1 Recently you've been writing about patient counseling, a significant shift from your interests in diagnostic audiology. What's stuck in your craw?
A disturbing realization that all the great counseling that I've done over many years has been for naught and a touch of self-flagellation for not realizing it earlier. Now that I do realize it, I want the rest of the profession to realize it too and change the way we communicate with patients to increase the effectiveness of our clinical services. The fact is, our patients don't remember what we tell them. We should not be surprised at that and we should be concerned that communicative ineffectiveness significantly and negatively affects outcomes.
2 But audiology is a communication field. Certainly this issue has occurred to others in the field, hasn't it?
Based on my review of the literature, the answer is—hardly. It occurred to a young master's degree audiologist named Frederick Martin and the otolaryngologist he worked with more than 40 years ago. They developed a set of form letters to patients with various types of hearing loss so the information would get to the patient and family accurately. Then Dr. Martin published a paper in 1990 in the Texas Journal of Speech and Hearing on information transfer to audiology patients. But, other than those contributions, there is almost nothing in our literature on patient recall of audiologic information.
3 What about other healthcare professions? Do they think about it?
Yes. There are publications on the topic in psychology, psychiatry, pharmacology, public health, dentistry, plastic surgery, and internal medicine. But that doesn't mean that clinicians in other disciplines communicate any better than we do when it comes to informational counseling. We all have had experiences with health professionals that left us saying “huh?”
4 What exactly do you mean by informational counseling?
Informational counseling provides the patient with the relevant information needed to understand the nature of the disorder and the steps that are recommended to manage it. When we explain the audiogram, discuss the effects of hearing loss on communication, or make recommendations for management, we are engaging in informational counseling. This is different from personal adjustment counseling, which also is important.
5 And what is personal adjustment counseling?
Personal adjustment counseling is the process of guiding the patient and family in dealing with the emotional impact of the information. When we encourage patients to confront their denial, help families get beyond their grief so they can initiate early intervention with a hearing-impaired child, or help patients understand the impact of their communication disorder on their family, we are doing personal adjustment counseling. Both types of counseling are necessary, but our literature deals mostly with personal adjustment counseling.
6 Is it really important if patients remember what we tell them about their hearing loss if they heed our instructions for follow-up?
That's a reasonable thought. If a patient gets to the right healthcare provider, takes the right medication, gets the right surgery, enrolls in the right rehab program, and otherwise complies with recommendations, then the outcome should be okay. But research findings show that those things don't happen unless the patient knows and understands the nature of the disorder and the recommendations for management.
The research shows that when patients do understand the information communicated by a healthcare provider, patient satisfaction, compliance with recommendations, and outcomes all improve significantly, and anxiety, treatment time, and cost all decrease significantly.
7 How much do patients actually remember after a counseling session?
About 50% of the information provided by healthcare providers is retained. Depending on conditions, 40%–80% may be forgotten immediately. In one study, when recall was measured at two points in time, there were no differences in recall measured soon after the consultation and at a later date. It seems that patients remember a small proportion of facts and those stay with them for at least several weeks.
However, of the information that patients do recall, they remember about half incorrectly. So half is forgotten immediately, and half of what is remembered is wrong. If you remove 50% of the facts relating to a health problem and distort half the remaining information, the result can be a dangerously misunderstood message with potentially life-threatening consequences.
8 But don't patients remember the really important things?
Unfortunately, no. Patients often forget their medical diagnoses. One study reported that patients could not recall 68% of the diagnoses told to them in a medical visit. When there were multiple diagnoses, patients couldn't recall the most important diagnosis 54% of the time. Some of the diagnoses were serious, even life-threatening, conditions such as diabetes, hypertension, and liver disease.
Another study found that after counseling, patients and physicians agreed on problems that required follow-up only 45% of the time. When there was disagreement between the physician and patient on the need for follow-up, the likelihood of appropriate management was significantly lower.
9 Which factors determine what patients will remember and what they will forget?
There are many factors, but we can group most into three categories. Let's start with patient factors. Although you might expect intelligence to affect the patient's ability to retain information, that has not been shown to be the case. However, familiarity with the information does have an effect. A patient who is familiar with hearing loss as a result of prior consultations, an affected family member, or professional knowledge tends to remember more. The degree of understanding of issues related to the diagnosis can have a significant effect. A finding that the patient expects is remembered more than one that is unexpected; a welcome or desired finding is more likely to be recalled than one that is unwelcome or unwanted.
Anxiety can have either a positive or negative effect on retention. Moderate anxiety enhances recall, but severe anxiety inhibits retention of information. Stress causes “attention narrowing,” which interferes with the patient's ability to redirect to a different topic.
