Stumblers, 39%. Where as the Purposeful 67%. So basically, when you look at these, “have you considered leaving? Would you do it again?” Which is kind of like was your lived experience really meaningful and valuable? And would you recommend it to others?

the early and later, Purposeful participants basically had a much more positive perspectives, they also are more likely to indicate that they’ve made changes in their clinical practice in order to to deal with changes in the marketplace. They had more creative changes that they were describing, they use more positive words, when they were talking about audiology. There’s someone who like “I never questioned what I was supposed to do. Audiology was it, I love it, I would do it again, I would tell everyone I know to do it.” And so the words they used, the phraseology, the emotion that was conveyed, and these percentages and this percentages, because it was a qualitative paper, I really didn’t report the percentages. But they all indicate that if you go into audiology very purposefully, and you know a lot about it, and you know that it’s going to basically meet your needs, your professional and career needs, that results in a much more positive perspective. And, you know, I even was searching for other research in other areas, like, has anyone else looked at this? Is this the age at which you determine something, indicate how well you’re going to do and how are you going to do it, there’s really not much that some dissertations from like 1960s about physicians, but there’s really not much out there. And I’ve seen informal things like you really should know what you’re doing before you choose audiology, but I’ve never seen that connection made. Now that doesn’t describe everything, though. Because there are three other pieces. And that was four actually, one is generational differences. So people of my generation. So I’m 56 now and I entered the field, I could have entered the field with a master’s degree I went on to get a PhD, which was fully funded. So I entered the field with no debt. And so very low costs and and I just entered a field where I could just explore what I liked, and I could really enjoy the field. Now when you look at what’s happening now the people who are sort of a different generation and the way that the participants described it was older and younger, younger participants are more likely to talk about student debt problems, they’re more likely to talk about you know, it’s a different field in terms of technology and we have the over the counter and we have like this de-valuing of healthcare expertise overall and it’s not just audiology. And some of the older generation audiologists saying, Well, you know, this is we, we entered it in golden age, you know, it was different then it was all more about focus on patients and rehab and less about technologies very different, a lot of differences in terms of generation. A lot, a lot of issues there relative to what I call value juxtaposition, meaning audiologists have tremendous self evaluation of value, great connections with patients, really good professional experiences. They value their expertise that doesn’t always match how physicians value us, other health care providers, administrators, patients. and so forth. And so we really need to connect that better in order for the lived experience to be more positive. And professional identity was the last that was the last piece student debt was a piece. But, so the audiologists were about split, I said, Do you think audiologists have a strong sense of professional identity? Do we know who we are as a profession? and they were about 50/50. And the ones who really had a strong sense of professional identity, they tended to be the ones in who were who had either moved positions for a while until they found their place where they really belonged, or they were in a niche, you know, specialty area, cochlear implants, pediatrics, research, private practice, and so forth. And the ones who were like, No, we don’t have a professional identity, and there’s lots of factions, and they’re always fighting with each other, you know, and they tended to be less satisfied for whatever reason, they hadn’t moved around and found a good fit. More often working in an ENT setting, sometimes private practice, though, because, you know, there, there’s a little concern about financial viability of practice and so forth. But yeah, the ones who had picked a specialty area and who would worked hard and move positions until they found the right place. They had a very strong sense of who audiologists are, and what we do, even though we have a lot of specialty areas.

Brian Taylor 21:19
And it’s really interesting about the origin story, and you said 60% of audiologists kind of stumbled into the profession.

Diana Emanuel 21:26
Yep. Yep. Yeah, it was dramatic. In some cases, like I was in line to get my diploma. And I didn’t know what I was going to do. And someone said, hey, I want to sign up for Speech Pathology and Audiology. I’m doing that. Like literally five minutes of exposure. Now it was that wasn’t always the case. But it it was pretty dramatic. How many people and I, my origin story is exactly the same. I’m a Stumbler. Yeah,

Brian Taylor 21:49
no, I am, too. That’s interesting. I guess, is there? Is there any takeaway for professional organizations or for universities or trying to recruit students? Is there any kind of takeaway message in your research that they try to, if somebody is stumbling into the profession? Do they treat that person differently than somebody who’s more internally focused or motivated? I mean, I would a university maybe use some of the research that you’ve conducted in this area?

