Informational Counseling in Health Professions: What do Patients Remember?

Robert H. Margolis

University of Minnesota

The Audiology counseling literature makes an important distinction between informational counseling and personal adjustment counseling (Hodgson, 1994; Kricos, 2000). Informational counseling, the subject of this article, is intended to provide to the patient the relevant information needed to understand the nature of the disorder and the steps that are recommended to manage it. Personal adjustment counseling helps the patient and family deal with the emotional impact of the information. Both are necessary. Information on the nature and severity of the disorder as well as the prognosis and management plan is necessary if the patient and family are to play an active, positive role in remediation, rehabilitation, and secondary prevention of long-term consequences. Although some patients are able immediately to take the necessary steps to manage the disorder, some require personal adjustment counseling to deal with the psychosocial consequences of the disorder. In this article I discuss the research findings of patient recall of information presented in various clinical situations and some recommendations for maximizing what patients remember.

We need to keep in mind that our patients lead busy lives and there are many things that work against the likelihood that they will remember what we tell them. The working mom whose son broke an ankle yesterday playing soccer, who is worried about missing work, who doesn’t have anything for dinner tonight, and whose husband may be laid off next week, is not likely to remember important details about a communicative disorder. We seldom know the complexities of our patients’ lives and their ability to comprehend and retain important information presented in a counseling session.

The research studies on patient recall are published primarily in medical and counseling journals. The issue is almost completely ignored in the Communication Sciences and Disorders literature. There is a brief discussion of the topic in Luterman’s excellent text on Counseling Persons with Communication Disorders and Their Families (Luterman, 2001) and one study published in the Texas Journal of Audiology and Speech Pathology (Martin, Krueger, & Bernstein, 1990). Luterman summarizes the problem well. Patients and family members

remember unimportant details such as the color of the doctor’s shirt or the kind of glasses he or she wore. They always vividly remember the date and can describe the trip to the hospital in explicit detail, but they usually fail to retain any of the important information. (p. 76-77)

Why is Patient Recall Important?

It does not necessarily follow that accurate recall of health information is necessary as long as the patient complies with recommendations. But studies have found that when patients understand the information that is communicated by a healthcare provider, there are significant enhancements of patient satisfaction, compliance with recommendations, and outcomes and decreases in anxiety, treatment time, and cost (Thomson, Cunningham, & Hunt 2001). One study showed that physicians underestimate patients’ desire for information and their ability to understand medical findings (Shapiro et al., 1992). When physicians were given specific strategies for enhancing communication, there were measurable improvements in patient recall (Ley, 1977). Recall of information, then, is important to the welfare of the patient and there are strategies that have been shown to increase what patients remember. A disturbing finding is that physicians’ impressions of what patients would remember were not correlated with measures of patients’ actual recall (Anderson et al., 1979). This finding reinforces the need to provide information in writing even for patients who appear to be absorbing everything.

How Much Do Patients Remember?

Recall of information communicated to patients has been measured under a variety of conditions. In these studies facts are given to the patient and the proportion of facts correctly recalled is measured at some point in time after the counseling session. Because many factors affect memory for health information, there is a wide range of results but overall studies indicate that about 50% of information provided by healthcare providers is retained (Shapiro et al., 1992). Depending on conditions, 40-80% can be forgotten immediately (Kessels, 2003). Studies in which recall was measured at two points in time do not show a difference when recall is measured soon after the consultation and at a later date (Joyce et al., 1969; Reynolds et al., 1981). It seems that patients remember a small proportion of facts and those stay with them for a period of at least several weeks.

Of the information that is recalled, about half is remembered incorrectly (Anderson et al., 1979; Kessels, 2003). So about half is forgotten immediately and half of what is remembered is wrong. If you take any complex message that has an information component and an advice component and you remove 50% of the facts, and distort half the remaining information, the result could be a dangerously misunderstood message that could have life-threatening consequences.

An even more disturbing finding is that patients often forget their medical diagnoses even when the conditions are serious. In one study patients could not recall 68% of the diagnoses told to them in a medical visit. When there were multiple diagnoses, patients could not recall the most important diagnosis 54% of the time (Scheitel et al., 1996). Some of the diagnoses in this study were serious, even life- threatening conditions such as diabetes, hypertension, and liver disease. In another study, patients and physicians agreed on problems that required followup for only 45% of the problems identified by the physician as requiring followup (Starfield et al., 1979). When there was disagreement between the physician and patient regarding the need for followup, the likelihood of appropriate management was significantly lower (Starfield et al., 1981).

A study of recall of information presented during an informed consent process preceding elective surgery found that 25% of the information was correctly recalled (Godwin, 2000).

Factors that Affect Patient Recall

Recall of information is dependent on many factors, some related to the patient, some related to the mode of presentation of the information, and some related to the clinician.

Patient Factors. Some factors that you might expect to affect the ability to retain information don’t appear to influence recall. Intelligence, for example, has not been shown to affect the proportion of information retained (Ley, 1979). However, familiarity with the information does have an affect (Tuckett et al., 1985). A patient who is familiar with hearing loss as a result of prior consultations, an affected family member, or professional knowledge tends to remember more. The degree of understanding of issues related to the diagnosis can have a significant effect (Ley, 1979). A finding that the patient expects is remembered more than one that is unexpected; a finding that is welcome or desired is more likely to be recalled than one that is unwelcome or unwanted (Tuckett et al., 1985). Interestingly, a patient is better able to recall information when they are in the same emotional and physical state they were in when they received the information (Kessels, 2003). If they were anxious at the time of the consultation they will remember more when they are in a similar state than when they are relaxed. Elderly patients tend to remember less than younger patients (Anderson et al., 1979; Kessels, 2003). When elderly patients are not included in the study, age effects are not seen (Ley, 1979). Anxiety can have a positive or negative effect on retention. Moderate anxiety enhances recall but severe anxiety inhibits retention of information (Anderson et al., 1979; Kessels, 2003; Ley & Spelman, 1965). Stress causes “attention narrowing” which interferes with the patient’s ability to redirect to a different topic (Kessels, 2003). Denial, a defense mechanism that is common in patients with a variety of diagnoses including hearing loss, may contribute to poor recall. Denial is such a powerful defense mechanism that it can interfere with recall of the most obvious findings. One study, for example, showed that patients frequently forgot diagnoses of excessive tobacco use and obesity (Scheitel et al., 1996). A patient who is in denial of their hearing loss, for example, is not likely to accurately convey information provided at the hearing evaluation to family members.

Mode of Presentation. Not surprisingly, information presented in a simple, easy- to-understand format is remembered better than information presented in a more complex manner (Bradshaw et al., 1975; Kessels, 2003; Tuckett et al. 1985). The more information presented, the lower the proportion that is recalled by the patient (Anderson et al., 1979; Kessels, 2003; Tuckett et al., 1985). Information that is presented first tends to be remembered better – the primacy effect (Ley , 1972).

Several studies have shown that categorizing information can improve retention and some authors discuss the method of explicit categorization (Kessels, 2003; Ley 1977, 1979; Tuckett et al., 1985). Information is organized in specific categories such as Explanation of Systems, Diagnostic Tests, Results, Prognosis, and Recommendations. The patient is told that the information will be presented in these categories, each category is announced, and the patient is asked if there are questions before moving on to the next category. One study found a significant enhancement of recall with this method (Kessels, 2003). Another found that in combination with asking the patient what information is wanted, the method provides a framework for enhancing retention (Reynolds et al., 1981).

A number of studies have investigated the effects of written and graphical material to supplement verbal presentation of information (Houts et al., 1998, 2001; Kessels, 2003). Written material, cartoons, and pictures, when used appropriately during the consultation can enhance recall of information. Thompson, Cunningham, & Hunt (2001) concluded from their study of information retention following an orthodontic consultation “that verbal information should not be given to patients unless supplemented by written and/or visual information” (p. 169).

Recommendations are more likely to be remembered and followed when they are specific rather than general (Bradshaw et al., 1975; Ley, 1977, 1979). A recommendation should be a specific statement telling the patient what to do rather than a more general statement of the goal. A recommendation to “stay home from work and rest for two weeks with no strenuous exercise” is more likely to be followed than “get some rest and take it easy for a while.”

Clinician Factors. The clinician’s communicative style can have a significant influence on retention of information by patients. Information given by clinicians who speak in clear language with simple sentence structure is more likely to be remembered than information provided in complex language loaded with scientific terms (Kessels, 2003). Clarity of communication requires that the clinician understand what the patient wishes to learn and what his/her level of understanding is. To communicate clearly in a manner that promotes retention of information, the consultation needs to be a dialog in which the clinician listens to the patient. When the patient’s ideas are evaded or inhibited, the patient is less likely to remember important information (Tuckett et al., 1985). Even the clinician’s anxiety affects recall. Patients remember less when the information is provided by an overtly anxious clinician (Shapiro et al., 1992). The perceived importance of the information also affects retention (Ley 1972; 1977). Information that is presented in a manner that emphasizes its importance is more likely to be remembered than information present in a matter-of-fact manner. Non-verbal communication is important in reflecting the clinician’s state (confident, anxious, distracted, empathetic) and in indicating the importance of information (Tuckett et al., 1985).

