creating successful professional-patient relationships · his books influence: science and practice...

Creating Successful Professional-Patient

RelationshipsBy DouGlaS l. BECk aND miChaEl a. harvEy

Audiology Today | SepOct200936

SepOct2009 | Audiology Today 37

u nfortunately, there’s no Holy Grail in relationships. Sometimes patients seek professional help with problems for which the professional is well trained

and competent, and sometimes they don’t. Sometimes patients want help with their hearing problems but they’re not sure they want to do the work or spend the time or money required to get the help they need. Each situation is unique. There’s no “one size fits all” solution.

Beck et al (2007) noted professionals typically don’t see the most difficult cases. That is, the ones that really, really, really are determined not to do anything about their hearing problems simply don’t walk through the door. Generally, professionals only see patients who choose to come through the door. Hearing loss is the third most prevalent chronic health problem in the United States,

Of the more than 36 million people with hearing loss in the United States, hearing professionals only fit about 23 percent with hearing aid amplification. Even among these, some leave the office without doing anything. Perhaps they leave because we have not effectively connected with them, or perhaps we failed to understand their moti-vation, situation, or purpose. The goal of this article is to offer suggestions, concepts, and insights regarding patients who leave with-out doing anything.P

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Creating Successful Professional-Patient relationship

exceeded only by arthritis and hypertension (Chisolm et al, 2007). Nonetheless, of the more than 31 million people with hearing loss in the United States, hearing profession-als only fit about 23 percent with hearing aid amplification (Hou and Dai, 2004; Kochkin, 2005). Therefore, some 77 percent of people with hearing loss are not receiving ben-efits from amplification and aural rehabilitation.

The patients we’ll address in this article are from the 23 percent we see. Even among these, some leave the office without doing anything. Perhaps they leave because we have not effectively connected with them, or perhaps we failed to understand their motivation, situation, or purpose. The goal of this article is to offer suggestions, concepts, and insights regarding patients who leave without doing anything. Unfortunately, if we don’t do all we can to establish successful relationships with each patient, the result may be no relationship.

The three primary themes we’ll address are connec-tivity, influence, and motivational interviewing. These are each somewhat intuitive, and many successful professionals use bits and pieces of these themes already. However, human interactions are diverse and compli-cated. The three themes are not mutually exclusive; they clearly interact, overlap, and intertwine. Acquiring a working knowledge of each allows us to be more cogni-zant of the invisible “forces” working for and against each professional-patient relationship.

ConnectivityBeck and Harvey (2009) framed connectivity as a shared internal experience founded on listening, feeling,

thinking, emotions, and cognition. Thus, connectivity is essentially a human experience. Connectivity may have been the essence of the famous Helen Keller quote, “Life has taught me that being blind separates me from things, but being deaf separates me from people.”

Connectivity is so primary and basic that it often goes unnoticed when thoughts, feelings, emotions, and

cognitive activities are healthy and stable. However, when connectivity fails to operate normally due to hearing loss, or loss of emotional content, or reduced cognitive ability secondary to the aging process, the failures of each exacerbate the other, often resulting in “negative synergy” (Schum and Beck, 2008; Beck and Clark, 2009).

Connectivity and untreated Hearing lossWhen hearing loss is untreated, social phobias, depres-sive symptoms, and frustration and anger in relationships are likely (Harvey, 2001; Kochkin, 2006). Engelund (2006, p. 174) noted that untreated hearing loss can even threaten one’s self identity.

Reduced connectivity often results in a reduced quality of life (QOL). Indeed, even pediatric patients have suffered negative QOL consequences secondary to hearing loss. In a study of 137 children, ages 8 to 17 years, treated for neuroblastoma, Gurney et al (2007) reported that children with hearing loss were at greatest risk for academic learning consequences as well as psychosocial difficulties and decreased self-reported QOL.

Engelund reported (see Beck, 2007) that if an individual does not self-identify as a person with hearing prob-lems, they are unlikely to seek or welcome solutions to

Given that amplification devices enhance connectivity and improve people’s quality of life, it follows that people with hearing loss should be banging on the audiologist’s door! Unfortunately,

most people who would benefit from amplification avoid the door at all costs.



hearing problems they neither recognize or acknowledge. Engelund (2006) addressed problem solving behaviors of hearing-impaired people and noted intentional change involves emotion, cognition, and behavior. Regarding the (approximate) four out of five of people with hearing loss who do not seek treatment, Engelund (2006) suggests that rather than viewing them as stigmatized or in denial, we (and they) would benefit from viewing them as being in different stages of the hearing loss recognition process and as needing different kinds of attention and rehabilita-tion. Not all people follow these stages step-by-step in a predictable or linear fashion. Some skip steps, and some repeat steps, and some get stuck in steps for extended periods of time, perhaps forever. Engelund’s (2006) four stages of recognition of hearing loss are:

Attracting Attention (people with an emerging hearing 1. problem)

Becoming Suspicious (people who start to think they 2. might have hearing problems)

Sensing Tribulation (awareness of hearing loss and 3. recognition of problems)

Jeopardizing Self (awareness of dangers related to 4. untreated hearing loss and awareness that their QOL can suffer from untreated hearing loss).

