Good afternoon, everybody, and welcome to the IHS webinar, How Motivational Interviewing Can Empower Your Clients, sponsored by Oticon. I'm your moderator, Diana Cheruvel, IHS's Associate Director of Marketing. Thank you so much for joining us. Before we get started, I want to share a few housekeeping items. Note that we are recording today's webinar so that it can be offered on demand through the IHS website in the future. Also, this webinar is available for one continuing education credit through the International Hearing Society. The CE quiz and information about how to receive credit can be found on our website, IHSinfo.org. Click on the webinar banner on the homepage or choose webinars from the navigation menu. Some handouts related to today's presentation can also be downloaded from the same page, and feel free to take a moment to do so now. Tomorrow, you're going to receive an email with a brief survey about this webinar. Your feedback is incredibly helpful as we continue to create valuable content for you moving forward. And lastly, please note that today's presentation is sponsored by Oticon, and it represents their view on industry trends and changes. The content has been specially developed for you by Oticon and may not necessarily reflect IHS's policy and stand on hearing health care issues. But now, on to our presenter. Motivational interviewing is a counseling approach that encourages intrinsic change and is built upon a goal-oriented strategic dialogue. To share more about this is audiologist Dr. Douglas L. Beck, Vice President of Academic Sciences at Oticon. Dr. Beck began his career in Los Angeles at the House Ear Institute in cochlear implant research and intraoperative cranial nerve monitoring. By 1988, he was Director of Audiology at St. Louis University. Eight years later, he co-founded a multi-office dispensing practice in St. Louis. In 1999, he became President and Editor-in-Chief of AudiologyOnline.com, SpeechPathology.com, and HealthyHearing.com. In 2005, Dr. Beck joined Oticon. From 2008 until 2015, he also served as Web Content Editor for the American Academy of Audiology, or AAA. In 2016, he became Senior Editor for Clinical Research at The Hearing Review, an Adjunct Clinical Professor at New York, excuse me, Adjunct Clinical Professor of Communication Disorders and Sciences at the State University of New York in Buffalo. Today, he is among the most prolific authors in audiology, with 188 publications and more than 1,250 abstract interviews and op-eds. And before we just started this webinar, he was jamming for us on his guitar. So Doug is a very smart man and a pretty cool one at that. So we're happy to have him here today. As you can see, Dr. Beck has a lot to cover. And at the end, we're going to move on to a Q&A session. On your bottom menu, you'll see icons for chat and Q&A. Please try to keep your general conversation in the chat box and all questions, which you can send in at any time in the Q&A box. And now let's get on to our main presentation. Take it away, Dr. Beck. Thank you, Diana. Thank you, Tara. Thank you, Chelsea. Thank you, IHS. It's always a joy to work with you guys, and I'm so appreciative of the opportunity. What we're going to do today is we're going to spend about 45 or 50 minutes talking about motivational interviewing. I'm going to try to get you a good, broad perspective of that. I'll give you a bunch of references. As Diana said, we have published quite a few papers at Oticon on this topic, and happy to have you download those. Those are on the site there. You can also find them at douglaslbeck.com if you can't find what you need on the website here. Okay, so what is motivational interviewing? Well, Miller and Rolnick wrote the authoritative text, but it came a few years before that. That was 2002. Motivational interviewing is a way of having a conversation in which the client, the patient, the other person, says what's happening and what's going to happen. The client voices their argument for change, and if we do this really, really well, what happens is they speak their desires, and when they hear themselves speak their desires, it's often the first time they've ever realized it. I know that sounds a little weird. Bear with me. So motivational interviewing is not therapy, per se. It's a tool for resolving ambivalence. So that, of course, gets us to the question of what's ambivalence, and ambivalence is the ability to see the good and the bad, yin and yang, north and south. You can see both sides of an argument, and what happens when people are ambivalent? Nothing happens. It's a deer in the headlights, right? Examples of ambivalence are all around you. You could say, oh, I really want to get a Mercedes, and anybody in this audience can afford a Mercedes if you're willing to have the payments, but that's the thing. It's more expensive, and then you have to park it at the end of the parking lot, and then if somebody crashes, they're a shopping cart into it. But you know you'd look really good in a Mercedes, and you know it's got the best service in the industry. Well, that's ambivalence. Most people don't own a Mercedes, not because they can't afford it, because there's payments, you get certified, you could get one if you want one, but most people are ambivalent about it because it's a little bit too much trouble, it's a little bit too much money for most people most of the time. So that's just a quick example of ambivalence. You know it's a great car, you know you'd look really sexy driving it, but most of us don't have a Mercedes because it's like, eh, do you want that much money in a car? Do you want to have to be that careful when you park it? So anyway, that's why I drive a Jeep. So ambivalence is, you know, you can see both sides, and people who are ambivalent tend to do nothing, so confused mind does nothing. So when we talk about the origins of motivational interviewing, people can be immobilized by their ambivalence, and this was what Miller and Rolnick and Archewitz were talking about. And so you want and you don't want the same thing, and people are often ambivalent about change. Let's be really fair here, nobody likes change. However, change happens every day, and you either stay on top of it and you stay involved with it, or you get run over by it. You can't be ambivalent about, you know, big issues in life. So people get stuck and they don't move and they don't progress. So MI is used to unstuck them. That's a technical term, to unstuck somebody. And what you're trying to do is to resolve their ambivalence. So MI works through ambivalence and readiness for change. So people learn what they believe by hearing themselves say it, and that's really an interesting viewpoint. You know, when I was a kid, right, you didn't talk about religion and sex and politics, right? And now, you know, it's a couple of years later, and people talk about these things all the time. And so they voice their opinions, and all of a sudden, you know, they take a stand and then they feel like they need to be true to that stand. There's a wonderful series of books called Influence by Robert Cialdini, and Cialdini talks about this a lot, that, you know, when you voice your viewpoint, that's it. You know, you may think about it and say, oh, that was really stupid. Or you may say, wow, I was wrong. But people don't voice that. They voice their opinion, and then they tend to stick with that. Anyway, a different topic for a different day. A brand-new book just came out. Adam Grant had a brilliant book called Think Again, came out about eight weeks ago. And I wasn't reading it because of motivational interviewing. I was reading it because he's a really smart guy. But he covers about a chapter on it, and so these are some of his thoughts. That motivational interviewing starts with humility and curiosity. Our goal is to hold a mirror up to the patient so they can see themselves more clearly. I really like that. MI has a statistically and clinically meaningful