We all know the head-nodding behavior often exhibited by people who hear only part of the message but don’t get enough to really be part of the conversation. The same phenomenon occurs in a consultation when the patient appears to understand but their understanding is not confirmed by the clinician and the patient is not encouraged to ask questions. Information that is unorganized, unclear, or incomplete can be interpreted by patients to confirm their pre-existing beliefs which may not be in concert with the message the clinician is attempting to communicate. One writer called this the “illusion of shared understanding” (Tuckett et al., 1985). When the clinician is oblivious to the patient’s lack of understanding, the entire consultation session may provide little benefit, or worse, do more harm than good.

Methods of Maximizing Retention

Studies of patient recall lead to effective strategies for presenting information in a manner that maximizes retention. Although the following strategies will improve retention, all patients will forget some information, even when presented in an optimal manner. Nevertheless, clinicians should incorporate these methods into their counseling sessions.

• Advice should be given as concrete instructions. “Use ear plugs when you use your power tools” rather than “Keep your noise exposure to a minimum.”

• Use easy to understand language. Short words and sentences are remembered better.

• Present the most important information first to capitalize on the primacy effect. Often the most important information is the recommendations such as “make an appointment with the ear doctor.”

• Stress the importance of recommendations or other information that you want the patient to remember.

• Use the method of explicit categorization. Tell the patient “We are going to go over recommendations, then we will talk about your specific hearing problem (diagnosis), then we will go over test results, then we will talk about how your hearing may change in the future (prognosis)”. Ask the patient for questions before moving on to the next category.

• Repeat the most important information.

• Don’t present too much information. Present only the information that is important for the patient to remember. Proportion of retention decreases with the amount of information presented.

• Be sure you understand what the patient wants from the evaluation and what his/her beliefs are concerning the problem. Specifically address the patient’s desires and beliefs.

• Supplement verbal information with written, graphical, and pictorial materials that the patient can take home.

These techniques will significantly enhance the accurate recall of information by our patients. But they will still forget. The best way to ensure that the information gets home is to provide the patient with a permanent record. One author recommended that the patient be instructed to write the information as the clinician presents it (Ley, 1979). For certain kinds of information this may be an effective teaching technique. Another author recommended tape recording the consultation which would allow the patient and family to review the results and recommendations together (Starfield et al., 1979). Another approach is to provide clearly written, illustrated, patient-specific, educational materials that ensure that the information is clear, accurate, complete, and available for review and discussion with family members and other professionals.

Patients are always encouraged to bring family members or friends to consultations. Of course, this is not always possible. At the time of the consultation, the patient may not be in a state of receptiveness to important information. They may have prior beliefs about the extent of a problem that may or may not be realistic or they may be in denial. The research findings discussed in this article indicate that information that is presented in the 5-10 minutes that are usually available for counseling will not be remembered accurately and it is not realistic to expect the patient to communicate the information accurately to family members.

The problem of patient recall of information related to hearing loss was pointed out over 40 years ago by Bailey and Martin (1961). Recognizing that patients often forget information related to their diagnostic findings, they prepared letters that could be given to patients that describe hearing loss and methods for remediation and management. Their recommendation to provide important information in writing has not been widely embraced in our professions. Although the professions of Audiology and Speech-Language Pathology are solely concerned with the communicative well-being of our patients, our own communication to patients is fundamentally disordered. We complain that our counseling efforts are not reimbursed but an analysis of our methods and outcomes would probably not convince payers that we are providing a valuable, reimbursable service when we verbally present complex information in a format that is known to be ineffective. I recommend the following guiding principle for our communication of results and recommendations to our patients.

Any information that is important for the patient to understand and remember should be provided in writing.

Robert H. Margolis, Ph.D., is professor of Audiology in the Department of Otolaryngology at the University of Minnesota. He has developed and marketed patient education materials for hearing-impaired patients and their families. The “Understanding …” series of patient education materials can be viewed at www.audiologyincorporated.com.

References

Anderson JL, Dodman S, Kopelman M, Fleming A (1979). Patient information recall in a rheumatology clinic. Rheumatol Rehabil 18:18-22.

Bailey HAT, Martin FN (1961). Letter to the patient with a sensori-neural hearing loss. Laryngoscope 71:3-8.

Bradshaw PW, Ley P, Kincey JA (1975). Recall of medical advice: comprehensibility and specificity. Br J Clin Psychol 14:55-82.

Godwin Y (2000). Do they listen? A review of information retained by patients following consent for reduction mammoplasty. Br J Plast Surg 53:121-125.

Hodgson WR (1994). Audiologic Counseling. In J Katz (Ed.) Handbook of Clinical Audiology. Baltimore: Williams & Wilkins.

Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA (1998). Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns 35:83-88.

Houts PS, Witmer JT, Egeth HE, Loscalzo MJ, Zabora JR (2001). Using pictographs to enhance recall of spoken medical instructions. II. Patient Educ Couns 43:231-242.

Joyce CRB, Caple G, Mason M, Reynolds E, Mathews JA (1969). Quantitative study of doctor-patient communication. Q J Med 38:183-194.

Kessels RPC (2003). Patients’ memory for medical information. J Roy Soc Med 96:219- 222.

Kricos PB (2000). Family counseling for children with hearing loss. In JG Alpiner and PA McCarthy (Eds.) Rehabilitative Audiology: Children and Adults. Philadelphia: Lippincott Williams & Williams.

Ley P (1972). Primacy, rated importance, and the recall of medical statements. J Health & Soc Beh 13:311-317.

Ley P (1977). in S Rachman (Ed.) Contributions to Medical Psychology. Oxford: Permagon Press. Vol. 1: 9-42.

Ley P (1979). Memory for medical information. Br J Soc Clin Psych 18:245-255.

Ley P, Bradshaw PW, Eaves D, Walker CM (1973). A method for increasing patients’ recall of information presented by doctors. Psychol Med 3:217-220.

Ley P, Spelman MS (1965). Communications in an outpatient setting. Br J Soc Clin Psych 4:114-116.

Luterman DM (2001). Counseling Persons with Communication Disorders and their Families. (4th ed.) Austin: Pro-Ed.

Martin FN, Krueger JS, Bernstein M (1990). Diagnostic information transfer to hearing- impaired adults. Texas J Aud SP Path 16:29-32.

Reynolds PM, Sanson-Fisher RW, Poole AD, Harker J, Byrne MJ (1981). Cancer and communication:information-giving in an oncology clinic. Br Med J 282:1449-1451.

Scheitel SM, Boland BJ, Wollan PC, Silverstein MD (1996). Patient-physician agreement about medical diagnoses and cardiovascular risk factors in the ambulatory general medical examination. Mayo Clin Proc 71: 1131-1137.

Shapiro DE, Boggs SR, Melamed BG, Graham-Pole J (1992). The effect of varied physician affect on recall, anziety, and perceptions in women at risk for breast cancer:an analogue study. Health Psychol 11:61-66.

Starfield B, Steinwachs D, Morris I, Bause G, Siebert S, Westin C (1979). Patient-doctor agreement about problems needing follow-up visit. JAMA 242:344-346.

Starfield B, Wrau C, Hess K, Gross R, Birk PS, D’Lugoff BC (1981). The influence of patient-practitioner agreement on outcome of care. Am J Public Health 71:127-131.

Thomson AM, Cunningham SJ, Hunt NP (2001). A comparison of information retention at an initial orthodontic consultation. Eur J Orthod 23:169-178.

Tuckett D, Boulton M, Olson C, Williams A (1985). Meetings Between Experts: An approach to sharing ideas in medical concultations. London: Tavistock Publications.