Connectivity and treated Hearing lossWhen hearing loss is treated via amplification, improve-ments in relationships as well as improved intimacy and warmth within family and group relationships are evi-dent. From an individual psychological level, emotional stability and a sense of control tend to improve when amplification is employed to treat hearing loss.

In their comprehensive report, Chisolm et al (2007) addressed QOL as it relates to hearing aid amplification in adults. After systematic review and meta-analysis of 16 previous studies, the authors concluded that hearing aids do improve health-related QOL by reducing psycho-logical, social, and emotional effects of sensorineural hearing loss.

As advanced amplification tools become commercially available, the opportunity for enhanced human connec-tivity and improved QOL also increases. When people connect seamlessly and wirelessly with ease and efficiency using intuitive and familiar tools, connectivity increases. Technical achievements that facilitate enhanced access between advanced hearing aids and more traditional



devices (such as television and landline-based telephones) through wireless systems (i.e., Bluetooth, WiFi, near field magnetic induction [NFMI], and FM systems) are of para-mount importance, as they facilitate increased connectivity.

In years past, audiologists provided hearing aid ampli-fication and then also provided multiple assistive listening device (ALD) systems to allow patients to communicate

via telephone, watch television, and appreciate music. Unfortunately, the ALD system was often perceived by the patient as “just one more thing” to learn about, purchase, and figure out how to use. Patients often responded with

“I’ll think about it,” and that was that. Now with integrated and wireless solutions to connect so many common sound sources to advanced hearing aids, connectivity has become seamless, easy, intuitive, and wireless and increases access to people.

the Clear dilemmaGiven that amplification devices enhance connectivity and improve people’s quality of life, it follows that people with hearing loss should be banging on the audiologist’s door! Unfortunately, most people (perhaps 77 percent) who would benefit from amplification don’t actually bang on the door. Rather, they avoid the door at all costs. How can we influ-ence or motivate those who request our assistance?

influenceThe ethical use of influence relates to having integrity, placing the needs of the patient above the needs of the professional, and understanding how people think. In his books Influence: Science and Practice (2008) and in Yes! 50 Scientifically Proven Ways to Be Persuasive (2008), psy-chologist Robert Cialdini, PhD, and coauthors Goldstein and Martin addressed six primary principles of ethical influence. The principles are extraordinarily easy to understand, are universal across all human relationships, and can specifically be applied to audiology and aural rehabilitation. The six principles are reciprocation, scar-city, authority, consistency, liking, and consensus.

reciprocation Reciprocation is the tendency to give back to others. In almost all human exchanges, when we give first, the other person is extremely likely to give back. If a friend or colleague offers you a service or acknowledgment, you’re very likely to return the gesture. When someone extends their hand to you, you extend your hand and shake.

People like to, and people tend to, reciprocate. Reciprocation occurs in marketing initiatives too.

When charitable groups send direct mail appeals for financial support, the return rate often approaches 25 percent. To achieve this stellar response they often send along an almost insignificant packet of personalized address labels or similar trinket. As a result of receiving a gift, many people respond with a financial donation.

Perhaps an effective application of the reciprocation principle (with regard to amplification) is a trial period with advanced amplification and connectivity devices. When individuals experience positive life-changing ben-efits through advanced technology within their personal and daily lives, they are more likely to pursue these tech-nologies than they would have been without experiencing the benefit firsthand. In other words, the offer of a trial and the trial itself represent the initial gesture from the professional to the patient.

scarcityScarcity is the tendency for people to want more of things they can only have less of. For example, rare coins, tickets to a sold-out Broadway show, Mickey Mantle or Babe Ruth baseball cards, never-opened original vinyl versions of The Beatles’s Sgt. Pepper album, and so on. People like rare, scarce, and unique. However, scarcity can go beyond physical items and may include unique or rare services combined with unique or rare products. For example, when advanced hearing products are introduced, pro-fessionals attend product-specific training to acquire knowledge to fit these products. The combination of a sophisticated product and a highly trained professional

People prefer to engage with people they like. You must genuinely like your patients,

and they must like you.



may infer the scarcity principle. Thus, the hearing-care professional markets their advanced training in tandem with the new product. Dentists, optometrists, and oph-thalmologists often market their talents combined with the latest tools in their professions, also.

AuthorityAuthority is straightforward. In essence, people like to know the professional they’re working with is an author-ity within their profession and has impressive credentials. Physicians, dentists, and optometrists, as well as accoun-tants, attorneys, psychologists, social workers, and cosmetologists, place their professionally framed creden-tials (diplomas, licenses, certificates, awards, etc.) in plain view. These credentials establish the professional as an educated person, a person with superior knowledge and talents—in brief, an authority.

ConsistencyPeople’s behavior tends to be consistent with what they say. This is a core tenet of motivational interviewing

(discussed below). Professionals must listen carefully and intentionally elicit patients’ verbalizations. The words the patient chooses to articulate their intentions and abili-ties to change (e.g., seek amplification) reflect their own thoughts processes and intentions. When we successfully incorporate their wants and needs into an aural rehabili-tation strategy, we increase the likelihood of connectivity and the chance that aural rehabilitation will progress and succeed.

liking (i.e., likability)People prefer to engage (or do business) with people they like. Conversely, they don’t like to do business with peo-ple they don’t like. If the professional or patient notices a sincere, real, or genuine reason to like the other person, it makes the relationship easier and makes connectiv-ity more probable. There are two corollaries to the liking principle. First, you must genuinely like your patients, and second, they must like you. It is difficult to establish connectivity with people you don’t like. Motivational interviewing (MI) is a counseling approach that is quiet



and friendly, not threatening, domineering, or persuasive. As such, MI has the ability to enhance likability.

