Working Through Student “Empathy Qualms”

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

Virtually every book and article on counseling and patient-centered care identifies empathy as an essential clinician characteristic. Given its importance, audiology students might harbor doubts about their ability to convey empathy. It’s certainly a concern shared by other healthcare trainees, who report worries about appearing unprofessional and feeling uncomfortable, vulnerable, and insecure (“what if I say the wrong thing?”)(Aper et al, 2015; Costa-Drolon et al, 2021; Plotkin & Shochet, 2018).

These “empathy qualms” are legitimate concerns for new clinicians, not taboo topics. Not addressing them could add even more pressure. Fortunately, recent articles on empathy in healthcare provide a platform to help students consider the topic from different angles, and find some guidance about their qualms.

Following are four suggestions for discussion, plus a comfortable starting point.

1. What does “clinical empathy” actually mean?

A popular assumption about empathy is reflected in a 2020 article in the New York Times, which describes passively experiencing another person’s pain or anguish. However, when the intention is to be person-centered, passive empathy is insufficient (Hall et al, 2021). Patients cannot perceive passive empathy, and could easily assume their clinician has none at all.

In comparison, a more meaningful definition for empathy is offered by Bas-Sarmiento et al. (2020): “the ability to perceive the feelings of another and to communicate that understanding, helping them to feel understood.” Question: why is it important to help patients feel understood?

2. Why might “helping patients feel understood” be described as “hard work” and “emotional labor”?

Ask students to read Cameron et al. (2019) and/or Vinson and Underman (2020) and develop a discussion question for their peers (see Reference section below). For example, what are the cognitive costs of empathy and how should we handle them? Why might our choice be empathy avoidance? What are the costs of emotional labor? How do we manage this effort?

3. Is there a risk of being overwhelmed by empathy?

It’s likely many students worry about this risk. To broach this topic, ask students to read and discuss this essay. For instance, how are empathy and self-care intricately interdependent?

4. How to address empathy dissonance and empathy inauthenticity?

Students might assume that because they lack similar life experiences, they will have limited ability to empathize with patients. But are shared life experiences really necessary? Ask students to read Laughey et. (2020) and/or Veen (2021) for insights. For instance, does this quote apply to audiology? Sartre describes inauthenticity as a person not embodying or ‘owning’ the situation they are in. He describes a waiter on a terrace who has the performance and attitude of a waiter, without being a waiter” (Veen, 2021, p. 142). Compare to this observation: “If empathy is viewed simply as a performance rather than as a deeply held commitment, there is a risk that it may become limited to patients similar to oneself rather than to all patients” (Jeffrey & Downey, 2016, p. 108). How to convey our personal “deeply held commitment” to all patients, even when we have little in common?

And Finally: A Comfortable Starting Point

As mentioned above, a likely self-doubt students might hold could be, “What if I say the wrong thing?” An evidence-based strategy to address this worry is to prioritize nonverbal communication. Given the option, students indicate they prefer “nonverbals” anyway (Laughey et al, 2020), and more importantly, patients perceive body language and other nonverbal empathic behaviors as more authentic than verbal statements (Plotkin & Shochet, 2018). Discussion items: What does nonverbal empathy look like, and what have students noticed when they’ve observed it? Why might patients find it authentic? Are some “nonverbals” more comfortable or feel more natural than others?

Developing communication skills that convey empathy can be a daunting challenge. Supporting small steps to help students increase their confidence seems worth the effort.


References

Aper L et al. (2015). ‘‘Should I prioritize medical problem solving or attentive listening?” The dilemmas and challenges that medical students experience when learning to conduct consultations. Patient Education and Counseling, 98, 77-84.

Bas-Sarmiento P et al. (2020). Empathy training in health sciences: A systematic review. Nursing Education in Practice, 44, 102739.

Cameron CD et al. (2019, April 18). Empathy Is hard work: People choose to avoid empathy because of Its cognitive costs. Journal of Experimental Psychology. Advance online publication. http://dx.doi.org/10.1037/xge0000595

Costa-Drolon E et al. (2021). Medical students’ perspectives on empathy: A systematic review and metasynthesis. Academic Medicine, 96(1), 142-154.

Hall J et al, (2021). What is clinical empathy? Perspectives of community members, university students, cancer patients, and physicians. Patient Education and Counseling, 104, 1237-1245.