Robert H. Margolis, Ph.D. – Curriculum Vitae

Current Information

Current Address

 

Audiology Incorporated
4410 Dellwood St
Arden Hills, MN 55112
rhmargo001@gmail.com
    Current Appointments

 

  • President, Audiology Incorporated
  • Adjunct Professor, Department of Speech and Hearing Science, Arizona State University, Tempe, Arizona
  • Professor Emeritus, Department of Otolaryngology, University of Minnesota Medical School

Education

Kent State University, Kent, Ohio B.S. Speech Pathology & Audiology 1968
Kent State University, Kent, Ohio M.A. Audiology 1969
University of Iowa, Iowa City, Iowa Ph.D. Audiology 1974
University of Wisconsin, Madison, Wisconsin Post-Doctoral Research Audiology 1975

 

 

 

 

 

Professional Employment

Jan 2012 – Present Professor Emeritus, Department of Otolaryngology, University of Minnesota
Jan 2000 – Present President, Audiology Incorporated
Sept 1988 – Jan 2012 Professor of Audiology, Department of Otolaryngology, University of Minnesota
Sept 1988 – 1999 Professor, Department of Communication Disorders, University of Minnesota
July, 1985 – August 1988 Professor of Communication Sciences and Disorders,
Professor of Neuroscience, Syracuse University
December 1984 – July 1985 Associate Professor of Neuroscience, Syracuse University
January 1980 – August 1988 Director of the Gebbie Hearing Clinic, Syracuse University
January 1980 – July 1985 Associate Professor of Communication Sciences and Disorders, Syracuse University
February 1975 – December 1979 Assistant Professor in Residence, Division of Head and Neck Surgery, UCLA School of Medicine
February 1974 – January 1975 NIH Post-doctoral Fellow, Department of Communicative Disorders, The University of Wisconsin, Madison
September 1971 – December 1973 NIH Pre-doctoral Trainee, Department of Speech Pathology and Audiology, The University of Iowa
September 1970 – August 1971 Audiology Trainee, VA Medical Center, Iowa City
September 1969 – June 1970 Instructor of Audiology, East Tennessee State University Johnson City, Tennessee
September 1968 – June 1969 Speech and Hearing Therapist, Midview Local Schools, Grafton, Ohio

 

Professional Memberships

American Academy of Audiology
American Auditory Society
International Society of Audiology
Minnesota Academy of Audiology

 

Service Memberships

1980-88
Central NY Association for the Hearing Impaired
Board of Directors; Vice President, 1984
1995 – Present
International Hearing Foundation
Board of Directors; Vice President 1999; President, 2000-2002
1996 – 2021 Minneapolis-University Rotary Club; Club Service Director 1998-99; President-Elect 1999-2000; President 2000-2001; Past President, Fundraising Chair 2001-2002; Foundation Chair 2002-2003; Program Chair 2003-2004; Membership Chair 2004-Present; Interim President 2016    

 

Honors, Fellowships, Awards, Appointments

University of Iowa Department of Communication Sciences and Disorders Distinguished Alumnus Award

1968 Sigma Alpha Eta, National Speech and Hearing Fraternity, Honorary Member
1970 VA Hospital Traineeship, VA Medical Center, Iowa City, Iowa
1971 NIH Pre-doctoral Traineeship, University of Iowa
1972 ASHA Certificate of Clinical Competence in Audiology
1974 NIH Post-doctoral Fellowship, University of Wisconsin
1974 Sigma XI – National Speech & Hearing Honorary Fraternity
1979 UCLA Division of Head and Neck Surgery Teaching Award
1981 New York State License in Audiology
1986-1988 Chair, ASHA Working Group on Aural Acoustic Immittance
1992-1994 Deafness Research Foundation Scientific Review Committee
1993-1995 American Academy of Audiology, Awards Committee
1993-1996 American Academy of Audiology, Task Force on Immittance Screening
1994-1997 American Academy of Audiology, Chair, Publications Committee
1994 Interim President, Minnesota Academy of Audiology
1995 President, Minnesota Academy of Audiology
1996 Past President, Treasurer, Minnesota Academy of Audiology
1998 Honors of the Association, Minnesota Academy of Audiology
1998 Rotarian of the Year, Minneapolis-University Rotary Club
1999-2001 Associate Editor, Journal of Speech-Language-Hearing Research
2000-2001 President, Minneapolis-University Rotary Club
2000 Humanitarian Award, American Academy of Audiology
2000-2002 President, International Hearing Foundation
2001 Editor’s Award, Journal of the American Academy of Audiology
2001 Larry Mauldin Award for Excellence in Education in Audiology
2003 Four Avenues of Service Citation, Rotary International
2005 American Academy of Audology 2006 Convention Program Committee, Chair, Featured Session Sub-committee
2007 James F. Jerger Career Research Award, American Academy of Audiology
2012-2015 American Academy of Audiology Honors and Awards Committee
2017 University of Iowa Department of Communication Sciences and Disorders Distinguished Alumnus Award
2023 Chair, ASA/ANSI Working Group 35, Audiometric Equipment

 

Editorial Consultantships

International Journal of Audiology
Ear and Hearing
Journal of the Acoustical Society of America
Journal of the American Academy of Audiology
Journal of Speech-Language-Hearing Research -Associate Editor 1999 – 2001

 

Patents

  1. Margolis, R.H. Adaptive Apparatus and Method for Testing Auditory Sensitivity. US Patent # 6,496,585, December 17, 2002.
  2. Margolis, R.H. Method For Assessing The Accuracy of Test Results, US Patent # 7,704,216, April 27, 2010.
  3. Margolis, R.H. Audiogram Classification System. US Patent # 8,075,494, December 13, 2011.
  4. Margolis, R.H., Saly, G,S,, Birck, J. Calibration of Audiometric Bone Conduction Vibrators. US Patent # 8,577,050, November 5, 2013.
  5. Margolis, R.H., Wilson, R.H., Saly, G.L. Test of Recognition of Speech-like Non-linguistic Sounds. Provisional Patent Application November 8, 2016.
  6. Margolis, R.H. Adjustable Headband for Bone Conduction Audiometric Testing. Submitted February 16, 2022.

Publications (* indicates student co-authors)

