“No man is an island, entire of itself…” wrote the poet John Donne. Oft quoted, but infrequently applied, the declaration is right on target for this month's cover story. Although the hearing care field has historically been riven by strife among and within the various professions that serve persons with hearing loss, this article looks at a happier side of the story. It focuses on some examples of the growing number of positive working relationships to be found between members of sometimes competing disciplines and between hearing professionals and those working in related fields. What these relationships demonstrate is that such partnerships deliver benefits both to the professionals involved and to their hearing-impaired patients.
Essentially, The Hearing Journal asked audiologists, hearing aid specialists, physicians, therapists, teachers, and members of other disciplines associated with helping the hearing-impaired if it is possible for them to set aside their differences, their rivalries, and their natural instincts toward protecting their turf in order to advance to a higher level of care for their patients.
Ha! You must be kidding!
That might have been the response only a few years ago. Too many egos in play, too many vested interests. But now, with more clearly defined identifications of the skills offered by closely related professions and, more importantly perhaps, acceptance of the contributions that each can make, productive alliances are creating better informed healthcare personnel better prepared to serve patients.
Audiologists and ENTs
Exploration and open-mindedness are keys to intelligent problem solving, says Paul Pessis, AuD, of the North Shore Audiovestibular Lab in Highland Park, IL. Pessis, who lectures frequently on the value of interdisciplinary associations, offers two compelling examples of how an alliance such as his with Alan Freint, MD, an otolaryngologist with North Shore Ear, Nose and Throat, contributes to the effective diagnosis and treatment of patients with hearing loss.
In the first example, a 35-year-old man comes to an audiologist complaining that he can't hear well. The audiologist tests the patient and discovers a significant hearing loss. Should the audiologist prescribe hearing aids? Maybe. In the same situation, many would. But, in doing so at the outset rather than trying to uncover the cause of the hearing loss, Pessis says, the audiologist short-changes the patient.
With a medical workup that might include blood work, MRI studies, a CT scan, and other diagnostic tests not within the audiologist's scope of practice, the cause might turn out to be a rheumatoid issue, an out-of-whack cholesterol level, reaction to medication, or some other condition treatable medically to reverse the hearing loss. In that instance, fitting the patient with hearing aids would be doing him a disservice, Pessis says.
Three professions: One goal
In another example, Pessis hypothesizes that a pediatrician concerned about a possible hearing problem sends a 6-month-old patient to an ear doctor. The physician, seeing no wax or fluid in the ears, has no medical alternatives, but suggests that the parents have the youngster's hearing tested. An audiologist performs an audiometric test battery which, indeed, reveals a hearing loss. Again, the audiologist can recommend hearing aids, but wouldn't it be helpful first to determine the root of the problem? Wouldn't it be preferable to try to zero in on the reasons for the hearing loss in the hope that further deterioration of the child's hearing could be prevented?
At the same time that the physician is beginning a medical workup, the audiologist can start educating the parents about possible speech and language delays, recommend the services of an educational audiologist, and address upcoming social concerns and other factors that will bear on the child's future. In essence, says Pessis, the audiologist becomes the “gatekeeper for the child's future needs.”
The services of an audiologist and an otologist are so clearly defined, Pessis says—the former detecting the hearing loss and identifying the type, the latter applying a medical interpretation of presenting symptoms—that each can participate actively in the evaluation of a patient's condition and its treatment.
In his alliance with Freint, Pessis points out that the practices are separate entities housed under the same roof, “with the patient benefiting from the dynamics and close interchange.”
Hearing instrument specialists and ENTs
Carolyn Piper, BC-HIS, screens and tests for her employer, Roberto Larrivey, MD, an otolaryngologist in Owosso, MI. If hearing aids are indicated by the test results and Larrivey's evaluation, she takes the impressions, places the orders, fits the aids, counsels the patients, and handles the follow-up care.
Piper acknowledges that her situation is atypical, as most ENTs hire audiologists rather than hearing aid specialists to perform these tasks. Nevertheless, she feels the relationship represents a growing trend. “I am confident in my skills and confident that I am contributing meaningfully to the practice,” she says. “And because of my association with a physician, I learn something new every day. I am growing in my profession.”