ConsensusPeople generally look around to see what happened to others in similar situations. When faced with major medi-cal decisions, all of us want to know the odds of success based on people who have been through it before. To address consensus, audiologists may provide written testimonials and photos in their waiting room, arranged in intuitive and easily navigable sections to make it easy for the patient to find others “just like me.”

Motivational interviewingMotivational interviewing (MI) was originally developed as a goal-directed, patient-centered counseling tool to help alcoholics who had been resistant to change (Miller and Rollnick, 2002). MI has been successfully applied to smoking cessation, weight reduction, drug programs, and more (Centers for Disease Control and Prevention, 2005). MI might be thought of as a protocol designed to

maximize effective and appropriate influence manage-ment. To successfully use MI, the audiologist directs conversational discourse to probe and reveal the desired outcomes—as seen by the patient (Rubak et al, 2005; Beck et al, 2007; Harvey, 2007). In other words, the audiologist sets up a context in which the patient states the reasons for change.

There are four categories of self-motivational state-ments (i.e., “change talk”) that the professional elicits from the patient via purposeful questioning. Problem recognition might be as simple as asking the patient, “Is it more difficult for you to hear in a cocktail party or noisy restaurant?” An expression of concern might be elicited by asking, “Do you have concerns about what your friends might think if you wear hearing aids?” The intention to change might be evaluated by asking, “If the hearing aids really helped, can you imagine wearing them?” Lastly, the degree of self-efficacy to change can be elicited with “Do you think you’ll be able to wear hearing aids at work and at home?” An audiologist’s dream scenario would be for the patient to respond as such:

stages of Change

Pre-contemplation Patient denies the problem.

Contemplation Patient is ambivalent, considers change, rejects change.

determination Patient’s motivational balance tips toward change.

Action May include hearing aid acquisition or aural rehabilitation.

Maintenance Help patient identify and use strategies to prevent relapse.

relapse Help patient avoid demoralization of relapse.

Source: Prochaska et al, 1994.



Wow, I guess there’s more of a problem than I thought and I’m really, really concerned about the effects of my hearing loss. I think it’s way past time for me to address this, and I’m ready, willing, and able to do this as soon as you can fit me in your busy schedule! How can you help me?

Fantasy aside, change is not always linear (see Engelund, 2006). Patients often experience repetitive stages in the course of acknowledging and addressing a problem, sometimes beginning with denial.

It is a common phenomenon; when professionals are confronted with a patient “in denial,” we become anxious. Then, to mitigate our anxiety, we talk more, lecture more, and use more impressive-sounding words. This strategy is very likely to backfire. As noted above, the patient and professional need to like each other. As our anxiety and syllable counts increase, our likeability index decreases. Professionals skilled in MI tend to talk less, ask more questions, and listen more. MI is a counseling style, and it is nonconfrontational.

The “Stages of Change” are summarized in the sidebar. (A similar illustration, the “Wheel of Change,” appears in the following sources: Prochaska et al, 1994; Harvey, 2003a, 2003b; Beck et al, 2007; Harvey, 2008)

Ambivalence and MiSigmund Freud may have had some strange ideas, but he was clearly correct when he said that every decision is characterized by some level of ambivalence. Ambivalence refers to the simultaneous feeling of wanting and not wanting something, a feeling of attraction and repulsion to the same thing. Ambivalence often means seeing the good and bad, the right and wrong, the advantages and disadvantages, while being uncertain as to which path to follow.

Freud’s dictum is absolutely relevant to the task of health-care professionals. Our task is more than giving advice; our task includes motivating patients to do what’s in their best interest. Sometimes, using traditional coun-seling techniques just gets one deeper and deeper into trouble. That is, when a professional voices one side of the patient’s ambivalence (change), it precipitates the patient voicing the other side of ambivalence (no change). Indeed, the more the audiologist advocates for change, the more the patient advocates for staying the same. The more we push, the more they pull.

For example, if the audiologist says, “Hearing aids will make it easier for you to hear,” the patient might say, “I

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stages of Change

Pre-contemplation Patient denies the problem.

Contemplation Patient is ambivalent, considers change, rejects change.

determination Patient’s motivational balance tips toward change.

Action May include hearing aid acquisition or aural rehabilitation.

Maintenance Help patient identify and use strategies to prevent relapse.

relapse Help patient avoid demoralization of relapse.

Source: Prochaska et al, 1994.