  1. Margolis, R.H. and Millin, J.P. An item-difficulty based speech discrimination test. J. Speech Hear. Res. 14, 865-873, 1971.
  2. Margolis, R.H. and Small, A.M., Jr. Masking with narrow band FM noise. J. Acoust. Soc. Amer. 56, 692-694, 1974.
  3. Margolis, R.H. and Small, A.M., Jr. The measurement of critical masking bands. J. Speech Hear. Res. 18, 571-587, 1975.
  4. *Margolis, R.H. and Popelka, G.R. Loudness and the acoustic reflex. J. Acoust. Soc. Amer. 58, 1330-1332, 1975.
  5. *Margolis, R.H. and Popelka, G.R. Static and dynamic acoustic impedance measurements in infant ears. J. Speech Hear. Res. 18, 435-443, 1975.
  6. *Margolis, R.H. and Popelka, G.R. Static and dynamic acoustic impedance measurements in infant ears, in Leavitt, L. and Morse, P. (eds.) Infant Development Laboratory: Research Status Report (Univ. Wisconsin Press) 325-341, 1975.
  7. *Popelka, G.R., Margolis, R.H., and Wiley, T.L. The effect of activating signal bandwidth on acoustic-reflex thresholds. J. Acoust. Soc. Amer. 59,153-159, 1976.
  8. Margolis, R.H. and Wiley, T.L. Monaural loudness adaptation at low sensation levels in normal and impaired ears. Acoust. Soc. Amer. 59, 222-224, 1976.
  9. Margolis, R.H. and Gilman, S. Method for measuring the temporal characteristics and filter response of electro-acoustic impedance instruments. J. Speech Hear. Res. 20, 409-414, 1977.
  10. Margolis, R.H. and Popelka, G.R. Interactions among tympanometric variables. Speech Hear. Res. 20, 447-462, 1977.
  11. *Margolis, R.H. and Smith, P. Tympanometric asymmetry. Speech Hear Res. 20, 437-446, 1977.
  12. Margolis, R.H. and Fox, C.M. A comparison of three methods for predicting hearing loss from acoustic reflex thresholds. Speech Hear. Res. 20, 241-253, 1977.
  13. *Handler, S. and Margolis, R.H., Predicting hearing loss from stapedial reflex thresholds in patients with sensorineural impairment. Am. Acad. Ophthal. and Otolaryngol. 84, 425-431, 1977.
  14. Dirks, D. and Margolis, R.H. Auditory evaluation of patients with eighth nerve disorders, in Rand, R. (ed.) Micro-neurosurgery (2nd ed.) St. Louis (C.V. Mosby Co.) Ch. 11, 182-194, 1978.
  15. Himelfarb, M., Shanon, E. Popelka, G. and Margolis, R.H. Acoustic reflex evaluation in neonates, in Gerber, S. and Mencher, G. (eds.) Early Diagnosis of Hearing Loss. New York (Grune and Stratton) Ch. 6, 109-127, 1978.
  16. *Margolis, R.H., Osguthorpe, J.D. and Popelka, G.R. The effects of experimentally-produced middle ear lesions on tympanometry in cats. Acta Otolaryngol. 86, 428-436, 1978.
  17. Wilson, R.H., Steckler, J.F., Jones, H.C. and Margolis, R.H. Adaptation of the acoustic reflex. Acoust. Soc. Amer. 64, 782-791, 1978.
  18. *Margolis, R.H., Popelka, G.R. and Smith, P. The significance of The Significant Asymmetrical Tympanogram, A reply to Pearlman and Graber. Speech Hear. Res. 21, 607, 1978.
  19. Margolis, R.H. Tympanometry in infants. in Harford, E.R. et al. (eds.) Impedance Screening for Middle Ear Disease in Children. New York, Grune and Stratton, 41-57, 1979.
  20. Margolis, R.H. On the use of tympanometry for the prediction of middle ear effusion. Arch. Otolaryngol. 105, 225, 1979.
  21. *Margolis, R.H. and Goldberg, S.M. Auditory frequency selectivity in normal and presbycusic subjects. J. Speech Hear. Res. 23, 603-613, 1980.
  22. Margolis, R.H., Dubno, J.R., and Wilson, R.H. Acoustic- reflex thresholds for noise stimuli. J. Acoust. Soc. Amer. 68, 892-895, 1980.
  23. Margolis, R.H., Dubno, J.R., and Hunt, S.M.J. Detection of tones in band-reject noise. J. Speech Hear. Res. 24, 336-344, 1981.
  24. Margolis, R.H. Detecting hearing loss from acoustic reflex thresholds, rationale and philosophy, in Popelka, G.R. (ed.) Hearing Assessment With the Acoustic Reflex. New York (Grune and Stratton), Ch. 1, pp. 1-4, 1981.
  25. Margolis, R.H., Fox, C., Lilly, D.J. Popelka, G.R., Silman, S., and Trumpf, M.S. The bivariate plotting procedure for detecting hearing loss from acoustic reflex thresholds. in Popelka, G.R. (Ed.). Hearing Assessment with the Acoustic Reflex. New York (Grune and Stratton), Ch. 5, pp. 59-84, 1981.
  26. *Margolis, R.H., Popelka, G.R., Handler, S.D., and Himelfarb, M.Z. The effects of age on acoustic reflex thresholds, in Popelka, G.R. (ed.) Hearing Assessment with the Acoustic Reflex. New York (Grune and Stratton), Ch. 6, pp. 85-96, 1981.
  27. Margolis, R.H. Fundamentals of acoustic immittance, in Popelka, G.R. (ed.) Hearing Assessment With the Acoustic Reflex. New York (Grune and Stratton), Appendix A. pp. 117-144, 1981
  28. *Green, K.W. and Margolis, R.H. The ipsilateral acoustic reflex in Silman, S. (ed.) Acoustic Reflex, Scientific Aspects and Clinical Applications, New York (Academic Press), pp. 275-299, 1981.
  29. Margolis, R.H., Wilson, R.J., and Van Camp, K.J. A technique for detecting the ipsilateral acoustic reflex. J. Acoust. Soc. Amer. 72, 278-279, 1982.
  30. *Margolis, R.H., Green K.W., Wilson, R.H., and Van Camp, K.J. Exploring the clinical utility of the ipsilateral acoustic reflex threshold. Scandinavian Audiology, Suppl. 17, 35-37, 1983.
  31. *Green, K.W. and Margolis, R.H. Detection of hearing loss with ipsilateral acoustic reflex thresholds. Audiology, 22, 471-479, 1983.
  32. Wilson, R.H. and Margolis, R.H. Measurements of Auditory Thresholds for Speech Stimuli. In Rintelmann, W.F.and Konkle, D.F. (Eds.) Principles of Speech Audiometry, Baltimore (University Park Press), pp. 79-126, 1983.
  33. *Geller, D. and Margolis, R.H. Magnitude estimation of loudness, I. Application to hearing aid selection. J. Speech Hear. Res. 27, 20-27, 1984.
  34. *Knight, K.K., and Margolis, R.H. Magnitude estimation of loudness. II. Loudness perception in presbycusic listeners. J. Speech Hear. Res. 27, 28-32, 1984.
  35. Margolis, R.H. and Shanks, J.E. Tympanometry. In Katz, J. (Ed.) Handbook of Clinical Audiology. (3rd ed.) Baltimore (Williams and Wilkins) 23, 1985.
  36. *Wilson, R.H., Civitello, B., and Margolis, R.H. Influence of interaural-level differences on the speech recognition masking-level difference. Audiology, 44, 15-24, 1985.
  37. Dirks, D.D., Margolis, R.H., and Noffsinger, D.W. Auditory evaluation of patients with eighth cranial nerve disorders. in Rand, R.W. (Ed.) Microneurosurgery (3rd. ed.) St. Louis (C.V. Mosby Co.), Ch. 14, pp. 236-247, 1985.
  38. *Cacace, A.T., and Margolis, R.H. On the loudness of complex stimuli and its relationship to cochlear excitation. J. Acoust. Soc. Amer., 78, 1568-1573, 1985.
  39. Margolis, R.H., Van Camp, R.J., Wilson, R.H., and Creten, W.F. Multifrequency tympanometry in normal ears. Audiology, 24, 44-53, 1985.
  40. Margolis, R.H. Magnitude estimation of loudness. III. Performance of selected hearing aid users. J. Speech Hear. Res., 28, 411-420, 1985.
  41. Van Camp, K.J., Margolis, R.H., Wilson, R.H., Creten, W., and Shanks, J.E. Principles of Tympanometry. ASHA Monograph, #24, 1986.
  42. *Koebsell, K. and Margolis, R.H. Tympanometric gradient measured from normal pre-school children. Audiology, 25, 149-157, 1986.
  43. Van Camp, K.J., Shanks, J.E. and Margolis, R.H. Simulation of pathological high impedance tympanograms. J. Speech Hear. Res., 29, 505-514, 1986.
  44. Margolis, R.H. Speech discrimination. Gallaudet Encyclopedia of Deaf People and Deafness, Volume 1, McGraw-Hill, pp. 56-57, 1986.
  45. Margolis, R.H. Loudness. Gallaudet Encyclopedia of Deaf People and Deafness, Volume 2. McGraw-Hill, pp. 304-305, 1986.
  46. *Holte, L. and Margolis, R.H. The relative loudness of third-octave bands of speech. J. Acoust. Soc. Amer., 81, 186-189, 1987.
  47. Margolis, R.H. and Heller, J. Screening tympanometry, criteria for medical referral, Audiology, 26, 197-208, 1987.
  48. *Margolis, R.H. & Cacace, A.T. Some characteristics of the ipsilateral stapedius reflex. Advanced International Master on Aural Acoustic Impedance. Amplifon Research Institute, 1987.
  49. Margolis, R.H. Role of impedance measurements in predicting hearing threshold. Advanced International Master on Aural Acoustic Impedance. Amplifon Research Institute, 1987.
  50. Margolis, R.H. Hearing aid dispensing in university clinics. Hearing Instruments, 38, 38-39, 67, 1987.
  51. *Holte, L. and Margolis, R.H. Screening tympanometry in J.W. Hall (Ed.) Immittance Audiometry. Seminars in Hearing 8, 329-338, 1987.
  52. Shanks, J.E., Lilly, D.J., Margolis, R.H., Wiley, T.L., and Wilson, R.H. Tympanometry. (A tutorial by the ASHA Working Group on Aural Acoustic Immittance Measurements). J. Speech Hear. Dis., 53, 354-377, 1988.
  53. Margolis, R.H., Block, M., Parnes, S., Roeser, R., Shanks, J.E., and Wilson, R.H. Guidelines for screening for hearing impairment and middle-ear disorders. ASHA, 32 (Suppl.), 17-24, 1990.
  54. *Holte, L., Cavanagh, R.M., and Margolis, R.H. Ear canal wall mobility and tympanometric shape in young infants. Pediatrics, 117, 77-80, 1990.
  55. Margolis, R.H. and Shanks, J.E. Tympanometry, principles and procedures. in Rintelmann, W.F. (Ed.) Hearing Assessment, (2nd ed.) Pro-Ed (Austin, TX) 1991, Chapter 4, pp. 179-246.
  56. Wilson, R.H. and Margolis, R.H. Acoustic reflex measurements. in Rintelmann, W.F. (Ed.) Hearing Assessment (2nd ed.) Pro-Ed (Austin, TX) 1991, Chapter 5, pp. 247-320.
  57. *Cacace, A.T., Margolis, R.H., and Relken, E.M. Threshold and suprathreshold temporal integration effects in the crossed and uncrossed human acoustic stapedius reflex. J. Acoust. Soc. Amer. 89, 1255-1261, 1991.
  58. Fournier, E.M. and Margolis, R.H. A microcomputer networked audiology clinic. Audiology Today, 3, 28-31, 1991.
