Are Your Patients Really Hearing You? Try these methods to modify communication strategies for patients with hearing loss to help them understand health information and participate in their care. Features
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Features  |   March 01, 2018
Are Your Patients Really Hearing You?
Author Notes
  • Jillian Kornak is writer/editor for The ASHA Leader. jkornak@asha.org
    Jillian Kornak is writer/editor for The ASHA Leader. jkornak@asha.org ×
Article Information
Hearing Disorders / Features
Features   |   March 01, 2018
Are Your Patients Really Hearing You?
The ASHA Leader, March 2018, Vol. 23, 52-61. doi:10.1044/leader.FTR2.23032018.52
The ASHA Leader, March 2018, Vol. 23, 52-61. doi:10.1044/leader.FTR2.23032018.52
“My husband signed that the doctor recommended immunotherapy, but we’re not sure what that means.”
“I think the nurse said to take two pills with each meal, but the noisy machines next to my bed interfered with my hearing aids.”
“The doctor turned away while describing my test results, so I may have misheard her, but I don’t want to ask more questions.”
These examples show how the tricky intersection of hearing loss, health literacy and communication skills can make a big difference to patients’ health care outcomes. When a patient with hearing loss is expected to self-advocate for their health care needs, navigating care can be a formidable challenge.
How can patients who are deaf or hard of hearing access the care they need if they encounter significant barriers to clear provider-patient communication? Clinicians can use a number of communication tactics to ensure that patients hear correct medical information, understand health care terminology, and feel comfortable making care decisions.
Based on the type of communication need, patients may simply need clinicians to address them directly in a well-lit room, or provide an in-office amplification device. Per the Americans With Disabilities Act, the Rehabilitation Act and Affordable Care Act, those with more severe hearing loss may need accommodation in the form of written information and/or qualified medical interpreters for appointments (see sources below). Here’s a closer look as what some hospitals and clinics are doing to address these needs.
Providence-Providence Park Hospital
A communication breakdown between a patient who is deaf and an oncologist was a watershed moment for Providence-Providence Park Hospital in Southfield, Michigan. As the physician attempted to explain the man’s cancer diagnosis to him and his wife, who was also deaf, it was obvious the patient didn’t understand and was frustrated and confused. Relying on the patient’s communication partner for interpretation was just not working. Then the social work department got involved.
“It’s a challenge to interpret on a subject you don’t understand,” says Abbie Gonzales, an inpatient oncology social worker at the hospital. “If I’m asking you to describe an ice cream cone and you’ve never had one, how does that work? How do you come up with the words to describe what that is?”
The social work team saw that both staff and patients needed to learn that interpreters (if needed) should be readily available to all patients who are deaf or hard of hearing. Federal law requires providers and facilities that receive funding from the U.S. Department of Health and Human Services to provide—and publicize the availability of—language-assistance services (see sources). This funding includes Medicaid and Medicare (Parts A and C).
“For the providers, it makes communication easier,” says Gonzales. “For the families, they don’t feel like they have to be the ones to interpret and that takes some of the burden off family members. But I also think it places an expectation on the staff to make sure that they’re doing a good job communicating.”
Social work staff made awareness of interpreter services a priority and positioned their department as the liaison for this service. “What the doctors and nurses and other staff needed to understand was: How can we easily get a sign language interpreter here for appointments and what resources are available to us?” says Linda Bender, lead oncology social worker for Providence Cancer Institute.
They posted signs—“You have the right to an interpreter”—throughout the hospital. The goal was to keep this statement at the forefront of patients’ and providers’ minds. According to Bender and Gonzales, this tactic worked. They saw an uptick in interpreter requests among patients who are deaf in advance of appointments, and hospital colleagues knew to phone the social work department immediately if interpreters were needed quickly.
Further complicating communication was a misconception among staff that patients who are deaf could simply read about their diagnosis and comprehend it as written. Social workers recruited a man with cancer who is deaf to review written patient educational materials. He told them the materials failed to adequately describe the disease.
The team and this patient worked together to produce a series of videos specifically for the deaf community. Using ASL, voiceover and overlay text captions, the videos explain what cancer means and define common cancer treatments and medical terms.