Joan’s Hearing Aid Balance Sheet

get Hearing Aids do not get Hearing Aids

More social and family involvement Continued feeling of isolation

Hearing the bids at bridge games Not playing bridge

Understanding the grandchildren more easily Difficulty with soft speech and mumblers

Hearing the TV easily Playing the TV very loud

Improved ability to use cell and landline phones Continue to avoid picking up the phone

Finally getting the last word Continue to argue with son

Cost issues Keep the money in the bank

Less frustration Same/worse frustration

Less anxiety Same/worse anxiety

Less stress Same/worse stress

hear pretty well most of the time.” If the professional says, “It’s been shown that hearing aids can improve the quality of your life,” the patient might say, “Uncle Fred is 89 years old, deaf, doesn’t want or wear hearing aids, and he’s doing just fine!” We’ve all been there.

Motivational interviewing guides the professional to talk less and ask more questions to encourage the patient to do most of the talking. There is an important caveat: What you don’t talk about can hurt you. Nietzche said,

“Silence is poison.” Keep in mind, the goal is not to elicit



just any talk. The professional must try to elicit change talk related to problem recognition, expression of con-cern, intention to change, and degree of self-efficacy. The audiologist’s task is to elicit, understand, and effectively manage the patient’s ambivalence.

For example, a patient with a mild hearing loss may experience ambivalence that pivots on her desire to hear more clearly combined with her reluctance to wear hearing aids due to cosmetic concerns. Or she may desire the ability to use her cell phone easily, while feeling reluctant to pay for hearing aids (as an aside, patients with mild and moderate degrees of hear-ing loss often have pronounced levels of ambivalence, whereas patients with severe and profound hearing loss have less ambivalence because their need to “manage” their hearing loss is greater). Thus, the audiologist who appreciates “amplification ambivalence” can respect-fully make ambivalence part of the audiologist-patient dialogue, thus voicing (airing) hidden concerns and managing them more effectively, while achieving and maintaining “likability.”

Joan is a 68-year-old who recently stunned her adult son by agreeing to an audiology appointment. The audi-ologist, trained in motivational interviewing, did not rush to be an “agent of change.” Rather, he said, “I believe hear-ing aids will help, but I’m sure you have some concerns, too.” He helped Joan fill out a Hearing Aid Balance Sheet (see sidebar) to help her acknowledge and amplify (pun intended) her ambivalence regarding pros and cons of wearing hearing aids.

Joan’s balance sheet reflects the concerns and thought processes Joan considered and worked through prior to arriving at her decision to try hearing aids. Once the issues were aired and placed “on the table,” the audiologist could directly affirm and validate Joan’s ambivalence and enter into a frank discussion of the issues important to Joan.

Motivation is not a general trait existing within…an individual...but is an important part of the counselor’s task…[which is] not only to dispense advice but to motivate—to increase the likelihood that the client will follow the recommended course of action. From this perspective, it is no longer sensible for a [health-care professional] to blame a client for being unmotivated to change, any more than a salesperson would blame a potential customer for being unmotivated to buy. Motivation is an inherent and central

Joan’s Hearing Aid Balance Sheet

get Hearing Aids do not get Hearing Aids

More social and family involvement Continued feeling of isolation

Hearing the bids at bridge games Not playing bridge

Understanding the grandchildren more easily Difficulty with soft speech and mumblers

Hearing the TV easily Playing the TV very loud

Improved ability to use cell and landline phones Continue to avoid picking up the phone

Finally getting the last word Continue to argue with son

Cost issues Keep the money in the bank

Less frustration Same/worse frustration

Less anxiety Same/worse anxiety

Less stress Same/worse stress

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part of the professional’s task. [Miller and Rollnick, 2002]

ConclusionRelationships are multilayered, diverse, and dynamic. There is much more to professional-patient relationships than diagnostics, hardware, and software. The quality of the relationship between the professional and patient impacts whether or not the patient accepts our guidance and recommendations. Successful professionals are able to draw on their personal qualities and skills to achieve a higher level of connectivity and to influence and motivate their patients to achieve an improved quality of life.

Motivational interviewing is a directive, patient-cen-tered counseling style for increasing intrinsic motivation by helping patients explore and resolve ambivalence. Through MI, the patient and the audiologist experience connectivity as the patient becomes an active participant in the discourse, as opposed to the patient serving as a recipient of professional information. The “decision to change” results from this collaborative discourse, which leaves the patient feeling validated, respected, and liked by the professional.

These principles (connectivity, influence, and moti-vational interviewing) remind us of the 76-year-old woman who joyfully reported to her family that she finally got hearing aids! She had previously visited and frustrated many audiologists. Her daughter asked her,

“Why now?” She replied, “He was the first person that asked me ‘How are you doing?,’ and, he really, really wanted to hear my answer.”

Douglas L. Beck, AuD, is director of professional relations at Oticon Inc. in Somerset, NJ. Michael A. Harvey, PhD, is a consulting faculty member at Salus University and a clinical psychologist in Framingham, MA.

Acknowledgments: Special thanks to Thomas Lunner, PhD (Oticon A/S Research Centre Eriksholm, Denmark Docent/Tekn Dr Technical Audiology, Department of Clinical and Experimental Medicine, Linköping University, Sweden; Professor [visiting], Linnaeus Center HEAD, Swedish Institute for Disability Research, Department of Behavioral Sciences and Learning, Linköping University) and Robert Cialdini, PhD (Regents’ Professor of Psychology and Marketing, Department of Psychology, Arizona State University), for their kind encouragement and thoughtful reviews and suggestions regarding this manuscript.

