Kris English, PhD

Professor Emeritus of Audiology

University of Akron

This article is posted as we near the three-year anniversary of George Floyd’s murder (May 25, 2020). In the US, this crime reignited the Black Lives Matter movement, as well as renewed support for the LGBTQ+ community, indigenous persons, and others experiencing injustice.

However, as often happens, momentous events lose their impact over time. Protest signs fade and attention is directed elsewhere … all the more reason to routinely recommit to cultural humility and equitable audiologic care.

Cultural humility includes treating others with dignity. Following is a discussion of relational dignity, and how it might be communicated in audiology appointments.

Dignity

The concept of dignity is both commonplace and difficult to define, apart from a generalized belief that “We know when we see it, and we know when we don’t see it.”^1-3 There is at least general agreement that dignity is a human right,^4-6 and is “attached to all human beings irrespective of any of their achievements” (p. 71).⁷

Jacobson⁸ describes this specific aspect of dignity as “dignity-in-self.” Another aspect, highly relevant to person-centered care, is known as “dignity-in-relation…[referring] to the ways in which respect and worth are conveyed through expression and recognition… a matter of action and interaction …” (p. 17)

Relational dignity is reciprocal and mutual: “I dignify you by recognizing your self-respect; by dignifying you, I also dignify myself…”(p. 16).⁸  When dignity is not acknowledged in either direction, trust breaks down.⁹

We are fully aware that not all humans are treated as though they had equal worth. However, we may not be aware of the many subtle breaches in relational dignity. Jacobson lists a continuum of 24 types of social violations of dignity, many of which are egregious (e.g., exploitation, assault) and would never be permitted in a clinic setting. But the “lesser” end of the continuum should give us pause: they include dismissal, disregard, and grouping.

Dismissal describes the experience of discounting a person’s knowledge, concerns, and feelings. “In health care settings, serious medical conditions go untreated because doctors and nurses dismiss their patients’ ability to recognize and report accurately when something is wrong” (p. 27)⁸, consistent with Dr. Susan Moore’s experience, reported after she passed away.

https://www.nytimes.com/2020/12/23/us/susan-moore-black-doctor-indiana.html

Disregard is behavior that communicates “I don’t believe you” when a patient reports concerns and needs. For example, a recent poll indicated that 60% of Black respondents reported higher rates of being disbelieved, and of being denied tests, treatments or pain medication they thought they needed.¹⁰ “Not being believed” has been a widely reported experience, much of it relating to the myth that Black individuals have a higher pain tolerance than Whites.^11-14

Another breach, grouping, is one we already know how to define: “when people are seen and treated not as individuals, but only as indistinguishable and interchangeable parts of a unit” – a type of othering, the separation of “them” from “us.”

Needless to say, these kinds of dignity violations are not limited to Black patient experiences.^15-17  As Jacobson¹⁸ points out: “Any human interaction can be a dignity encounter—an interaction in which dignity comes to the fore and is either violated or promoted” (p. 1538). Relevant to our commitment to cultural humility, equitable health care, and counseling applications, Jacobson poses this thought-provoking question: How can relational dignity be enacted in the design and delivery of healthcare?

Part 2 of this article will consider the Patient Dignity Question: “What do I need to know about you as a person to take the best care of you that I can?”

https://medium.com/@megansaxelby/dignity-a-framework-to-transform-school-culture-b50a7ace9ec7

References

1. Dutra PEP, et al. (2022). Improving the perception of respect for and the dignity of inpatients: A systematic review. BMJ Open, 12:e059129.
2. McClellan FM. (2020). Healthcare and human dignity: Law matters. New Jersey: Rutgers University Press.
3. Schulman A. (2009). Bioethics and the question of human dignity. In B.T. Lanigan (Ed.), Human Dignity and Bioethics (pp. 3-13). Nova Science Publishers, Inc
4. Baillie L, Matiti M. (2013). Dignity, equality and diversity: An exploration of how discriminatory behaviour of healthcare workers affects patient dignity. Diversity and Equality in Health and Care, 10, 5–12.
5. Jones DA. (2015). Human dignity in health care: A virtue ethics approach. The New Bioethics, 21(1), 87–97.
6. Miller, SC. (2017). Reconsidering dignity relationally. Ethics and Social Welfare, 11(2), 108-121.
7. Nordenfelt L. (2004). The varieties of dignity. Health Care Analysis, 12(2), 69-81.
8. Jacobson N. (2012). Dignity and health. Nashville: Vanderbilt University Press.
9. Bazargan M, et al. (2021). Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. Annals of Family Medicine, 19(1), 4-15.
10. Kaiser Family Foundation/Undefeated Survey on Race and Health. (2020). Race, health, and COVID-19: The views and experiences of Black Americans.
11. Akinlade, O. (2020). Taking Black pain seriously. New England Journal of Medicine, e68(1-2).
12. Hoffman KM, et al. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS, 113(6), 4296–4301. 
13. Schoenthaler A, Williams, N. (2022). Looking beneath the surface: Racial bias in the treatment and management of pain. JAMA Network Open, 5(6):e2216281.
14. O’Connor MI. (2021). Equity360: Gender, Race, and Ethnicity: Why Don’t We Believe our patients? Clinical Orthopædics and Related Research, 479, 897-900
15. Kamen CS, et al.(2019). “Treat us with dignity”: A qualitative study of the experiences and recommendations of lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients with cancer. Support Care Cancer, 27, 2525–2532.
16. Guadagnolo BA, et al. (2009). Medical mistrust and less satisfaction with health care among Native Americans presenting for cancer treatment. Journal for the Health Care of the Poor and Underserved, 20 (1), 210–226. doi.org/10.1353/hpu.0.0108
17. Staats K, et al. (2020. )Dignity and loss of dignity: Experiences of older women living with incurable cancer at home, Health Care for Women International, 41(9), 1036-1058.
18. Jacobson, N. (2009). Dignity violation in health care. Qualitative Health Research, 19(11), 1536-1547.