effect on behavior change. It requires a genuine desire to help people achieve their goals. And the goal is a trusting relationship. If you present information without permission, nobody's going to listen to you. So you have to ask permission. And this became a big thing with the internet and with emails and corporate emails, right, is allowing people to opt out and asking their permission to send them stuff. And this turns out to be true also in motivational interviewing, is the approach should be that you should ask for permission. Because if you offer advice or information without permission, it's not good. So you want to do it with permission. And so when a patient says, so what do you think I should do, the approach is very much, well, would it be helpful if I told you about my last client, my last patient? Wow, thanks for asking. You know, you may or may not agree, but let me tell you what some of my clients have said to me. So what you're doing there is even though they've asked you, you want to ask their permission to respond. You could say something like, I'm not sure that this is going to help. It's your decision. But let me tell you what I think. At least I'll give you my initial thoughts. And when you do that, it makes you a little bit more vulnerable, but it makes you trustworthy. When experts express doubt, they become more persuasive. So I'm just trying to see. I think my video turned itself off. Maybe it's back on. And so that's kind of an interesting perspective. And then he goes on to talk about accurate empathy, and he's quoting Miller. And Miller and Rolnick, again, wrote the premier textbook on motivational interviewing. It came out in 2002. Miller says that MI causes clients to verbalize their own arguments for change. And again, if they verbalize their own arguments, they hear themselves say it. You go back to Robert Cialdini, PhD clinical psychologist, and Cialdini says when they hear themselves say it, they're going to stick to that. So what does that mean? Well, that means people only change if they want to. I could say to you, hey, you should lose weight. Or I could say, hey, you should quit smoking, or you should quit drinking. But you know what? That's never really made anybody change. People change if and when they want to. It's got to be internally motivated. So all meaningful change comes from within. It's intrinsic. Extrinsic suggestions, ideas, thoughts. They're nice. They're interesting. They're fine. But people don't quit smoking because somebody said you should quit smoking. The goal of motivational interviewing then is to strategically explore the status quo. Where is the patient now versus where do they want to be? What are their specific goals? And to assess and reinforce their ability to achieve those goals. So when we think about MI, I will tell you historically, it has been used very successfully with drug addicts, with smokers, with obese patients, and with alcoholics. And so this approach is very, very different from traditional behavior change counseling and interviewing. And we'll get very, very specific in just a few minutes. So what we're trying to do with our patients is elicit from them an intrinsic motivation to change. If we do MI well, if we do it really strategically, the patient states the reasons for change, which is very different than you and I saying, well, Mr. Smith, according to my audiogram, you have a mild to moderate sensorineural high frequency loss. That means that you're not hearing the consonants well because that's the high frequency loss. They don't want to hear that. And frankly, when you go into that talk, about 50% of everything you tell them is immediately forgotten. If you don't believe me, Robert Margolis wrote that from the University of Minneapolis, Minnesota, 2004. Half of everything you tell a patient is immediately forgotten. And then of the half they remember, they get half of that wrong. So they actually only accurately own about 25% of the information that you've given them, which is why it's so important to do MI and to write everything down and to reinforce your key points through written materials because they're going to forget. This is not their whole world. This is a small part of their world. And for many, it's somewhat less important than their cardiac threat or their depressive threats or their dementia threats or diabetes. So hearing loss, sometimes, as you know, people think they can just self-manage it and they'll do fine. That's probably not going to happen. If they self-manage it, they're probably going to be in a world of hurt, but they won't know that. So my point is that you telling them they need hearing aids because they have hearing loss or listening difficulty, that's good. What's better is for the patient to say, I need help. So what we're trying to do with motivational interviewing is to get the patient to intrinsically motivate themselves by speaking words consistent with their status quo and their goals. Just a quick acronym rule. Resist the writing reflex. What that means is roll with resistance. Nobody likes to be corrected. Now, if you're not sure about that, if you're married, ask your spouse. Nobody likes to be corrected. If you, when a patient comes in and they say, gee, I'm not going to get hearing aids because my dad had a hearing aid and every time somebody hugged him, it whistled. Don't get into it. Don't say, oh, they don't do that now. There are new hearing aids that not only do they not feedback, but they say, what the patient just heard when you defended that, they heard, yes, hearing aids whistle. It's very important to not correct people. And I know this is really hard because we're really smart and want to tell everybody everything we know and we want to be the ultimate clinician in the patient's eyes. It's probably better to not correct people. Allow them to make mistakes. They're adults. If they say something crazy that you really need to, great, use your judgment there. But on little things that are relatively insignificant, roll with resistance. You, as understand the client's motivation, develop the discrepancy. That's what we're going to focus on today. I will show you how to develop the discrepancy between where they are and where they want to be so they say it in their words. And listen to your client. Obviously, you don't want to be arguing with them. And empower your client. That's self-efficacy. OK, so rules of engagement. Confrontation increases resistance. If you're that clinician who has to be right all the time, that's not working for you. I just promise you that. It's better to engage and to interact than to be Mr. Smarty Pants. Excuse me. Dose. Length and number of sessions is irrelevant. When you're doing motivational interviewing, if you do it well, it takes less time than what you're spending now on intake. It's all about trust. Nothing happens without trust. The experience in your office matters. The experience in your office builds trust and commoditization. One thing that most of us do that you shouldn't do at all, go to my website, download the form, fill it in, blah, blah, blah. Nobody likes that. Stop doing that. Horrible. The very best thing to do, let them come in, meet them, have a nice chat with them and say, Mr. Smith, I want to go through this questionnaire with you. Because then you're establishing trust. Particularly like if it's a tinnitus patient, I'll do the THI. I will never give the patient the form and say, here, fill this in. I want to ask them those 25 questions. You know why? Because it allows me to have a conversation with the patient that's relevant. It allows me to be a little bit silly and to establish a personal relationship. It allows them to be a little silly. We get to know each other. And none of us like filling in forms online and sending them in. So stop it. Build a better relationship. It takes longer. Yep. Yep. And that's fine. But in my private practice, when I used to have one, I would have like two hours for