References and Recommended Reading

Beck DL. (2007) Identifying the time for improved hearing.

Oticon Clin Update 1:8–9.

Beck DL and Clark DL. (2009) Audition Matters More as

Cognition Declines, Cognition Matters More as Audition Declines.

Audiol Today 21(2).

Beck DL, Harvey MA. (2009) Traditional and nontraditional

communication and connectivity. Hear Rev January. www.hear-

ingreview.com/issues/articles/2009-01_04.asp.

Beck DL, Harvey M, Schum DJ. (2007) Motivational interviewing.

Hear Rev October.

Centers for Disease Control and Prevention (CDC). (2005)

WISEWOMAN uses motivational interviewing to help Alaska

Native women quit tobacco. www.cdc.gov/wisewoman/pdf/

vol_2/success_2.pdf.

Chisolm TH, Johnson CE, Danhauer JL, Portz LJP, Abrams HB,

Lessner S, McCarthy PA, Newman CW. (2007) A systematic

review of health-related quality of life and hearing aids—final

report of the American Academy of Audiology Task Force on the

Health-Related Quality of Life Benefits of Amplification in Adults.

J Am Acad Audiol 18:151–183.

Cialdini R. (2008) Influence: Science and Practice. Boston: Allyn

and Bacon.

Dillon H, James A, Ginis J. (1997) Client Oriented Scale of

Improvement (COSI) and its relationship to several other mea-

sures of benefit and satisfaction provided by hearing aids. J Am

Acad Audiol 8:27–43.

Engelund G. (2006) Time for hearing—recognising process for

the individual. A grounded theory. PhD thesis, Department of

Nordic Studies and Linguistics Audiologopedics, University of

Copenhagen, and Oticon Research Centre, Eriksholm, Denmark.

Goldstein NJ, Martin SJ, Cialdini RB. (2008) Yes! 50 Scientifically

Proven Ways to Be Persuasive. New York: Free Press.

Gurney JG, Tersak JM, Ness KK, Landier W, Matthay KK,

Schmidt L. (2007) Hearing loss, quality of life, and academic

problems in long term neuroblastoma survivors: a report from the

children’s oncology group. Pediatrics 120(5):1229–1236.



Harvey MA. (2001) Listen with the Heart: Relationships and

Hearing Loss. San Diego, CA: Dawn Sign Press.

Harvey MA. (2003a) Audiology and motivational interviewing: a

psychologist’s perspective. www.audiologyonline.com.

Harvey MA. (2003b) When a patient requests hearing aids

but doesn’t want them: psychological strategies of managing

ambivalence. Feedback 14(3):7–13.

Harvey MA. (2007) Motivational interviewing. Oticon Clin

Update 12–13.

Harvey MA. (2008) I never wanted to be a salesman but here I

am. Hear Rev.

Hou Z, Dai H. (2004) An online hearing screening test. Hear Rev

October.

Kochkin S. (2005) Marke Trak VII—hearing loss population tops

31 million. Hear Rev July.

Kochkin S. (2006) Hearing solutions—the impact of treated hear-

ing loss on quality of life. Better Hearing Institute. http://

betterhearing.org/hearing_solutions/qualityoflife.efm.

Miller WR, Rollnick S. (2002) Motivational Interviewing:

Preparing People for Change. 2nd ed. New York: Guilford Press.

Prochaska JO, Norcross JC, Diclemente CC. (1994) Changing for

Good: A Revolutionary Six-Stage Program for Overcoming Bad

Habits and Moving Your Life Positively Forward. New York: Quill.

Rollnick S, Miller WR. (1995) What is motivational interviewing?

Behav Cogn Psychother 23:325–334.

Rubak S, Sandbaek A, Lauritzen T, Christensen B. (2005)

Motivational interviewing: a systematic review and meta-analysis.

Br J Gen Pract 55(513):305–312.

Schum DJ, Beck DL. (2008) Negative synergy—hearing loss

and aging. Audiology Online. www.audiologyonline.com/articles/

article_detail.asp?article_id=2045.

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16 HEARINGREVIEW.COM I APRIL 2014

COVER STORY // MARKETING

Right Product; Wrong MessageIt’s time we all become committed to establishing a new social norm in hearing care—one that focuses on “maximal hearing and listening”

There are some 35 million people in the United States with hearing loss.1 Amlani and Taylor2 reported market

penetration has previously been thought to be 20% whereas MarkeTrak VIII3 assumed market penetration was closer to 25% (based on 8.2 million hearing aid users and some 33.4 million people with hearing loss). Of note, Amlani and Taylor2 reported perhaps only half of those with demonstrable hearing loss actu-ally have a compelling need for amplification (in conventional audiological terms, consider a patient with normal thresholds from 250 to 6000 Hz and a 40 dB loss at 8000 Hz, or perhaps a patient with normal thresholds from 250 to 8000 Hz, but a 40 dB notch at 750 Hz). Therefore, one might argue market penetra-tion is as high as 50%. Nonetheless, that still leaves an enormous pool of patients (50%) with significant hearing loss without ampli-fication! (Also see Barbra Timmer’s article about mild losses in this edition of HR.)