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

Chochinov³ laid the groundwork for an intervention designed for vulnerable patients to help them feel seen, known as the Patient Dignity Question: “What do I need to know about you as a person to take the best care of you that I can?”

Some Background

The Patient Dignity Question (PDQ) was designed to help healthcare providers understand their patients in settings where one’s dignity can feel especially diminished: palliative care, nursing homes, and end-of-life care.^3-8  The question, “What do I need to know about you as a person to take the best care of you that I can?” was informed by empirical research to help health care providers (HCPs) understand each patient as a person, not as a mere embodiment of their diagnosis.

The PDQ is described as a “dignity conserving intervention,” and while each PDQ interview will be unique, pre- and post-intervention measures have indicated positive outcomes, including the appreciation for “being seen.” ^9,10 It is a validated process, well received by patients and clinicians, and has been recommended as a routine component of care.¹¹ Perhaps because of its simplicity and implied humility, this question has been shown to be quite effective. One example:¹¹

A total of 126 participants (66 patients and 60 family members) responded to the PDQ…93% felt that the information was important for HCPs to know, and 99% would recommend the PDQ for others. A total of 137 HCPs completed 293 evaluations of individual PDQs; 90% indicated that they learned something new from it, 64% that they were emotionally affected by it, 59% that it influenced their sense of empathy, and 44% that it influenced their care.

As noted, the PDQ was designed specifically for palliative and end-of-life care settings. Recently, an additional consideration of patients in the LGBTQ community receiving care in these settings indicated comparably positive PDQ results,¹² but also raises a question: why wait until the end stage of healthcare?  Social dignity violations (e.g., dismissal, disregard, grouping) routinely occur across a wide range of healthcare encounters throughout a lifetime.^13-18 There seems no reason to wait: researchers very familiar with the PDQ have pointed out that the PDQ “can be used by any provider type and in numerous care settings to understand patient values” as a standard of care.¹⁹ Since all patients seek relational dignity throughout their lives, extending the PDQ intervention to all patients in all settings seems feasible, or at the minimum to those with historical concerns regarding inequitable care.

Proposal: Pose the PDQ…

… optimally to all patients! And especially within discordant dyad audiology encounters as an intervention to override implicit bias.

The Patient Dignity Question communicates our goal to be person-centered, and certainly qualifies as another addition to the counseling tool box. It is similar to the “What Matters to You?” query but says more than “tell me about yourself.” By also adding “to take the best care of you that I can” may (hopefully) also be heard as “what matters to you also matters to me” – that is, an authentically humble, respectful outreach, committed to relational dignity.

Concerned about saying the question accurately?  We could:

• Preview the conversation with a handout for the patient beforehand, with the explanation: “I look forward to our appointment, and as we get to know each other, I would like to ask you this question….”
• Develop an intake “PDQ form” for contemporaneous notetaking: “To make sure my services are personalized to your needs, I have this form that starts out….” and after reading the Patient Dignity Question, jot down the patient’s responses and incorporate “what I need to know” into the treatment plan.

We can work out several approaches that feel comfortable and appropriate to the moment and setting – but ultimately, find a way to “go there.”

https://www.weforum.org/agenda/2018/10/why-we-need-dignity-more-than-ever-70-years-after-the-universal-declaration-of-human-rights/

Conclusion

Public attention to social inequities in healthcare will ebb and flow, but on a daily basis, individual practitioners can maintain vigilant attention and keep the issue at top of mind.

Can the “Patient Dignity Question” reduce healthcare inequities? Let’s try it and find out – and share experiences and insights with the profession.

“Not everything that is faced can be changed. But nothing can be changed until it is faced.” — James Baldwin

References

1. Chochinov HM. (2007). Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. British Medical Journal, 3359(9761), 184-187.
2. Jacobson N. (2012). Dignity and health. Nashville: Vanderbilt University Press.
3. Chochinov HM, et al. (2005). Dignity therapy: A novel psychotherapeutic intervention for patients near the end of life. Journal of Clinical Oncology, 23(24), 5520-5525.
4. Hadler RA et al. (2022). “What do I need to know about you?”: The Patient Dignity Question, age, and proximity to death among patients with cancer. Supportive Care in Cancer, 30, 5175–5186.
5. Johnston B, et al. (2015a). The person behind the patient: A feasibility study using the Patient Dignity Question for patients with palliative care needs in hospital. International Journal of Palliative Nursing, 21(2), 71-77.
6. Johnston B, et al. (2015b). The dignified approach to care: A pilot study using the patient dignity question as an intervention to enhance dignity and person-centred care for people with palliative care needs in the acute hospital setting. BMC Palliative Care, 14(9).
7. Łabuś-Centek M, et al. (2020). The meaning of dignity patient question and changes in the approach to this issue of cancer patients during home hospice care. Palliative Medicine in Practice, 14(2), 89–94.
8. McDermott P. (2019). Patient Dignity Question: Feasible, dignity-conserving intervention in a rural hospice. Canadian Family Physician, 65(11), 812-819.
9. Arantzamendi M, et al.(2016). Promoting patient-centred palliative care: A scoping review of the patient dignity question. Current Opinion in Supportive and Palliative Care, 10(4), 324-329.
10. Meier E, et al.( 2019). Conversations regarding personhood: Use of the Patient Dignity Question in an outpatient psycho-oncology clinic. Journal of Palliative Medicine, 22(12), 1574-1577.
11. Chochinov HM, et al. (2015). Eliciting personhood within clinical practice: Effects on patients, families, and health care providers. Journal of Pain Symptom and Management, 49(6), 974–980.
12. Javier NM. (2021). Palliative care needs, concerns, and affirmative strategies for the LGBTQ population.Palliative Care and Social Practice, 15(1), 1-17.
13. Banerjee D, et al. (2021). Role of dignity in mental healthcare: Impact on ageism and human rights of older persons. American Journal of Geriatric Psychiatry, 29(10),  1000−1008.
14. Blair I, et al. (2013). Clinicians’ implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Annals of Family Medicine, 11(1), 43-52.
15. Carlström R, et al. (2021). ‘Treat me with respect’: Transgender persons’ experiences of encounters with healthcare staff. Scandinavian Journal of Caring Sciences, 35, 600-607
16. Job C, et al. (2022). Health professional’s implicit bias of adult patients with low socioeconomic status (SES) and its effects on clinical decision-making: A scoping review protocol. BMJ Open, 12:e059837
17. Schnierle J, et al. (2019). Implicit bias: What every pediatrician should know about the effect of bias on health and future directions. Current Problems in Pediatric and Adolescent Health Care, 49, 34-44.
18. van der Geugten W, Goossensen A. (2020). Dignifying and undignifying aspects of care for people with dementia: A narrative review. Scandinavian Journal of Caring Science, 34, 818–838.
19. Hadler RA, et al. (2022). “What do I need to know about you?” The Patient Dignity Question, age, and proximity to death among patients with cancer. Supportive Care in Cancer, 30, 5175–5186.