a new patient. I'm not advocating that you spend two hours. But what I am advocating is don't rush. People don't like to be rushed. It's a big thing that you're trying to build trust and a nurturing relationship and a helping relationship because you're a licensed health care provider. Slow down. Be nice. Take the time. Because in every transaction, human factors matter. In particular, they have to like you. They have to feel like it's personal. You have to adapt to them, not that they're going to adapt to you. You have to be kind, respectful. You know this stuff. There was a wonderful book written, gosh, it must have been like 1995, 1997. The guy's name was, I'll think of it. The title of the book was Everything I Needed to Know I Learned in Kindergarten. You know, when crossing a busy street, hold hands. When you're in a public restroom or at home, flush. Smile. Be nice. Wash your hands often. Robert Fulgham, he was a Unitarian minister. The book came out in 96, 97, something like that. And it was brilliant. Everything I Needed to Know I Learned in Kindergarten. That's the thing about human factors. They matter. Being nice, being kind, being wise, being a nice human being is really, really important, particularly as a professional. I just did a lecture a few days ago with my dear friend and neurotologist, Dr. James Banneke. And Dr. Banneke was saying, you know, there's the three A's. Be affable, be available, and be able. And that's the thing. So what happens when you take away those human factors? What if you're just abrupt and quick with people and stuff like that? Then you're left with price. That's it. Because if they don't really like you, trust you, know you, then it's just a transaction. Then you're left with price. And you can't win a price war with OTC or eBay or Amazon or PSAPs. I mean, there's always going to be a cheaper product out there. So don't make it about price. Make it about trust. Make it about compassion. Make it about empathy. Make it about the things you can realistically enable the patient to do to enjoy a better quality of life. So when it's about human factors, you're good. We can do that. We can make that work. Mother Teresa said, they're not going to remember what you said or what you did. People remember how you made them feel. And if you Google this, you'll see it's attributed to like 12 million people. But I like to think that Mother Teresa was the first one who said it. Maybe she didn't. I don't know. But it's attributed to her, one of the many 12 million people. And I think it's so important. People, and it's just what Dr. Margolis said. Half of everything you tell them is immediately forgotten. Half of what they remember, they remember wrong. So it's not really about the specific content. It's about how you make them feel. OK, so don't we counsel already? Well, what you and I generally do is informational counseling. How to change the battery of a hearing aid. How to clean wax guards. How to put a hearing aid in your ear. How to hook it up to your phone. How to hook it up to Bluetooth. Blah, blah, blah. That's informational counseling. What counselors do, psychologists, psychiatrists, social workers, people like that, they do behavior change counseling. And so it's kind of different. And here's a perspective from the Journal of the American Medical Association, 2018. Patients are better informed via the internet and social media. They are less dependent on health care professionals for health care information and resources. They asked Dr. Google. The patient-provider relationship is moving away from medical paternalism and towards patient-centric care. Now, this is the JAMA. This is the Journal of the American Medical Association three years ago. And patient-centered care is what it's all about. It's meeting the patient where they are and allowing them the choice and to be part of the decision-making. So one critical component of patient-centered care is indeed shared decision-making. And the time and the words we share with patients are precious, and I would urge that we need to be more strategic. So motivational interviewing, a client-centered directive method. It's not just a willy-nilly, loosey-goosey conversation. It's totally strategic, as I'll show you in a few moments. And to change by exploring and resolving ambivalence. So number one is develop the discrepancy. What am I talking about? So the patient comes in, and they say to you, so listen, I don't even have hearing loss. I'm here because my husband, my wife, my fill in the blank, says that I don't understand when we're in a restaurant. So I'm just here to prove that my hearing is fine. I don't have any troubles hearing, blah. So what you say to develop the discrepancy, this is example number one. You might say something like, OK, so when you're in a crowded restaurant, he or she thinks it's hard for you to understand. And you're thinking you're doing fine there. Is that right? Yes. OK, well, how do you do, this is you talking, how do you do if you're at, supposing you go to a crowded bar, and you're there with a couple of people you work with. You're having drinks after work, and the band is playing. Can you understand everybody around you? No, of course I can't. And nobody could understand that situation. That's a really difficult situation. And the band is, right, OK, no. And how do you do at home if your wife is like, she's making dinner, and you're working out in the garage because you're a traditional male-female, occupationally driven couple. So you're in the garage working on the car. She's cooking dinner. Does that happen anymore? But let's suppose it did. And she says, hey, dinner's ready. And you say, 4.30, because you didn't hear her. But you thought she asked, what time are you going to be ready? Or does that ever happen? Do you get confused? Or do you guys miscommunicate? Yeah, well, sometimes. But she's not talking loud enough. I'm two rooms away, blah. And you're writing all this down. That's developing the discrepancy. You're not going to deny that he does or does not have trouble hearing. What you're going to do is, as soon as you get cues, like he may say, well, when I'm in the front seat and my daughter's in the passenger seat and I'm driving, my wife's in the back seat with the grandkids, I can't understand them. Then you write that down. And you want to develop the discrepancy. So you might say, how do you do when you take the kids to McDonald's for breakfast on Sunday morning? Oh, that's terrible. I can't understand a word they're saying. And you just want to think instantly of all the worst situations you can and ask him about it. Because that's he or she saying about how bad it is. That's developing the discrepancy. I'll give you more on that in a little bit. Roll with resistance. Don't correct people. And match your strategy to their readiness to change because our goal is to move them along the continuum. It's not every time you see a patient, it's not a home run. But if you slightly move them along the continuum, that's good. So you're going to direct the discourse to probe and reveal the desired outcome of the patient. So you set up the context. So here's what we do. We already covered this. Confrontational styles, that's bad. You don't want to be demonstrably Ms. or Mr. Smarty Pants. And Dr. Phil is really good at this stuff, motivational interviewing. And he comes very rapidly to the correct answer. And he doesn't waste a lot of time. So is this the best question to ask an alcoholic? So do you have trouble drinking? Because an alcoholic is going to say, no, I don't have trouble drinking. I drink, I fall down, it's no problem. But we do this with hearing impaired patients. We say, do you have a problem hearing? Well, that allows them to say, no, they don't. And then they're going to tell you why they don't and whose fault it is and blah. So stop asking that question. If they're in my chair, my office says Dr. Douglas Beck, audiologist, hearing aid dispenser, blah, blah, blah. And so if they're sitting in my chair, I'm going to presume they have hearing loss. I'm not going to ask this question. Because if I ask, it's not a good strategic question. Because if they say no, what did they hear themselves say? They heard themselves say, no, I don't have hearing loss. So that's what they're going to be true to. But you need to ask the right questions. And more importantly, you can't ask the wrong questions. We have to stop doing that. So let me give you some examples. Here's a wrong question. Do you think you have hearing loss? Well, I'm sorry. But most people with hearing loss don't think they have hearing loss. So why are we asking that question? And here are the numbers. 