MAXIMIZING YOUR QUALITY OF LIFE:� THE IMPORTANCE OF A GOOD CLINICIAN

Larry Medwetsky, Ph.D

Professor, Gallaudet University

larry.medwetsky@gallaudet.edu

PRESENTATION OBJECTIVES

• Provide a distinction between the various professionals’ credentials/primary tasks who address hearing related needs
• Discuss various audiometric procedures and the audiogram
• Importance of client (family)-centered care and how it can ensure your communication needs are best addressed

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THE ROLES/QUALIFICATIONS OF VARIOUS HEARING HEALTH CARE PROFESSIONALS

• Consumers are often confused to whom they should go to address their hearing related needs
• The following is an overview of the credentials of the professionals who serve individuals with hearing loss:

OTOLARYNGOLOGISTS: Ear, Nose, and Throat doctors (ENTs)

• Medical specialists: medical degree, with residency specializing in ear, nose, throat problems
• If there appears to be medically related issues, the ENT is the professional who medically treats the client
• ENTs are not the experts as it pertains to hearing, listening/processing, and amplification needs, as have received little education in these areas

THE ROLES/QUALIFICATIONS OF VARIOUS HEARING HEALTH CARE PROFESSIONALS

AUDIOLOGISTS

• Clinical doctoral degrees (Doctorate in Audiology: AuD), with a minimum of seven years post-secondary education; possibly also has a Ph.D in Audiology (or Hearing and Speech Sciences)
• Audiologists are the experts who diagnose hearing and balance disorders, and provide non-medical interventions for deficits in these areas:
• An audiologist conducts hearing, tinnitus, and/or balance test batteries and interprets the test findings
• If there is a hearing loss and no medical issues, the audiologist can address the issues (such as via amplification and/or hearing assistive technology)

THE ROLES/QUALIFICATIONS OF VARIOUS HEARING HEALTH CARE PROFESSIONALS

Hearing Instrument Specialists

• Educational Background (minimum of a high school diploma)
• Depending on the state, they may also need (a) state license for hearing instrument dispensing; and (b) professional certification from a national organization (requires dispensing license/two years of full-time relevant work experience or a diploma from an approved college in this area)
• In Florida, a hearing dispenser needs a state license and meet various qualifying aspects- such as graduated from a Florida sponsored training program (minimum of six months training) or obtained the above national certification
• Is able to do hearing testing for purpose of fitting hearing aids, but unable to do hearing testing for the purpose of diagnosing hearing, tinnitus, vesitibular (balance) status

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THE ROLES/QUALIFICATIONS OF VARIOUS HEARING HEALTH CARE PROFESSIONALS

Thus, the main differences between an audiologist and a hearing instrument specialist are:

• Amount of education obtained: minimum of 7 years post-secondary education for audiologist versus 6 months for hearing instrument specialist
• Audiologists are the experts for diagnosing hearing, tinnitus, and balance related disorders; note audiologists also have much more foundational training in hearing aids, hearing aid fitting, evaluation measures of listener need/benefit, hearing assistive technology

UNDERSTANDING THE VARIOUS HEARING TEST PROCEDURES�

Speech Reception Threshold (SRT) Testing

• Consists of presenting compound words of equal stress (spondees), such as “Cow-Boy”; “Hot-Dog”
• The audiologist starts at a level client can easily hear; client is first familiarized to all of the spondees at a comfortable listening level, then audiologist decreases the level until softest level individual can repeat approximately ½ of the words correctly
• The SRT typically approximates average of the hearing thresholds obtained at 500, 1,000 Hz and 2,000 Hz
• SRT results provide audiologist a basis for estimating the level to conduct pure tone testing (next slide)
• If the results do not agree with what is expected relative to the thresholds, the audiologist will retest, as the client may have misunderstood what to do

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PURE-TONE AUDIOMETRY

Tones of different frequencies are presented:

• Goal is to find softest intensity level at which an individual can hear tones at different frequencies

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PURE-TONE AUDIOMETRY

• Pre-tone audiometry is usually administered in one of two ways:
• Air Conduction Audiometry
• Bone Conduction Audiometry

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PURE-TONE AUDIOMETRY

• Air Conduction Audiometry- placement of (A) headphones over the ears or (b) insert earphones- placing foam tips into the individual’s ear canal

