There is a current need to improve health care delivery to deaf and hearing-impaired persons. At Dalhousie University, Nova Scotia, Canada, I designed an educational workshop as an initial step to address this need. The workshop was offered electively during two consecutive years (1997 and 1998) to first-year and second-year medical students and others. In this article, I describe the design, goals, and execution of the workshop. The workshop involved a broad, multidisciplinary scope, may have been the first of its kind in Canada, and is still one of the few documented ways to approach medical education about deafness and hearing impairments. Throughout the article, I have used the term “deaf and hearing impaired” to refer to persons with a variety of hearing impairments, who may consider themselves Deaf (the term typically used to denote belonging to the cultural and linguistic entity called “the Deaf community”), deaf, hard of hearing, and/or late deafened.
Provision of appropriate and effective health care for deaf and hearing-impaired persons has remained a challenge for health care professionals for many years.1–11 It is well documented that the majority of deaf and hearing-impaired persons demonstrate difficulties accessing health care and communicating with health care professionals.1–3,5–8,10,11 As summarized by Barnett,1 several studies show that this group's health status and use of services differ from those of hearing persons. The literature suggests that misinformation, miscommunication, and lack of basic knowledge about deafness and hearing impairments may contribute to problems in the legal, ethical, and general delivery of health care to the deaf and hearing-impaired population.1,2,4,5,7,8,10,11 Deaf and hearing-impaired patients frequently encounter these preventable problems, often perceived as “barriers,” in all areas of health care.1,2,4,6,7,10,11 Amelioration of these preventable problems is a necessary and attainable goal. As clearly discussed by Barnett,1 improving health care of deaf and hearing-impaired persons may be effectively achieved through education of medical professionals.1,2,4,10
The United States offers several health care services staffed by personnel with expertise in deafness and hearing impairments,2,7 and has several organizations that take proactive roles in improving the health care of the deaf and hearing-impaired population by creating medical education initiatives. However, such advances are not countrywide, and may not be available in other countries, such as Canada. Also, there is a paucity of literature about how to educate physicians or medical students about deafness. Barnett1,10 gives a clear description of this educational need. In addition, there are few current reports of workshops that have been used to supplement the education of health care professionals about deafness,12 deafness and blindness,13 and overlapping topics of cross-cultural medicine and communication in medicine.14–18 The workshop described here may be the first of its kind in Canada that featured these particular teaching methods, covered such a wide breadth of knowledge, incorporated deaf lecturers and volunteers (as simulated patients), and was created to address the health care of deaf and hearing impaired persons. This paper is not intended to examine the effectiveness of this unique intervention, but to qualitatively describe it to facilitate further study and stimulate interest in the approaches it uses.
Currently, there are gaps in medical education about deafness and hearing impairments. First, the literature suggests that despite the high prevalence of hearing impairments (which affect approximately 10% of the population, making hearing impairments the sixth most common disability) and the widespread use of American Sign Language (ASL) (the third most widely used language in the United States), most physicians greatly underestimate the needs of this population.1,2,4–7,9,11 Second, the literature reports that health care professionals are unfamiliar with the major barriers faced by deaf and hearing-impaired persons in accessing quality health care.1,2,4,6–8,10,11 Third, the literature suggests that most physicians hold the same misconceptions as do laypersons about the communication abilities, intelligence, language acquisition, and sociocultural issues of deaf and hearing-impaired persons.2,7,8,10 Although physicians are taught the etiology and biomechanics of hearing impairments, they apparently do not have sufficient knowledge to understand and therefore improve the quality of health care of the deaf and hearing-impaired population.1,2,7,10,11
Medical care of deaf and hearing-impaired persons may be improved if medical professionals have basic, current knowledge of (1) social, cultural, and linguistic aspects of deafness and hearing impairment; (2) current problems with health care delivery to this population; and (3) resources to rectify the situation.1,2,4,6,7,12 Thus, as a preliminary step, the educational workshop described here was designed and offered to two consecutive cohorts of medical students, in 1997 and 1998, before their entry into clinical settings.
