Draft - Be there for your patients

Sometimes it is easy to forget that our patients are more than just a medical record number, a case history, a hearing test, a diagnosis, a report awaiting to be finished.  Sometimes it is easy for us to get into a routine, and go through the motions.  I know I am guilty of doing so; after  a while, everything blurs together, back to back patients, day after day.  A patient can get lost in a miasma of diagnostic codes and statistics.  Yet, the truth remains while they are one of many, to our patients we may simply be the one and only.

The beauty of becoming an audiologist, at least one that appeals to me strongly is the sheer amount of time we get to spend with our patients.  By virtue of exposure, and by virtue of the nature of our work, we suddenly become more than just a doctor- we become their confidant, their nurturer, their advocate.  We may joke amongst ourselves about things like keeping within our scope of practice and avoid becoming marriage counselors.  Yet, frequently, and as my supervisor once commented, that first set of hearing aids a patient buys are not for themselves but rather for their relationships.  More often than not, that soundbooth becomes almost a confessional, a sacred space in which patients confess to us their deepest fears, their feelings of inadequacy, their frustrations, their dreams and desires.  When we sit with them, when we walk them through the test, when we discuss with them about hearing loss, about their tinnitus, about their balance problems we often end up talking about a whole lot more.  If we listen carefully, pay close attention and read between the lines, we would realize our patients have actually divulge to us beyond a list of symptoms and red flags.  We are invited to take a glimpse into their lives, their secrets.  We are entrusted with so much more; never take that duty lightly.

It is such a blessing, albeit at times a blessing in a "hideous" disguise, when our patients feel comfortable enough to be true with us.  It is a blessing when a patient can feel our unconditional positive regards for them to the point of letting slide their strong fronts.  There are many tears of joy shed in an audiologist's office.  You have seen it on youtube and heard tell from many people who have experienced the activation of a CI, the wonders of hearing sounds again because of hearing aids and ALDs.  Similarly there are a lot of tears shed because of fear and the sensation of helplessness.  We may not always be able to fix the problem they present to us, but one thing we can be darn sure of is we can be there for them.  We are in the business of hearing and balance, and more importantly, we are in the vocation of listening and keeping centered; two things essential to  helping people stay engaged in their world.

We may not be priests, psychologists and counselors, but that should not deter us from being the best ministers, healers, and nurturers that we can be.  Stop, listen.  Time is relative, and when you can lose track of time, and have a moment with a patient, you might just step back and realize you have made better use of that second, minute, hour than had you worried about getting by the minute and making it to the next.

What I am trying to say is this:  be there for your patients.  Let your love for your patients pervade all your actions.  You may feel the need to help many, but focus on helping the one in front of you, and you will be surprised by just how much and many you have helped at the end of the day.

Quo Vadis

“The revolution remains incomplete; my fellow comrades, you must continue to work hard towards that end.”

- parting words by Dr. Sun Yat-sen

There is no denying that the field of audiology has grown in leaps and bounds since its inception following the Second World War.  Our greatest achievement yet, besides the numerous advancements we have seen in the field of hearing aids, is moving from a master level degree to a doctoral degree.  Now we are in the midst of attaining Limited License Physician Status, Direct Access and Expanded Audiology Benefits under Medicare

While this is all good, I must ask of the field to pause and consider for a moment, where are we really in our growth spurt?  Are we growing incrementally in a logical fashion, or have we made some leaps prematurely thereby placing the cart before the horse so to speak.  I expect a lot of raised eyebrow by now from those of you who are reading this.  Some of you may even be feeling incredulous that I should even dare post such a question.  Yet, as I look at our internal struggles, review the commentaries and attacks from our opposition, and observe our rebuttals to those aforementioned challenges; I cannot help but liken the experience to watching an angst-filled teenager trying to figure out their place and identity in the “real world”.  What is more, I am forced to entertain the notion that we are not ready quite yet.  I do believe that we still have ways to go to establish ourselves before we can ask of others to regard us with respect and entrust us with the responsibilities that we are asking to undertake.  To continue with the analogy- we haven’t quite earned the rights to the car keys just yet. 