Jeffrey D, Downie R. (2016). Empathy: Can it be taught? Journal of Royal College of Physicians of Edinburgh, 46, 107–12 http://dx.doi.org/10.4997/JRCPE.2016.210

Laughey W. et al. (2020). ‘I’m sorry to hear that’—Empathy and empathic dissonance: The perspectives of PA students. Medical Science Educator, 30, 955–964. https://doi.org/10.1007/s40670-020-00979-0

Plotkin J, Shochet R. (2018). Beyond words: What can help first year medical students practice effective empathic communication? Patient Education and Counseling, 101, 2005-2010.

Veen M. (2021). Wrestling with (in)authenticity. Perspectives in Medical Education, 10,141–144. https://doi.org/10.1007/s40037-021-00656-x

Vinson A, Underman K. (2020). Clinical empathy as emotional labor in medical work. Social Science and Medicine, 251, 112904.

Centering the Patient in Our Research

Kris English, PhD

Emeritus Professor of Audiology

The University of Akron

 

The verb “centering” is becoming popular lately, typically used to spotlight a call for social change. Some examples:

  • Headline: “Centering Racial Equity in a New Administration” (Solomon & Roberts, 2020)
  • Research article title: “Beyond Seeing Race: Centering Racism and Acknowledging Agency Within Bioethics” (James & Iacopetti, 2021)
  • An author’s bio, whose work is focused on “empowering individuals – centering the marginalized – in an effort to create inclusive and compassionate communities” (Burke & Brown, 2021, p. 220)

The concept of “centering” resonates with audiologists committed to patient-centered care. Consistent with the Institute of Medicine’s (2001) definition, we strive to provide “care that is respectful and responsive to individual patient preferences, needs and values; ensuring patient values guide all clinical decisions” (p. 3). A range of clinical skills have been described to help us provide patient-centered care, for instance:

However, there still seems to be a lack of clarity about patient-centeredness, most recently represented in the World Health Organization’s (2021) World Report on Hearing. The eagerly-awaited report includes a figure with the caption, “Person-Centred Ear and Hearing Care” (p. 96), listing the care components as obtaining a case history, determining communication needs and preferences, and identifying the patient’s available resources. In this model, each patient’s needs will certainly be individualized, or we could say personalized; however, these data points can be collected and treated with absolutely no application of patient-centered care practices as described above.

This confusion in terms is likely due (in part) to the fact that the patient’s voice, the patient’s perception of being “centered,” is not consistently represented in our professional literature. It’s not an unusual situation: in reviewing a set of studies exploring the intersection of patient-centeredness and innovation, Makoul (2021) noted that patient perspectives and input were not included. We do have valuable N-of-1 reports from patient advocates such as Shari Eberts (2020), but we are overdue in developing a patient-centered research base that will accurately inform the World Health Organization and other policy influencers. A genuinely patient-centered profession centers the patient in its research (e.g., Sharp et al., 2016; Tzelepis et al., 2015).


References

Burke, T., & Brown, B. (2021). You are your best thing. NY: Random House.

Eberts, S. (2020). Person-centered care from a patient’s perspective. Hearing Journal, 73(1), 28.

James J. & Iacopetti, C.L. (2021). Beyond seeing race: Centering racism and acknowledging agency within bioethics. The American Journal of Bioethics, 21(2), 56-58.

Makoul, G. (2021). Patient-centered innovation: Lessons learned. Patient Education and Counseling, 104, 677-678.

Sharp, S. et al. (2016). The vital blend of clinical competence and compassion: How patients experience patient-centered care. Contemporary Nurse, 52(2-3), 300-312. DOI: 10.1080/10376178.2015.1020981

Solomon, D. & Robers, L. (2020, November 13).  Centering racial equity in a new administration.

Tzelepis, F. (2015). Measuring the quality of patient-centered care: Why patient-reported measures are critical to reliable assessment. Patient Preferences and Adherence, 9, 831-835.

World Health Organization. (2021). World report on hearing.

Empathy, Interrupted

 

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

 

Scene: Audiology Clinic

New Patient: My main concern about hearing aids is what people will think when they see them. I dread that kind of negative attention.

Audiologist: I understand why that would worry you.

New Patient: You do? Why? Are most people embarrassed about hearing aids?

And suddenly, the conversation has been derailed. While attempting to convey empathy, the audiologist inadvertently distracted the patient from her main concern – even though the “I understand” comment, on the surface, seemed patient-centered.  What went wrong?