This article focuses on considerations relat-ed to how to present amplification to hearing aid candidates, such that we facilitate effective and appropriate change to the social norm.

The Status QuoThe majority of people with signifi-

cant hearing loss and/or who have diffi-culty understanding speech in quiet or noise appear to avoid hearing aid amplification. The traditionally accepted—and often quot-ed—time lapse between a person noticing a reduction in hearing (and/or listening ability) and subsequently acquiring a professional consultation and/or acquiring hearing aids is

seven long and frustrating years. Of course, some people seek amplification sooner and some delay longer. However, “seven years” appears to be the average “lag time” for those who acquire amplification.

Once this person with hearing-impairment finally seeks professional consultation, the hear-ing healthcare professional (HHP; note we’ll use “HHP” to refer to the practitioners, the indus-try, and the associations) must often address and dispel the negative attitudes and impres-sions brought into the consultation room.

Indeed, widespread negativity associated with hearing aids is indicative of an underly-ing social norm, which views hearing health-care (at best) as generally irrelevant and (at worst) as a threat.

As professionals, we often find ourselves simply accepting this state of affairs and, by default, responding in a manner that unin-tentionally reinforces the social norm. For example, we (in general) assure society we can hide the technology, and in doing so we affirm that using hearing aids—and, by infer-ence, having hearing loss—is something to be hidden, or ashamed of, or embarrassed by.

Thus, the attitudes of society and the mes-sages from the HHPs become locked into a vicious, negative, self-defeating circle.

The GoalThe goal of this article is to offer analysis

and suggestions as to how we might break this self-perpetuating negative pattern by introducing a systematic framework designed to ultimately change the social norm. Central to accomplishing this goal is the identifica-tion of key stages at which hearing healthcare has the opportunity to become relevant to the public, while assuring the information pro-vided facilitates positive images and attitudes. The specific goal might best be described as “maximal hearing and listening.”

AttitudesResearch into attitudes such as “The

Elaboration Likelihood Method”4,5 and the

The goal of this article is to

offer analysis and suggestions

as to how we might break

this self-perpetuating negative

pattern by introducing a

systematic framework designed

to ultimately change the

social norm associated with

hearing healthcare. Central to

accomplishing this goal is the

identification of key stages at

which hearing healthcare has the

opportunity to become relevant

to the public, while assuring the

information provided facilitates

positive images and attitudes.

The specific goal might best be

described as “maximal hearing

and listening.”

BY DOULAS L. BECK, AuD, AND CURTIS J. ALCOCK

Douglas L. Beck, AuD, is the director of professional relations at Oticon Inc, Somerset, NJ. Curtis J. Alcock is founder of Audira »Think Tank for Hearing (www.audira.org.uk) and has worked as a hearing care professional in the United Kingdom.

Adapted and reprinted with permission of The Hearing Review (www.hearingreview.com). All rights reserved. Citation: Beck DL, Alcock CJ. Right product; wrong message. Hearing Review. 2014;21(4):16-20.

APRIL 2014 I HEARINGREVIEW.COM 17

“Heuristic Systemic Model”6 reveals people formulate their attitudes differently depend-ing on how personally important or relevant a topic is. The less involved someone is, the more they rely on mental shortcuts (or heu-ristics) in formulating their attitude. Heuristics might facilitate a “follow the crowd” or per-haps “follow the experts” scenario. Indeed, they may consider (and ultimately base their opinion on) reasonably shallow questions such as “Does this make me feel good?” and perhaps “How attractive is the person telling me this?” However, as they become more involved, they likely become more willing to “do their home-work,” dig deeper, consider, weigh pro-and-con arguments, and examine the evidence.

Therefore, to address the underlying social norm across the spectrum, the messages we (HHPs) present to society must facilitate pos-itive and beneficial messages to those who do not believe hearing aids are currently relevant to them, and to those for whom hearing aids may already be relevant. Many of the people who currently consider hearing aids relevant have come through a process of change. So, one might argue, what we should focus on is “preparing the unready” for a time at which they become ready. That is, we must facilitate strategic and well thought through ideas and images that are truthful, positive, and “sticky” (ie, ideas that cling to you).

Further, the way in which the informa-tion is presented is of enormous consequence. “Framing” and “Priming” are two examples of how the presentation itself impacts the received and processed message. Framing refers to the way a person’s perception of the same information can be altered simply by wording it differently, which in turn will affect their reaction and acceptance of it. For exam-ple, suppose you had just watched a long and boring movie and then your colleague asked “How long was the movie?” you’re likely to overestimate the time spent! However, if you were enjoying a comedy special and then your colleague asked, “How short was the show?” you might underestimate the total time.7

The way healthcare messages are framed has been shown to influence likelihood of peo-ple accepting/adopting or rejecting a recom-mended health behavior.8,9 People respond bet-

ter to messages framed in a way that empowers them to avoid a threat (eg, loss of health) and enables them to maintain how they want to see themselves (ie, maintenance of their cur-rent status quo). Priming is the effect whereby a prior stimulus (eg, marketing material) will influence a person’s response to a later stimulus (eg, advice about amplification).