First and foremost, while we have given ourselves a proper title, we haven’t really established a model or office that goes with that prestige.  What I mean by that is we haven’t really able to promote a mode of care that encompass our scope of practice and recognized by those whom we serve.  Currently, we are split between either an ENT model (where we play an almost auxiliary role), or a dispensing model.  There really isn't an "audiology" model, or at least one that is readily identifiable or distinguishable by the populace.  There remains a dissonance in our potential patient’s paradigm of what an audiologist actually does.   Insofar when people still say “what?” and literally means it when we introduce ourselves as audiologists; or associate us only with hearing aids, we remain severely limited. 

This is problematic, this disparity that exists as compared to when a lawyer, an optometrist, a chiropractor, a dentist steps up to introduce themselves. People almost usually know their respective scope of practice.  We need to promote ourselves beyond hearing. Truly, and more accurately, we are the doctors of the inner ear (with outer and middle ear attached).  This definition extends beyond hearing, and entails balance and listening.  I want to see the day when audiologists introduce themselves, people would immediately conjure up a profession who caters to their hearing, listening, and balancing needs.

We do so, not by asking for the keys to the car immediately so to speak, but to demonstrate that we are the mature adult everyone else expects of us.  We do so by (1) unifying our curriculum and strengthening our boards, (2) increasing our appeal to attract audiology candidates beyond CSD/ Speech path majors, especially to pre-med and science related majors, and (3) establishing a diagnostic and treatment protocol that is uniquely audiology. 

The ACAE and ABA have been making progress towards achieving objective 1.  My rationale for objective 2 is to ensure that moving forward, audiologists will have friends and network in fellow medical professions.  Historically, audiology has attracted candidates primarily from Speech Pathology, Communication programs.  Often times, these candidates do not have a lot of interaction with students from pre-med programs by virtue of their curriculum requirements (i.e. fewer science courses).  From a networking perspective, this is detrimental to our field in the long run as we would have fewer friends and allies in the medical fields to support our cause. We need their friendship from undergraduate all the way through graduate years.  Beyond networking, a candidate who has gone through the rigorous discipline of science provides a different insight and approach to problem solving than someone who has a therapeutic background. At the risk of oversimplifying the situation, but more to the point, it is the difference between being active and reactive. Active would be asking the questions of how and why, reactive would be what we do about it. As audiologists, we should be able to do both nicely.  We should be able to take the initiative and understand the pathophysiology, anticipate the symptoms and subsequently treat them.  Our weakness in this area, namely our projected image of over-reliance on hearing aids, has subjected ourselves to attacks from physicians. We are doctors, and our knowledge base, our way of thinking needs to be more proactive.  Ultimately, I want audiology to be a discipline that is attractive to anyone, and audiology programs have the ability to build everyone up to be the desirable audiologist regardless of their background.  After all, as it is true in genetics, we need diversity to ensure better survival; I believe different disciplines coming to audiology will do just that.

This brings me back to the audiology model, and the current preconception that audiologists sell hearing aids.  The problem with building a profession around the sales of hearing aids, especially in the era of plug and play, is we risk being ousted by technology. When the focus is placed on a product and not the person, we are doomed.  A profession should not be built around a product; rather it should be built upon the person.  Getting hearing aids should not be like getting a pill.  The cost of a hearing aid may be dictated by research and design costs, but the value of our services must prove more worthwhile.  We are the human quotient in a world that is ever becoming impersonal.  In a field that specializes and espouse better communication we need to bring the focus back to human relationships.  We need to be the reputable doctor who knows and understands.  We bring value to the experience; our compassion, our understanding, our motivation, and our involvement in helping a patient attain success should be the key.  In order for that to happen, we need a clear protocol. This way, when people talks about us, they know we are more than capable of dispensing hearing aids.  They know what to expect beyond that.  We listen to their needs, we help them hear, and we can treat their balance problems. 