  59. Margolis, R.H. and Thornton A.R. Spreadsheet systems for tracking audiology patients. Audiology Today, 3, 24-26, 1991.
  60. Margolis, R.H. and Levine, S.C. Acoustic reflex measures in audiologic evaluation. Otolaryngology Clinics of North America, 24, 329-347, 1991.
  61. *Margolis, R.H. and Hunter L.L. Audiologic evaluation of the otitis media patient. Otolaryngology Clinics of North America, 24, 877-899, 1991.
  62. *Holte, L., Margolis, R.H., and Cavanagh, R.M. Developmental changes in multifrequency tympanograms. Audiology, 30, 1-24, 1991.
  63. Liston, S.L., Levine, S.C., Margolis, R.H., Yanz, J.L. Use of intraoperative ABR to guide prosthesis positioning. Laryngoscope, 101, 1009-1012, 1991.
  64. *Margolis, R.H., Levine, S.C., Fournier, E.M., Hunter, L.L., Smith, S.L., and Lilly, D.J. Tympanic electrocochleography, normal and abnormal patterns of response. Audiology, 31, 8-24, 1992.
  65. *Naeve, S.L., Margolis, R.H., Levine, S.C., Fournier, E.M. Effect of ear-canal air pressure on evoked otoacoustic emissions. J. Acoust. Soc. Amer., 91, 2091-2095, 1992.
  66. *Cacace, A.T., Margolis, R.H., Relken, E.M. Short-term poststimulatory response characteristics of the human acoustic stapedius reflex, monotic and dichotic stimulation. J. Acoust. Soc. Amer., 91, 203-214, 1992.
  67. *Levine, S.C., Margolis, R.H., Fournier, E.M., Winzenburg, S.M. Tympanic electrocochleography for evaluation of endolymphatic hydrops. Laryngoscope, 102, 614-622, 1992.
  68. *Filion, P.R., Margolis, R.H. Comparison of clinical and real-life judgments of loudness discomfort. J. Amer. Acad. Audiol., 3, 193-199, 1992.
  69. *Hirsch, J.E., Margolis, R.H., Rykken, J.R. A comparison of acoustic reflex and auditory brainstem response screening of high-risk infants. Ear and Hearing, 13, 181-186, 1992.
  70. *Hunter, L.L., Margolis, R.H. Multifrequency tympanometry, current clinical application. Am.  J. Audiology, 1, 33-43, 1992.
  71. Fournier, E.M., Margolis, R.H. Computers and complexity in the audiologist’s clinical life. Audiology Today, 4, 18-21, 1992.
  72. Margolis, R.H. Screening Issues. Hearing, newborn period and early childhood. Audio Digest (Pediatrics), 38, No. 17, 1992.
  73. Le, C.T., Daly, K.A., Margolis, R.H., Lindgren, B.R., Giebink, G.S. A clinical profile of otitis media. Archives of Otolaryngology, 118, 1225-1228, 1992.
  74. Oliviera, R.J., Hammer, B., Stillman, A., Holm, J., Jons, C., Margolis, R.H. The living ear, a look at ear canal changes with jaw motion. Ear and Hearing, 13, 464-466, 1992.
  75. *Winzenburg, S.M., Margolis, R.H., Levine, S.C., Haines, S.J., Fournier, E.M. A comparison of tympanic and transtympanic electrocochleography in patients undergoing acoustic neuroma and vestibular nerve section surgery. American Journal of Otology, 14, 63-69, 1993.
  76. *Margolis, R.H., Hunter, L.L., Saupe, J.R., Giebink, G.S. Effects of otitis media on extended high frequency hearing in children. Annals of Otology, Rhinology, and Laryngology, 102, 1-5, 1993.
  77. *Johnson, J.H., Turner, C.W., Zwislocki, J.J., Margolis, R.H. Just noticeable differences for intensity and their relation to loudness. J. Acoust. Soc. Amer., 93, 983-991, 1993.
  78. Margolis, R.H. Detection of hearing impairment with the acoustic stapedius reflex. Ear and Hearing, 14, 3-10, 1993.
  79. Margolis, R.H., Nelson, D.A. Acute otitis media with transient sensorineural hearing loss, a case study. Archives of Otolaryngology-Head & Neck Surgery, 119, 682-686, 1993.
  80. *Margolis, R.H., Hunter, L.L., Saupe, J.R., Giebink, G.S. Efectos de la otitis media sobre la audición de frecuencias altas ampliadas en niños. ORL Digest, 4, 11-13, Septiembre 1993.
  81. *Hunter, L.L., Margolis, R.H., Rykken, J.R., Giebink, G.S. Multifrequency tympanometry in normal children and children recovering from otitis media – a preliminary report. In Lim, D.J. et al., eds., Recent Advances in Otitis Media. Decker Periodicals, 1993, pp. 46-49.
  82. Daly, K.A., Giebink, G.S., Margolis, R.H., Le, C.T., Westover, D.E., Juhn, S.K., Buran, D. Chronic otitis media with effusion morbidity in a prospective cohort: risk determinants for short-term outcomes in children treated with tympanostomy tubes. In Lim, D.J. et al., eds., Recent Advances in Otitis Media. Decker Periodicals, 1993, pp. 7-10.
  83. *Margolis, R.H., Hunter, L.L., Rykken, J.R., Giebink, G.S. Effects of otitis media on extended high frequency hearing in children. A preliminary report. In Lim, D.J. et al., eds., Recent Advances in Otitis Media. Decker Periodicals, 1993, pp.540-542.
  84. Westover, D.W., Daly, K.A., Margolis, R.H., Le, C.T., Juhn, S.K., Buran, D., Giebink, G.S. Chronic otitis media with effusion morbidity in a prospective cohort: study design implications and a preliminary report of long-term outcomes in children treated with tympanostomy tubes. In Lim, D.J. et al., eds., Recent Advances in Otitis Media. Decker Periodicals, 1993, pp. 11-14.
  85. *Margolis, R.H., Goycoolea, H.G. Multifrequency tympanometry in normal adults. Ear and Hearing, 14, 408-413, 1993.
  86. *Trine, M.B., Hirsch, J.E., Margolis, R.H. The effect of middle ear pressure on transient evoked otoacoustic emissions. Ear and Hearing, 14, 401-407, 1993.
  87. Le, C.T., Hunter, L.L., Margolis, R.H., Daly, K.A., Lindgren, B.R., Giebink, G.S. A clinical profile of otitis media without an intact tympanic membrane. Archives of Otolaryngology-Head & Neck Surgery, 120, 513-516, 1994.
  88. *Margolis, R.H., Hunter, L.L, Giebink, G.S. Tympanometric evaluation of middle ear function. Annals of Otology, Rhinology, and Laryngology, 103 (Suppl. 163), 34-38, 1994.
  89. *Hunter, L.L., Margolis, R.H., Giebink, G.S. Identification of hearing loss in children with otitis media. Annals of Otology, Rhinology, and Laryngology, 103 (Suppl. 163), 59-61, 1994.
  90. *Daly, K.A., Giebink, G.S., Lindgren, B., Margolis, R.H., Westover, D., Hunter, LL, Le, C.T., Buran, D. A randomized trial of the efficacy of sulfatrimethoprim and prednisone in preventing post-tympanostomy tube morbidity. The Pediatric Infectious Disease Journal, 14, 1068-1074, 1995.
  91. *Margolis, R.H., Rieks, D., Fournier, E.M., Levine, S.C. Tympanic electrocochleography for the diagnosis of Ménière’s disease. Archives of Otolaryngology-Head & Neck Surgery, 121, 44-55, 1995.
  92. *Lee, C.-S., Paparella, M.M., Margolis, R.H., Le, C. Audiological profiles and Meniere’s Disease. Ear Nose & Throat Journal, 74, 527-532, 1995.
  93. Margolis, R.H., Schachern, P.L., Hunter, L.L., Sutherland, C. Multifrequency tympanometry in chinchillas. Audiology, 34, 232-247, 1995.
  94. Hunter, L.L., Margolis, R.H., Rykken, J.R., Le, C.T., Daly, K.A., Giebink, G.S. High frequency hearing loss associated with otitis media. Ear and Hearing, 17, 1-11, 1996.
  95. Daly, K.A., Rich, S.S., Levine, S., Margolis, R.H., Le, C.T., Lindgren, B., Giebink, G.S. The Family Study of Otitis Media: Design and Disease and Risk Factor Profiles. Genetic Epidemiology 15:451-68, 1996.
  96. Margolis, R.H., Schachern, P.L., Fulton, S. Multifrequency tympanometry and histopathology in chinchillas with experimentally-produced middle-ear pathologies – a preliminary report. In Lim, D.J. et al., eds., Recent Advances in Otitis Media. Decker Periodicals, 1996, 383-386.
  97. Hunter, L.L., Margolis, R.H., Giebink, G.S., Schmitz, J.L., Le, C.T., Daly, K.A. Long-term prospective study of hearing loss in children after tympanostomy tube treatment of chronic otitis media with effusion. In Lim, D.J. et al., eds., Recent Advances in Otitis Media. Decker Periodicals, 1996, 383-386.
  98. Margolis, R.H., Anderson, J.H., Fourner, E.M., Friedman, B., Hirsch, J.E., Hunter, L.L., Jons, C., Schmitz, J.L., Smith, S.L. Audiology Clinical Protocols. Allyn and Bacon, 1997.
  99. *Margolis, R.H., Trine, M.B. Effects of middle ear disease on otoacoustic emissions. In Robinette, M.S., Glattke, T. (Eds.) Otoacoustic Emissions: Clinical Applications. Thieme (New York), 1997. Chapter 7, pp. 130-150. Otitis Media. Decker Periodicals, 1996, 277-279.
  100. Hunter, L.L., Margolis, R.H. Effects of tympanic membrane abnormalities on auditory function. J. Amer. Acad. Aud. 8, 431-446, 1998.
  101. Margolis, R.H., Schachern, P.A., Fulton, S. Multifrequency Tympanometry and Histopathology in Chinchillas with Experimentally-Produced Middle Ear Pathologies. Acta Otolaryngologica (Stockh), 118, 216-225, 1998.
  102. Levine, S.C., Margolis, R.H., Daly, K.A. Use of electrocochleography in the diagnosis of Meniere’s disease. Laryngoscope, 108, 993-1000, 1998.
  103. Margolis, R.H. Electrocochleography. Seminars in Hearing, 20, 45-62, 1999.
  104. Margolis, R.H., Hunter, L.L. Tympanometry: Basic Principles and Clinical Applications. In Musiek, F.E., Rintelmann, W.F. (Eds.) Contermporary Perspectives in Hearing Assessment, Allyn & Bacon (Boston), 89-130, 1999.
  105. Wilson, R.H., Margolis, R.H. Acoustic-Reflex Measurements. In Musiek, F.E., Rintelmann, W.F. (Eds.) Contermporary Perspectives in Hearing Assessment, Allyn & Bacon (Boston), 131-166, 1999.
  106. *Rhodes M.C., Margolis, R.H., Hirsch, J.E., Napp, A.P. Hearing screening in the newborn intensive care nursery: a comparison of methods. Otolaryngology Head & Neck Surgery, 120, 799-808, 1999.
  107. *Margolis, R.H., Saly, G.S., Keefe, D.H. Wideband reflectance tympanometry in normal adults. J. Acoust. Soc. Am., 106, 265-280, 1999.
  108. *Li, Y., Hunter, L.L., Margolis, R.H., Levine, S.C., Lindgren, B., Daly, K., Giebink, G.S. Prospective study of tympanic membrane retraction, hearing loss, and middle ear function. Otolaryngology Head and Neck Surgery, 121, 514-522, 1999.