Diana Emanuel 22:18
Yeah, so I did address that in the discussion section, I made some recommendations. And again, you know, it’s hard to say whether any other recommendations are actually going to make a difference you until you do it, you can’t you can’t see. But yeah, so basically, my advice is, well, first of all, as a profession, we have to increase visibility, and we have to increase visibility at younger ages. It’s very difficult. You know, all professions want to be right there front center, in high schoolers minds, you know, you want to do this when it is but, but that that’s a challenge the profession has to face. But what I suggested for advisors, and I’ve been, you know, when you’re when you teach at undergraduate and graduate levels, and you inspire because I teach hearing science, I’ve taught intro to audiology, and I’ve been an undergraduate advisor. And so it’s like, I really think I want to do audiology. And you get really excited, because first of all, you remember how excited you were when you found audiology and fell in love with it. And you think about the potential. But we have to learn as advisors to put the brakes on and really ask, How much do you know about the field? And my suggestion even was, if they know very little, you’re taking a gap year, become a hearing aid dispenser, become a newborn hearing screener, get CAOHC certification and do industrial audiology, you know, volunteer shadow, get as much exposure as you can. And the funny thing is, and like I said, I was a director for a while and then I was chair and then I took a sabbatical to finish this project. But now I’m the acting director. And I’m looking through applications and I’m starting to see it so it’s not like I you know, expose this amazing you know, thing that was hidden, I think that audiology directors have done this for a while and and I think it plays into why our attrition rates are higher than they are for speech pathology, which which I, which I saw a lot when I was on the the CAE board that audiology programs had a lot more attrition during their programs. Some of it is mathematical speech pathology is two years and audiology is four years, a lot more can happen in four years then and then in two but but you know, I’m starting to see in these applications, students reporting that they’re doing more shadowing I have a number of audiology assistants applying for the AuD program. And people are putting in that they’ve been volunteering. They’ve been doing research. We require them to write essays and do interviews and the essays are like, what are the you know trends in audiology? In other words, we’re forcing them to tell us or at least do some research in into it. And then during the interview, like why audiology? When did you choose? And I think other directors are, are starting to do this. But I think we do have to, you know, there’s unfortunately there’s there’s this need as audiology directors, we need to fill our cohorts, you know, and it’s very difficult to do because audiology is a low visibility profession. Okay, so we’re a speech pathology may have 400 applicants, and we will have 80. Now, clearly, they’re their cohorts are larger, but still, you know, we’re competing over a too small applicant pool. And so that your is sort of the need as a director for you to get people interested and excited and applying and enrolled in audiology. You know, that’s one piece and then saying, oh, put on the brakes take a year or two off and make sure it’s the I mean, it seems counterintuitive where this role and this role, don’t meet. But I think that it’s an important thing that we need to do is make absolutely sure that that audiology is a good match for where people should be based on their talents and their goals and the desires and

Brian Taylor 26:10
The increased visibility is going to help also

Diana Emanuel 26:15
it would help with a lot of the the issues, it would also help with the value juxtaposition, like a lot of the the the poor value from others is not because we don’t have high value in the marketplace, it’s because they don’t know what we do is they have no idea, or they have a little bit of idea, or they just think we do hearing testing. But but the number of people during the interviews that are like, you know this, the administrator is so frustrated, because we’re like, we need a $20,000 piece of equipment – like, who are you? And what do you do? And first of all, you have to educate them on what you do. And and so it’s just like when a physician comes and says, you know, I need whatever I need a sonogram machine or another x ray, well, everyone knows what that piece of equipment is. And they know what physicians do, when audiologists go, and they say, well, I need an audiometer and is $20,000 Oh, yeah, the hearing test thing? Well, can’t you get a cheaper? Or why don’t you just use the other one? And can’t you share? So visibility and value are just really linked. And there’s we got to work on both of them. At the same time, I think