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• Bone Conduction Audiometry- placement of a vibrating device on a person’s skull

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AIR VERSUS BONE CONDUCTION AUDIOMETRY

• By comparing results of both procedures, one can determine if there is a hearing loss present and the degree of severity
• If the results across all frequencies are similar using both techniques:
• Means no difference whether tones are presented via outer/middle and inner ear (air conduction) versus the inner ear (bone conduction)
• Thus, no conductive component is present (i.e., no problem with either the outer/middle ear- such as thick wax or middle ear fluid, etc.)
• If a hearing loss present in this case, referred to as sensorineural hearing loss

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Example of a Sensorineural Hearing Loss

Notice the arrows (representing the Bone Conduction ( Inner Ear ) thresholds, are essentially the same as the Air Conduction (Outer, Middle and Inner Ear) thresholds.

AIR VERSUS BONE CONDUCTION AUDIOMETRY (CONDUCTIVE LOSS PRESENT)

• If the results are better for bone conduction than air conduction for at least some frequencies, then:
• Means there is a difference when tones are presented via outer/middle and inner ear (air conduction) versus the inner ear (bone conduction)
• That is, presenting via air conduction needs to be louder so that the tones can be heard in the inner ear
• This indicates that there is some issue involving the outer ear (very thick wax) or middle ear (possible middle ear fluid or the bones not moving as well as it should); it is usually the latter

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EXAMPLE OF A CONDUCTIVE HEARING LOSS�

Note the open rectangles (representing the Bone Conduction ( Inner Ear ) thresholds, are better than the Air Conduction (Outer, Middle and Inner Ear) thresholds, indicating that there is some disorder impacting the outer/middle ear

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Note any speech sounds above the threshold lines are audible, while any below cannot be heard.

UNDERSTANDING WHAT UNDERLIES HEARING DIFFICULTIES FOR SPEECH

EARLY SIGNS OF HEARING LOSS

• The previous slide shows a typical hearing loss for someone in their 60s-70s; consequently, this individual would:
• have trouble hearing when people talk softly
• hear but not always understand what is being said
• say that people may sound as if they are mumbling
• often find him (her) self straining to hear others
• have difficulty hearing when people don’t look at him (her) or if they are in another room
• have TV turned up loud
• have trouble hearing when there is much noise (usually first sign/most problematic)

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WORD RECOGNITION SCORE (WRS)

An audiologist typically presents 25 or 50, single syllable words at one or more listening levels:

1. Everyday Conversational Level (approximately 50 dB HL at 5 feet distance)

• Goal, to see how easy to perceive/recognize words in quiet, at everyday talking levels

2. Most Comfortable Listening Level (MCL)

• The level depends on the degree of hearing loss and listener’s preference; once audiologist determines how much louder an individual needs to comfortably follow conversation, assesses how individual does at their preferred listening level
• Allows the audiologist to understand how much better the client hears words at that level, and in turn, can guide decision-making and audiologic counseling (e.g., would hearing aids or CI enhance speech reception?)

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WORD RECOGNITION SCORE (WRS)

• Individuals with a mild hearing loss often indicate hearing okay 1-1 in quiet at 5 feet, but complain of hearing at a distance or when people talk at a soft level:
• The audiologist can conduct WRS testing at 35 dB HL- that is, at a soft speaking level to see how the individual does for soft speech versus at everyday conversation level

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SPEECH RECOGNITION IN NOISE

• In addition to presenting words in quiet, an audiologist can also examine how well the client does when speech is presented in noise
• Typically, this is done by presenting sentences in cocktail party noise, with the noise increasing over time, while speech is presented at a constant level
• The results inform the audiologist:
• to the degree of hearing difficulty the client has in background noise and whether hearing aid(s) would likely provide sufficient benefit in noise, or,
• whether a remote microphone would need to be paired to the hearing aids

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PLEASE NOTE:

• I have not mentioned all of the testing that can be done (such as tympanometry- which assesses how well the eardrum is able to move, loudness tolerance levels, etc.)
• Depending on the test results, an audiologist may also do other tests to derive a more composite profile of an individual’s hearing
• And, depending on their expertise and client’s needs, the audiologist might possibly conduct various procedures to assess balance related issues, tinnitus, etc., or refer to another audiologist to do such testing