After a review of the literature, review of the need in the Dalhousie University curriculum, and consultation with national and local deaf and hearing professionals who work with deafness and hearing impairments and the local deaf community, I determined the objectives and content of the workshop and procured main community contacts though telephone and in-person meetings. My previous training in deafness and hearing impairments helped me to design and deliver the workshop. I sought to make the workshop as inexpensive and as easily reproducible as possible, so that replication and testing could be done in the future. If this intervention is later shown, through qualitative research, to be effective, it could eventually be included in medical school and continuing medical education curricula. The following is a description of the goals, design, structure, content, and execution of the workshop.
The main workshop goals were to
* increase general awareness among physicians of the need for improved medical education on deafness and hearing impairments;
* provide a cohort of medical students, before the initiation of their clerkships, with needed information on deafness and hearing impairments;
* serve as an introduction to specific communication methods and techniques to maximize effective communication with deaf and hearing-impaired patients;
* give medical students information on the multicultural, linguistic, developmental, and technological aspects of treating persons with deafness and hearing impairments;
* allow students an opportunity to interact with deaf persons;
* discuss the ethical and legal responsibilities involved in caring for deaf and hearing-impaired persons; and
* begin to bridge the gap between the community of Canadian physicians and the community of deaf persons.
The three-hour workshops consisted of a questionnaire, six lecture sessions, discussion periods, a display table, and sessions in case-based (simulated patient) groups (described later). Lecture sessions were given by a variety of deaf and hearing speakers. Although the guest speakers in 1997 and 1998 were not always the same, the general content remained unchanged. Deaf persons gave personal accounts in 1998. Speakers used either ASL or English, and the workshop was ASL/voice interpreted.
The workshop was held at Dalhousie University Medical School, Nova Scotia, Canada, on a single weekday evening. An auditorium and small teaching rooms were used at no charge. There was media coverage by a local television station and a local newspaper. The workshop was advertised and offered as an elective first to medical students on a sign-up basis, and remaining seating was offered to others. Only first-year and second-year medical students were invited because it was believed that the workshop would be most beneficial before the clerkship years. Additional attendees included members of the deaf community, members of the deaf-blind community, members of a local sign language class, and interested medical staff from Dalhousie University.
Two volunteers and I arranged the room booking, advertising to students, photocopying, room setup, and display table setup. The medical school granted permission for the workshop, and covered the cost of the paper, photocopying, interpreting, and refreshment trays. Permission for the workshop was granted by the dean and the Dalhousie Medical Student's Society after meetings I had with them to present the needs for such a workshop, the workshop's goals and outline, a breakdown of proposed costs, and a request to use the medical school's facilities.
The list of workshop sessions given in 1997 and 1998 is shown in List 1. The time allotted for each session is also shown; these times were adhered to as closely as possible. In each year, the workshop began with a questionnaire as part of the introduction session. This was followed by a case-based (simulated patient) group session and six lecture sessions. All students attended all sessions in the given order. The sessions were separated by feedback and question opportunities (1997 session) and by deaf and deaf-blind persons’ short personal accounts of past health care experiences (1998 session). The workshop concluded with a discussion and question period, completion of evaluation sheets, and perusal of display tables. There was a short break in the middle. Of note, only medical students participated in the case-based group session; other attendees had a discussion period at that time.
The workshop content was carefully chosen based on current literature on the problems of medical care of the deaf and hearing-impaired population and the misconceptions most commonly held by physicians, as described previously. During the workshop, there was a ten-minute break in which students could peruse the display table, speak personally with the presenters and other attendees, and snack from provided refreshments. At the end of the workshop, participants were again encouraged to peruse display tables and talk with presenters.
Attendees were welcomed, given a questionnaire based on common misconceptions about deafness and hearing impairments, and told that answers would be discovered throughout the workshop. Students were informed about the format and purpose of the workshop. The various types and classifications of hearing impairments and the prevalence and general characteristics of the each (deaf, hard of hearing, late deafened, and oral deaf) were presented. General information on current problems in the delivery of health care to deaf and hearing-impaired persons was introduced and served to highlight the purpose for the workshop design and content.