After working closely with people with cancer who are deaf, oncology social worker Jennifer Gillette started the Journey of Hope Cancer Support Group for patients who are deaf in the metropolitan Detroit area. The group meets quarterly throughout the year and is open to patients of all cancer diagnoses as well as caregivers. Gonzales now continues Gillette’s work in facilitating the group.
Meeting structure is similar to most cancer support groups, with introductions and catching-up among attendees followed by a presentation and discussion. The group decides on the topic of the presentation (past topics included education on grief, loss, goal-setting and nutrition) and schedules the speakers. Gonzales notes that presenters who are also deaf have a big impact on the group.
“What better way to receive information than from your peer? Helping them to educate each other is one of the primary focuses of what we’re trying to do with the group,” she says.
One of the medical interpreters who often interprets for the local medical community is a frequent attendee of the group. Gonzales credits this interpreter as a great referral source for the group and helps facilitate discussion as a familiar face who actively attends appointments with the patients.

“If I’m asking you to describe an ice cream cone and you’ve never had one, how does that work? How do you come up with the words to describe what that is?”

It’s in the EMR
For patients who are deaf and communicate using American Sign Language (ASL), access to qualified medical interpreters fluent in ASL is essential to high-quality health care.
When Sara Toth noticed interpreters were not booked within adequate timeframes to meet the actual needs of patient visits, she took action.
“The original procedure just said that patients had a right to an interpreter and it should be accommodated,” says Toth, then an oncology social worker at Rutgers Cancer Institute. “But there wasn’t anything in place on how that should go. We started getting more patients with more needs and we couldn’t keep up with doing things the way they were being handled.”
Toth, who now works at Memorial Sloan Kettering Cancer Center, began her process change with staff education on the needs of patients who are deaf or hard of hearing. Toth emphasizes that the concept of cancer is difficult to explain in ASL.
“There’s a whole lot more conversation that needs to happen around one sentence than we realize,” she says. “And the providers just didn’t know. They would talk to patients and say words like ‘immunotherapy’ or ‘the BRCA 1 gene.’ Then interpreters try to find that concept, because it’s not as easy to find quickly. It was just education for the providers: You can’t just say ‘BRCA 1 gene’ or ‘immunotherapy.’ Explain what that actually means.”
Toth held general education sessions for all staff: doctors, nurses and front desk personnel. She gave an overview of the specific needs of this patient population and the difference between ASL and written English, underscoring the same lessons from Gonzales’ hospital: that it isn’t enough to just write things down. Toth also invited a representative from the New Jersey Division of the Deaf and Hard of Hearing to come in for an in-service training with staff.
Then Toth tackled the issue of patient schedulers frantically calling her department last-minute to get interpreters to appointments. Sometimes they failed to book an interpreter at all. The problems largely stemmed from how providers documented hearing loss in patients’ electronic medical records (EMRs). Toth looked into the EMR setup.
“Patients who have any sort of extra need must be identified easily in the EMR,” says Toth. “It shouldn’t be buried in the demographics or somewhere deep in the chart, like the notes section, that the patient is deaf or hard of hearing.”
She connected with her institute’s IT department and had an interpreter icon embedded into the system. This symbol now appears next to the patient name on the EMR of every patient with documented hearing loss. It automatically triggers the front desk staff to contact the social work department to schedule an interpreter.
“That was huge and it was super, super easy … everybody that was scheduling could identify that this patient had a need and it was another step to booking their services,” says Toth.
Interventional audiology
But what about patients with mild to moderate hearing loss, a population whose amplification needs aren’t as readily apparent as those with more severe hearing loss? This is a large, underserved population when it comes to communication access, say audiologists Catherine Palmer and Lori Zitelli from the University of Pittsburgh Medical Center (UPMC).
When their audiology group would test the hearing of hospital inpatients and troubleshoot their hearing aids, it was clear that many patients (especially those over 65) needed hearing assistance to fully participate in health care decision-making.
To address this communication need, they suggested providing simple, inexpensive non-custom headset amplifiers to patients with mild to moderate hearing loss who don’t use or have hearing aids. It didn’t take much convincing to prove the value of this service.
