Consider the wasps of the Sphex genus. The Sphex preys on other insects, paralyzing them with a sting, takes them back to a nest where she lays eggs, and when the eggs hatch, the larvae feed on the insect.
This technique isn't unusual among wasps of other genera, but there is one behavior in particular that makes the Sphex, well, sphexish. When the mother wasp arrives back at the hole she has prepared for the insect and her eggs, she rests the insect at the edge of the hole, and goes inside, apparently to inspect the nest for anything that will make it less than a home for her offspring. Once she emerges from the home tour, she drags the insect inside, and proceeds with her motherly duties.
If, however, a grad student with nothing better to do moves the insect a few centimeters away from the hole while she is inside, the Sphex will drag the insect up to the opening again, and go inside to reinspect the nest. The wasp will reportedly continue this cycle of reinspection until the grad student runs out of patience and quits.
I couldn't help thinking about our clinical protocols when I read an editorial by Barry Goldman in the Los Angeles Times (2011, May 15). Using the Sphex wasp as an example, he listed several human behaviors that we tend to repeat as though we are following some unquestionable internal rule that is hard-wired in us.
When we see a new patient, especially a potential new hearing aid candidate, we have an opportunity as well as a responsibility. We can provide him with a knowledge base and recommendations that he may choose to follow or that he may react to by waiting a few more years, becoming part of the undertreated statistics. Of course, the patient is free to act as he wishes, but how do we respond if we think waiting to address the hearing loss is not in the patient's best interest? Do we follow essentially the same sphexish routine with every patient and move on to the next appointment, or do we take other steps?
When faced with this situation, I have to admit that I want to treat the patient the way I would like to be treated, and that causes me to hold back some. I don't like to be pestered, but if I am merely procrastinating, I don't mind a nudge. Without crossing the line to resentment, what are the steps that will take us beyond what we do today and positively influence patients who otherwise will not follow our recommendations in a timely manner?
Discovery: When we take a history from a new patient, we are looking for a number of things to help us with the global management of his needs. Initially, we may be primarily in the diagnostic mode, focusing on medical history and life experiences such as noise exposure. At some point in the process, however, we have to determine what the patient's priorities are. The patient will need the information we provide to answer the question meaningfully and the response will typically be dependent upon our findings. The patient's wants and needs will be different for a cerumen impaction versus a permanent hearing loss, and similarly, our recommendations will be different if we know his priorities. Are we listening carefully to patients’ priorities and matching our recommendations accordingly, or are we following the hard-wired path that works for us most of the time?
Treatment: Because the treatment for hearing loss so often involves hearing aids, it is easy to drop into a comfortable routine, especially if the hearing loss is a common one. Before we follow that path, have we asked ourselves if there are other options that we should consider? Other models, feature sets, or brands than those with which we are familiar? Are hearing aids the best choice for today? Maybe it is better to solve a problem without a hearing aid today and have a patient for life than to sell one set of hearing aids today and not have a chance for the future. I'm not suggesting that we have these conversations with the patient, but that we have them with ourselves so that the dialogue with the patient has a good range of options, all of which were the result of careful thought.
Follow-up: When we make a recommendation, and the patient's decision is to think it over, what do we do to keep the relationship alive? An appointment scheduled on the way out is helpful, but doesn't always happen. Do we have a system that keeps us and the topic of our recommendations in the forefront of the patient's thoughts? Whether or not the patient has made a decision to follow our recommendations, do we call to see if he has any questions? I always appreciate it when my dentist calls to ask how I am doing after I've been in his office that day. He doesn't need to do that; I would call if there were issues, but he knows that our professional bond is strengthened with a call.
The Final Word? Much of what we do is formulaic, and following a familiar path can work up to a point. What we shouldn't do is allow the formula to substitute for critical thinking. We must follow the needs of the patient rather than our own comfortable patterns. The path of least resistance is a rule of physics, but it is a rule that we can break to be more effective clinicians.