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

In early February 2023, the Ida Institute in Denmark announced that it is “significantly scaling back activities” as its funding comes to an end. Fortunately, its deep library of tools, online courses and other resources will remain available. These developments are highlighted here to honor Ida’s direct and enduring impact on audiologic counseling.

An Easy-to-Miss “Ida Impact:” A Consistent Focus on Person-Centeredness

Because of the many contributions Ida has made to audiologic practices in the past 15 years, its philosophical commitment to the concept of person-centered care could go unnoticed. When the organization began to define itself in 2007, the term had not been widely used; just 6 years prior, the Institute of Medicine’s (2001) report identified the concept of patient-centered care as a pillar of quality health care. Because of IOM’s stature, “PCC” became a widely accepted concept. Soon, however, concerns were raised about the term’s inherent limitations (e.g, Clarke & Fawcett, 2016; Mezzich et al, 2010; Miles & Mezzich, 2011). By listening carefully to those concerns as expressed by persons and families living with hearing loss and by thought leaders in audiology, Ida became one of the early adopters of another version of “PCC:” the more empowering concept of person-centered care.

The difference in wording may not have been immediately appreciated, but over time it began to sink in: the shift from patient to person reflects a difference in power, focus, and priorities. Compare these distinctions (Eklund et al., 2019):

The goal of Patient-Centered Care is to support a functional life…

• as defined by clinicians
• determined by test results (words, sentences in quiet, noise, etc)
• to address listening challenges at home, work.

Whereas … the focus of Person-Centered Care is to support a meaningful life…

• as defined by individuals with hearing loss and family
• determined by understanding the whole person (“what matters to you?”)
• whose individual goals may change over time.

Implications: Checking Our Priorities

These two models of centeredness represent different priorities, which by definition means assigning more weight or importance to one “thing” than to other things. For instance, clinician trainees understandably prioritize the dozens of details involved with assessment and treatment — there is indeed a lot to remember and apply. However, when those tasks have been mastered, we can shift to a broader priority, i.e, “being more focused on the person than on the task” (DiLollo & Favreau, 2010; Granberg & Skagerstrand, 2022; Grosch et al, 2008).

“Being More Focused on the Person Than on the Task”

This short phrase is easy to remember and carries two salient points: (1) being “focused” implicitly includes behaviors typically associated with counseling (active listening, empathy, shared decision-making, etc), and (2) it doesn’t dismiss the importance of our tasks. We can attend to both the person and the tasks in the time allotted, but only if we actively prioritize. When we focus our undivided attention to someone’s personhood for even a very brief time, that person’s experience is about feeling unique, being heard, and sharing responsibility (Feldthusen et al, 2022). Students may not perceive this balance as they master the necessary tasks, but we need to advise them: once these are mastered, move on! Figuring out how to focus more on the person in front of us is our life-long goal.

To the Ida Team…

… Lotte, Ena, Hans, Cher, Natalie, Clint, Anne, Mei and all the change agents at Ida: You brought audiologists together, helped us move forward, and helped persons with hearing loss be heard.

References

Clarke PN, Fawcett J. (2016). Nursing knowledge driving person-centered care. Nursing Science Quarterly, 29(4), 285-287.

DiLollo A, Favreau C. (2010). Person-centered care and speech and language therapy. Seminars in Speech and Language, 31(1), 90-97.

Eklund JH, et al. (2019). “Same same or different?” A review of reviews of person-centered and patient-centered care. Patient Education and Counseling, 102, 3-11. 

Feldthusen C et al. (2022). Centredness in health care: A systematic overview of reviews. Health Expectations, 25, 885–901.

Granberg S, Skagerstrand Å. (2022). Enhancing person-centered audiologic rehabilitation: Exploring the use of an interview tool based on the International Classification of Functioning, Disability, and Health Core Sets for Hearing Loss. Frontiers in Rehabilitation Sciences, 3, Article 945464.

Grosch K, Medvene L. (2008).  Person-centered caregiving instruction for geriatric nursing assistant students. Journal of Gerontological Nursing, 34, 23–31.

Institute of Medicine. (2001). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.

Mezzich J et al. (2010). Toward person-centered medicine: From disease to patient to person. Mount Sinai Journal of Medicine, 77, 304-306.