Brian Taylor 27:21
No doubt, no doubt about it, it’s good information to think about, I wanted to move on to the second topic of these articles. And that’s around occupational stress. And I think that this was really interesting information, too, if you could talk a little bit about your occupational stress findings, and maybe relate that information, those findings to what clinicians are going through on a daily basis in their own practice,

Diana Emanuel 27:48
right. So there hasn’t been a lot of research on us audiologists. In terms of stress, there’s been a couple on burnout, not a lot have been a couple of jobs, satisfaction and so forth. There have been some done in Europe and Sweden and and think Sweden, and then there’s New Zealand and India. So there have been other studies done across the globe. And what they found were things like they make connections with some of the demographics, like stress varies based on experience or stress, based on you know, work setting or stress. And I didn’t find I didn’t find that in my study. And in the second study the survey study by Zimmer at all which should be coming out soon, same kind of thing. And so I don’t think that you can talk about stress being associated with one specific workplaces or with people who are older versus younger. Ingrid Gordon Blood did some work years ago with educational audiologists. And they said that, you know, that they were finding a lot more burnout with their younger audiologists and less with older audiologists. But but they suggested what happens is, if someone is prone to burnout, they leave the field. And so by the time they’re experienced, you’ve already lost the people who have a tendency to perceive stress and burnout in a certain way. But neither one of these two current studies have indicated the connection with demographics. So let me let me talk to you about what the stressors are. Yes. And it’s remarkable. I won’t talk too much about the Zimmer study. You’ll see that in a couple of months. But the basically we found similar things regardless of methodology. So the top ranked stressor were Time Issues, okay. 68% of the interviews, they talked about things related to time, ‘don’t have enough time with patients’ have ‘too much time doing paperwork’, medical records, all of those things. The second was Patient Issues. And so that was kind of split which was interesting. So you’d think that all of the issues would be negativity, mistrust and all that stuff, but we did see some of that Zimmer saw a lot of that, but in our in my study Basically, it was split 50/50. But half were sort of like, patients were non compliant with mask requirements, patients didn’t trust me, patients thought I was ripping them off. But if patients were rude, okay, so patient related issues are very stressful. But there was also a lot of patient data, the patient came in, and they were crying because they couldn’t afford a hearing aid, or the patient had such a complex problem, I couldn’t solve it. So some of the patient’s stressors are that for whatever reason, I can’t help this patient the way I’d like to. And the other was the patient was a problem. And the problem stems from the patient being difficult, resistant to care. So the family is dragging them in, and the person’s like, I don’t want to hear any of my family makes sense. So it’s a patient related issues. The third was administration. And some of that I sort of alluded to before, which is that you’ve got these multi level multiple layers of administration, and you’re not getting the support that you need. And there, you know, you have an assistant other healthcare professionals have an assistant and they’re they’re firing your assistant when when the money’s tight, but not theirs. So this administration, not understanding our needs not supporting us with equipment and so forth. The next was Financial, and that basically came from the private practitioners, which is, you know, I want to give my staff as much time as possible with patients to provide the best care possible. But I also have to look at the bottom line, and especially for practices that have a lot of Medicare patients. And I know, people seem to think that, Oh, if we have direct access to these Medicare patients, everything, no, the practices that see a lot of Medicare patients, they’re like, our bottom line is just extraordinarily difficult to navigate, because the reimbursement is so low. And so the financial issues that that came in as number four. And so Lack of Support was the next one, which is I don’t have the equipment I need, I don’t have the personnel that I need. And as we start getting down lower and lower, number six, about 25% have complained about colleagues. So, you know, my colleague is not testing right, my colleague is irritating the workload that I work with a physician and that yelled at me, so. So colleagues, and then at the very bottom was work life balance that basically, though was not all that many, so our top ones, basically our Time Issues, Patient Issues, and Administrative Issues. And those three are the they’re the big three, actually,

Brian Taylor 32:24
patients and administration. Right.

