Otologist John Dornhoffer, MD, was diagnosed with a hereditary form of hearing loss at the age of 5. Although it is difficult for him to understand speech and hear higher tones, his condition most certainly has not affected his long and distinguished medical career. Dr. Dornhoffer, who is professor, vice chair of adult services, director of otology and neurotology, and the Samuel D. McGill, Jr., Chair in Otolaryngology Research in the department of otolaryngology-head and neck surgery at the University of Arkansas and Arkansas Children’s Hospital in Little Rock, has used a variety of high- and low-tech methods to accommodate his condition.
Explore this issue:May 2015
“Back during my early practice, all pagers beeped, which I couldn’t hear well,” he said. “I would set the pager to vibrate, set it in a brass bowl full of pennies, and place the whole thing on a glass-top table—it would really make a racket. You end up figuring out ways to get by, although it wasn’t always easy,” he added. “I have had a few medical students who have hearing issues come stay with me, and we discuss what it is like being in the medical profession today.”
Although some challenges remain, technological advances in communication devices and time-tested strategies for practice have made all medical specialties increasingly accessible to physicians who are deaf or hard of hearing (DHoH).
A common challenge for these physicians is maintaining clear communication. “The tools available to us are light years beyond what was available in the 1980s and 1990s,” said Christopher Moreland, MD, clinical assistant professor and associate program director for the internal medicine residency program in the division of hospital medicine at the University of Texas Health Science Center at San Antonio.
“The real challenge is how to determine the most appropriate interfaces for communication with patients and colleagues that fit with what we need,” said Dr. Moreland. “For instance, communication needs for working at a hospital are different than those for working at a clinic and can range from the right telephone system to use, to the best environment for hearing, to whether or not an interpreter is needed.”
Environment can make a difference. Dr. Dornhoffer has moved away from the traditional practice of discussing rounds with residents in stairwells. Although the environment is away from other patients and physicians, echoes in the tight space can play havoc with hearing.
The advent of electronic communications technology, including speech-to-text, instant messaging, electronic media, and electronic medical records, works to the advantage of DHoH physicians. “Although we have had video relay services for quite a while [the equivalent of Skyping through an interpreter],” said Dr. Moreland, who regularly uses an interpreter, “devices like the Apple watch and iPads are becoming more prevalent in everyday use in the healthcare system.”
Dr. Dornhoffer has found that telephone conversations can be problematic. “Before texting became so common, referrals done over the phone were difficult, as other physicians often didn’t want to give details to a nurse or send a letter with patient information,” he said. “Today it is very easy to e-mail details or to speak through instant messages. I can type almost as quickly as I can speak.”
Paul E. Hammerschlag, MD, a clinical associate professor of otolaryngology at New York University Langone Medical Center who has had a hearing impairment since birth, received a cochlear implant in July 2014 after his hearing seriously deteriorated over the previous four years. “The change was very dramatic, and a little emotional,” he said. “I was oblivious to what I wasn’t hearing, so it has been a real transition. I still struggle with hearing over noise. In the end, though, when my hearing loss increased, I could not hear properly over the phone, and it is much easier to be in conversation now.”
DHoH physicians who perform surgery as part of their specialty must contend with loss of lip reading as an aid to communication. “I am a surgeon, and being in the operating room [OR] is difficult because I cannot read lips due to the surgical mask,” said Dr. Dornhoffer. “Carrying on a significant conversation is impossible for me.”
Dr. Hammerschlag agreed. “I am a superb lip reader, but in the operating room, masks get in the way. If medical supply companies could make a transparent-material mask, it would solve the problem.”
Effective communication is achievable, however, said Dr. Moreland. “For example, I receive a lot of questions about surgery rotation from students, and I let them know there are several good options—there is no one-size-fits-all solution that will be successful for everyone,” he said. “I worked with interpreters as a medical student; sometimes they would scrub in because we both needed to be close to the surgical field. I know of one physician who used CART [computer assisted real-time captioning] on a screen, which was an iPad that is enclosed in a sleeve to remain sterile; a typist transcribed what was being said in the OR, and it appeared instantly on the screen.”
Assistive medical technology for DHoH practitioners, such as electronic and visual stethoscopes, has been available for years. “Any challenges with these would most likely be technological,” said Dr. Moreland. “’How do I adapt my cochlear implant to the electronic stethoscope?’ or ‘How do I use the display from the visual stethoscope?’ Ultrasound is an amazing tool that can be extremely helpful for DHoH physicians—it does not replace the stethoscope, but it can provide a great deal of supplemental information in a visual way. DHoH physicians, like anyhone else, would need to spend increased time to determine how best to use it technically.”
Dr. Dornhoffer hopes for an increase in Bluetooth technology to allow for connection with hearing aids for listening to a patient’s heart, as well as more visual representations of alerts. “Making sounds directly clear to a hearing aid or quickly visually represented would be helpful,” he said. “For example, on facial nerve monitors, you must ensure colleagues recognize that you cannot hear the beep of the monitor—I ask a resident to let me know if the alarm goes off. When using a drill, you cannot hear the pitch changing as you get close to important structures; you must rely on visual cues.”
Dr. Dornhoffer has often felt frustration at conferences and committee meetings, particularly when sitting near the front of the room. “It is a struggle to hear what people have to say,” he said. “I would like to see more real-time captioning for all lectures and question-and-answer sessions—even as a single screen near the front of the room. This is particularly important, as I have found that sign language interpretation seems to be less frequent as cochlear implants become more common.”
“I came from an era when we were not comfortable talking about hearing loss,” added Dr. Hammerschlag. “Many doctors rely on PowerPoint during their presentations, and you can miss out on the flow of meeting if it varies from the information on the slides. Attendees talk from all sides of the room, particularly during question-and-answer sessions. By the time you locate the person asking the question, he or she is finished with the question, and the moderator routinely does not repeat the question. Then you have to figure out the question from the answer.”
Dr. Dornhoffer finds this to be an issue on the other side of the podium as well. “I am in an academic position, and when I am on stage giving a presentation, I get quite self-conscious about wanting to answer questions. I am expected to teach new, innovative techniques, but it is difficult to take questions from the audience if I cannot see their lips in the dark. I try to always have someone sit up close to the podium to help interpret, but it would be better to have monitors that can show captioning as I speak.”
Although there are challenges, Dr. Moreland stressed that DHoH medical students and residents are becoming more common, and they share the same goals of excellence in patient care and improvement of the healthcare system as other physicians. “I have been asked occasionally over the years by colleagues how we communicate with patients,” he noted. “Our experience has clearly shown that we communicate as effectively as anyone else, especially with reasonable accommodation and creativity. It isn’t just about how I communicate with patients—it is about the outcome. So long as the goals of providing the care patients need and communicating that information back to patients are being met, it is not quite as important what modality we use to communicate.”
“Because of my hearing loss, I might be a little more motivated than your average otologist; I understand what a 10-decibel difference really means,” said Dr. Dornhoffer. “There are many conditions that we cannot fix completely, and patients can become frustrated. Sometimes having a laugh or two with them commiserating over a lost hearing aid, can help them realize they are not alone.”
Amy Hamaker is a freelance medical journalist based in California.Multi-Page