325 million people in the USA. 37 to 38 million of them have difficulty, have hearing loss on an audiogram. But there's another 26 million in the USA who have hearing difficulty, which I refer to as listening difficulty. Normal thresholds. And how could they have normal thresholds yet have listening difficulty? Well, they could have ADD, ADHD, dyslexia, cochlear synoptopathy, neurocognitive disorders, Alzheimer's disease, traumatic brain injury. They could have, did I say cochlear synoptopathy? Auditory neuropathy spectrum disorder, auditory processing disorders. They could have a million things that they can't understand what they heard, but they heard it loud enough, right? So do you think you have hearing loss? It's kind of not a great question because they could say no and then they're gonna hear themselves say that. Do you think you need hearing aids? Here's the funny thing. No patient has ever said, yes, I need hearing aids. So why are we, if we ask them that question, they're gonna say no, probably. They're gonna say, not only don't I need hearing aids, but my husband needs to learn to speak more clearly. And my son needs to enunciate better. And these kids today, they all mumble. I mean, we're gonna get those conversations and we don't want those conversations. It's a waste of our time, it's a waste of their time. Are you concerned about your hearing loss? Well, they're not usually concerned. The only time they're concerned is if there are medical referral, right? They have pain in their ear, they have otalgia, they have drainage, they have blood coming from their ear, they have vertigo, they have unilateral tinnitus, then they're concerned. But that would be fewer than 5% of all patients with hearing loss. 95% of all patients with hearing loss, of the 38 million, do not have medical signs or symptoms that warrant referral. You know, there are presbycusics, age-related hearing loss, noise-induced hearing loss, et cetera, et cetera. So are you concerned? Well, the other thing about being concerned is, of course, you probably learned that it takes seven years from the time you realize you have a hearing difficulty until you do something about it. Well, that was true maybe in the 70s and 80s. The most current literature shows it's nine to 10 years between the time somebody realizes they have a problem hearing until they do something about that. And that's peer-reviewed. I can show you that some other time. The ultimate wrong question, the question you should never ask. So you fit a patient with brand new, extraordinarily good hearing aids. You've done real ear, you've done speech and noise, you've done everything you're supposed to do according to IHS best practices, and you have done a perfect job fitting these people. And then you say to them the absolute worst question you can. Brand new patient, and you say, how does that sound? Because you know they're gonna say, oh, it's a little tinny, I'm hearing like a... And then you're gonna have to say, well, see, because you have hearing loss in the high frequencies, you don't usually hear that. Now you hear them suddenly, they're back. And so it'll take your brain a little while to get used to that. And then while you're having that discussion, then they're gonna say, oh, my voice, my voice sounds terrible. Oh my God, I feel like I'm in a barrel. Don't ask this question. This is not a good question. You're the professional. If you have fit your hearing aids according to IHS best practices, which I hope you do, and please look them up if you're not sure what they are, you know it's gonna sound fine. And this is part of your pre-fitting counseling is to say, listen, when you first get your hearing aids, it's gonna be very interesting because you're gonna hear yourself. You're gonna hear your own voice. You're not used to that. You're gonna hear sounds around you that you're not used to. And it's gonna take three, four, five weeks to get used to it. There's no shortcut. The easiest way to do it is to wear them from sunup to sundown seven days a week. And in about a month, you'll be totally used to it. In fact, you're gonna feel when you take them off, like when you take off your reading glasses, you know, everything's a little bit fuzzy, you can still see. But that's kind of what we're going for because we know that you need a little bit of help and these are gonna help you, but are they gonna sound perfectly natural and normal to you immediately? No, they're not. So what? We shouldn't ask that. This question, my friend, Craig Dunkel, Craig died a few years ago, but he was genius. And he was such a nice person. Craig used to say, we fit to the butt. And what he meant by that was when you ask a patient, how does it sound? And they say, oh, well, your voice is pretty good, but my, right. So then we start tweaking the hearing aids and adjusting them. And it was really a counseling issue. We didn't need to change the hearing aid. It was set properly. If you've done real ear-aided response, if you've done speech and noise, and you've shown that their signal to, their SNR 50, the signal to noise ratio, your 50% of the words correct has improved. You've done it right. The rest is counseling. So let's not fart around with hearing aids that are set well. Let's counsel. Here's some good questions. What caused your hearing loss? Why is this a good question? Because virtually, whether they admit they have a hearing loss or not, they wanna tell you a story. And so the question is, so what caused your hearing loss? And you might have some old crotchety guy who says, well, you know, I was in a World War II, you know, the big one, right? And they're gonna go into their story. Great, let them say that. Because once they're done with that story, then you're gonna say, wow, that must be really difficult. So I presume that, you know, cause you were in the big one that you had a lot of noise exposure. I mean, there must've been munitions going off around you. I'll bet you fired guns hundreds of times without any hearing protection, right? It was before hearing protection was a thing. And he's probably gonna say, oh yeah, we didn't know anything about that. You know, and great. And you're writing it down. You know, military artillery explosions, no hearing protection, blah, blah, blah. Because later on in the discussion, when he says he doesn't need hearing aids, you're gonna be able to say, Mr. Smith, you told me about being in World War II and how you had all of these noises that your ears weren't protected. And as I said, your hearing loss is consistent with noise exposure and, you know, and with what we would expect in your age, which doesn't make it normal. In fact, people in your age group who have hearing loss have a far more difficult time. The quality of life is quite often lower. They are socially isolated often. And this type of hearing loss, untreated, does contribute to social isolation, depression, anxiety, stress. So, you know, you're gonna use these things strategically, but not without asking the right questions because they have to tell you the story first. One question that I used to ask a lot is I would say, so Mr. Smith, thanks for coming in today. You know, it's May 20th, 2021, and you're here today. So my question is, has your hearing loss