Diana Emanuel 32:27
And, yep, that’s,

Brian Taylor 32:32
So I guess, I’m curious to know, you know, thinking about it, say, there’s a lot of audiologists out there that watch this channel occasionally. And they might have 20-30 years of experience, experiencing some of these stressors, what advice would you have for them to lessen their stress?

Diana Emanuel 32:50
Okay, so, um, I, when I was thinking about this, and a lot of this, by the way, I’m still investigating. And so I’ll tell you what I know, I’ll tell you what I think we might do, and I will also indicate how I think we might want to consider it. So first off, there are a number of articles that are out there already. The talk about how to deal with stress and audiology and a remarkable number considering that audiology keeps popping up as it’s the least stressful profession, which I think is I’m actually working on an article right now about why that is really not encapsulating the field. But Brian Kreisman has an Audiology Today article from 2017. On stress, Kasper 2009 in Audiology Today, Glans 2015. Hearing Jounral, Nema in 2004. So there’s a bunch of them out there. One of them I can’t recall. Now I’m blanking on which one of these words it’s like the zen of Audiology How do you mindfulness meditation and so forth. And so that sort of gets to, there’s two ways to view it. One is how the individual reacts to stress and what they can do about that. And the other is what we can do as a profession or as a clinic or as a as an audiologist to chip away at the things that are creating stress. So I’m talking from the individual perspective first. So there were indicators in the interview study from a lot of audiologists, where they were talking about how, you know, stress is very individualized based on personality, you know, and they’ll say something like, Well, you know, I don’t stress about it, but my colleague does, or I really stress about it, but my colleague doesn’t, I mean, and this was in about a quarter of the interviews, this unsolicited popped up. And so and I also see evidence that there’s a lot of individual variability in reaction to stress based on some of the numbers so I asked people to rate stress on an average day and also on their worst day, okay. Now, they were significantly different, which means that looking at stress as a as a static point, like this is how stressful your job is, is just completely erroneous because it vary so much. And the other is that they were highly correlated. So people who had low stress on their average, they also reported a relatively low stress on their worst day. And so individuals tend to react so differently to stress. So another thing that that Maddie Zimmer’s paper, you’ll will see in J AAA and basically what she said is, there was a significant difference. When you look at responses to the question, are you concerned about over the counter hearing aids? You can say yes, no, or undecided. Right. And that was related to stress rating. So people who tended to be stressed about over the counter hearing aids had a very high overall stress rating. So some people are just stressed about everything about their day to day job about over the counter hearing aids. Though my interview study over the counter hearing aids was was almost a non issue. Costco and non traditional vendors were a big issue, because they didn’t know how to compete financially. But over the counter hearing aids, they’re like, ah, you know, it’s a poor quality hearing aid, there’ll be in my office eventually, that basically, they weren’t as concerned about over the counter hearing. So. So when we look it up, from an individual perspective, my next research project is going to do look at personality type, compared with, you know, stress in in the audiology workplace, and to really look at is this, is this a thing? Because if it is, it’s like, what are your allergies, low stress, unless you happen to be one of these, you know, and I’m one of them, I suffer from a lot of anxiety. And so the way I react to stress is quite different from someone who’s sort of a type being nothing bothers them type of person. And so that’s the research project. But we do know from other fields we know from from research and other healthcare professions, and business and so forth, that when they do these personality types, and then we take a look at responses to job related stressors, there’s definitely a correlation there. And so people, you know, industry, people who are reporting a lot of job stress happen to have this personality type. There’s been a little bit of personality type research and audiology, but nothing compared with stressors. So I will say that we don’t know enough yet. However,