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ENSURING THE BEST HEARING RELATED HEALTHCARE POSSIBLE

• Finding the right hearing healthcare provider is vital to ensuring the best care possible
• If one suspects a hearing loss and has never had a complete hearing test, I am recommending the individual see an audiologist. Why?
• To ensure that there is no underlying medical cause for the hearing loss
• Audiologists have the greatest degree of background experience to assess the impact of hearing loss on an individual’s lifestyle, and craft an intervention plan that will best meet an individual’s listening/communication needs (be it communication strategies, amplification, hearing assistive technology, auditory training)

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ENSURING THE BEST HEARING RELATED HEALTHCARE POSSIBLE

As part of learning and ultimately addressing your needs, an audiologist will conduct a comprehensive case history:

• The audiologist will ascertain if there are possible indicators of a medical issue underlying the hearing difficulties
• Determine the specific listening difficulties you are experiencing, and the settings these difficulties are being encountered
• Your goals and expectations for addressing the hearing related issues

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ENSURING THE BEST HEARING RELATED HEALTHCARE POSSIBLE

• If hearing testing reveals no possible underlying medical issue, based on:
• the hearing test results, and information the audiologist has obtained, the audiologist will determine which interventions best meet your hearing needs
• However, it is not enough to just see an audiologist, since audiologists vary in terms of their approaches and skill level
• It is not always easy to determine an audiologist’s skill level, but one can be very aware of how an audiologist interfaces with you
• I will focus here as it relates to how I believe audiologists should engage with clients and their significant others/family

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FAMILY-CENTERED CARE

• Because communication involves not only the client but also their family members, I strongly believe audiologists need to include family members when engaging with clients whenever possible,
• This should not only include obtaining a family member’s input as to what they have observed concerning the client’s hearing difficulties, but also discuss how the client’s hearing difficulties have impacted them

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• Consequently, I strongly believe in family-centered care, whereby the client/family and audiologist work as a “team”, in a collaborative fashion. The audiologist’s role is to :
• Understand the client’s listening and client/family’s communication needs, and,
• Share the findings and recommendations so that the client and family have the information that can then empower the client to make decisions that will best meet their needs

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HOW CAN AN AUDIOLOGIST BEST UNDERSTAND YOUR NEEDS?�

• The following are ways that an audiologist can better understand a client’s listening needs:
• Ask a few simple questions to start off a session:
• What brings in you in today?
• Can you share with me those listening situations that are difficult for you and that you find very frustrating?
• Administer:
• Client’s Socio-Emotional Assessment regarding reactions to their hearing loss
• Communication Needs Assessment evaluating difficulties as shown in the following slide:

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C. Compton-Conley

CLIENT-CENTERED CARE

Audiologist’s Engagement Style

Does the audiologist:

• “listen” and ask you to explain how your hearing loss is impacting you in everyday life?
• explain the test procedures before proceeding with each test?
• explain/provide the results and recommendations in a manner that you can easily follow? If the audiologist does not automatically provide the results, ask for a copy of the audiogram
• provide visuals, making it easier to process/retain information?
• develop a trust within you that demonstrates they are focused on your hearing well-being rather than trying to push a product?

CLIENT-CENTERED CARE

• An excellent audiologist will not rush a client. They will build into their schedule sufficient time/appointments to better understand your listening needs

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• If there is a hearing loss, depending on what the audiologist determines best meet your hearing needs, they will also schedule time to:
• Demonstrate hearing aids, and/or assistive technology
• If you have a severe/ profound hearing loss, they may discuss the pros/cons of cochlear implants, if you meet current criteria

FINAL POINTS

• Hearing related difficulties not only can significantly impact your life but of others with whom you interact (family, friends, co-workers)
• There has been a tremendous explosion of technological advances that can make a significant difference in the life of an individual with hearing loss
• For one to best benefit from what is available, become as knowledgeable as possible prior to moving forward
• I believe the best way to do so, is to go to an audiologist who is totally devoted to “Client/Family Centered Care”, one whom you trust and does all to ensure that you have all of the information you need to move forward
• If you are seeking hearing help, you deserve to “Enjoy the Independence and Quality of Life that Good Hearing Brings”

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