“Once they [providers] realize how much the hearing loss was impacting their ability to evaluate and treat their patient—and how easy it is to mitigate those effects with a non-custom amplifier—they become converts,” says Zitelli, audiologist at UPMC.
Zitelli and Palmer refer to this initiative as “interventional audiology.”
“Our motto is to ‘get out of the booth’ and bring audiology services to the patient,” says Palmer, director of audiology at UPMC and associate professor at the University of Pittsburgh. “Our focus is interventional audiology, which means you are treating hearing when hearing is not the primary concern but will impact the health outcome negatively if not resolved.”
Patients, families and providers have embraced the program, noting increased patient involvement in care discussions with providers. Many patients and families who use the device as part of their outpatient care are so pleased with the amplifiers that they end up purchasing them to take home. For inpatients, the UPMC system provides the amplifier during the hospital stay and patients take the device home at no charge. The hospital looks at this as a communication accessibility issue.
“Just as you wouldn’t charge to make a facility physically accessible, we don’t charge to make the same environment communication accessible. We know that individuals will need to continue to communicate well as they recover at home or in a rehab facility,” says Palmer.
Amplifiers are provided in the inpatient setting, the geriatric outpatient clinics and several interdisciplinary clinics. (For more on this intervention across UPMC’s system, see “Amplifying Patient Care,” July 2017.)

Imagine only hearing part of your medical team’s care instructions or description of a procedure and then being expected to make a decision about your care.

Keep it simple
But the situation is not so rosy for patients without amplification. Imagine hearing only part of your medical team’s care instructions or description of a procedure and then being expected to make a decision about your care. This may put patients with hearing loss at increased risk for poor medical care (see sources).
However, amplification aside, environmental factors can make a big difference to the effectiveness of provider-patient communication, notes Tricia Ashby-Scabis, ASHA’s director of audiology.
A patient with hearing aids lying in bed with a pillow behind their head can experience a whistling type of feedback because the microphones are partially covered. Visual cues important to communication may be lost if doctors share instructions in dimly lit rooms or accidentally turn away. A piece of equipment next to the patient’s hospital bed makes just enough noise to affect their mild hearing loss and they may miss key components of the information the doctor is sharing.
Even without these distractions, an undiagnosed mild to moderate hearing loss can still be a barrier, Ashby-Scabis says. “A lot of times patients don’t want to advocate for themselves,” she says. “They don’t want to draw attention to the fact that they have hearing loss. Their natural response is ‘Yeah, I can hear you talking.’ But if you just told them what you had for dinner or the name of your dog … they can’t repeat the specifics back to you. Often the more complex information is not easily understood. Think of how much information you have to take in to understand a medical diagnosis.”
Ashby-Scabis also emphasizes that having more people—friends and family—at the appointment doesn’t make medical information any less complicated: “All of sudden, their communication partner has to take on the responsibility of understanding. It’s like telling someone they have to speak a whole new language without any foundation of that language.”
To help, audiologists can use simple strategies to educate their peers and give other health care providers a reminder about a patient’s hearing loss. For example, when she worked in clinical practices in Washington D.C., Ashby-Scabis would ask her patients for their physicians’ names and send letters that outlined the degree of the patient’s hearing loss. This simple prompt, she said, would act as a reminder to other providers to practice good communication with these patients and to identify her role in collaboration in patient communication.
“When you have patients in your office, make sure they can see your face, that you don’t have the patient reclining or turn out the lights when you share important information. Make sure the patient can repeat back the key points of what you said. Give people condensed information,” she says.
And, when people who typically wear hearing aids are hospitalized, they may not even have their devices with them. Just as patients are asked to remove jewelry, hearing aids are often viewed as an expensive item that should be left home to avoid being lost or accidentally thrown away.
“Many health care providers, especially in facilities, want patients to have their own hearing aids for that communication opportunity, but the cost-risk for the facility is often the determining factor for sending the device home with a family member,” says Ashby-Scabis.