gotten worse lately? I mean, why are you here today? Oh, you know, well, I'm just here because, you know, they do that story. But whatever they say, you wanna develop a discrepancy. You know, if they say, well, I really don't have hearing loss, I'm just here to prove, then great question. Well, who around you thinks you have hearing loss? What is their perception? What do they think? And then you're gonna query into those areas. Here's another great question. How long have you had hearing loss? Again, most people have a story and, you know, they'll say, well, maybe, you know, my mom and dad had hearing loss when they were older. So I kind of expected it would happen to me. And, you know, blah, blah, blah. But the reason these are brilliant questions is because the patient is talking about their hearing loss. They're talking about how they got there. They're talking about their experience with hearing loss. You see, and then later, it's very hard for them to deny that they have hearing loss because they just spent 20 minutes telling you about how difficult it is. This is my favorite question because I don't even care what the answer is. Which is worse, Mr. Smith, a noisy cocktail party or a noisy restaurant? I don't care what he says because he or she is absolutely gonna tell me one is worse than the other. And when they tell me that one is worse than the other, I'm gonna go, wow, that must be really difficult. And how do you do that when the waiter comes up and the waiter is telling you about the specials for the day? Is that easy or hard? Well, you know, they're talking right here to me. I get it. But when they're across the table, oh my gosh, yeah, of course, of course. And what happens? So you're at that busy restaurant. The waiter just took the order and you're chatting with your workmate or your neighbor at dinner. And now the band starts. How do you do that? Oh, when the band starts, forget you're developing the discrepancy. Many of my patients tell me, this is a great question. You can use this till the cows come home. Many of my patients tell me that women and children's voices are the most difficult. Is that true for you? It's just a great opening question because they're gonna say yes or no. If they say no, then you put them in the car going to McDonald's with their grandkids. Can you understand the little kids in the back? Because the answer is probably gonna be no. What about when you're on the telephone with your granddaughter or your grandson? Can you understand what he or she is saying? Oh, no. And so this is what you're looking for. Develop the discrepancy. So whose voice is the most difficult to understand? They're gonna tell you. And when is that voice the most difficult to understand? So supposing he says, it's my favorite person, it's Olga. And then you say, so how is it when you and Olga are at a restaurant and it's really, really noisy and the band started playing? And you wanna just keep going back there, keep going to that well. You know, that's very, very useful once you find something that resonates with the patient. When you find that difficult situation, you know, you wanna build it up. How long have you had hearing difficulty? Good question. And the thing is, right, you don't wanna wrestle with them. This is the strategy, is to get them to tell you about the most difficult listening situations. Because when you push, they're gonna pull. So you don't wanna challenge them. You don't wanna threaten them. You don't wanna draw a line in the sand. You don't wanna annoy them. You don't wanna scare them. And you don't wanna use the audiogram as a weapon, right? Well, Mr. Smith, you have to get hearing aids because you have a mild to moderate sensory neural high-frequency loss. Don't do that. Don't do that. Don't be that guy. Because again, Mother Teresa said, you know, they're not gonna remember what you said or did. They're gonna remember how you made them feel. So make them feel good. Make them feel smart. Make them feel like their observations are really clever and write down everything they say. Because patients really like it. If you're my patient, I'll continue to go back so we can see, you know, and I'm sitting here with a pad and I'm writing down your answers, they think I care. And if we're just chit-chatting, not so much. You know, it's part of the magical thing that we do as clinicians is we're having a conversation but their responses are the ones that are important. Their responses are what we're writing down. Their responses are what the treatment revolves around. Pardon me. So I wanna just draw your attention to the Ida Institute. About six months ago, I did a lecture series with Cheryl Lee Rutherford. Dr. Rutherford's an audiologist in South Africa. And she is the director of audiology at the Ida Institute. And the Ida Institute is free. You can go visit it and you get a lot of really cool tools. And some of them are on motivational interviewing. And this PowerPoint is from them. The patient's task is to articulate and resolve their own ambivalence. And the practitioner's task is to help the patient examine and resolve their ambivalence. And they have simple, simple, simple tools like a line. You say to the patient, how important is it for you to improve your hearing right now? And they may say, well, it's a two or it's a six. Whatever they say, you have a really good answer. Like if they say it's a six, you might say, so you gave yourself a six. You didn't give yourself a one. And you're clearly more than halfway on the line. What more can I tell you? What else do you need to know in order to help you make this decision? So it's tools like that that are not threatening. They don't take a lot of time. So the patient, again, begins to articulate their reasons, perhaps thinking deeply about this for the first time. Again, IDA Institute, you're always more likely to be convinced by yourself than by somebody else. So you need to ask strategic questions that set them up to state what's going on and why they should change. So the patient should do most of the talking because what the patient says is probably what's gonna happen. So hearing aid evaluation, step one, if you go to the International Hearing Society, IHS, you look at best practices, you already know this. You're supposed to be doing a listening and or communication assessment, right? And that's very important because that tells you so much more about the patient than an audiogram. I mean, to me, audiograms, listen, you have to be great at it. And it's a very, very important tool. It's the gold standard of hearing after all. But does it mean that much to me as a doctor, as a clinician, as an audiologist, as a dispenser? No, if I have to pick the single most significant number, it's their SNR 50, the signal to noise ratio it takes to get 50% of the words correct. In other words, their speech and noise score. That to me represents the real world ability and difficulty. An audiogram, audiograms are important for medical purposes and to get you oriented as to how to set the hearing aid. Of course, I'm not saying they're not important, but I'm saying if I only had one measure on a patient and I knew they had a mild to moderate loss, well, yeah, I got that. And they may or may not, only one out of 10 people with that loss do anything about it. But if I know that that person's SNR 50 is nine, even though they have normal thresholds, I know that they're in a world of hurt and they need a better signal to noise ratio. So if I had to pick one, it wouldn't be an audiogram, it would be an SNR 50. But anyway, so the IHS says you're supposed to do this as best practices, a listening or communication assessment, something like the PACA, the personal assessment of communication ability, because that tells you how they're getting by in their life. It doesn't tell you their pure tone thresholds, but I'm gonna say that your pure tone thresholds although incredibly important, when you're talking about counseling and