10 I'm betting that some clinicians are better than others at presenting the information, right?
You're brilliant! So let's talk a little about clinician factors. Information given by clinicians who speak in clear language with simple sentence structure is more likely to be remembered than information provided in complex, scientific language. Clarity of communication requires that the clinician understand what patients wish to learn and their level of understanding.
To communicate clearly and in a manner that promotes retention of information, the consultation needs to be a dialog in which the clinician listens to the patient as well as the other way around. If the patient's ideas are evaded or inhibited, the patient is less likely to remember important information. Even the clinician's anxiety affects recall. Patients remember less when the information is provided by an overtly anxious clinician. Information presented in a manner that emphasizes its importance is more likely to be remembered than information presented in a matter-of-fact manner. Non-verbal communication is important in reflecting the clinician's state (e.g., confident, anxious, distracted, empathetic) and in indicating the importance of information.
11 Makes sense to me. What's the third category?
Mode of presentation. Not surprisingly, information presented in a simple, easy-to-understand format is remembered better than information presented in a more complex manner. The more information presented, the lower the proportion that is recalled by the patient. Information that is presented first tends to be remembered better—the primacy effect.
Categorizing information can improve retention; some authors discuss the method of explicit categorization.
12 What's that?
Explicit categorization means that information is organized in specific categories such as explanation of systems, diagnostic tests, results, prognosis, and recommendations. The patient is told that the information will be presented in these categories, each category is announced, and the patient is asked if he/she has any questions before moving on to the next category. The method can significantly enhance recall.
13 What other presentation techniques can help?
Supplementing verbal presentation with written and graphic material such as written explanations, cartoons, and pictures, can significantly enhance recall. Also, patients are more likely to remember recommendations that are specific rather than general. A recommendation should be a specific statement telling the patient what to do rather than a more general statement of the goal. A recommendation to “stay home from work and rest for 2 weeks with no strenuous exercise” is more likely to be followed than “get some rest and take it easy for a while.”
14 How is it possible for patients to come away from a counseling session with a completely wrong recollection of what we told them?
Our patients lead busy lives and there are many things that work against the likelihood that they will remember what we tell them. The working mom whose son broke an ankle yesterday playing soccer, who is worried about missing work, who doesn't have anything ready for dinner tonight, and whose husband may be laid off next week, is unlikely to remember the difference between conductive loss and a sensorineural hearing loss. We seldom know the complexities of our patients'' lives or their ability to comprehend and retain important information. Yet retention of diagnostic information and recommendations is critical to treatment outcomes.
We all know that denial is a defense mechanism commonly associated with hearing loss. Denial can interfere with recall of the most obvious findings. One study showed that patients frequently forgot diagnoses of excessive tobacco use and obesity. When patients are in denial of their hearing loss, they are not receptive to information about it or suggestions for managing it. Later, as they begin to accept the reality of the hearing loss, we are not there, so we must make sure the information is available.
Having gone to graduate school in Iowa, I naturally turn to Meredith Willson for wisdom.
15 Is Meredith a famous Iowa audiologist?
You need to get out more. Or as Meredith would say, “You've got trouble.” No, Meredith Willson wrote my favorite show, The Music Man. Remember the scene where Mayor Schinn announces, “Members of the school board will now present a patriotic tableau”? Then a school board member whispers in the mayor's ear and the mayor corrects himself: “Members of the school board will not present a patriotic tableau.”
The mayor had one phonetic unit wrong and it completely changed the meaning. I often think of that when I talk to a patient. Which phonetic unit will be missed that will completely change the message? I'll never know.
16 I was taught that a family member should always come with the patient. Shouldn't we insist that patients bring a family member or friend to help them remember?
Get real. Maybe last millennium you could do that, but nowadays people are just too busy for us to count on having someone accompany the patient.
17 But can't an observant listener tell if the patient is getting it?
No. One study found that physicians' impressions of what patients would remember did not correlate with measures of actual recall. Patients can fool the most astute observers. One author wrote of the “illusion of shared understanding.” Patients hear the information and use it to confirm their preconceived and incorrect notions of their communicative disorder. They appear to understand, because they think they do.
18 So, what can I do to communicate information to my patients so they will remember it?
Studies have shown that when healthcare providers followed specific strategies for enhancing communication, there were measurable improvements in patient recall. Here are some techniques for informational counseling that have been shown to improve recall:
- Be sure you understand what patients want from the evaluation and what their beliefs are concerning the problem. Specifically address the patient's desires and beliefs.
- Give advice in the form of concrete instructions. For example, say “Use earplugs when you use your power tools” rather than “Keep your noise exposure to a minimum.”
- Use easy-to-understand language. Short words and sentences are remembered better.
- Repeat the most important information.
- Present the most important information first to capitalize on the primacy effect. Often the most important information is a recommendation such as “make an appointment with the ear doctor.”