This is unfortunate, she notes, as it creates an obvious communication barrier for patients who regularly wear hearing aids. She recommends patients and families advocate to keep the hearing aids with the patient to use in the hospital.

“Make sure the patient can repeat back the key points of what you said. Give people condensed information.”

Hearing testing: It’s not just for kids
Another patient advocacy avenue for audiologists is promoting regular hearing testing for adult patients. Most adults have not had their hearing screened since they were children.
“Hearing loss occurs slowly without notice in most people,” says Ashby-Scabis. “It’s such a slow process. For kids, screening makes sense, because hearing is tied to language development and literacy. But in adult life it’s like ‘good luck to you’ because few adults are being routinely screened for baseline hearing abilities!”
With the estimated number of people with hearing loss expected to increase by 30 million by 2060 (see sources), regular hearing screening could help identify patients earlier. Ashby-Scabis recommends audiologists reach out to primary care practices or general practitioners to promote referrals for suspected hearing loss.
Once a hearing loss is identified, more frequent follow-up is needed. Consultations for communication strategies or technologies can be pursued with a documented record of the patient’s hearing ability.
Interdisciplinary relationship-building is an important part of a career in health care and, accordingly, interprofessional practice is being taught to the next generation of audiologists, notes Ashby-Scabis. “We’re promoting it. We’re teaching the new generation to be willing to call the oncologist to say, ‘The patient you referred to me to monitor for ototoxicity to see if they’ve got hearing loss is really struggling. I can consult with them regarding amplification but the treatment may cause continued hearing degradation that may impact their ability to use certain hearing devices. Are there alternative treatment options?’” These options should focus on the patient’s primary oncologic needs while also focusing on their changing hearing loss.
The emphasis for students and early-career professionals, she says, should be to avoid complacency. “We teach students about good communication skills and aural rehabilitation,” she says. “Go get involved. You’re the subject matter expert. Don’t sit and wait for someone to tell you what to say. Have a voice and represent your patients and this amazing profession.”
Sources
Cudmore, V., Henn, P., O’Tuathaigh, C., & Smith, S. (2017). Age-related hearing loss and communication breakdown in the clinical setting. JAMA Otolaryngology Head & Neck Surgery, 143(10),1054–1055. [Article] [PubMed]
Cudmore, V., Henn, P., O’Tuathaigh, C., & Smith, S. (2017). Age-related hearing loss and communication breakdown in the clinical setting. JAMA Otolaryngology Head & Neck Surgery, 143(10),1054–1055. [Article] [PubMed]×
Goman, A., Reed, N., & Lin, F. (2017). Addressing estimated hearing loss in adults in 2060. JAMA Otolaryngology Head & Neck Surgery, 143(7),733–734. [Article] [PubMed]
Goman, A., Reed, N., & Lin, F. (2017). Addressing estimated hearing loss in adults in 2060. JAMA Otolaryngology Head & Neck Surgery, 143(7),733–734. [Article] [PubMed]×
Grooms, D., & Polovoy, C. (2017). Are your services accessible to all The ASHA Leader?, 22(11), 54–58.
Grooms, D., & Polovoy, C. (2017). Are your services accessible to all The ASHA Leader?, 22(11), 54–58.×
Mick, P., Foley, D., & Lin, F. (2014). Hearing loss is associated with poorer ratings of patient-physician communication and healthcare quality. Journal of the American Geriatrics Society, 62(11), 2207–2209. [Article] [PubMed]
Mick, P., Foley, D., & Lin, F. (2014). Hearing loss is associated with poorer ratings of patient-physician communication and healthcare quality. Journal of the American Geriatrics Society, 62(11), 2207–2209. [Article] [PubMed]×
U.S. Department of Justice. (2003). ADA business BRIEF: Communicating with people who are deaf or hard of hearing in hospital settings. Americans with Disabilities Act. Available from: https://www.ada.gov/hospcombr.htm.
U.S. Department of Justice. (2003). ADA business BRIEF: Communicating with people who are deaf or hard of hearing in hospital settings. Americans with Disabilities Act. Available from: https://www.ada.gov/hospcombr.htm.×
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March 2018
Volume 23, Issue 3