From a counseling perspective, the audiologist’s response could be considered an unintended empathy disruption. In more blunt terms, sociologist Charles Derber (2000) would describe it as “conversational narcissism.”  As an expert in everyday conversations, he provides a simple way to understand how our responses either shift or support the topic at hand.

Shift or Support?

Our example above is a shiftresponse, because it redirects the conversational focus to the audiologist, even though it was not intended to do so. In a clinical encounter, a shift-response temporarily interrupts the “empathy moment” by inserting the clinician’s presumptions of understanding, rather than keeping attention fully focused on the patient.

A shift-response can even unintentionally redirect the conversation altogether. For example, consider this purposely exaggerated response:

Of course, we would not let ourselves get carried away like this, but as we see in the opening scenario, even one sentence can inadvertently inject us into the patient’s narrative.

On the other hand, a supportresponse’s only goal is to acknowledge the other person’s comments. If the audiologist provided a support-response such as, “Could you tell me more about your concerns?” the empathic focus would have remained fully on the patient.

Worth Evaluating

How we strive to communicate empathy is important. When we say:

  • I know how you feel…
  • I understand why this is worrying you…
  • I can see how this is difficult…

… we are effectively saying “This is me empathizing with you” and although it appears to be selfless, for a brief moment we are shifting attention to ourselves. Our ongoing goal, then: support, not shift or interrupt empathy.

There is No “I” in “Empathy”

Sample Shift-Responses Sample Support-Responses
I know how you feel. How are you feeling about the situation?
I understand why this is worrying you. This is weighing on your mind?
I can see how this is difficult. This is a difficult stage for you.

Note that the examples above are efforts to respond to a patient’s emotional state or “feeling mind” (Goleman, 2006). In comparison, when patients ask for help with technical issues such as changing hearing aid settings or using the phone (using their “thinking mind”), our “I” responses (“I understand what you are saying” or “I see what you are getting at”) do not derail the conversation but instead, represent an effort to co-construct understanding at the “thinking mind” level.

Conclusion

Consistent with support-responses, Josselman (1996) wrote that to be empathic, we must “put aside our own experience, at least momentarily” (p. 203) – a professional way of saying that, for the moment, “It’s not about us.”


References

Derber, C.  (2000). The power of attention: Power and ego in everyday life (2nd ed.). NY: Oxford University Press.

Goleman, D. (2006). Emotional intelligence: Why it can matter more than IQ (2nd ed). New York: Bantam Books.

Josselman, R. (1996). The space between us: Exploring the dimensions of human relationships. Thousand Oaks, CA: Sage Publications.

Improving Cross-Racial Communication: Start by Using Honorifics and Last Names

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

As noted elsewhere, racial health disparities have been shown more likely to occur when the clinician and patient are of different races (Hagiwara et al., 2016). When the clinician is White and the patient is Black, disparities may even present in the quality of communication, specifically clinician verbal dominance and less patient-centered dialogue (Shen et al., 2018).

In the US, audiology appointments are statistically likely to be cross-racial, so we would hope for specific guidance to improve overall communication. A review of the current literature yields very little advice regarding modifiable and measurable behaviors, but an easy first step would be this one:

Address Patients by a Title and Their Last Name

Why? First, Evans (1992) pointed out that “many groups of people express regard through formality. In considering black Americans specifically, it is again important to recall history. For decades blacks were required to address whites, even immature ones, with surnames and honorifics, while whites called adult blacks by their first names or even generic first names that did not belong to them” (p. 681) (emphases added).

Formally addressing a patient by title (Mr, Mrs, Ms, Dr, Pastor, Doctor, Professor, etc.) and last name conveys not only regard, but also dignity and respect.

Second, although there is a paucity of research on the subject, what is available is consistent:

  • In 1992, Gillette et al. asked, “First name or last name: Which do patients prefer?” and in their study found that in new relationships, more Black patients preferred to be addressed by their last names (with title, of course) more often than did white patients.
  • Makoul and colleagues’ 2007 study yielded very similar results. They also include this guidance:

…when physicians ask how patients want to be addressed at the beginning of their encounter, patients may feel pressure to answer that the more familiar form of address is acceptable before rapport has been established. For some, this may increase a sense of familiarity; for others, it can exacerbate a sense of power imbalance, especially if physicians refer to themselves with formal titles (e.g., Dr. Jones).(p. 1175)

The patient decides when using a first name is acceptable

Third, Brown-Hinds (2010) describes many issues involved with “Whites calling Blacks by first names,” including historical reasons why “naming is a big deal to Black people.” She also supports Makoul: “Avoid even asking Black people if it was okay to call them by their first name because this puts the patient at an immediate disadvantage. If the patient says ‘no,’ this may cause the patient to have the afterthought of possibly being sabotaged by that staff member.”