- Stress the importance of recommendations or other information that you want the patient to remember.
- Use the method of explicit categorization. Tell the patient, “We are going to go over recommendations, then we will talk about your specific hearing problem (diagnosis), then we will go over test results, and then we will talk about how your hearing may change in the future (prognosis).” Ask for questions and confirm the patient's understanding before moving on to the next category.
- Repeat the most important information.
- Don't present too much information. Present only the information that is important for the patient to remember. Proportion of retention decreases as the amount of information presented increases.
- Repeat the most important information.
- Remember that these techniques are even more important for seniors. Plan to spend more time with older patients.
- Supplement verbal information with written, graphic, and pictorial materials that the patient can take home. These materials should include a description of the patient's hearing loss, the effects of the hearing loss on communication, recommendations, and treatment options.
Although proper communication techniques can significantly enhance accurate recall, patients will still forget. The best way to ensure that the information gets home is to provide the patient with a permanent record. One author recommended that patients be instructed to write the information down as the clinician presents it. Another recommended tape-recording the consultation. Another approach is to provide clearly written, illustrated, patient-specific educational materials that ensure the information is clear, accurate, complete, and available for review and discussion with family members and other professionals.
There are many excellent printed materials that can be sent home with a patient. I developed the Understanding… series of patient-education materials to provide tools for clinicians to impart accurate information about the nature and consequences of hearing loss, test results, and recommendations.
I believe strongly that when we have important information to communicate to a patient and family, we should put it in writing, and include illustrations that will make it more clearly understood. For example, the audiogram, if it is understood clearly, provides a great deal of important information. But patients will not retain an understanding of the audiogram from a single counseling session. Enhancing the audiogram with information about the speech area and degrees of hearing loss can provide a powerful means for imparting information to the family and for communication among family members. But it has to be supplemented with teaching that will guide the patient and family members to an accurate understanding.
19 You're starting to make me feel guilty. Any final tips regarding what I can do better?
Well, if we remember that the likelihood of orally presented information being remembered is about 50%, we should not depend upon spoken communication as a clinical technique without also providing supplemental written material that can be taken home, read, reread, discussed with family members, and reviewed at a future time when the patient and family are more likely to act on the information.
The 5 or 10 minutes that we typically have to present the results of our evaluation to the patient may be the most critical part of the visit. It has enormous impact on the outcome. Yet, despite its importance, it is usually not reimbursable. Although our field hasn't paid much attention to the techniques or effectiveness of the informational counseling component of our services, there is a fairly substantial literature outside of our discipline that can guide us in our efforts to communicate information to our patients. Perhaps if this important service gets more attention, third-party payers will someday realize that communicating to patients is critical and they will provide reimbursement as they do for physicians.
20 Where can I get more information about informational counseling in audiology?
First, let me say that I have never been interviewed by anyone as informed, insightful, and knowledgeable as you. For additional information and references on the topic, go to my web site, www.audiologyincorporated.com. The Understanding… series of patient-education materials can be viewed there too.
We know that patient counseling is a critical part of the overall hearing aid fitting process, and in fact, we've devoted several Page Tens to this topic over the years. Surveys by Sergei Kochkin and others have shown that satisfaction with hearing aids is directly related to the amount of counseling provided. But an adequate amount of counseling is only part of the solution; our patients must also understand and remember what we tell them. We all have some problems remembering important information, but consider that most people with hearing loss are older, and most older persons experience age-related cognitive changes that often influence memory. This makes our task even more difficult.
One type of counseling that we all provide is “informational.” That's when we tell the patients about their degree of hearing loss, a little about ear anatomy and physiology, the probable cause of the hearing loss, and a proposed treatment plan. Hearing professionals usually are pretty good (or at least long-winded) at this type of counseling, probably better than professionals in many other disciplines. But after our 10-minute “presentation,” do we really know how much information the patient understood? Or will remember tomorrow? And if they don't remember, how good were we?
To help us understand the problem and to provide some helpful guidelines, we recruited Robert H. Margolis, PhD. Yes, this is the same Bob Margolis who within 10 pages of a book chapter once included 34 mathematical formulas explaining tympanometry! But don't worry, folks, there are no formulas in this article.
Dr. Margolis is professor and director of audiology at the University of Minnesota Medical School, a position he has held since 1988. He is a prolific researcher, with over 100 publications, and has been awarded numerous grants from the Deafness Research Foundation and the NIH. He has served as president of the Minnesota Academy of Audiology, which awarded him the Honors of the Association. He also has received the Larry Mauldin Award for Excellence in Education in Audiology.
Recently, Bob has become interested in the counseling area of audiology, and I think you'll like what he has to say. He provides us with some good “informational counseling.” Now, let's make sure we remember what he says.
Page Ten Editor