Case-based group session
For the case-based group session, students were randomly divided into groups of five or six, with one deaf “patient” in each group. Members of the deaf community had volunteered to act as “patients” and had practiced one of six preassigned medical scenarios for the session. The medical students were asked to conduct a medical interview to determine the chief complaint of the patient. The scenarios were simple presentations of common illnesses that were not easily indicated by simple pointing or gesture. (See List 2 for examples.) Most deaf volunteers’ first language was ASL, but they used a variety of communication methods in response to attempts of medical students. After the case-based group session, two representatives from each group gave feedback on their respective experiences of “patient” and “doctor.”
The session entitled “The Deaf, Hard-of-Hearing, and Late-deafened Patient” presented cultural and linguistic needs of patients with different types of hearing losses. The importance of understanding that it is the patient's preference (cultural and linguistic) that facilitates effective communication was emphasized.
The Patient–Doctor Relationship session highlighted the importance of effective communication between patient and physician. It was suggested that communication between the physician and his or her deaf and hearing-impaired patients can improve when there is understanding of the commonly perceived “barriers” and misconceptions about deafness and hearing impairments.1,2,4,6–8,10 In particular, misconceptions about the effectiveness of writing or using speech or speech-reading with deaf and hearing-impaired persons were discussed.2,6,7 The benefits of and misconceptions about other methods, such as ASL, Langue des Signes Quebecois, oral interpreting, and cued speech were also reviewed. Additional factors that often contribute to lack of informed consent were discussed (e.g., nonsalient language, English literacy, English vocabulary, no direct discussion with the patient).
The Diagnosis session provided information on delays in early diagnosis of hearing impairments and how this could be ameliorated. Signs of hearing loss, the importance of listening to family suspicions of hearing loss, and how and when to obtain an audiologic diagnosis were discussed. The role of physicians following an audiologic diagnosis was discussed in terms of support, advocacy, and continuing care.
The forth session, entitled “Access to Medical Care,” discussed the difficulties that deaf and hearing-impaired persons have accessing adequate medical care on a personal level (professional interpreters, provision of interpreters) and a social level (community health fairs, health projects, health promotions), and how such difficulties can be avoided by cultural and linguistic sensitivity (i.e., using interpreters, assistive communication methods, and specialized services). Use of a team approach was advised.
The Ethics and Legal Issues session reviewed ethical and legal aspects of caring for deaf and hearing-impaired persons. Issues such as the quality of care, potential for paternalism, lack of informed consent, the use of professional interpreters, and the use of cochlear implants were presented.2,4,10,11
The last session, Issues for Future Physicians, summarized the importance of eliminating barriers in the health care of the deaf and hearing-impaired population by being cognizant of sociocultural and linguistic differences of deaf and hearing-impaired persons. The need for earlier diagnosis, use of interpreters, assistive devices, and a team approach was also summarized.
Conclusion and discussion sessions
The learning objectives for the evening were reviewed, and answers for the initial questionnaire were provided. The lectures and their major learning points were summarized. Students were reminded that they could peruse the display tables or talk with presenters after the final general discussion. The display tables had a variety of technological and audiologic equipment such as hearing aids, alarm devices, and Teletype devices for perusal. Various research articles and pamphlets on hearing loss, the care of hearing-impaired patients, and local service organizations for deaf and hearing-impaired persons were available. Students were asked to ensure that they had filled out an evaluation form on the workshop before leaving.
Written feedback that was elicited from medical students during both years to qualitatively examine their immediate opinions about the workshop suggested that the students found the workshop both positive and educational. Most students reported that they had not felt well informed on these subjects before the workshop, and all students stated that this type of workshop should be included in their curriculum. Students suggested the use of more deaf speakers in 1997; also, they felt that the case-based session was the most valuable part of the workshop in both years. The written feedback was obtained by use of an evaluation sheet consisting of four questions, using a Likert scale and with space for additional comments. There were approximately 60 workshop attendees per year; 40 were medical students in 1997, and 30 were medical students in 1998. In total, only 41% of the students in attendance returned evaluation sheets. Return rates of evaluation sheets may have been low because students were requested to drop off sheets as they left the room. Thus, while some students were perusing tables, others were leaving, and there was no structured collection of evaluation sheets. Response rates would likely be improved if there was a designated evaluation-sheet collector who stood at the doorway reminding each student to complete and hand in the sheet before he or she departed. The spontaneous verbal feedback that I received (during the workshop and throughout the following two years) mirrored the written feedback.
