The Common Sense of Considering the Senses in Patient Communication

To the Editor: In this issue, Cohen and colleagues¹ report on a systematic review that addresses a question that is elegant in its simplicity and logic: How often do studies of physician–patient communication in older adults consider the patient’s hearing status? The (perhaps not so) surprising answer is that fewer than one-quarter of the 67 reviewed studies contained any mention of hearing. Only three of the manuscripts reported whether the patient’s hearing status was associated with the quality of physician–patient communication, and only one study described a communication intervention that included strategies to mitigate hearing impairment. Provider–patient communication is the cornerstone of effective, high-quality care, and it is wonderful to see a multitude of studies aimed at understanding the wide range of factors that threaten good communication, including literacy levels, cultural and language barriers, cognitive status, and environmental factors, but this systematic review should also serve as a wake-up call: How could we have overlooked the common and often modifiable risk factor of hearing loss?

Effortless, bidirectional spoken communication plays such a critical role in much of what we do on a daily basis —asking a spouse about their his or her day, talking on the telephone with a friend—that we often forget what happens when it is not effortless for the other person. Hearing depends on the ability of the cochlea to transduce and encode sound energy (speech is particularly complex) into a precise neural signal that the brain then has to decode into meaning in real time. As this process breaks down with age-related changes in the inner ear that lead to hearing loss, individuals notice that they can often hear, but cannot understand, because the sounds that the inner ear transduces are encoded with much less fidelity. The effect of hearing loss on patient–provider communication has received surprisingly little study, as demonstrated in this systematic review, but the implications are clear. Recent epidemiological studies have demonstrated independent associations between greater hearing impairment and risk and duration of hospitalizations and other adverse outcomes,² and it is likely that impaired patient–provider communication mediates these associations in part (e.g., consider what happens when a patient cannot fully understand a doctor’s instructions or questions, or an underlying hearing loss limits the flow and quality of communication between a patient and his medical provider).

Fortunately, solutions that mitigate hearing loss to optimize patient–provider communication are available. Simply striving always to communicate with a patient face to face from no further than 3 feet away (no hiding behind a computer monitor while typing!) while ensuring minimal background noise (e.g., TV muted, beeping monitors silenced, door to room closed) and speaking slowly (not loudly) can often ensure effective communication even with individuals who have severe hearing loss. One unintended consequence of electronic medical records is that clinicians often alternate between facing the computer screen and facing the patient; we should be mindful that this practice may annoy all patients but creates particular communication challenges for sensory-impaired individuals. Such common-sense strategies as facing the patient are applicable to communication with anyone, and geriatricians should apply these strategies universally with all patients simply by virtue of probability. Namely, if nearly two-thirds of adults aged 70 and older have a hearing loss significant enough to impair daily communication,³ there is no need for even a cursory screening test (e.g., whispered voice, finger rub) before proceeding to speak deliberately, face to face, at a measured pace. For individuals who appear to have continued difficulty understanding, routinely keeping a simple and inexpensive body-worn amplifier in a white coat pocket for use in such situations can make an immediate and substantive difference.

The broader implications of sensory loss for population health are also now being recognized and addressed at the national level. Recent consensus study reports from the National Academies of Sciences, Engineering, and Medicine on hearing and vision loss are providing the framework for short-and long-term changes needed to address sensory deficits to optimize the lives of older adults.^4,5 Specific to hearing loss, with which accessibility to and affordability of hearing care remain massive barriers (the average cost of bilateral hearing aids in the U.S. is $4,700 and requires several visits to a hearing professional’s office), a recommendation by the National Academies for the Food and Drug Administration to create a new regulatory classification for hearing aids immediately that could be sold over the counter offers the immediate possibility of ensuring greater access and affordability. Such a recommendation received the direct support of the President’s Council of Advisors on Science and Technology in 2015 and was the basis for a bipartisan bill in Congress from Senators Warren and Grassley.⁶

Likewise, the National Academies report on vision health recommended immediate action to address the preventable burden of vision loss.⁵ A large proportion of vision loss in U.S. older adults is due to cataracts and refractive errors, which can be readily treated with avail-able care, yet these conditions are underdiagnosed and undertreated, resulting in unacceptable rates of vision impairment that could be immediately eliminated with the right medical attention. Additionally, in part because coverage for assistive devices is limited, the millions of older adults with chronic, uncorrectable vision impairment underuse vision rehabilitation. To motivate nationwide action to lessen the preventable burden of vision loss, the National Academies report urged the U.S. Department of Health and Human Services to issue a call to action and launch a coordinated public awareness campaign.

Both National Academies reports acknowledge a relative underappreciation of sensory health within the broader population health agenda. The tendency, in clinical practice and research, to overlook sensory health as a central component of the human experience, as Cohen’s systematic review evidences, may have several root causes. First, in the modern medical delivery model, sensory care has become so specialized that services for hearing and vision are often rendered in silos alongside, rather than fully incorporated within, the “House of Medicine,” and clinical investigators with general health backgrounds often lead clinical studies that address population health and health services research. Although investigators from general medical backgrounds may intuitively recognize that vision and hearing status are important, many lack familiarity with or expertise in assessing or treating vision and hearing. Another explanation for underappreciation of sensory health may have to do with disparity. Much of the burden of sensory loss in older adults is treatable (with hearing aids, cataract surgery, corrective lenses); untreated sensory loss often reflects problems with access to care, which introduces opportunities for disparity. The consequence is that many older adults who need sensory accommodation may be in a limited position to advocate for it. Finally, and somewhat counterintuitively, the staggeringly high prevalence of sensory loss in older adults may serve to reduce the emphasis on addressing the problem. Many providers may consider moderate hearing impairment or vision loss as a “normal” part of aging, despite a growing body of evidence that failure to address these impairments results in measurable patient harm.

Whatever the historical reason, Cohen and colleagues’ review highlights a clear gap in patient–provider communication research and likewise offers a major opportunity for practice improvement. Common-sense, low-(or no-) cost strategies can be used to mitigate the negative effects of hearing and vision loss in patient communication. Even when formal audiometric and visual assessments are not feasible, most patients can reliably self-report whether they have problems with hearing or vision that may require special accommodation, and some accommodations (e.g., minimizing ambient noise, speaking face to face, creating patient education materials with large-print font) are so simple and potentially beneficial that they could be implemented universally. We can start improving the evidence base—and clinical practice—by simply remembering to ask.