Of note, priming can occur even when the first stimulus is outside their conscious aware-ness. Expose someone to stereotypical ideas about the elderly, and it will often make them behave and feel older —even exacerbating memory problems.10-12 This begs the question, “What have we been priming all these years?”13

Unfortunately, HHPs have traditionally followed a path in direct opposition to the principles and lessons of attitudes, framing, and priming. One might argue we have unin-tentionally helped create the status quo (ie, “The Law of Unintended Consequences”).

The Four QuestionsAlcock14 proposed four pivotal questions

to understand the social norm as it relates to hearing healthcare. The response (of the patient, or of society) determines how likely they are to embrace hearing healthcare.

1) When should I have my hearing checked?2) How can I tell if I have hearing loss?3) Who uses hearing aids and is that rel-

evant to me?4) When should I use hearing aids?

To answer these questions, people depend on information they have access to at that moment in time. The obvious and prominent information exercises the greatest influence over thought processes and behaviors.15 If an answer is “common knowledge,” it has great impact.16 For example, When should I brush my teeth? [After meals or twice a day.] When should I get my vision examined? [When print is blurry and/or your “arms aren’t long enough” to read the fine print.] When should I have a physical? [Annually to maintain ideal health.]

The list goes on and on... However—and of significant importance—there are no “com-mon knowledge” answers to the four ques-tions posed above.

The Four Questions Answered Via the Current Social Norm

Indeed, we suspect if someone were to run a poll consisting of the four questions, the answers would approximate something like the following:

Q1. When should I have my hearing checked?

n When it’s hard to hear.n When I need hearing aids. n When I cannot understand anything.n When I cannot hear spoken words.n When I have to turn the television up

really loud.

Q2. How can I tell if I have hearing loss?n When I can no longer hear.n When I cannot hear something I can

hear now.

Q3. Who currently uses hearing aids and is that relevant to me?

n Old people, disabled people, deaf people (and it’s not relevant because I do not see myself as old, deaf, or disabled).

Q4. When should I use hearing aids?n When I get older.n In a few years.n When I cannot get by without them. Specifically, the current social norm does

not offer useful (or correct) common knowl-edge or information—and this lack of clear guidance (to society) results in ambiguity and ambivalence; it becomes easier for a person to do nothing. Compounding this confusion is the reality that we only perceive sounds within our “hearing range.” That is, we can-not subjectively verify what we cannot hear. For many people, sounds that cannot be perceived simply cease to exist.

Shifting Our Focus: Changing the Social Norm

Traditionally, HHPs have invited people to discover they have a “condition” or a hear-ing impairment, while detailing how bad their condition is (ie, how flawed the person is) while pointing out the negatives (ie, “these

Hearing healthcare has a truly remarkable and transformative product that already has many millions of satisfied

users. What it suffers from is an image problem. It’s time for us to change that.

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COVER STORY // MARKETING

are the sounds you can’t hear…”). HHPs subsequently offer a solution (hearing aids) that is often unexpectedly expensive and may come loaded with negative associations attached to it.

Kahneman et al17 demonstrated people are averse to the perception of loss. Others9,18-20 have shown that the threat of “having a con-dition” (ie, a perceived loss of health) explains why people avoid discovering they have a condition, especially if they feel powerless to minimize or prevent that loss.

Unfortunately, our traditional message/invitation is inherently negative and aversive (ie, having a hearing test or using hearing aids doesn’t minimize or prevent a hearing loss; it confirms it), and we cannot expect to change the social norm without changing the message/invitation. As Albert Einstein noted, “Insanity is doing the same thing over and over and expecting a different result.” Therefore, it may be reasonable that only 1 in 4 people with hearing loss seeks help, or that half the people who seek help choose to do nothing!

The Eight Principles for Approaching the New Social Norm

To initiate a change in the social norm, we must change the discussion from tests, loss, disability, and hearing aids, to prevention (of hearing loss and/or mishearing), evaluation/assessment, maintaining and/or improving the ability to listen and communicate maxi-mally, and hearing technology. The hear-ing assessment is used to assure the patient can maximally perceive speech sounds and assures the patient can communicate maxi-mally in work, social, and recreational situ-ations. When we frame the discussion in terms of a loss that society can avoid, such as mishearing, we empower people to reduce that risk and maintain their status quo.

Principle 1: Focus on maximal hearing and listening. HHPs need to move away from pure-tones as the “gold standard” mea-sure of hearing. Pure-tones are correctly used for diagnostic purposes, but do not measure listening ability or correlate at all with dif-ficulties listening in noise. We should imple-ment functional tests that directly record and quantify the hearing and listening ability that patients perceive, and that directly relate to their real world experience, of which the primary tool is the speech in noise (SIN) test. We also should be able to demonstrate to the

patient the functional improvement through our intervention.21,22

Principle 2: Empower people through hearing technology. People want to improve or maintain their situation. Traditionally, hearing aid amplification is viewed as a nega-tive and announces “I am flawed” because it is seen as confirmation of having a condition, rather than evidence of maintaining “maxi-mal hearing and listening.” To be acceptable, hearing technology must allow people to maintain or increase their self-image, not decrease/deflate the same.23 People approach things that empower them and they avoid things that weaken them.24

Principle 3: Our marketing, conversa-tions, and explanations must “mirror the perception of the patient.” When we con-sider hearing from the perspective of the patient with moderate or moderately severe hearing loss, we must realize they do perceive sound. As best they know, they already hear “everything,”25 but the desired sound source is not clear.