Miles A, Mezzich J. (2011). Person-centered medicine: Advancing methods, promoting implementation. International Journal of Person Centered Medicine, 1(3), 423-428.

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

Supervising audiology students is always rewarding. When it comes to supporting a student’s development in counseling skills, it is also complicated. “Teachable moments” often depend on personally observing a missed counseling opportunity, immediately modeling a relevant person-centered response, and then carving out time to discuss it later – but it is unknown if the student is better prepared for the next time (Fanai et al, 2018). Feedback provided at the end of the day (e.g., with the “Four Habits Rubric” [Saltrøe et al, 2021]) is helpful but still leaves professional growth more to chance than to pedagogical planning. Either way, the process places the student in a passive role.

Positioning the Learner to Take the Lead

In classroom instruction, students are provided syllabi that explicitly describe what they need to do to master course content, giving them agency over their outcomes. How to provide students agency re: counseling skill development in clinic? To address the limitations described above, healthcare educators are applying Bandera’s (1977) concept of self-efficacy. He defined self-efficacy as “people’s judgments of their capabilities to organize and execute courses of action required to attain designated types of performances. It is concerned not with the skills one has but with judgments of what one can do with whatever skills one possesses” (1986, p. 391). More simply, “The factors that influence behavior are embedded in the belief that one has the capability to accomplish that behavior” (Klassen & Klassen, 2018, p. 76).

We rarely highlight “belief” in audiology, but we do refer to it indirectly when we ask students to reflect on past challenges, what they learned about themselves, and how they apply that learning when new challenges arise (what they believe they are capable of accomplishing)(Zimmerman et al., 2017).

A Recent Application

In 2021, Wolderslund et al reported on delivering a communication skills program for healthcare professionals. Instead of measuring conventional learning outcomes (e.g., “What is the definition of shared decision-making?”), they applied Bandura’s concept of self-efficacy and asked attendees pre- and post-training questions such as, “How certain are you that you can successfully make a plan based on shared decisions between you and the patient?” Their pre-post assessment was a 12-item self-efficacy tool (SE-12) (Ammentorp et al, 2007; Norgaard et al, 2012), represented below. The items include well-known person-centered practices and use the word can to explore one’s sense of capability to achieve them.

Self-Efficacy (SE) 12 (Wolderslund et al, 2021)

The SE-12 is a valid and reliable tool (Axboe et al, 2016), and is applicable to most healthcare training situations, including audiology. For example: students would complete a baseline SE-12 at the beginning of their clinical placement, and then identify personally relevant goals, design an improvement plan, and learn how to evaluate and trust their progress. By end of term, they would provide meaningful documentation for the supervisor’s final assessment, while confirming to themselves their capability to develop  counseling skills.

A Secondary Benefit

When students become comfortable with increasing their own sense of self-efficacy in counseling, it can become easier to carry over the concept to patient care. After all, self-efficacy is one of the variables that affect life with hearing loss: i.e., the belief that one can or cannot face and deal with the challenge. We often broach this psychological aspect when discussing recommendations (first-time device use, modifying existing devices, using communication strategies) by asking, “Now that we’ve reviewed options and agreed on a plan moving forward…How confident do you feel about it?” (Cuevas et al, 2019). We may only then learn about harbored doubts, distress, and perceived barriers that our patient had not disclosed before.

Conclusion

There is more to counseling, of course. The SE-12 items provide a framework for person-centered care – the “what to do.” The art of “how to do” these steps advances the learner to essential interpersonal/counseling skills, for example:

• Responding to patient emotions
• Attention to nonverbal communication
• Conversations about stigma
• Cultural humility

…just to name a few (Ammentorp et al, 2022). Developing a strong track record in managing person-centered care will enhance self-efficacy in mastering the many counseling nuances.

References

Ammentorp J et al. (2007). The effect of training in communication skills on medical doctors’ and nurses’ self-efficacy. A randomized controlled trial. Patient Educ Couns, 66, 270–277.

Ammentorp J et al. (2022). Translating knowledge into practice for communication skills training for health care professionals. Patient Educ Couns, 105, 3334-3338.

Axboe, MK et al. (2016). Development and validation of a self-efficacy questionnaire (SE-12) measuring the clinical communication skills of healthcare professionals. BMC Medical Educ, 16, 272. https://doi.org/10.1186/s12909-016-0798-7

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev, 84,191–215.

Bandura, A. (1986). Social foundation of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.

Cuevas S et al. (2019).  Determinants of self-efficacy among individuals who are hard-of-hearing. J Rehab, 85(2), 37-46. 

Fanai JK et al. (2018). Performance feedback to increase use of counseling skills. Seminars Hrg, 39(1), 44-51.

Klassen RM & Klassen JRL. (2018). Self-efficacy beliefs of medical students: a critical review, Perspect Med Educ, 7, 76–82.

Norgaard B et al. (2012). Communication skills training increases self-efficacy of health care professionals. J Contin Educ Health Prof, 32(2), 90–97.

Saltrøe E el. (2021). Registered nurses’ assessments of the ‘Four Habits Model’ course – across-sectional study. Sykepleien Forskning,16, e-87671.

Wolderslund M et al. (2021). The effectiveness of a person-centred communication skills training programme for the health care professionals of a large hospital in Denmark. Patient Educ Counseling, 104, 1423-1430. 

Zimmerman B et al. (2017). The role of self-efficacy and related beliefs in self-regulation of learning and performance. In A. Elliot, C. Dweck, and D. Yeager (Eds.), Handbook of competence and motivation (2nd ed.) (pp. 313-333). New York: Guildford Press.