James Bernath, BC-HIS, operates Hitech Hearing, Inc., a dispensing office located within an ENT practice in Pembroke Pines, FL. Bernath sees his alliance as part of the medical community's new-found acceptance of the skills and contributions of the traditional dispenser.
Audiologists and hearing instrument specialists
Among audiologists who employ traditional dispensers is Linda Donaldson, BC-HIS, CCC-A, of Avada Audiology & Hearing Care in Springfield, OH. Her staff includes 10 hearing aid specialists (HIS) and 3 audiologists who take a team approach in testing hearing and fitting hearing aids. Donaldson says that she finds that HIS tend to have had more hands-on experience than audiologists and work better with patients needing amplification.
On the other hand, physicians sometimes feel more comfortable referring patients to an audiologist than to a dispenser. Also, audiologists are eligible for some third-party reimbursements not available to traditional dispensers. These factors help explain why some HIS-led practices have audiologists on staff, such as Ex-Cell Hearing Centres in Saskatoon, Sask. John Letts, BC-HIS, who heads the firm, says he employs audiologists to take advantage of their training in special testing, but that he himself trains them in how to fit hearing aids.
The two professions working together provide “a wonderful blend of skills,” Donaldson concludes, calling an audiologist/HIS alliance “a winning combination.”
Audiologists, traditional dispensers, and ENTs
Paul Tuveson, BC-HIS, is one of two HIS working with eight ENTs and eight audiologists at Midwest Hearing in St. Paul, MN. In some practices, Tuveson says, he might have been relegated to a support role, both because he does not have a professional degree and because of his own hearing impairment, which he has had since age 2. After all, although he has largely overcome the speech problems stemming from his hearing loss, Tuveson says that he was asked to withdraw from a college teacher-training program because of speech and hearing problems and he subsequently failed the word test in an audiology program in which he tried to enroll. He learned hearing aid fitting and dispensing on the job, through continuing education seminars, and in a private practice.
But, he says, his current position at Midwest Hearing is the most rewarding career choice he could have asked for. In addition to his other tasks, Tuveson is called upon by colleagues to demonstrate to patients from his first-hand experience how amplification can enhance their lives. He works with adults and also with hearing-impaired children and their parents, helping them come to terms with their hearing loss and to look positively at the prospects for their future.
“I have been hearing-impaired since childhood, but I have not let it impair my life,” Tuveson says. “I am a contributing professional, working side by side with other professionals.”
Audiology, speech pathology, and occupational therapy
Alison Grimes is director of audiology, and Elizabeth Ward is director of speech-language services at the Providence Speech & Hearing Center in Orange, CA, a practice that caters largely to children with special needs. A commonly found professional alliance, hearing and speech practices provide access to both professions, which is a convenience to patients, most of whom struggle with difficulties in both areas. “Hearing loss may be at the root of language delays, and speech problems may be the result of hearing loss,” Grimes says. “We see a lot of multi-involved kids.”
What makes the practice unusual, however, is its recent hiring of an occupational therapist, a profession not typically associated with private-practice speech and hearing, but one the two women believe will serve their patients well. Ward explains: “Many special-needs children have sensory issues in addition to speech and hearing deficits. They have trouble dressing and feeding themselves and in mastering fine motor skills. In addition to their auditory and tactile difficulties, their nervous systems can't deal with all the stimuli that come at them.
“Sensory integration therapy, the purview of occupational therapy, is certainly not a new idea,” Ward points out, “but acceptance of the theories is growing,” she says. “In the past, many children with these sensory problems have been misdiagnosed as learning disabled or ADD [attention deficit disorder] children. We feel we can do more for our patients with this new alliance.”
Multidisciplinary alliances are especially prevalent in school settings. Here, when funds allow, audiologists may work not only with speech therapists, but also with psychologists, classroom teachers, occupational and physical therapists, teachers of the deaf, school administrators, and other specialists hired to shepherd youngsters with physical and learning deficits through the educational system.