To them, that’s the problem: it’s an exter-nal one rather than internal. In a nutshell, it’s not denial or stubbornness—it’s their obser-vation—that the sounds they want to hear are not clear! We advise making the discussion about what the patient would like to hear more of, not about what they cannot hear.

Principle 4: Situations, not shortcom-ings. Address the situation in which it is difficult to hear clearly, rather than requiring someone to see themselves as a person with a condition or who is impaired. The focus should be about empowering people to solve external problems rather than “spoiling their (internal) self-identity.”26

Principle 5: Ascribe positive images and attributes to hearing technology and its users. Dentists show smiling people with beautiful white teeth, not yellow crooked ones. People respond to such imagery because it models them as they want to be seen, enjoy-ing the desired outcome. Likewise, our own marketing—from manufacturers and HHPs alike—needs to “create positive associations” in the real world by linking our own products to desired outcomes.

Principle 6: Use branding to stimulate desire for hearing technology. Brands are a powerful force in shaping consumer behav-ior. A good brand will extend the individual through its symbolism and associations.23,27-29

Principle 7: Normalize hearing health-

care. If hearing healthcare remains the arena of those suspected of having a condition, then those who do not see themselves as having that condition will avoid it. If the act of hav-ing your hearing checked implies you have a socially unacceptable problem, then we a pri-ori stigmatize anyone who has their hearing tested. The role of hearing healthcare must therefore be expanded to the maintenance of “maximal hearing and listening” throughout life, and presented as normal and routine as getting a dental exam, a vision exam, and a physical.

Principle 8: Hearing healthcare must present a unified message to society. If the manufacturers, the professionals, and the state and national associations consistently repeat the same messages over and over, they supply “evidence” to the consumer to validate the same, and the message becomes “com-mon knowledge.”30 That is, if all the “experts” say it, it must be right31 and the message becomes perceived as the social norm, which in turn influences individuals to act in accor-dance with that social norm.32

So then, with the above eight principles in mind, let’s address the same four questions—now reframed appropriately—as they would ideally be answered using the desired social norm so we can be clear on the direction we need to move society.

The Four Questions Answered by the Desired Social Norm and with the Eight Principles

So here are the answers to the four ques-tions using the eight principles:

Q1. When should I have my hearing checked?

Hearing should be checked routinely throughout your lifespan, just like eyes and teeth, to maintain “maximal hearing and listening” and to avoid the consequences of mishearing in business, social, and recre-ational settings.

Q2. How can I tell if my hearing has changed?

Most of the time you can’t tell! Changes in hearing generally occur gradually—one hardly notices a change unless it’s a sudden onset. Indeed, if you are mishearing, it is more likely to be noticed by your family and friends before you’re aware of it.

APRIL 2014 I HEARINGREVIEW.COM 19

Q3. Who currently uses hearing technol-ogy and is that relevant to me?

Frankly, it’s often impossible to tell who is wearing hearing aids because 21st century styles and technologies often render hearing technol-ogy virtually undetectable to others. In fact, many celebrities and performers use custom-ized hearing systems to hear and listen maxi-mally while performing as they cannot afford to miss a sound cue, direction, or discussion.

Q4. When should I use hearing technol-ogy?

Whenever the situation and/or the limi-tations of your hearing range compromise “maximal hearing and listening,” or increase your risk of mishearing.

Discussion, Sticky Hints, and Statistics

Sticky messages. Having established the desired responses, the hearing healthcare community must work together so our mes-sages become “common knowledge.” The messages must be relevant, remembered, and repeatable. The best messages, quotes, and concepts are not (necessarily) yet defined. Nonetheless, here are some examples that may prove useful as a starting point:

1) Eyes checked. Teeth checked. Hearing checked.

2) Be wise, check hearing like eyes!3) If you ask to repeat, check your hear-

ing’s complete. 4) Others will tell if I’m not hearing well.5) Better to know before problems show.6) Hear to stay, not fade away.

Social Proof. Ultimately, social norms are about the perception of most people in soci-ety. If people assume hearing healthcare is for the minority, those people who are uncertain (about the relevance of hearing healthcare) will follow the majority and do nothing. Cialdini32 refers to this as “social proof.”

Therefore, it’s generally not wise to tell the public “10% of the people in the USA have hearing loss” and “only 1 in 4 seek help for their hearing difficulty.” Clearly, the other side of that coin, and the message the public is getting, is 90% of all people don’t have hearing loss, and even if they do, 75% don’t seek help for their hearing difficulty (so you probably don’t need to either!).

Maximal hearing and listening. When

we focus on “maximal hearing and listening,” the message is relevant to the majority and about maintaining (or improving) your place among that majority. When we combine this with consistent messages and marketing to increase people’s awareness that hearing healthcare is commonplace, we create a self-fulfilling prophecy.

Hearing healthcare has a truly remark-able and transformative product that already has many millions of satisfied users. What it suffers from is an image problem. It’s time for us to change that. The principles offered in this article are the first step in accomplish-ing this. ◗

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CORRESPONDENCE can be addressed to Dr Beck at: [email protected]

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