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

In 2012, Barry and Egman-Levitan¹ wrote a “perspectives” piece for the New England Journal of Medicine about the challenge of engaging patients in shared decision-making. While acknowledging the need to invite and support patients through this process, the authors also highlight a (still new at the time) requisite cultural shift among healthcare providers: “Clinicians, in turn, need to relinquish their role as the single, paternalistic authority and train to become more effective coaches or partners — learning, in other words, how to ask, ‘What matters to you?’ as well as ‘What is the matter?’” (p. 780).

NHS Scotland Guide for Patients

Their suggestion to ask the simple question, “What matters to you?” (WMTY) inspired a world-wide conversation. Just two examples: the Institute for Healthcare Improvement (IHI)² in Boston (U.S.) now promotes the practice of asking this question as well as providing support for those who are skeptical or uncomfortable with the idea. The National Health System in Scotland³ has designed materials to support their “what matters” philosophy, as well as outreach programs to inform patients that “this is what we do/this is who we are.”

Trying Something New

If we see potential with this question but find the wording too direct, abrupt, or just awkward, we can always find ways to communicate its intent in our own style. Examples from a “What Matters to You” guideline³ are provided below.

20190304-WMTY-Guide.pdf

An Additional Consideration: Racial Equity

The President/CEO of IHI brings up another issue: that of racial heath care equity. She asks us to consider not just how we ask “what matters,” but also who we ask.⁴

I believe it’s safe to say that how we ask and whom we’ve asked, “What matters to you?” has often been — and too often continues to be — inequitable. Are we asking this question of our patients who may never have been asked what matters to them about their concerns and their needs? … We must consider not only what has already been expressed, but also the needs that have not yet been stated where there has been systematic underrepresentation or intentional exclusion of what matters to communities of color and other historically oppressed and marginalized populations. As we ask, “What matters to you?” in the coming 10 years, asking it more equitably will be essential for developing systems of care capable of delivering on the promise of health equity.

Along these lines, persons interested in this topic are referred to a handbook from British Columbia: Culturally Safe Engagement: What Matters to Indigenous (First Nations, Métis and Inuit) Patient Partners?⁵ It can serve as a model for asking “what matters” to patients in our communities who have endured healthcare disparities.

Conclusion

Consider for a moment this article title: “We Think We are Patient-Centered But the Evidence Shows All of Us Have a Few Things to Learn…”⁶ As we humbly absorb this truth, we are advised that one of the “few things to learn” is this: “In order to provide patient-centered care, an audiologist must individualize.” Perhaps the most straightforward way to individualize is to ask, “What matters to you?”

Clinics around the world report that this simple expression of care improves patient-clinician relationships and patient satisfaction.^7-10 It is likely that many audiology centers are already asking their patients,”What matters to you?” If so, hopefully they will report on their experiences.

For more info, visit the WMTY.world website for:

• Links to websites of organizations around the world that have championed WMTY implementation
• Downloadable resources to start an implementation journey including:
  • Annual WMTY implementation reports from multiple health systems
  • A WMTY literature review
  • A WMTY implementation toolkit

References

1. Barry MJ & Edgman-Levitan S. (2012). Shared decision making – The pinnacle of patient centered care. New England Journal of Medicine, 366(9), 780-781.
2. Institute for Healthcare Improvement. (2016). A simple question to put patients in the driver’s seat.
3. Healthcare Improvement Scotland. (n.d.) Will you join the “What Matters to You?” conversation?
4. Mate K. (2022). Why asking “What matters to you” matters.
5. British Columbia Patient Safety and Quality Council. (2021). Culturally safe engagement: What matters to Indigenous (First Nations, Métis and Inuit) patient partners?
6. Grenness C. (2022). We think we are patient-centered but the evidences says all of us have a few things to learn ….
7. British Columbia Patient Safety and Quality Council. (2019). “What matters to you?” Evaluation report, 2018/2019.
8. Montefiore Hudson Valley Collaborative. (2020). Implementation toolkit: What matters to you?
9. Healthcare Improvement Scotland. (2019). “What matters to you?” – Supporting more meaningful conversations in day-to-day practice: A multiple case study evaluation.
10. Pittaway H. et al (2022). Asking the question ‘What Matters to You?’ in a London intensive care unit. Journal of Patient-Centered Research and Reviews, 9(3), 166-73. doi: 17294/2330-0698.1922

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

Not to worry: the title above looks like a typo, but is actually a kind of mantra to help us find and maintain what is being called clinician presence during patient encounters:¹

• NOW. I am not distracted / I am fully focused on the moment. 
• HERE. I am aware of how this space and consultation affects my patient.
• THIS. I am fully attending to this patient’s unique narrative.

“Clinician presence” may not be familiar to student trainees, but working with the concept might help them recognize the impact we have on patient impressions and patient outcomes. Clinician presence is defined as a “purposeful practice of awareness, focus, and attention with the intent to understand and connect” (emphasis added) with our patient. Core elements include familiar person/patient-centered behaviors and attributes:²

• Listening without interrupting
• Finding out what the patient cares about
• Exploring emotional cues (noticing, naming, validating)
• Humility ^3,4 (i.e., no matter how many patients we’ve served, we don’t know what this patient will say or need)
• Signposting before note-taking (stepping away from Now.Here.This. as needed)

The “intent to connect” adds an important relational dimension to person-centered care, reminiscent of the Relationship-Centered Care model.^5,6 Sustaining clinician presence involves mental and emotional labor⁷ so taking brief re-centering breaks throughout the day is recommended. That said, it’s encouraging to know that relational communication has been associated with reducing burnout.⁸

Conclusion

Because of its brevity, this mantra could serve as a nonthreatening framework for in-depth student discussions. (For example: What does “Now.Here.This.” bring to mind? Would this kind of focus support patient trust? How is patient trust related to healthcare decisions? How would a patient describe their audiology experience?) Trainees may be surprised to learn how important they are, beyond the role of collecting case histories and test data. If we are responsible for student development, we can nurture this growth by routinely asking them, “Did it feel like you connected with your patient today?”

