As we enter the 21st century, hearing healthcare practitioners are confronted with the paradox of an increase in the number of individuals experiencing hearing loss, but a decline in the percentage of individuals who elect to improve their hearing and communication skills through the use of hearing instruments. This begs the question of how to more effectively encourage individuals with hearing loss to seek hearing assistance. One suggestion that seems to make sense is to expand the role of the historic "gatekeeper" to the healthcare system - the primary care physician - in hearing loss identification and counseling.
The important role the primary care physician can have in the identification and treatment of hearing loss was highlighted by the findings of a recent study that showed 63 percent of people listed their primary care physician as the most important source of information about where to go for hearing health care services. Based on the results of another study, Kochkin found "that individuals with hearing loss, reluctant as they are, will listen to their doctors." He concluded that if the physician reports a positive experience with hearing instruments, a hearing-impaired individual will be more motivated to seek treatment for hearing loss. Kochkin further illustrated the importance of the physician's role in hearing loss identification and treatment when he reported that persons with hearing loss are eight times more likely to be positively inclined to purchase a hearing instrument if their physician has recommended one.
Recognition of the primary care physician's role in hearing loss identification and treatment is not new. Fifteen years ago, the noted ear specialist J. W. House stated that one reason for the limited acceptance of hearing instruments was the belief by many physicians that such devices will not significantly help in the treatment of sensorineural hearing loss. House also noted that "...because patients trust their physician and look to him for advice about hearing aids...it is important for physicians to become aware of the indications and benefits of amplification." In addition, in 1991, the U.S. Public Health Service and the Institute of Medicine of the National Academy of Science set as a goal for the year 2000 that at least 60 percent of primary care providers would evaluate adults over age 65 for hearing-impairment.
Past research into physician behavior regarding hearing loss identification suggests that in order for primary care physicians to perform effectively in the role of "hearing healthcare gatekeepers," substantial changes will have to take place regarding (a) the frequency of hearing screening and (b) their knowledge of treatment alternatives available for hearing improvement. For example, on the issue of how often physicians screened their patients for hearing loss, Sullivan reported that less than one in five screened for hearing loss during routine physical examinations (Sullivan 1992). Kochkin also reported a low frequency of hearing screenings by physicians during routine physical examinations (Kochkin 1994). In addition, he noted that if the comments by physicians regarding hearing instruments are negative, then the hearing-impaired individual "...has a great excuse to postpone purchase of a hearing instrument."
Furthermore, despite the remarkable advancements in hearing instrument technology that occurred in the late 1980s and 1990s, disappointing findings have been reported concerning the primary care physician's knowledge of available treatment alternatives. Jones, for example, found that for every positive hearing instrument recommendation made by a physician, three negative recommendations were given, even though the patients were bona fide candidates for amplification. In another study, Whichard found that physicians too often gave outdated information and discouraging advice to patients who ask about hearing loss and hearing instruments.
Physician Survey
This study was undertaken to assess the extent of hearing loss identification and counseling that occurred among primary care physicians. Inquiries were also made as to physician referral to hearing healthcare practitioners; cerumen removal; knowledge of medical treatment options for hearing loss; knowledge of hearing instruments and other auditory prostheses (implants); incidence of hearing loss among the respondents; and, interest in continuing education regarding hearing loss identification and treatment.
A letter of transmittal and a nine-item, one-page questionnaire were mailed to randomly selected primary care physicians. Twenty-seven of 131 questionnaires were returned for a 20.6% response rate.
Summary of Survey Responses
Frequency of Hearing Evaluation - 37% of the physicians reported screening all of their patients [irrespective of age] for hearing loss during their first physical examination.
Examination of the Ear - 92.5% of the physicians performed a visual inspection of the pinna and otoscopy during the first physical examination of the patient. Furthermore, when significant cerumen accumulation was found, 33% removed the cerumen themselves; 67% indicated they assigned this procedure to a nurse/technician. The results of this survey are similar to an earlier study that found "...fewer than 20% of physicians performed cerumen removal themselves...the remainder delegated the task to nurses, some of whom had received no instruction [in cerumen removal]."
Threshold Testing - 55.5% of physicians performed some form of "threshold" testing. Five used an audiometer. The remainder used tuning forks, whisper test, watch test, or a scratch test to determine hearing acuity.
Comprehensive Hearing Evaluation - when hearing loss has been identified, 48% of the physicians suggest the patient schedule a comprehensive hearing evaluation. Even fewer - 22% - counsel the patient on the possible causes of hearing loss or treatment options. One physician reported that he/she suggested to the patient that they consider the use of hearing instruments.
