The purpose of this study was to investigate the perceived role of the GP in managing age-related hearing loss, from the perspective of GPs, adults with hearing loss, and professionals working with GPs. At a time when GPs are considered not just medical specialists, but specialist in life, it is unsurprising that GPs are perceived to play a role in the biomedical and psychosocial aspects of hearing loss.
Hearing loss is described as an invisible disability, as people do not often recognise hearing loss in themselves. As a result, many adults live for years, or even decades with the psychosocial impacts of unmanaged hearing loss (Simpson et al., 2019). Participants in the current study described the role of the GP in facilitating early detection of hearing loss. Statements put forward by participants described the need for GPs to detect the subtle signs of hearing loss, raise their concerns, normalise conversations about hearing loss, and monitor patients as they age. Although previous research has called for GPs to improve their hearing loss detection and intervention rates (Schneider et al., 2010; Wallhagen & Pettengill, 2008), there does not appear to be a simple solution for this. GPs are responsible for detecting the widest range of conditions of any speciality. To cover 75% of the conditions they manage, GPs need to have knowledge of more than 100 problems (Cooke, Valenti, Glasziou, & Britt, 2013). Furthermore, GPs will manage on average 1.5 health problems in each consultation (Britt et al., 2016). They are time poor, and often need to prioritise perceived more pressing health conditions. Given the invisibility of hearing loss, and the unlikeliness that patients will spontaneously raise their hearing concerns with the GP, it is no wonder that GPs do not routinely detect hearing loss in their patients. However, given their frequent contact with patients at risk for hearing loss (older adults and those with co-morbid health conditions), GPs are well placed to support people to recognise and manage their age-related hearing loss. Targeted interventions are needed to help GPs to improve their rates of detection and intervention for hearing loss.
Participants in this study recommended the incorporation of routine hearing screening programs in general practice. Implementing hearing screening programs targeting older adults has been shown to increase the detection rate for hearing loss (Hands, 2000; Trumble & Piterman, 1992), and subsequently increase the number of patients receiving hearing loss intervention, including hearing aids (van den Berg, Prins, Verschuure, & Hoes, 1999). In a trial of a hearing screening program in the Netherlands, hearing loss was detected in 57% of general practice patients screened (Eekhof, De Bock, Schaapveld, & Springer, 2000). This was new information to the GP in 54% of cases and resulted in GPs recommending intervention in 84% of cases. Similarly, a screening program in Austria identified hearing loss in 15% of general practice patients, 23% of which were new cases previously unknown to the GP, and 100% of which were referred for specialist hearing assessment (Eichler, Scrabal, Steurer, & Mann, 2007). Participants in the present study recommended that hearing screening programs be incorporated into existing health checks. Routine hearing assessments are already endorsed by the Australian Government through Medicare-funded health checks for adults aged 75 years and older (Australian Government Department of Health, 2013); however, our findings suggest that there is scope to increase the degree to which hearing is addressed as part of these assessments (Schneider et al., 2010).
One potential option to support GPs in prioritising hearing discussions might be the redistribution of tasks within the primary care setting. Over time, the work of the GP has shifted towards the management of chronic disease, and general practice itself has become organised through increasingly complex groups of doctors, Practice Nurses, administrative managers and support staff (Charles-Jones, Latimer, & May, 2003). Consistent with previous research describing the role of the Practice Nurse in screening for and providing education around hearing loss (Wallhagen & Reed, 2018), two of the statements put forward by participants in the current study described the role of the Practice Nurse in supporting the GP with hearing loss detection and management. Routine hearing screening is not difficult nor time consuming. The various methods currently used in the general practice setting include direct inquiry regarding hearing difficulties, use of questionnaires (such as the Hearing Handicap Inventory for the Elderly: Ventry & Weinstein, 1982), tunning forks, the finger rub test, the whispered voice test, handheld screening devices, and audiometers (Freedman, Pimlott, & Naglie, 2000; McBride, Mulrow, Aguilar, & Tuley, 1994; Strawbridge & Wallhagen, 2017). By incorporating screening for hearing loss among older adults in the workflow of Practice Nurses, some of the negative effects of untreated hearing loss could be prevented or reduced.
Patient-centred care is central to the mission of healthcare, especially self-management of chronic disease (Richards, Coulter, & Wicks, 2015). In this context, participants in the present study identified a number of areas in which GPs could ‘partner’ with their patients, for example: developing an understanding of their experience of hearing loss, encouraging help-seeking, providing education and training on hearing loss management (including ear wax management and communication training), promoting compliance with intervention options (including hearing aid use), and working with health professionals to take a multidisciplinary approach to patient care. The rising number of people living with chronic (and multiple) health conditions requires GPs to be patient-focussed, to seek understanding of what individual patients need from health and social services, and to provide tailored support, to reduce dependency and improve quality of life (Hibbard, 2017; Robert et al., 2015). Emphasis has been placed on the need for GPs to better listen to patients, and improve shared decision making based on patients’ individual priorities and preferences (Agoritsas et al., 2015). This need for a patient-centred approach is not unique to people with hearing loss.
The importance of multidisciplinary care and the GP’s role in coordinating this was particularly highlighted through the Know - Refer - Coordinate concept. The statements contained within this theme described not only the process of referral to specialist audiology services, but the importance of the GP having knowledge of who they are referring to, and to refer to reputable hearing services. A comparable scenario is a 2015 enquiry into mental health management in the primary care setting explored the barriers and facilitators to GP referral for specialist mental health services (Queensland Mental Health Commission, 2015). Improving relationships between GPs and allied health practitioners was identified as the most effective strategy to address barriers to successful referrals. Requesting and providing feedback (monitoring quality) and delivering training and/or resources were equally identified as the second most effective strategy to address barriers to referral. However, given that GPs do not necessarily have the time to build relationships with potential referrers, thus there may be a role for audiologists to play regarding the upskilling of local GPs with regards to hearing loss detection, discussion and referral. In rural and remote locations, a lack of local audiology and/or ENT services presents as an additional barrier to GPs developing referral networks (Brennan-Jones et al., 2016), and despite an increase in tele-audiology services (Saunders, 2019) additional support and upskilling for GPs in these underserved areas may be required.
The Know - Refer - Coordinate concept also described the importance for the GP to have an understanding of the “next steps”, and to assist and encourage the patient through the referral process. The notion of ‘warm’ referral has started to emerge in the medical literature and practice (Network of Alcohol and Drug Agencies, 2013). Traditional ‘cold’ referral involves providing the patient with information about another agency or service. This places onus on the patient to actively follow-up and seek help from the recommended service, and also requires the patient to retell their story and effectively communicate their needs. Alternatively, a ‘warm’ referral sees the GP contact the agency or service on the patient’s behalf and explain patient's circumstances and the reason for referral. This may occur via telephone, scheduling a group meeting, or writing a report or case history. The additional time commitment that warm referrals can involve means they are not always feasible for GPs. However, there may be opportunities for other practice staff to facilitate warm referrals or for the development of system improvements to assist.
Limitations & Future Directions
Participants self-selected for the study, and although the sample sizes were sufficient for concept mapping procedures, data from only 35 participants may have biased the content of the statements captured. Furthermore, participants described their experiences within the Australian context of service delivery, potentially biasing the findings. Future research could also explore the experience of non-help-seekers to better understand the barriers to seeking support for hearing loss in the General Practice setting.