  109. Margolis, R.H., Hunter, L.L. Acoustic Immittance Measurements. In Roeser, R.J., Valente, M., Hosford-Dunn, H., (Eds.), Audiology: Diagnosis, Thieme Medical Publishers (New York), 381-42, 2000.
  110. *Jaisinghani, V.J., Hunter, L.L., Li, Y., Margolis, R.H. Quantitative analysis of tympanic membrane pathology using video-otoscopy. Laryngoscope, 110, 1726-1730, 2000.
  111. *Margolis, R.H., Saly, G.S., Hunter, L.L. High frequency hearing loss and wideband middle ear impedance in children with otitis media histories. Ear & Hearing, 21, 206-211, 2000.
  112. *Hsu, G.S., Margolis, R.H., Schachern, P.A. The Development of the Middle Ear in Neonatal Chinchillas. I. Birth to 14 Days. Acta Otolaryngologica 120, 922-932, 2000.
  113. *Hsu, R., Margolis, R.H., Schachern, P.A., Javel, E. The Development of the Middle Ear in Neonatal Chinchillas. II. 2 Weeks to Adulthood. Acta Otolaryngologica, 121, 679-688, 2001.
  114. *Margolis, R. H., Saly, G. L., Paul, S., Schachern, P.L. Wideband Reflectance Tympanometry in Chinchillas and Humans. J. Acoust. Soc. Am. 110,1453-1464, 2001.
  115. Casselbrant ML, Gravel GS, Margolis RH et al. Diagnosis and Screening. In DJ Lim, CD Bluestone, ML Casselbrant (Eds.) Recent Advances in Otitis Media: Report of the Seventh Research Conference. Ann Otol Rhinol Laryngol 111, Suppl 188, 95_101, 2002.
  116. Margolis, R.H. Effects of middle ear disease on otoacoustic emissions. In Robinette, M.S., Glattke, T. (Eds.) Otoacoustic Emissions: Clinical Applications. 2nd ed. Thieme (New York), 2002, pp. 190-212.
  117. *Margolis, R.H., Saly, G.L., Hunter, L.L. Relationship Between Middle Ear Mechanics and High Frequency Hearing in Children with Otitis Media Histories. In Lim, D.J. et al., eds., Recent Advances in Otitis Media with Effusion, Hamilton, Ontario: B.C. Decker, 77-78, 2002
  118. *Margolis, R.H., Hsu, G.S., Hsu, R.W., Saly, G.S., Schachern, P.A. Development of middle ear function and structure in neonatal chinchilla. In Lim, D.J. et al., eds., Recent Advances in Otitis Media with Effusion, Hamilton, Ontario: B.C. Decker, 625-627, 2002.
  119. *Jaisinghani, V.J., Hunter, L.L., Li, Y, Margolis, R.H. Method for quantifying tympanic membrane pathology using video-otoscopy In Lim, D.J. et al., eds., Recent Advances in Otitis Media with Effusion, Hamilton, Ontario: B.C. Decker, 100-102, 2002.
  120. Daly, K.A., Hunter, L.L., Lindgren, B.R., Margolis, R.H., Giebink, G.S. Chronic Otitis Media with Effusion Sequelae in Children Treated with Tubes. Archives of Otolaryngology Head & Neck Surgery 517-522, 2003.
  121. Margolis, R.H., Bass-Ringdahl, S., Hanks, W.D., Holte, K., Zapala, D.A. Tympanometry in Newborn Infants – 1 kHz Norms. J. Amer. Acad. Audiol., 14, 383-392,
  122. Margolis, R.H. In one ear and out the other – what patients remember. SpeechPathology.com (speechpathology.com/articles), January 5, 2004; Audiology Online (www.audiologyonline.com/articles). February 23, 2004; HealthyHearing.com (www.healthyhearing.com/articles). January 17, 2005, February 15, 2005
  123. Margolis, R.H. Boosting memory with informational counseling. ASHA Leader, 9 (4), 10-11, 28, 2004.
  124. Margolis, R.H. Audiology Information Counseling – What Do Patients Remember? Audiology Today, 16, 14-15, 2004.
  125. Margolis, R.H. Automated Audiometry – Progress or Pariah? Audiology Online (audiologyonline.com/articles). January 17, 2005, February 8, 2005.
  126. Margolis, R.H. Automated Audiometry: Progress or Pariah. Audiology Today 17, 21, 2005.
  127. *Margolis, R.H., Saly, G., Le, C., Laurence, J. Qualind™: A Method for Assessing the Accuracy of Automated Tests. J. Amer. Acad. Audiol., 18, 78-89, 2007.
  128. Margolis, R.H., Saly, G.S. Toward a standard description of hearing loss. Int. J. Audiology 46, 746-758, 2007.
  129. Margolis, R.H. Conflict of Interest in Audiology. Audiology Today 19, 32-34, 2007.
  130. Margolis, R.H., Saly, G.L. Distribution of Hearing Loss Characteristics in a Clinical Population. Ear and Hearing, 29, 524-532, 2008.
  131. Margolis, R.H., Saly, G.L. Asymmetrical Hearing Loss: Definition, Validation, Prevalence. Otology and Neurotology, 29, 422-431, 2008.
  132. Margolis, R.H., Morgan, D.E.. Automated Pure-Tone Audiometry: An Analysis of Capacity, Need, and Benefit. Amer. J. Audiol., 17, 109-113, 2008.
  133. Margolis, R.H. The Vanishing Air-Bone Gap – Audiology’s Dirty Little Secret. Audiology Online (audiologyonline.com/articles), October 20, 2008.
  134. Margolis, R.H., Glasberg, B.R., Creeke, S., Moore, B.C.J. AMTAS® – Automated Method for Testing Auditory Sensitivity: Validation Studies. Int. J. Audiology, 49, 185-194, 2010.
  135. Margolis, R.H. A Few Secrets about Bone-Conduction Testing. Hearing Journal, 63 (2). Pp. 10, 12, 14, 16-17, 2010.
  136. Margolis, R.H., Frisina, R., Walton, J.P. (2011). Automated method for testing auditory sensitivity: II. Air Conduction Audiograms in Children and Adults. Int. J. Audiology, 50, 434-439, 2011.
  137. Margolis, R.H., Moore, B.C.J. Automated method for testing auditory sensitivity: III. Sensorineural hearing loss and air-bone gaps. Int. J. Audiology, 50, 440-447, 2011.
  138. *Margolis, R.H., Stiepan, S.M. Acoustic Method for Calibration of Audiometric Bone Vibrators. J. Acoust. Soc. Amer. 131, 1221-1225, 2012.
  139. Margolis, R.H. Automated Audiometry Then and Now. Audiology Practices, 4, 9-15, 2012.
  140. *Ginter, S.M., Margolis, R.H. Acoustic Method for Calibration of Audiometric Bone Vibrators. II. Harmonic Distortion. JASA Express Letters 134, EL33-EL37, 2013.
  141. *Margolis, R.H., Eikelboom, R.H., Johnson, C., Ginter, S.M., Swanepoel, D.W., Moore, B.C.J. False Air-Bone Gaps at 4 kHz in Listeners with Normal Hearing and Sensorineural Hearing Loss. Int. J. Audiology 52, 526-532, 2013.
  142. Jerger, J., Wilson, R., Margolis, R. Suggestion of terminological reform in speech audiometry. Amer. Acad. Audiol.,    25, 229-230, 2014.
  143. Margolis, R.H., Popelka, G.R. Bone Conduction Calibration. Seminars in Hearing, 35, 329-345, 2014.
  144. Swanepoel, R.H., Eikelboom, R.H., Margolis, R.H. Tympanometry Screening Criteria in Children 5 to 7 Years of Age. J. Amer. Acad. Audiol. 25, 927-936, 2014.
  145. Wilson, R.H., Margolis, R.H. Hearing loss terminology should be evidence based: a reply to Clark and Martin. J. Am. Acad. Audiol. 26, 524-525, 2015.
  146. *Margolis, R.H., Madsen, B. Acoustic Environment for Hearing Testing. J. Amer. Acad. Audiol., 26,784-791, 2015.
  147. Margolis, R.H., Wilson, R.H., Popelka, G.R., Eikelboom, R.H., Swanepoel, D.W. Distribution characteristics of normal pure-tone thresholds. Int. J. Audiology, 54, 796-805, 2015.
  148. Margolis, R.H., Wilson, R.H., Popelka, G.R., Eikelboom, R.H., Swanepoel, D.W. Distribution Characteristics of Air-Bone Gaps: Evidence of Bias in Pure-Tone Audiometry. Ear & Hearing, 37, 177-188, 2016.
  149. Margolis, R.H., Killion, M.C, Bratt, G.W., Saly, G.L. Validation of the Home Hearing Test. J. Amer. Acad. Audiol., 27, 416-420, 2016.
  150. Margolis, R.H., Bratt, G., Feeney, M.P., Killion, M.C, Saly, G.L. Home Hearing Test™: Within Subjects Threshold Variability. Ear and Hearing, 39, 906-909, 2018.
  151. *Smull, C.C., Madsen, B., Margolis, R.H. Evaluation of two circumaural earphones for audiometry.  Ear and Hearing, 40, 177-183, 2019.
  152. Margolis, R.H., Eikelboom, R.H., Moore, B.C.J., Swanepoel, D.W. False 4-kHz Air-BoneGaps – A Failure of Standards. Audiology Today, 31, 14-21, 2019.
  153. *Rao, A., Altus, B., Schroeder, R., Margolis, R.H. Comparison of thresholds obtained with the Radioear B-71 and B-81 Bone-Conduction Transducers. Ear and Hearing, 41, 1775-1778, 2020.
  154. Simpson, M.J., Jennings, S.G., Margolis, R.H. Techniques for obtaining high-quality recordings in electrocochleography. Frontiers in Systems: Neuroscience, Apr 15;14:18, 2020.
  155. Folmer, R.L., Saunders, G.H., Vachhani, J.J., Margolis, R.H., Saly, G., Yueh, B., McCardle, R.A., Feth, L.L., Roup, C.M., Feeney, M.P. Hearing health care utilization following automated hearing screening. J. Amer. Acad. Audiol., 32, 235-245, 2021.
  156. *Margolis, R.H., Wilson, R.H., Saly, G.L., Gregoire, H.M., Madsen, B.M. Automated forced choice tests of speech recognition. J. Amer. Acad. Audiol. 32, 606-615, 2021.
  157. Margolis, R.H., Saly, G.L., Wilson, R.H. Ambient noise monitoring during pure-tone audiometry. J. Amer. Acad. Audiol. 33, 45-55, 2022.
  158. Margolis, R.H., Wilson, R.H. Evaluation of binomial distribution estimates of confidence intervals of speech-recognition test scores. J. Acoust. Soc. Amer., 152, 1404-1415, 2022.
  159. Margolis, R.H., Margolis, J.C. AMBAND Bone Conduction Headband. J. Amer. Acad. Audiol. 33, 214-219, 2022.
  160. Margolis, R.H., Rao, A., Wilson, R.H., Saly, G.L. Non-linguistic Auditory Speech Processing. Int. J. Audiology, 62, 217-226, 2023.
  161. Margolis, R.H., Wilson, R.H., Saly, G.L. Clinical Interpretation of Word-Recognition Scores for Listeners with Sensorineural Hearing Loss: Confidence Intervals, Limits, and Levels. Ear and Hearing 44, 1133-1139, 2023.
  162. Margolis, R.H., Hornsby, B.W.Y., Saly, G.L., Wilson, R.H. Predicted and Measured Word-Recognition Scores Unmask Distortion in the Impaired Auditory System. Ear and Hearing, submitted for publication, 2023.
  163. Margolis, R.H., Sanchez, V., Hunter, L.L., Rao, A., Boyle, S., Motlagh Zadeh, L., Wong, A,N, Air-Conduction and Bone-Conduction Reference-Threshold Levels – A Multicenter Study, Int. J. Audiology, Submitted for publication 2023.
  164. Margolis, R.H. False air-bone gaps and false calibration – a cautionary tale. Audiology Today, Submitted for publication 2023.