from my personal experience, I think if if you feel like you are compared to your colleagues far more stressed, you know, that would be on an individual basis, where you’re looking at, you know, go and see a mental health provider, accept therapy, accept medication, if necessary, look into the strategies like the meditation that this that the other, okay, so that from an individual basis is something that we’re not going to be able to do his profession by changing the profession. Because no matter what profession you’re in, you’re going to be stressed. That’s so individualized. I mean, I have tried to meditate for 40 years, it doesn’t work for me, I can’t turn off my brain. But exercise does, and it was incredibly individualized. We do know that. I mean, our our, our Student Affairs Office is telling us as professors that we’re looking at 40% of the current student population, or more having significant mood disorders, which is anxiety and depression. And so it’s under diagnosed and people who are above college age, but the reality is, and then you add the pandemic to it. Right. So audiology is 85% Women approximately. And we know who the people are, who suffered most from the pandemic, basically, I mean, obviously, it was people who are minorities, and people who are in poverty and so forth. But when you look at gender, right, women tend to be the ones who are working virtually, and teaching their kids virtually and dealing.

Brian Taylor 38:46
So taking care of the house. Right.

Diana Emanuel 38:48
Right my and it’s, you know, that if you can solve societal problems relative to gender, work roles, you know, yay but but the but that’s the reality 85% of it audiologists are women and it, it accounts for some of the stress and accounts also for things like salary differentials, and so forth, but other interview. So I would definitely encourage people to, to do a lot of self reflection, take some personality tests, ask for help. I’m one of those people that I don’t need help. I don’t need to help them most my career. Sure I can get tenure, I can raise two kids, I can do this. I can do that. I can do the other never ask for help. But the reality is, you add the increasing workload and you add the pandemic and so forth. I think far more people need to find individual responses. But let’s put that aside. And let’s talk about at the professional level so we can pick away I don’t think there’s a magic bullet. But I think we can pick away at things that we have to deal with as a profession that are stressful. So let’s take a look at time. All healthcare professionals are really complaining about time, reimbursement is low, you know, electronic medical records, all of these requirements are getting worse and worse and worse. But what was revealed in a lot of the interviews was that audiologists have, for whatever reason accepted the fact that they do everything. So audiologists come in, they sanitize their sound booth, they get the patient from the waiting room, they photocopy their own audiograms. They do all of their own charting. They sit with a patient for a half an hour, I’ve also seen this on social media, and figure out why the hearing aid is not connected with the Bluetooth are showing the person how to use, why are we doing everything? we have a doctorate. And so we should be practicing at the top of the profession, and should be focusing a lot more on hierarchial business models where you have assistants, you have interns, you have whatever. And some of that is planning and some of that is advocacy. You know, if you go into the workplace and one of the, if there’s a good thing to say about the pandemic, I would say this, this, the mass resignation might work in our favor, which is if you go into the workplace, and you’re like, look, this is what I expect, I expect to be called Dr. So and so not referred to as the girl down the hall, I expect to make this much, I expect for your office staff to do the sanitizing of the soundbooth to make sure that I have the appropriate supplies, I expect the assistant to be able to go into the initial intake and work with the patient if they need extra time. And if they say no, then walk out the door. And it’s it’s really hard on an individual basis. But I’m hoping that more and more audiologists will do that and embrace this hierarchical model. What, Unfortunately, what? No, it’s slow, like you can pick away at it, but it will not solve the time crunch. No, because we’ll be redirected into seeing more patients. But, you know, I think we need to embrace that. Another thing is, and so going back in time, patients, okay, I think we can improve some of the stress associated with patients. Again, the visibility and the value and so forth, but with transparent pricing, and you know, you see a lot in the in the