References

1. Brown-Johnson C. et al (2019). What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection. BMJ Open, 9, e0308831
2. Zulman et al. (2020). Practices to foster physician presence and connection with patients in the clinical encounter. JAMA, 323(1), 70-81.
3. Huynh HP et al. (2021). What do humble doctors do? A conceptualization of clinician humility from the patient’s perspective. Patient Education and Counseling, 104, 3066-3071.
4. Wadwa A, Mahant S. (2022). Humility in medical practice: A qualitative study of peer-nominated excellent clinicians. BMC Medical Education, 22, 88.
5. Maitra A. et al. (2021). Using ethnographic methods to classify the human experience in medicine: a case study of the presence ontology. Journal of the American Medical Informatics Association, 28(9), 1900–1909.
6. Tresolini C. et al. (2000). Health professions education and relationship-centered care. Fetzer Institute.
7. Kerasidou A, Horn R. (2016), Making space for empathy: Supporting doctors in the emotional labour of clinical care. BMC Medical Ethics,17, 8.
8. Boissy A et al. (2016). Communication skills training for physicians improves patient satisfaction. J General Internal Medicine, 31, 755–61.

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

In 1989, Stone and Olswang¹ published a seminal article on a universal counseling challenge: recognizing and managing professional boundaries within clinical relationships. Their guidance provided an essential foundation for counseling coursework that would soon be included in new Audiology Doctorate programs.

Since its publication over 30 years ago, much has changed within the field of audiology, including new issues regarding boundaries. Here we review their original contributions, and follow up with one additional boundary consideration: screening for related health and safety issues.

1989: Key Concepts

“Boundaries define relationships that are helpful, realistic, and ethical. In fact, establishing boundaries is a preparatory step to effective counseling” (p. 27).

Stone and Olswang organized boundaries into two easy-to-understand categories:

• Content/Focus: What we talk about. We are within “focus boundaries” when a patient’s emotions, attitudes, or problems are directly related to living with hearing loss or balance issues; e.g., reactions to diagnosis, concerns about recommendations, or uncertainties about shared decision-making.

• Interaction Style/ Dynamics: How we communicate, share power and responsibility. We are within “dynamic boundaries” when interactions are mutually respectful, the audiologist is supporting patient autonomy, and the patient is active and empowered.

Also invaluable is advice about “crossed boundaries,” when what we talk about and how it’s talked about is inappropriate or makes us uncomfortable. “Red flags” include a patient who cannot or will not maintain respectful interactions, repeatedly fluctuates in emotions or behaviors, develops an over-dependence on the clinician, or continues to use offensive language or “overshares”² after being asked to stop. Clinicians, of course, may also find themselves crossing a boundary, by becoming overly involved with a patient or oversharing about one’s own personal life.

How to manage these complicated situations? Trust our instincts! “Persistent uncomfortable feelings are an important clinical signal …[the clinician] does not have to be able to analyze relationships in depth or understand all the dynamics in order to recognize the signs of boundary problems … we may not need consultation [with colleagues  or supervisors] to decide that a relationship is beyond his or her boundaries, based on observation, self-evaluation, and level of experience” (p. 29).

The 2020’s: What We Now Also Talk About

References

1. Stone JR, Olswang LB (1989). The hidden challenge in counseling. Asha, 31, 27-31.
2. Brandt A. (2019, Dec. 2) How to set boundaries in the age of oversharing/ Oversharing has become normalized. Psychology Today.
3. Thomas H et al. (2020). Whole-person care in general practice: The doctor–patient relationship. Australian J Gen Practitioners, 49(3), 139-144.
4. American Speech-Language-Hearing Association. (2020). Audiology information series: Ototoxic medications.
5. Ganesen P et al. (2018). Ototoxicity: A challenge in diagnosis and treatment. J Audiology & Otology, 22(2), 59-68.
6. Khoza-Shangase K. (2017). Risk versus benefit: Who assesses this in the management of patients on ototoxic drugs? J Pharmacy & Bioallied Sciences, 9(3), 171–177.
7. Wium A, Gerber A. (2016). Ototoxicity management: An investigation into doctors’ knowledge and practices, and the roles of audiologists in a tertiary hospital. South African J Comm Disorders, 63(1), a174.
8. Clark J et al. (2021). Heightening our vigilance toward patient well-being. International J Audiology, 60(Suppl. 2), S4-S11.
9. Clark JG, English K. (2022). Elder abuse: A need for heightened vigilance. Audiology Today, 34(6), 32-36
10. Wesby C. (2007). Child maltreatment: A global issue. Lang, Speech, Hearing Services in Schools, 38, 140-148. 
11. Busacco D (2010). Dual sensory loss in adults: an overview for audiologists. Audiology Online.
12. McGilton KS et al. (2016). Hearing and vision screening tools for long-term care residents with dementia: protocol for a scoping review. BMJ Open, 6:e011945.
13. Davis J. (2021). Cognitive screening in audiology: Considerations for nonverbal instructions. The Hearing Journal, 74(5), 34-35.
14. Dawes P et al. 2022. Hearing assessment and rehabilitation for people living with dementia. Ear & Hearing, 43(4), 1089–1102
15. Shen J et al. (2016). Using cognitive screening tests in audiology. Am J Audiology, 25(4), 319-331.
16. Bennett R et al. (2021). Perspectives on mental health screening in the audiology setting: A focus group study involving clinical and non-clinical staff. Am J Audiology, 30(4), 980-983.
17. Radloff LS. (1977). The CES-D (Center of Epidemiologic Studies-Depression) scale: A self report depression scale for research in the general population. Applied Psych Measurements, 1, 385-401.
18. Radloff LS. (1991). The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. J Youth and Adolescence, 20(2), 149-166.
19. Cejas I et al. (2021). Prevalence and anxiety in adolescents with hearing loss. J Otology & Neurotology, 42(4), e470-e475.
20. Squires M et al. (2013). Bullying is a safety and health issue: How pediatric audiologists can help. Audiology Today, 25(5),18-26.