doing motivational interviewing, we need to address the patient where they are, their needs, not their threshold results. And their threshold results are part of it, of course, but hearing is simply perceiving sound. That's all an audiogram measures. Listening is attributing meaning to sound. Listening is decoding the neural signal. Listening is comprehending sound. So these measures of listening and communication assessment, these are measures that tell you how the patient's doing in the real world. How are they responding? One-to-one conversation, maybe in small groups, maybe in large groups, maybe outdoors, maybe at a concert, maybe in a movie, maybe in places of worship and lectures. That's why communication and listening assessments are so important. And there's a bazillion of them. The COSI, of course, Harvey Dillon created that about 30 years ago, client-oriented skill improvement. I'm not gonna go through it because of time constraints, but you've seen it before. You just fill in the blank. Tell me your most difficult situations. Tell me your easiest situations. And then you touch base 30 days later and see if you solve those problems. My favorite is the International Outcomes Inventory. That one's also been out there since the late 90s, I think. And it's also just a Likert scale, one through seven, and you grade the patients. And again, I would really urge you to not give them the paperwork and have them fill it in. You should have the discussion with them. Spend the time, develop trust, get to know them. It could work really well. Red flags for mental health referral. Because when we're doing things like motivational interviewing and we're digging deeper into their psyche and we're getting to know them better and they're getting to know us better, stuff happens. There are many people who have hearing loss, who are depressed, who are socially isolated, who are anxious, who are in trouble. And so I want you to be aware of some red flags for mental health referral. There are times when it's okay for people to tear up in my office. I remember telling young parents that their children were deaf, their child was deaf. And for me, if they don't get teary and start crying there, that's a little awkward. So that's okay, but it's not okay if every time they come in, they're crying about something. Of course, suicidal verbalizations, expressions of hopelessness because these are people who have hearing or listening disabilities. Their world is not as easy as everybody else's. So we have to be aware of these things. And if we don't dig deeper, nobody else is going to. So I'm going to leave it there. Again, we were trying for just about 45 minutes, which we kind of nailed. And I don't have the time in one hour to give you in-depth, but I hope I gave you the right framework so you can think this through and say, yes, this does make sense. And I need to look deeper into this because it really makes your job easier and it makes it so much easier to converse with the patient when we stay focused on the reason that they are there. We tend to do a lot of chitchat to be friendly and neighborly and professional, which sometimes works against us. Sometimes we ask questions of the patients that become detrimental because they hear themselves saying, I don't really need hearing aids. It's not me. Everybody mumbles. And we don't want to go down that street. We can avoid that if we think strategically and if we think ahead before we ask a question. The line in the sand might be just for you to say, is there a potential for an answer that the patient will speak that they will then adhere to? Because you only want to ask questions that are beneficial for you and for the patient. We're not trying to lie, cheat, or steal. We're trying to actually get the patient to focus on his or her problem, which is what brought them in to begin with. And if we can get them to do that, undoubtedly, we can develop the discrepancy. Undoubtedly, we can help them say those words about the difficulty they're having. And then it makes it easier for us to frame a solution because the words came out of their mouth. It's now apparent to them what's going on with them. They're thinking of it in a way they hadn't thought of it previously. And they're more open to solutions. So with that, I'm going to turn it back over to Diana or Tara or Chelsea. I'm not sure who's moderating our Q&A, but I'm not in any hurry. I will stay here until the last question is answered or until they turn us off. And I thank you for your time. Thank you so much, Doug. That was great. We are ready to take some questions, as you have said. So if you've got anything for Dr. Beck, please go ahead and enter that into the Q&A box there at the bottom of your screen. We're going to take as many questions as we have in the time we have allotted, so go ahead and share. Our first question today is from Ashley. And Ashley wants to know, what is the best way to handle a patient who wants the cheapest hearing aid for their hearing who wants the cheapest hearing aid possible and they're not really interested in receiving your information otherwise? You know, that's been an issue of debate in my 39 years as an audiologist, right? What do you do in that situation? I try to make it all about service and about me and my practice. When a patient is, you know, if they're honest enough to tell you that they just want the very cheapest solution, you know, that's up to you then, you know. And at that point, I would say to most of them, let me give you some advice from Mike Valente. Mike Valente just retired after 40 years as the head of adult audiology at Washington University. And what Mike said is that it was so important for Wash U in St. Louis to compete in that low end because, you know, there's a lot of people in the lower socioeconomic group who need help. So they developed an inexpensive hearing aid program, they didn't call it that, but they could sell two relatively inexpensive hearing aids with diagnostic testing, with warranty, with, you know, hearing aid checks and we'll clean out the filters for you, we'll honor the warranty for a year or two. And they could do that for about a thousand bucks. So if you look at your major manufacturers, and, you know, everybody's not going to be fit with premium technology. So if the patient is honest enough to disclose to you that they want the very cheapest thing they can, I would have something ready. I would say, you know, Mr. Smith, thank you for being honest. I appreciate that you're in that situation and I want to work with you. We have two hearing aids made by, you know, a major manufacturer. These are high quality hearing aids. These are, they come with a two year warranty. You can come in once every two or three months, I'll change the wax cards with you. So you'll learn to do that when the warranty is over, you'll know how to do that. If the hearing aid needs to be serviced, it's covered. Here's the thing, you know, if you go and you buy hearing aids for 400, 600, $700 over the counter direct to consumer, what are you going to do when it fails? Because we know that hearing aids are a high touch product. They need service and the really good ones, we can reprogram as many times as we need. You could give them an example of, you know, your favorite manufacturer, probably Oticon, I would guess. But, you know, you could, so I would handle it that way. I like that approach. I don't want to be selling hearing aids for 299. I know there's some audiologists who say, oh, OTC is great. Well, I don't see that. I see people being frustrated. I don't see who's going to take care of them. When they buy them at Walmart or Walgreens and they spend 299, 499, and, you know, 97 days later, it's filled with wax, you're going to bring it to the kid at Walmart and say, hey, this stopped working. Because the kid's going to say, you had 30 days to return it. You didn't. You got to buy another one. I mean, I, you know, we can deliver low end products if