As a result of these alliances, information crosses from one discipline to another, so that students enjoy the benefits of a team approach, a kind of interdisciplinary assurance that they will succeed to the best of their capabilities, says Susan Chorost, program coordinator for amplification and hearing aid technology at the Summit Speech School in New Providence, NJ.
An early-intervention program
The Summit Speech School, an early-intervention pre-school for hearing-impaired and language-delayed newborns through 5-year-old children, attracts families from throughout New Jersey. The staff includes a range of resource personnel—audiologists and speech pathologists, physical and occupational therapists, psychologists, and teachers of the deaf. In addition, it employs five itinerant teachers who travel throughout the state, helping to mainstream the school's graduates by explaining to their classroom teachers the special needs of hearing-impaired children and the degree of language proficiency each one has reached.
At the school, regular meetings and detailed reports about each child ensure that no student falls through the cracks, Chorost says, and that no specialist is left to work alone, without consulting and cross-pollinating with the child's team members.
If an audiologist works with children, in private practice or in a school setting, “an effort must be made to come out from behind our audiometers and get into the educational settings where our young clients function on a daily basis,” Chorost wrote in The Hearing Journal (March 2001, p. 65). “This is especially true since we are often the professional most consistently a part of the hearing-impaired child's life.
“Audiologists can assume a leadership role in forging an on-going partnership that includes teachers of the deaf, speech pathologists, parents, mainstream educators, and manufacturers of amplification devices.”
Cheryl DeConde Johnson, EdD, agrees. As senior consultant for audiology and deaf/hard-of-hearing disabilities in the Colorado Department of Education, she recognizes that hearing is a multidisciplinary arena. “The mechanism of hearing is physiological, not just auditory,” she says. “Memory, cognition, pathology—all these disciplines, among many other elements, are involved in dealing with a hearing impairment. We do patients a disservice by thinking locally rather than globally with respect to their care.”
According to DeConde Johnson, private-practice audiologists, may, in their desire to fit hearing aids to address hearing loss, neglect other issues that are involved. Often, amplification is appropriate, she says, but adds that, for the best patient care, practitioners need to form alliances with other categories of professionals. “We need to understand all the processes involved in treating the hearing-impaired patient and, at the same time, recognize our own limitations. For therapy outside what we are comfortable offering, we need to know what kind of help is available and where to find it.”
Colorado relies on a team approach similar to that of the Summit School in New Jersey. According to DeConde Johnson, the Colorado team includes the school nurse, speech teachers, psychologists, sociologists, speech-language pathologists, audiologists, and instructional specialists, all contributing to a multidisciplinary assessment, she says.
Rebecca Kooper is an educational audiologist with the Nassau County (NY) BOCES Program for Hearing and Vision. Her experience differs from that of Susan Chorost in that she is a consultant to public schools, not a member of any individual school's staff. Moreover, in her Long Island district, because there are too few hearing-impaired children in the system to warrant hiring an audiologist for each school, she must rely on the school's speech therapist to troubleshoot for her by monitoring the hearing test equipment for accuracy and identifying students with a perceptible hearing loss as candidates for intervention. “Speech therapists are my conduits of information,” she says.
But speech therapists are not hearing specialists, as Kooper is aware. Therefore, she conducts after-school workshops and demonstrations on hearing loss, basic hearing care vocabulary, cochlear implants, auditory processing, and other topics that give speech pathologists and, to a lesser degree, classroom teachers, a crash course in hearing technology. “Teachers often can identify students who seem to have a hearing loss,” Kooper says, “but they are less effective on follow-up because students typically remain with a teacher for only a year. The speech pathologist is a resource for as long as the student remains in that school.”
ORGANIZATIONS AND ASSOCIATIONS
Another opportunity for a blending of professions with a common goal occurs in service organizations and associations dedicated to hearing care. The League for the Hard of Hearing in New York and, now, Fort Lauderdale, FL, offers comprehensive rehabilitation and services for more than 17,000 individuals and their families each year, according to Laurie Hanin, PhD, the league's director of audiology. Clients come to the league through friends' recommendations, physician referrals, school referrals, pediatricians, funding agencies, and referrals from audiologists and dispensers. Some clients simply walk in the door because they can't hear well, and they don't know where else to go, Hanin says.