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

In an earlier installment, we learned that clinicians-in-training tend to report feeling more comfortable conveying empathy with nonverbal communication, compared to the worry about “finding the right words” – and on the receiving end, patients seem to prefer and appreciate “nonverbals” as well.

However, complications occur when clinicians and patients differ by race: in these circumstances, “nonverbals” may not communicate empathy as intended. Nonverbal communication behaviors (NCBs) – eye gaze, body language, facial expressions, tone of voice – are usually unconscious and automatically activated, and therefore difficult to control and monitor.¹ Since the 1930’s, researchers have consistently found that NCBs tend to communicate our unconscious (implicit) biases, usually without our awareness or intention.^2,3 For example, in cross-racial appointments, clinicians with high implicit bias are likely (without realizing it) to speak faster, make less eye contact, rush appointments, and be less patient-centered.^4,5 It is vital to appreciate that NCBs “reflect feelings and intentions that often go unspoken; they mirror and reinforce dominance and status hierarchies; they illustrate, buttress, and occasionally contradict the verbal stream…“ (p. 671).²

(Click here for an indepth description of “The Neuroscience of Prejudice and Stereotyping”)

Not surprisingly, within a matter of seconds, racial and ethnic minority patients perceive the “unspoken” and understandably distrust the overall situation, including clinical recommendations.^6,7 We cannot ignore how this dynamic undermines our goal of providing racially equitable healthcare – indeed, we are obligated to address the problem.

Implicit racial biases are “habits of mind,” acquired and over-learned across time, and may seem intractable, given the uneven record for intervention effectiveness.⁸ However, when research focuses specifically on patient-centeredness, the results are more encouraging.⁹ For example, a systematic review (2017) showed that “irrespective of patient or physician race… when the physician displayed [nonverbal behaviors such as] positive emotion, made eye contact, and appeared attentive, physician race was not correlated to [negative] patient evaluations” (p. 416).¹⁰  

The research on patient-centered care reports similar results when measuring verbal behaviors.^11,12  Not yet explained, however: when we actively strive for patient-centeredness, either verbally or nonverbally, the positive experience seems to matter more to a patient than the negative impact of implicitly biased “nonverbals.” While researchers work on this question, we should continue to encourage students to use “nonverbals” to communicate patient-centered, respectful empathy.

Time to “Reframe”?

Students of counseling theory will recall a basic principle of cognitive behavioral therapy (CBT):¹³ “changing how we think helps us change how we feel and act.” Because of the emphasis on thinking, the interactivity of this theory’s components is often overlooked: in fact, each component influences the others. Using a classic CBT strategy, we can reframe the usual process, and describe a different approach: “changing how we act helps us change how we feel and think” as we work to break implicit-bias habits. Or, to put it more simply, “We are what we repeatedly do.”¹⁴

Three Take-Away Points

1. Clinicians are generally unaware that their nonverbal behaviors can communicate implicit racial bias.
2. Patients, on the other hand, can quickly “read” those behaviors and decide the clinician is not trustworthy.
3. Intentional, mindful nonverbal patient-centered behaviors have the potential to assure patients that their clinician is committed to equitable health care.

References

1. Baugh A., et al. (2020). Communication training is inadequate: The role of deception, non-verbal communication, and cultural proficiency. Medical Education Online, 25:1
2. Dovidio JF, LaFrance M. (2013). Race, ethnicity, and nonverbal behavior. In J.A. Hall & M.L. Knapp, M. L. (Eds.), Nonverbal communication (pp. 671-695). Berlin: De Gruyter, Inc.
3. Halberstadt AG. (1985). Race, socioeconomic status, and nonverbal behavior. In A. W. Siegman & S. Feldstein (Eds.), Multichannel integrations of nonverbal behavior (pp. 227–266). Hillsdale, NJ: Erlbaum.
4. Penner LA, et al. (2010). Aversive racism and medical interactions with Black patients: A field study. Journal of Experimental Social Psychology, 46, 436–440.
5. Cooper LA, et al. (2012). The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health, 102, 979-987.
6. Castelli L, et al. (2012). The power of the unsaid: The influence of nonverbal cues on implicit attitudes. Journal of Applied Social Psychology, 42(6), 1376–1393.
7. Dovidio JF, et al. (2002). Why can’t we just get along? Interpersonal biases and interracial distrust. Cultural Diversity & Ethnic Minority Psychology, 8, 88–102.
8. FitzGerald C, et al (2019). Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: A systematic review. BMC Psychology, 7(29).
9. Street R, et al. (2008). Understanding concordance in patient-physician relationships: Personal and ethnic dimensions of shared identity. Annals of Family Medicine, 6(3), 198-205.
10. Lorié A, et al. (2017). Culture and nonverbal expressions of empathy in clinical settings: A systematic review. Patient Education and Counseling, 100, 411–424.
11. Burgess D., et al. (2007). Reducing racial bias among health care providers: Lessons from social-cognitive psychology. Journal of General Internal Medicine, 22, 282-287.
12. Penner LA, et al. (2014). A social psychological approach to improving the outcomes of racially discordant medical interactions. Journal of General Internal Medicine, 28(9), 1143-1149.
13. Ellis A. (1992). Group rational-emotive and cognitive-behavioral therapy. International Journal of Group Psychotherapy, 42(1), 63-80.
14. Durrant, W. (1927). The story of philosophy. NY: Simon & Schuster.