Knowledge Center

In One Ear and Out the Other

In One Ear and Out the Other – What Patients Remember

Robert H. Margolis

University of Minnesota

In Meredith Willson’s The Music Man, Mayor Shinn announces to the July 4th crowd in the River City High School Madison Auditorium, “Members of the school board will now present a patriotic tableau.” Up jumps a school board member who whispers in the Mayor’s ear and the Mayor corrects himself: “Members of the school board will not present a patriotic tableau.”

Nine out of ten semantic units were correct. The scene shows how easily the loss of one information unit can completely change the message. Can’t you just see the Iowa farmer with noise-induced hearing loss from years in the tractor seat wondering why he is being subjected to Eulalie McKecknie Shinn’s impersonation of a Grecian urn instead of the promised patriotic tableau?

How often do our patients miss one or two critical facts resulting in a complete misunderstanding of their communicative problem and what to do about it? This question gnawed at me for years until I came to the conclusion that every important fact or recommendation that is given to a patient should be given in writing, in an easily understood format that can be shared with family members, read, reread, and kept for future reference.

I recently saw a patient who is an intelligent professional and had been seen previously by two audiologists. I know the audiologists well and I don’t believe it is possible that they did not thoroughly and clearly explain the results. After I discussed the findings and provided the results and recommendations in a clear, written format, the patient thanked me and said no one had ever explained that before. I think he forgot.

We need to keep in mind that our patients lead busy lives and there are many things that work against the likelihood that they will remember what we tell them. The working mom whose son broke an ankle yesterday playing soccer, who is worried about missing work for just a hearing evaluation, who doesn’t have anything for dinner tonight, and whose husband may be laid off next week, might not remember the difference between a conductive loss and a sensorineural loss. And when relating the information to her husband that night, “Your hearing will probably not get better” can easily become “Your hearing will probably now get better.” Most of the semantic units were correct.

Recently it occurred to me that ours is not the only field with information that is important for patients to understand and remember. I consulted the Audiology counseling literature but found only one study of patient recall following audiologic consultation and a brief reference to the issue in Luterman’s excellent text on Counseling Persons with Communication Disorders and Their Families (Austin: Pro-Ed, 2001). I was shocked that Audiology, a communication profession, has almost completely neglected to be concerned with the effectiveness of our communication of information to patients. Other professions have addressed the issue and there are many research studies and discussions of patient recall in the medical literature, most by British authors. A list of references can be found at www.audiologyincorporated.com.

The Audiology counseling literature makes an important distinction between informational counseling and personal adjustment counseling. Informational counseling, the subject of this article, is intended to provide to the patient the relevant information needed to understand the nature of the disorder and the steps that are recommended to manage it. Because of the emotional impact of the information, personal adjustment counseling may be necessary to assist the patient and family so they can take positive measures to manage the condition. But without effective communication of the nature, extent, prognosis and management plan, the patient and family are unable to play an active, positive role in remediation, rehabilitation, and secondary prevention of long-term consequences. In this article I discuss the research findings of patient recall in various clinical situations and some recommendations for maximizing what patients remember.

Why is Patient Recall Important?