in various conferences on how to sell hearing aids and how to, you know, finish the sale and how to do this, whatever. And, and there’s a lot of stress associated with that. There’s, there’s goodness, a couple interviews, studies that came out in and colleagues and clinics, I’m blanking on the other one, they did interviews. And basically, there’s this moral dilemma where audiologists feel like they’re pressured into selling hearing aids when perhaps it’s not the best choice. And so I think we have to really back off on, you know, this the sales perspective, use transparent pricing. And unbundled, we still have the majority of audiologist using a bundled pricing model. I know because I had a student just complete a survey on that. And if you look over time, we were at about 84%, bundling in 2004 of the hearing journal, audiology online survey all the way down to I think, blanking on it as my own data is slightly over 50%. There’s still bundling. We are seeing though a nice increase in hybrid pricing, which is, you know, offering patients choice of bundled or unbundled under whatever circumstance. But I think if we can do sort of transparent, more transparent pricing, and a lot fewer people just really set on saving on using bundled pricing. I had a couple things memorize, but there’s so many people, David Fabry, Kim Cavitt, there’s a bunch of articles out there. So there were about three or four articles and seminars and hearing on, here’s how to do a financial analysis to determine exactly how you should price using unbundling to survive in the marketplace. There’s so much out there. And I think if we really all as a profession focus on here’s our value, here’s what it is, if you want to, you know, purchase the device here, great if you don’t want to pursue this versus that right here. Right? When I go into I for my eye care. There’s an ophthalmologist who did my eyelid surgery and who does the medical stuff. There’s an optometrist who deals with my vision care. And then in a completely different side of the office, all shiny and beautiful. There’s the optician who sells the glasses, but the physician and the optometrist on factor of optometry, they don’t sell. You know, they’re not involved in talking about pricing or in selling devices that give you your prescription. If you want to go to their shiny center and buy really beautiful glasses great if you don’t you go somewhere else. But I don’t necessarily think that we’re as far along as we could be relative to that, relative to setting hierarchy model where our value is clearly invisibly projected prices are transparent and if you don’t want to buy from us, that’s fine. Here’s our hourly rate on on programming a hearing aid if you purchase it somewhere else, and then follow the rules. that people smarter than me in business have told you.

Brian Taylor 45:06
Well, that seems like fairly valuable advice. Thank you any final before we as we wrap things up here. Any final thoughts or comments with respect to your research? Or you mentioned a couple other papers that are in the pipeline, if you could maybe talk a little bit about those or where we could find them? J AAA, I think you said,

Diana Emanuel 45:25
yeah, so this Zimmer paper, it’s Zimmer, Emanuel and Reed- Nick Reed, who’s at Hopkins. We have the paper coming out that’s on. We look at when we tried, we measured resistance to change and whether that was related to use of service extended personnel or on bundling with a paper coming up out J AAA on burnout. That’s Maddie Zimmer, me and Nick Reed. We have another paper we’re going to submit soon. That was the and co authors and that’s on looking at change, resistance to change and whether that impacts clinical decision making use of service of standard personnel and bundling and unbundling so forth. And I have three or four more studies, we’re looking at lived experience relative to people of color, as in audiology. We’re jumping back in to take a look at connections between origin stories. So there’s a pipeline of projects. I’ve got seven running now I’ve got seven that’ll start next year. But the to the Zimmer looking at burnout stress and then looking at change resistances to be the ones hopefully will come out this year.

Brian Taylor 46:42
No. Well and for those of you that maybe didn’t catch the very beginning. The two papers we’ve referenced throughout this interview are both published in 2021. I think an American Journal of audiology am I correct about that.

Diana Emanuel 46:57
Yeah. So and, Brian thank you for letting me talk.

Brian Taylor 47:02
Yeah. Well, Professor Diana Emanuel at Towson University, thank you for your contributions to the profession. And it’s great having you on the on the broadcast this week. Thank you.

Diana Emanuel 47:16
Thank you