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

(Originally published in Hear It! Newsletter #4, International Association of Communication Sciences and Disorders, Aug 2021. At the time of this posting, more than 3.6 million Ukrainian citizens had crossed their borders seeking safety.)

The World Health Organization (2019) estimates that 14% of the world’s population (one billion people) are “on the move” from their countries of origin. Approximately half are refugees fleeing persecution, dangerous governments, or physical danger; others are immigrants crossing international borders to find work or unite with family, among other reasons (United Nations, 2016).

Refugees wait for transfer to border crossing (Reuters/english.alrabiya.net)

Once refugees and immigrants are temporarily or permanently resettled, their engagement with local healthcare systems can be problematic, since cultural belief systems about wellness, illness, preventive and curative care, and attitudes about healthcare providers vary widely (Murray & Skull, 2004). Optimally, healthcare systems engage cultural liaisons and interpreters to help clinicians manage appointment logistics.

Providing Care From a “Not-Knowing”  Stance

To support trust-building during patient encounters, audiologists might consider an approach used in the field of social work called a “not-knowing stance” or a learner’s attitude (DeFehr et al., 2012). By assuming a “not-knowing stance,” we consciously put aside any distracting assumptions and stereotypes and ask our patients to teach us about their situation. This approach has much in common with person-centeredness and narrative medicine (Charon et al., 2017) while also striving for cross-cultural understanding.

Examples of modeling a “not-knowing stance” (adapted from Annamalai, 2014) include these invitations to a learning conversation:

• Do you have thoughts about the cause of your symptoms?
• Have you tried any remedies?
• What kind of help do you seek?
• Are traditional healers part of your culture?
• If we have recommendations, would you want to consult with elders or family?
• Would you feel comfortable working as partners in decision-making?
• What should I know about your culture that would help me help you?

In addition to the verbal conversation, the “not-knowing stance” also requires attention to nonverbal communication behaviors, including comfort levels with touch, personal space, and eye contact.

Watch for Instinctive “I Know How You Feel”

Importantly, anathema to a “not-knowing stance” is the almost instinctive response, “I know how you feel.” Bearing in mind that the patient’s history likely includes trauma, migration stressors, and resettlement difficulties, it’s not only unlikely the audiologist knows how the patient feels, but the response also belies a learning attitude.

Putting aside our assumptions and stereotypes is easier said than done. As we attempt the “not-knowing stance” with culturally different patients, we simultaneously need to evaluate what we do know about our own cultural self-awareness. What are our personal biases, and how can we manage them?  The goal of developing cultural competence has been expanded to include cultural humility, which positions us as participants in a growth process with no end point (English, 2020). Like our patients, we too have much to learn.

References

Annamalai, A. (Ed.) (2014). Refugee health care: An essential medical guide. NY: Springer. DOI 10.1007/978-1-4939-0271-2.

Charon, R. et al. (2017). The principles and practice of narrative medicine. Oxford, England: Oxford Press.

English, K. (2020). Counseling with cultural humility: An introduction (Part 1 of 4).

DeFehr, J., et al. (2012). “Not-knowing” and “assumption” in Canadian social services for refugees and immigrants: A conversational inquiry into practitioner stance. International Journal of Collaborative Practices, 3(1), 75-88.

Murray, S.B., & Skull, S.A. (2005). Hurdles to health: Immigrant and refugee health care in Australia. Australian Health Review, 29(1), 25-29.

United Nations. (2016). “Refugees” and “migrants:” Frequently asked questions.

World Health Organization. (2019). Promoting the health of refugees and migrants: Draft global action plan, 2019-2023.

Laura Gaeta, PhD

Assistant Professor

California State University, Sacramento

What does graduate education in audiology look like in 2022? In addition to changes within our profession, changes in our society have been in the news as well as our classrooms and clinics, particularly about diversity, equity, and inclusion (DEI). We have discussed racism, gender and sexual orientation, and stereotypes with students and colleagues, but how do we continue the conversation by including it in our curricula? How do we make it an intentional part of our coursework and clinical practica, rather than an ad hoc conversation?

Academic and clinical faculty are tasked with identifying how, where, and when topics related to diversity are covered in the curriculum, as well as how students will demonstrate competence in these areas through their courses and clinical practica.

A Pilot Seminar for First Years

As we begin 2022 and pivot back to in-person instruction, we plan to increase our attention to DEI issues with a new one-credit seminar for 1st Year AuD students. Below is a course outline that combines introductory counseling skills, rehab concerns, and instruction and experience related to care for patients with diverse backgrounds. (Note: Instructors may seek to invite or co-teach the course with faculty from a related health profession, including allied health fields, psychology, or a second language program, e.g., ESL or linguistics departments.)

Course – Clinical Methods: Communicating with Patients (1 cr, 50 min/week)

Examples of learning outcomes:

1. Describe strategies to facilitate the shared decision-making process.
2. Evaluate clinical scenarios for appropriate use of interpreters.
3. Use clinical, ethical, and legal guidelines for the provision of culturally- and linguistically-appropriate services.
4. Establish appropriate assessment and rehabilitative approaches and procedures for non-English speaking populations.

Conclusion

This one-credit course outline is only one example of a way to introduce communication and counseling skills early in an Au.D. program. These topics, along with hands-on practice in class, can help students translate concepts and beginning skills into practice. The topics covered here reflect some issues that deserve greater attention, and by creating a safe place for students to discuss, share, and reflect, we can hopefully graduate students who are even more patient-centered, inclusive, and prepared for clinical practice and our profession.