Physician Referral - when a physician finds or suspects that a patient has hearing loss, 24% refer the patient only to an ENT for further evaluation, 32% refer the patient only to an audiologist, and 32% refer their patients to some combination of ENTs, audiologists, and/or hearing instrument specialists. One physician referred patients exclusively to a hearing instrument specialist. This finding has a similar pattern to the physician referral profile reported by Jones (1993), i.e., 65% to ENTs, 39% to audiologists, and 10% to hearing instrument specialists.
Physician Counseling on Hearing Loss - on the question of what action was taken by the physician when the patient asked about hearing instruments, the study found that 22% discussed with the patient their understanding of the benefits and capabilities of hearing instruments. On the larger question of physician referral to learn more about hearing treatment alternatives, 24% referred only to an ENT; 28% referred only to an audiologist; 12% referred to both ENTs and audiologists; and, 1 physician referred only to a hearing instrument specialist.
Knowledge of Medical Treatment Options - 67% of the physicians rated their knowledge of the medical treatment options for hearing loss to be good or satisfactory. A somewhat surprisingly large number (33%) reported their knowledge of the medical treatment options to be fair or poor. This response corroborates McSpaden's observation that a lack of attention to hearing loss (and hearing treatment alternatives) is not uncommon in medical school curricula.
Knowledge of Hearing Instruments - 60% of the physicians rated their knowledge of hearing instruments as poor or fair, 36% indicated they had good or satisfactory knowledge, while one physician rated his or her knowledge to be excellent (this individual also indicated a moderate hearing loss and use of hearing instruments).
Hearing Loss Among Respondents - Three of the 27 physicians reported having hearing loss; however, only one physician used a hearing instrument(s).
Continuing Education - 81% of the physicians indicated they would attend continuing education seminars on hearing loss and hearing instruments if available.
Discussion
The responses to the primary care physician survey questionnaire, although limited in number, support the following inferences:
- Greater emphasis needs to be placed on the role of the primary care physician in hearing loss identification and counseling if we are to have any meaningful success in increasing the number of individuals who receive the benefit of timely and efficacious treatment for their hearing loss. In addition, physicians must become aware of the fact that auditory prosthetics (hearing instruments and implants) are the only treatment alternatives available for the type of hearing loss that affects more than 90% of all hearing-impaired individuals - sensorineural dysfunction due to cochlear hair cell loss.
- The issue of an individual other than the physician performing cerumen removal should be addressed. We concur with Ballanchanda that it is essential for all non-physician individuals engaged in cerumen removal to supplement their basic education in anatomy, physiology, and pathology of the auditory system with specific didactic and practical cerumen removal training before attempting to extract cerumen from the ear canal;
- The issue of physician referral of patients for the purpose of further hearing loss evaluation and/or hearing loss treatment must also be addressed. Developing a greater understanding of the "Hearing Healthcare Team" - physicians specializing in treatment of the ear, audiologists, and hearing instrument specialists - will ensure that all members of the "team" will be represented with regard to physician referral for hearing loss evaluation and/or hearing instrument fitting.
- There exists a clear need in both academic and continuing education venues for the development of educational programming for primary care physicians that focuses on hearing loss identification, patient counseling, and treatment alternatives.
Conclusion
The results of this study suggest several conclusions that warrant further consideration. First, the survey highlights the need to provide more extensive academic and continuing education programming for physicians regarding hearing loss. The result of this effort should be a substantial increase in the number of persons who seek treatment alternatives to remedy their hearing and communication difficulties. In addition, the creation of a greater number of hearing-loss related academic and continuing education opportunities for physicians can serve to complement the Better Hearing Institute/Hearing Industries Association initiative to establish more effective interactive relationships between physicians and hearing healthcare practitioners.
Second, a reliable, easy to use, and cost effective method of establishing basic auditory sensitivity data should be developed and made available to primary care physicians. If this were to occur, we could expect a decline in the primary care physician's reliance on such ineffective methods of hearing assessment as the whisper test, the scratch test, etc.
Finally, it is reasonable to conclude that if an effort is not made toward increasing the primary care physician's role in hearing loss identification and counseling, the number of persons receiving timely and efficacious treatment for hearing loss will continue to be 15 percent or less of those affected.
Paul Popp Ph.D., BC-HIS, MCAP and Gregg Hackett BC-HIS, ACA, MCAP are hearing healthcare practitioners in Santa Rosa, CA. The study was funded by the North American Institute for Auditory Prosthetics. Correspondence to Dr. Popp at NAIAP, 1525 Farmers Lane - Suite B, Santa Rosa, CA 95405: 707.575.3591, e-mail: drpp@aol.com.
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