we know that that's the goal. I don't really think that's the goal. I, you know, in my practice, I always showed people peer review data and I would talk about quality of life and I would talk about why, why are hearing aids expensive? Well, you know, hearing aids are not inexpensive, but the point is that when you're buying a premium quality hearing aid, I can show you it's less listening effort. I can show you it's better sound quality. I mean, you could look at the UBS studies. You could look at the studies from Jefferies. You could, and, and, you know, you're getting better sound quality, you're getting better noise reduction, less listening effort. We've seen some indications that it makes it much easier to listen in difficult sound, difficult, noisy situations when you have premium hearing aids. Now, some people would say, oh, they're all the same. They're not. The peer reviewed literature is fairly clear that different levels of technology give you different benefits. So, so I would approach it that way. I would make it about me. I would make it about my office. I would make it about service. I would make it about, you know, you get what you pay for. Value is what did you pay versus what did you get? Now, if you're looking for the very cheapest, and, and if you want to read how Mike Valente did that, you can go to hearingreview.com. And I think it was in July of 2020, Mike and I did his exit interview, his exit from the profession. And it runs about four or five pages, but he talks about that in there and how important it was to have a product for people who are in that socioeconomic group. And that's all they can do. That's really interesting. I think, you know, having those options is amazing. So we've got another question here from Patricia. She's interested to know if you've got any recommendations on books to read, and more generally, if you've got recommendations on how to learn more about motivation interviewing. Yes. I, there are a number of books on motivational interviewing. Very few of them deal specifically with audiology or hearing aids. Greenberg has a very good clinical guideline. It came out 2012, 2014, something like that. That one's really good. You have to apply it yourself to our scenario. You know, the ultimate text is Miller and Rolnick. And if you get that one, and if you get that one, you won't find a word about audiology, but you'll see example after example, after example, across all psychology arenas where patients using standard intake protocols versus MI, MI always did better because it got the patient to say, you know, what they would like to do and whether they're able to do that or not and what the impediments are and how they would like it to go. So I would start with Miller and Rolnick, although it's a bit of a snoozer. It's like 900 pages, but, you know, send me a note. I'll let you borrow mine. But, but, you know, so the Rosenberg book I think is better because it's more clinically relevant. Great. Thank you. So we've got a question here from Ann and she's asking, with the emphasis now more on counseling, do you feel that hearing instrument specialists should have some kind of a qualification with counseling? She's got a master's in CBT and she doesn't have any problems dealing with any degree of anxiety, depression, but some colleagues are rightfully wary of delving into that sphere if they're not really equipped with the proper tools. CBT is cognitive behavioral therapy and it's brilliant. And it is the go-to therapy in America in 2021. So I'm not sure Diana, if I understood. So she is certified as at a master's level with CBT. So that's brilliant. And I think that's great. Most of us aren't going to put in that time. There, there are CBT courses you can take and you can, you can develop a credential for that. I would urge you to go to the IDA Institute and you can get, you take their classes and you can get credentials that are very, very specific to audiology and hearing and dispensing. And so it's endorsed by IDA and it's a sticker you could put, you know, on your website and on your business cards when you take their motivational interviewing course and things like that. So I do, you know, these things aren't things that you just, Oh, I heard Doug talk about motivational interviewing. I think I'll do that. Step two, after you get interested is you got to read about it. You got to read a lot about it. And really it's good to do, you know, kind of role-playing, you know, if you have a trusted colleague who you could say, I want you to be a really nasty patient, let me see how I can handle this. And you go back and forth because you'd be surprised, you know, once you develop that script and how to strategically deal with these people who are nasty or antagonistic or ambivalent, you know, when you have gone through and you've spoken it, you start to develop the mindset of how to do it. So I think that this is a really good opportunity for role-playing. Dr. Mike Harvey and I taught a course at Asher AAA or ADA, it must've been eight or 10 years ago on motivational interviewing. And he's a clinical psychologist. And we did role-playing for three hours with this massive group. There were 200 people who took the course and we broke them into groups of 10. And you know, it was, it was magical. I mean, because, you know, of course everybody gets goofy at first, but then once we get down to the serious work and you start to speak it and hear it coming out of your own mouth, you're really very well prepared to do it. So you can't just do it after taking this course, but read the papers that Diana has referred to. They're on the website and each one of those has like 50 or 60 references. Look up some of the more interesting ones and definitely get the Rosenberg book, good clinical guideline. And you, you know, you'll be ready to go in 30 days. But what I'd rather do for most people is say, you know, the Ida Institute courses, I believe they're free and you get to earn CEUs for them and you get a certificate saying that, you know, you've taken the class in whatever area you chose. Great. Thank you. I hope that helped you, Ann. We've got another question and this is in regards to family and their interactions. So how would you overcome a parent, for example, taking over answering for a teenage child without upsetting those involved? While both are important, sometimes parents like to control the show, even when their child is able to answer the questions on their own. Yeah. So that's a dynamic that everybody struggles with. So you may have noticed I have a lot of gray in my beard and I don't, have you noticed, I don't have a lot of hair. Diane, I know you noticed. So it's different. You know, when I was 28 or 29, when I became an audiologist and I would have, you know, a 45 year old parent who didn't let their child answer, it was difficult because I was closer to the child's age than I was perhaps to the parent, you know, that sort of thing. Now that I'm an old guy, it's really easy for me to, I would allow the mom or the dad to finish what they're saying and I'd say, oh, thanks. I appreciate that. Listen, what I want to do now, I'm going to direct a few questions to Johnny or to Susie and I want to, let's hear what he has to say for a little bit, but thank you so much. I'm so glad you told me that. That's great. And I'd write it down because you want to really make them understand that you did think it was great. You don't want to lie to them, but, but it's, you know, that whole thing, like some places, you know, audiologists, which are, you know, 85% female, right? They're introduced to, oh, this is Diana versus this is Dr. Gervil. You know, to me, that's just wrong. You should be respectful. If it's a, you know, a hearing aid dispenser, you should use their real name. You should say, you know, this is Mr. Smith. He's a licensed dispenser. He's going to be taking care of you or whatever the right words are for that. If it's a doctor level person, I think