Development of a medical education workshop on deafness presents several challenges in addition to its possible benefits. In many Canadian cities there is a lack of medical professionals trained in deafness and hearing impairments. It is also important to realize that because of the nature of hearing impairments and deafness, many medical professionals underestimate the need for an intervention such as a workshop. Therefore, some preparatory discussion with them is likely warranted for such an intervention to be seen as potentially beneficial. A lack of awareness among the medical school faculty for the need of such an intervention may make introducing it a challenge. For this reason, I encourage those interested in creating similar educational events to ensure they first find out how aware the faculty is of the need for a workshop as part of the curriculum. Then, involving deaf and hearing professionals trained in this specific area of health care is crucial; their “insider's” insight, perspective, and practical contributions will ensure better design and execution of the workshop by avoiding the misconceptions that are common in those without personal experience or much specialized training in this area.
Participation could be increased if the workshop was required as part of an existing curriculum. In the workshop described here, participation was fully elective. Because this workshop was not part of the existing curriculum, it was offered in a compact format (a three-hour block) so that students would need only one evening of their time. This may make such an intervention easier to include as an initial step in continuing education or the residency curriculum. Then, it could be further developed and included into the existing curriculum if found to be effective. Extending the teaching over a longer period may provide benefit by increasing exposure to the topic over time, and would also allow for division of the material covered into more manageable segments.
As stated earlier, the workshop began with a questionnaire and an experience with a deaf “patient” because I postulated that these activities would create a natural curiosity among the students to learn more, making them more receptive to the information sessions that followed. Because most of the medical students were probably not familiar with various aspects of medicine and deafness, ample time was given for feedback, questions, and discussion throughout the workshop. Also, I assumed that most of the students had never seen hearing aids, Teletype devices for the deaf, and numerous other equipment, which was why a display table was very beneficial to this workshop. Written materials (such as research, articles, and pamphlets on various topics) also proved to be important, and numerous students took copies of these.
Having speakers and volunteers from the deaf community (with interpreting available) gave students an open, nonthreatening environment to ask questions or explore the views of deaf persons on health care and the topics discussed at the workshop. Exposure of this kind may also increase cross-cultural sensitivity, which in turn may improve the encounters between physicians and deaf and hearing-impaired patients in the future.
In the two years following the workshop, several attendees spontaneously reported to me (during their clinical rotations) that they had been involved in the care of deaf and hearing-impaired clients since the workshop and felt confident in their knowledge and roles. In reflecting upon their statements, I postulate that experiences with the deaf “patients” and deaf speakers at the workshop sparked students’ interest in caring for this population (although I cannot document this conclusion). Such interest may have, in turn, improved the students’ retention of information from the workshop, and thus may have also helped improve their care of deaf and hearing-impaired clients. These hypotheses could be studied in future workshops.
During and after the creation and delivery of each year's workshop, those involved in planning continued to discuss the various ways the case-based session could be most effective. For example, it would be interesting to know whether it is better to have students attempt the “patient” interview as best they can (without an interpreter), or whether half of the groups (or each group for half of the allotted time) should be provided with an interpreter to experience the interaction with and without an interpreter.
A limitation of this paper is that the evaluation that was carried out reflected only the immediate, self-reported views of participants who chose to fill out the evaluation form. An additional limitation was that the response rate was low, and therefore the views reported may not be representative of the group. Although the feedback received was positive, future studies are necessary to test the effectiveness of this educational intervention on increasing students’ comprehension and retention of the information, and on the effectiveness on their subsequent quality of care of deaf and hearing-impaired persons. Replicating the workshop with careful pretesting and posttesting of attendees at various increments after the workshop could assess these effects. For example, the workshop could be replicated with a pretest and posttest of how well students perform in interviewing a simulated deaf patient (in a testing scenario), and also how comfortable they are with the deaf patient (in a testing scenario).
I hope that this report will stimulate the investigation and use of workshops such as the one I have described. But even more important, I hope it increases awareness among medical educators of the need for more extensive and improved ways of teaching future physicians about deafness and to explore what those improved ways of teaching should be. In turn, improved education will hopefully yield improvements of the quality of health care provided to deaf and hearing-impaired persons.