Just because we feel compelled to explain our test results doesn’t mean that it is important that our patients remember the information. It doesn’t matter if a patient understands what was found on an x-ray if the appropriate action was taken, right? Wrong. Studies have found that when patients understand the information that is communicated by a healthcare provider, there are significant enhancements of patient satisfaction, compliance with recommendations, and outcomes. In addition, there are significant decreases in anxiety, treatment time, and cost. One study showed that physicians underestimate patients’ desire for information and their ability to understand medical information. To withhold information because the patient probably won’t understand it is a presumption that can significantly impair the clinical process. When physicians were given specific strategies for enhancing communication, there were measurable improvements in patient recall. Recall of information, then, is important to the welfare of the patient and there are strategies that have been shown to increase what patients remember. A disturbing finding is that physicians’ impressions of what patients would remember were not correlated with measures of patients’ actual recall. This finding reinforces the need to provide information in writing even for patients who appear to be absorbing everything.

How Much Do Patients Remember?

Recall of information communicated to patients has been measured under a variety of conditions. In these studies facts are given to the patient and the proportion of facts correctly recalled is measured. Because many factors affect memory for health information, there is a wide range of results but overall studies indicate that about 50% of information provided by healthcare providers is retained. Depending on conditions, 40-80% can be forgotten immediately. Studies in which recall was measured at two points in time do not show a difference when recall is measured soon after the consultation and at a later date. It seems that patients remember a small proportion of facts and those stay with them for a period of at least several weeks.

Of the information that is recalled, about half is remembered incorrectly – the Mayor Shinn effect. So about half is forgotten immediately and half of what is remembered is wrong. If you take any complex message that has an information component and an advice component and you remove 50% of the facts, and distort half the remaining information, the result could be a dangerously misunderstood message that could have life-threatening consequences.

An even more disturbing finding is that patients often forget their medical diagnoses even when the conditions are serious. In one study patients could not recall 68% of the diagnoses told to them in a medical visit. When there were multiple diagnoses, patients could not recall the most important diagnosis 54% of the time. Some of the diagnoses in this study were serious, even life-threatening conditions such as diabetes, hypertension, and liver disease. In another study, patients and physicians agreed on problems that required followup for only 45% of the problems identified by the physician as requiring followup. When there was disagreement between the physician and patient regarding the need for followup, the likelihood of appropriate management was significantly lower.

Factors that Affect Patient Recall

Recall of information is dependent on many factors, some related to the patient, some related to the mode of presentation of the information, and some related to the clinician.

Patient Factors. Some factors that you might expect to affect the ability to retain information don’t appear to influence recall. Intelligence, for example, has not been shown to affect the proportion of information retained. However, familiarity with the information does have an affect. A patient who is familiar with hearing loss as a result of prior consultations, an affected family member, or professional knowledge tends to remember more. The degree of understanding of issues related to the diagnosis can have a significant effect. A finding that the patient expects is remembered more than one that is unexpected. A finding that is welcome or desired is more likely to be recalled than one that is unwelcome or unwanted. Interestingly, a patient is better able to recall information when they are in the same emotional and physical state they were in when they received the information. If they were anxious at the time of the consultation they will remember more when they are in a similar state than when they are relaxed. Elderly patients tend to remember less than younger patients. When elderly patients are not included in the study, age effects are not seen. Anxiety can have a positive or negative effect on retention. Moderate anxiety enhances recall but severe anxiety inhibits retention of information. Stress causes “attention narrowing” which interferes with the patient’s ability to redirect to a different topic. Denial, a defense mechanism that is common in patients with a variety of diagnoses including hearing loss, may contribute to poor recall. A patient who is in denial of their hearing loss is not likely to convey information provided at the hearing evaluation accurately to family members.

Mode of Presentation. Not surprisingly, information presented in a simple, easy- to-understand format is remembered better than information presented in a more complex manner. The more information presented, the lower the proportion that is recalled by the patient. Information that is presented first tends to be remembered better (the primacy effect).

Several studies have shown that categorizing information can improve retention and some authors discuss the method of explicit categorization. Information is organized in specific categories such as Explanation of Systems, Diagnostic Tests, Results, Prognosis, and Recommendations. The patient is told that the information will be presented in these categories, each category is announced, and the patient is asked if there are questions before moving on to the next category. One study found a significant enhancement of recall with this method. Another found that in combination with asking the patient what information is wanted, the method provides a framework for enhancing retention.

A number of studies have investigated the effects of written and graphical material to supplement verbal presentation of information. Written material, cartoons, and pictures, when used appropriately during the consultation can enhance recall of information.

Recommendations are more likely to be remembered and followed when they are specific rather than general. A recommendation should be a specific statement telling the patient what to do rather than a more general statement of the goal. A recommendation to “stay home from work and rest for two weeks with no strenuous exercise” is more likely to be followed than “get some rest and take it easy for a while.”

Clinician Factors. The clinician’s communicative style can have a significant influence on retention of information by patients. Information given by clinicians who speak in clear language with simple sentence structure is more likely to be remembered than information provided in complex language loaded with scientific terms. Clarity of communication requires that the clinician understand what the patient wishes to learn and what his/her level of understanding is. To communicate clearly in a manner that promotes retention of information, the consultation needs to be a dialog in which the clinician listens to the patient. When the patients ideas are evaded or inhibited, the patient is less likely to remember important information. Even the clinician’s anxiety affects recall. Patients remember less when the information is provided by an overtly anxious clinician. The perceived importance of the information also affects retention. Information that is presented in a manner that emphasizes its importance is more likely to be remembered than information present in a matter-of-fact manner. Non-verbal communication is important in reflecting the clinician’s state (confident, anxious, distracted, empathetic) and in indicating the importance of information.

We all know the head-nodding behavior often exhibited by people who hear only part of the message but don’t get enough to really be part of the conversation. The same phenomenon occurs in a consultation when the patient appears to understand but their understanding is not confirmed by the clinician and the patient is not encouraged to ask questions. Information that is unorganized, unclear, or incomplete can be interpreted by patients to confirm their pre-existing beliefs which may not be in concert with the message the clinician is attempting to communicate. One writer called this the “illusion of shared understanding.” When the clinician is oblivious to the patient’s lack of understanding of the information, the entire consultation session may provide little benefit, or worse, do more harm than good.

Methods of Maximizing Retention

Studies of patient recall lead to effective strategies for presenting information in a manner that maximizes retention. Although the following strategies will improve retention, all patients will forget some information, even when presented in an optimal manner. Nevertheless, clinicians should incorporate these methods into their counseling sessions.

• Advice should be given as concrete instructions. “Use ear plugs when you use your power tools” rather than “Keep your noise exposure to a minimum.”
• Use easy to understand language. Short words and sentences are remembered better.
• Present the most important information first to capitalize on the primacy effect. Often the most important information is the recommendations such as “make an appointment with the ear doctor.”
• Stress the importance of recommendations or other information that you want the patient to remember.
• Use the method of explicit categorization. Tell the patient “We are going to go over recommendations, then we will talk about your specific hearing problem (diagnosis), then we will go over test results, then we will talk about how your hearing may change in the future (prognosis)”. Ask the patient for questions before moving on to the next category.
• Repeat the most important information.
• Don’t present too much information. Present only the information that is important for the patient to remember. Proportion of retention decreases with the amount of information presented.
• Be sure you understand what the patient wants from the evaluation and what his/her beliefs are concerning the problem. Specifically address the patient’s desires and beliefs.
• Supplement verbal information with written, graphical, and pictorial materials that the patient can take home.

These techniques will significantly enhance the accurate recall of information by our patients. But they will still forget. The best way to ensure that the information gets home is to provide the patient with a permanent record. One author recommended that the patient be instructed to write the information as the clinician presents it. For certain kinds of information this may be an effective teaching technique. Another author recommended tape recording the consultation which would allow the patient and family to review the results and recommendations together. Another approach provides clearly written, illustrated, patient-specific, educational materials that ensure that the information is clear, accurate, complete, and available for review and discussion with family members and other professionals.

Patients are always encouraged to bring family members or friends to the consultation. Of course, this is not always possible. We’ve all seen the elderly patient whose spouse encouraged him/her to have a hearing evaluation but can’t accompany the patient to the clinic. The patient has prior beliefs about the extent of the hearing problem that may or may not be realistic or the patient may be in denial. We present information in the 5-10 minutes we have for counseling at the end of the evaluation and we expect the patient to communicate the information to family members. Given what is known about retention of information by patients we should not expect the patient to be able to explain the results and recommendations accurately.

Our profession is solely concerned with the communicative well-being of our patients. Yet our own communication to patients is fundamentally disordered. Although we complain that our counseling efforts are not reimbursed, an analysis of our methods and outcomes would probably not convince payers that we are providing a valuable, reimbursable service when we verbally present complex information in a format that is known to be ineffective. I recommend the following guiding principle for our communication of results and recommendations to our patients.

Any information that is important for the patient to understand and remember should be provided in writing.

Robert H. Margolis, Ph.D., is professor of Audiology in the Department of Otolaryngology at the University of Minnesota. He has developed and marketed patient education materials for hearing-impaired patients and their families. The “Understanding …” series of patient education materials can be viewed at www.audiologyincorporated.com.