you should use that title. You never go wrong by being too polite. And so I think that that's really, really good. So with a mom who's imposing herself on the conversation or a dad, it's easier for me now that I'm old to just listen to them, understand that they want to tell me everything. I got that. And maybe I would even encourage them with another question or two before I cut them off because I don't want them to feel like I was rude. So even if they jumped in and they were rude, okay, I'm going to ask them another question or two. And then I would say, okay, now listen, here's what I want to do. I thank you for sharing that with me. That really helps me a lot. What I want to do now, I'm going to talk to Johnny specifically and Johnny, so you heard what your mom said, but I want to get your thoughts directly from you because it's important because you're actually the person who's going to be wearing these hearing aids. So, you know, or not, but I want to speak to you for a few minutes. So I handle it that way, but listen, I totally get that when you're a 35-year-old female and you're dealing with some crotchety old guy who won't shut up, you're not, in his mind, perhaps on a level playing field, even though in the real world, you kind of are, and you're the expert here. But socially, people treat you differently when you're young and when you're old and when you're male and when you're female and more and more. And so, you know, it's harder for some people because they're younger, because they're female, and that's just a bunch of nonsense. So the way that I would handle it now is, as I said, and what I would suggest for you, probably the same thing, let the adult talk. Don't cut them off. Realize that, you know, they're looking for, you know, to help their kid. That's why they're there. And so if they're a little bit rude or awkward or out of order, let it go. You know, don't correct people. Remember, we covered that. So let them do their thing. And then maybe before I ask Johnny a question specifically, what I would recommend is say, Mrs. Smith, I have one more question for you, and then I want to talk specifically to your son or your daughter and see what they think. You know, so actually feed them another question. Don't let them think you're rude, because if they think you're rude, that's the end of it right there. Because remember we said, it's got to be built on trust. Validation is important. So thank you. Yeah, you bet. Joel is asking a question about right and wrong questions. So if we assume that a patient is there because they have a hearing loss, what is a better way to ask, what have you noticed about your hearing? So that they don't open the door for them to say, I haven't noticed anything, or I hear just fine. Yeah, that's exactly the point, Joel. Well done. You have to ask strategic questions. And so I would almost always start with something like this. Mr. Smith, thanks for coming in today. It's great to see you. Hey, listen, was it okay parking? Because I know it was jammed. You know, be nice. Get a little bit of rapport going. And then I would say, before I do any tests, you know, it really helps me to understand. So I can see what I'm looking for. I'm going to give you a scenario. And you just tell me your answer off the cuff. So what's the most difficult listening situation? Is it more difficult for you if you're in a crowded restaurant, or if you're at a bar after work with a couple of your friends? Which one is more difficult? I would open with something like that. Because if you ask them specifically about hearing loss, you know, again, there's a likelihood they're going to say they don't have hearing loss. Everybody mumbles. When I was a lad, everybody had to enunciate, you know. So you're right. Don't go down that door. Go down, you know, don't open that door. Go down a pathway that's going to be more productive, most likely. Great. Thank you. We've got a question from Jessica. And she wants to know if you've got any recommendations for working with teens who do not wear their hearing aids at all or very consistently. And maybe that's something that's not just for teens, but for people. Yeah. You know, listen, being a teenager is the toughest thing in growing up, you know, because you have the body of an adult, but you have the brain of a child, right? And each child is different. And, you know, when there's a one-size-fits-all solution for a teenager, it's probably wrong. So what I would do, and I think this is very, very valuable, is you have to talk to the individual and child. And I would ask some leading questions like, you know, what's the best thing about wearing a hearing aid? How are you doing in school? Hey, look, do your friends make a fuss that you wear hearing aids? Talk about it. Because if you don't talk about it, they feel like they're the only ones. If you don't talk about it, they feel like it's only them. If you don't talk about it, they're isolated. They have nobody to share that with. So if you suspect there's a problem or mom and dad tells you there's a problem, I think open communication is good. I think honest communication is good. And I would ask what I think are probably the most difficult questions because that's what's causing the most problems, right? Do the other kids make fun of you? I don't know. You know, I'm not a psychologist. I'm just a simple country audiologist. But I think that if it were, you know, if it were me dealing with that and mom and dad says, you know, gee, the hearing aids do great when he's wearing them, but when he leaves the house, he doesn't wear them. You know, I'd be really honest with them and say, listen, you know, you're hanging out with your friends, you're listening to loud music, you're yelling at each other, you probably don't need them there. But do you at least take them with you in case you get into a difficult situation? I mean, you have that little pocket pack, you can put them in, or do you just leave them home? What are you doing? Why do you do that? And he'll say, well, you know, but you got to have the conversation. And so the conversation and the personality leads you to the answer. Anytime somebody has a one size fits all answer for hearing aids, adults, children, teenagers, it's probably wrong. So, you know, and I hate to say that because I know it sounds like a cop out, but I've been saying this, maybe I've been copying out for 25 years, but everything depends on everything. There's no one solution in anything to do with audiology that's good for every patient, whether it's a teenager, an infant, or an adult. Very good information. So thank you, Doug, so much. We have run out of time, and I think we could probably go quite a bit with all of these questions that are coming in, but we appreciate your time so much, Dr. Beck. And that's our presentation for how motivational interviewing can empower your clients. A big thank you to Oticon for sponsoring this webinar today. Thank you, Diana. And thank you, IHS. Wonderful. To get in touch with Dr. Beck, you can email him at the address here on your screen, dbec at oticon.com. And a friendly reminder for information on receiving a CE credit for this webinar, you can visit the IHS website at ihsinfo.org. You can click on the webinar banner on the webinar tab on our navigation menu. And also keep an eye out for the feedback survey that you'll receive tomorrow via email. We'll ask that you just take a few moments to answer some brief questions about the quality of today's presentation. We will also be sharing the best practices in there as well that Dr. Beck mentioned a few times today. And once again, thank you so much for Oticon for sponsoring this webinar, and all of you for joining us today. We hope to see you at the next IHS webinar. Thanks, Diana. Take care.

Motivational Interviewing

Healthcare

Trusting relationship

Empathy

Active listening

Intrinsic motivation

Strategic questioning

Hearing healthcare

Hearing loss

Rapport building