Why are professionals willing to turn their patients over to this association? One reason is its reputation for offering patients a high quality of care. But, another factor, one in keeping with the professions-working-together theme of this article, is that the league employs persons from every profession associated with hearing care. In addition, it offers courses, such as speech-reading and auditory training, which are not readily available elsewhere, and it can supply and fit all products necessary and devices beneficial to helping its hearing-impaired patients. The league understands the values of an umbrella service, and clients appreciate the convenience, Hanin says.
“Our hearing professionals interact daily with social workers, speech pathologists, vocational rehabilitation counselors, ENTs, social workers, psychologists—all experienced in working with people suffering with a hearing loss,” Hanin says. “We don't have time or a need to compete with one another. We're too busy helping people hear better.”
Other organizations employ professionals to work together toward a common goal, including, for example, the Department of Veterans Affairs, which offers veterans around the country comprehensive hearing help. The House Ear Institute in Los Angeles comprises a staff of 175 professionals in 19 departments. Its programs attract physicians, hearing healthcare practitioners, and educators of the deaf from around the world. Through its visiting doctors program, more than 26,000 specialists from 50 states and 68 countries have visited and studied at the institute, bringing increased know-how back to their patients.
Paul Pessis notes that his job description is always “under construction,” his way of saying that he's always open to new dimensions of care for hearing-impaired patients. The same might be said for hearing health care in general—still under construction and constantly forming new working relationships, an expansion that is opening up exciting possibilities for the professions and critical gains for patients.
“You could look at these partnerships as a one-stop-shopping experience for hearing loss patients,” says Laurie Hanin of the League For the Hard of Hearing. “It's nice to know we can offer so much.”
FORGING PROFESSIONAL PARTNERSHIPS
Writing on the “Hearing & Children” page in the March 2001 Hearing Journal, Susan Chorost, program coordinator for amplification and hearing aid technology at the Summit Speech School in New Providence, NJ, offered seven ways in which an educational audiologist can forge partnerships with other professionals to benefit patients. Originally writing from an educational point of view, Chorost amended her comments in a follow-up telephone interview for this article to include any hearing healthcare professional working with young people in any setting. “My thoughts represent the ideal,” Chorost says, “but I think as professionals we have to make the effort to reach out to other professionals if it helps our patients.”
Here are Chorost's recommendations for how audiologists with pediatric patients can forge productive professional partnerships:
* Promote a complete annual audiologic evaluation, including evaluation of any assistive listening devices in use, as part of every hearing-impaired child's IEP (Individual Education Program). Whether in private practice or an educational setting, an audiologist has a responsibility to his or her patient to follow up with the school's case manager to review the child study team, test results, and progress. Confining care to the four walls of an office cheats the patient, she says.
* Develop in-service training workshops on the effects of hearing loss and how best to use and maintain amplification devices. Chorost has developed a 2-hour seminar for teachers, aides, and school nurses. Topics include how to work with FM systems, techniques for checking hearing aids for wax or other obstruction, and, most startling to those encountering hearing loss for the first time, Chorost says, a simulated demonstration of what a hearing loss sounds like.
* Provide feedback to manufacturers on how their equipment is holding up in daily use.
* Review acoustics in classrooms and recommend modifications to technology departments that will benefit all students, not just those with a hearing loss. Research studies show that all students do better when ambient sound is even slightly amplified and level throughout the classroom, with no hollow pockets.
* Work with boards of education and school administrators to support the need for every hearing-impaired child to be assigned to a teacher of the deaf.
* Lobby school superintendents for funding to pay for services to help hearing-impaired students succeed.
* Encourage parents to observe their children in school, be knowledgeable about their children's acoustic equipment, and consider you, the hearing professional, as a resource for any concerns they may have. Parents are part of the winning formula and must not be left out of the equation, Chorost says.