This is the direction of audiology that I envision-  a profession that is unified in its education experience, fully acknowledged/ esteemed by the other professions, so much so that eventually we can even be involved in some therapeutic rights (e.g. prescribing drops or antibiotics for ear infections).  We are young, and we have some ground to cover.  Yet I firmly believe we can accomplish and continue the efforts of our trailblazers before us.  I envision a day when wanting to become an audiologist is as cliché as wanting to become an astronaut, a lawyer, a doctor, a policemen or a fireman.

Balancing Act

Some of the most difficult patients that an audiologist will ever encounter are those who presents with dizziness problems.  "Dizziness" is a very generic term, but at the core of it is that a very fundamental faculty critical to survival is completely askew. In other words, and no pun intended, these patients are quite imbalanced in all sense of the word as they no longer have a reference point. One can therefore only imagine the emotional and physiological burden that these patients carry with them when they walk through the door. 

To further exacerbate the problem, much of what the patients would read regarding the diagnostic tests involved are typically reviews latent with terminology that liken the experience to what a spy would endure should they be caught by the enemy (e.g. you will be strapped into place, a harness placed upon you,  your vision is obscured, there is a dark enclosure, you would be spun/rotate around, and water will be flushed into your ears etc.) As one patient who has underwent repeated balance tests described to me, "it is an ordeal built upon an ordeal, a strain upon what is already strenuous".  Already, it is an uphill battle from the start.  

It is therefore critical for the audiologist not only to be aware of the all the symptoms and potential differential diagnostics so as to speed up the diagnostic process; but to be ever ready to cater to the psychological and emotional needs of these patients.  Yes, it can be quite difficult at times, and we forever run the risk of being cynical as clinicians, especially if you have seen your fair share of malingerers and conversion disorder patients. The truth of the matter is, all dizzy patients will present you with anxiety, with doubt.  

They may want to believe in you, they may want to trust you, but their fear pervades their actions.  It behooves the audiologist to alleviate that fear as much as possible.  For the reality is this, good raw data are hard to come by when they are convoluted by anxiety and augmentation of psychosomatic manifestations.  Technique is essential, but more importantly ministry, compassion, motivation, and encouragement attributes to a significant portion to the success of a balance diagnostic battery. After all, it is an exhaustive battery in all sense of the word.   

Little things such as reminding the patient to breath, to unlock their knees, to relax the neck and shoulders go a long way in clearing the data of outliers and artifact.  In my personal experience, unconditional positive regards have far reaching effect in making the whole experience for the patient an enlightening and even at times a fun experience.   What is more, I have truly found that laughter indeed is the best medicine in those situations.  While anecdotal at this point, I have found more often than not when I am capable of making a patient laugh, despite how scared they are, or when i can turn them onto talking about something that is dear to their hearts as means of tasking, I get amazingly clear data.  Contrastingly, when I am unable to engage the patient, when I am unable to wholeheartedly cheer them, I get mediocre data which while textbook by virtue of the patient's pathology, is not beautiful.  

It is a balancing act to keep the patient engaged and at the same time diverge their attention away from their symptoms.  It may also require some acting initially to ward off the negative energy/ vibes that is emitted by a patient when you first encounter them.  It is necessary to build a positive rapport from the very beginning; after all, the testing process can become personable for both parties involved.    

I have heard a lot of reasons why audiologists have "shy" away from balance testing;  from not getting enough reimbursement to testing equipment being hard to come by.  Yet, I sincerely urge all of you out there to give it a try.  As much as I enjoy helping someone to hear better, as much as I find hearing test to be fascinating, I find my interactions with dizzy patients to be most rewarding.  It is a challenge for sure, but when you can connect with a dizzy patient, when you can engage them, be their coach, listen to their life stories, cheer them on, you both walk away from that experience enriched.  It is a balancing act, and it is a tough act to follow.