Conclusion

Formality is uncommon in today’s world, but starting an appointment with formality and intentional courtesy has the potential to promote more person-centeredness throughout the entire appointment. And if patients ask us to use first names, of course we would honor that request, because as Brown-Hinds (2010) reminds us, naming is a big deal.

(Caveat: It must be noted that the perspectives described above are US-centric. In comparison, Parsons et al. [2016] indicate that in Australia, 99% of the hospital patients in their study preferred first names. Unfortunately, no racial demographics were reported.)


References

Brown-Hinds, P. (2010, January 21). Whites calling Blacks by first names.  (Accessed May 5, 2021)

Evans, J. (1992). What occupational therapists can do to eliminate racial barriers to health care access. The American Journal of Occupational Therapy, 46(8), 679-683.

Gillette, RD et al. (1992). First name or last name: Which do patients prefer? Journal of American Board of Family Practitioners, 5, 517-522.

Hagiwara, N et al. (2016). The effects of racial attitudes on affect and engagement in racially discordant medical interactions between non-Black physicians and Black patients. Group Processes & Intergroup Relations, 19(4) 509–527. doi: 10.1177/1368430216641306

Makoul, G. et al. (2007). An evidence-based perspective on greetings in medical encounters. Archives in Internal Medicine, 167, 1172-1176.

Parsons, SR et al. (2016) ‘Please don’t call me Mister’: Patient preferences of how they are addressed and their knowledge of their treating medical team in an Australian hospital. BMJ Open, 6, e008473. doi:10.1136/bmjopen-2015-008473

Shen, MJ et al. (2018). The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. Journal of Racial and Ethnic Health Disparities, 5(1),117–140.doi:10.1007/s40615-017-0350-4.

Cultural Humility, Part 4/4: Perspective-Getting/Radical Empathy

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

In a recent conversation about the Black Lives Matter movement in the United States, this quote from W.E.B. Dubois (1903) regarding the challenges of “living while Black” was cited: “It is a peculiar sensation, this double-consciousness, this always looking at oneself through the eyes of others, of measuring one’s soul by the tape of a world that looks on in amused contempt and pity. One ever feels his twoness” (p. 13).

The conversation struggled with this concept: clearly more than self-consciousness, or scanning for threat or danger, or sharp awareness of relentless judgment… Is it possible to understand “double consciousness” if one hasn’t lived it? Eventually it was asked, “So the task for someone like me [a White person] would be: don’t think ‘How would I feel in that situation?’ but instead ‘How would I feel if I were a Black person in that situation?’”—in other words, the classic concept of “putting oneself in another person’s shoes,” familiar to every person-centered individual.

Unlocking Assumptions re: “Others’ Shoes”

Recent studies indicate this genuinely respectful discussion was naïvely based on a faulty assumption: that we can accurately imagine another person’s feelings based on our own experiences. For instance, Eyal et al. (2018) recently conducted an exhaustive study about perspective-taking accuracy and did not find evidence supporting this assumption. They recruited more than 2800 volunteers to participate in one of 25 experiments. The first 24 experiments measured participants’ accuracy about taking another person’s perspective (strangers, acquaintances, friends, spouses) by predicting how those persons were feeling, measured by a range of assessments. Results indicated that, even though participants felt confident about their judgements, their predictions of others’ perspectives were generally inaccurate.

The 25th experiment explored another approach: instead of predicting someone’s agreement or disagreement to a series of opinion statements, participants were given the opportunity to first ask their assigned partners about the opinion statements, and then predict how the partner would respond on a numerical scale about the statements. The researchers found that getting a person’s perspective first (asking directly and listening actively, a bottom-up approach) significantly increased accuracy compared to the top-down approach of “putting oneself in the other’s shoes” without inquiry. Their conclusion: “Understanding the mind of another is therefore enabled by getting perspective, not simply taking perspective” (p. 547).

“Radical Empathy”

(p. 386)

Habits are hard to break, and this one is no exception, especially since it means minimizing our own experiences as we open up to another’s. Regardless, Wilkerson (2020) exhorts us to recognize the limitations of “role-playing” empathy and also go deeper:

“Empathy is commonly viewed as putting yourself in someone else’s shoes and imagining how you would feel. That could be seen as a start, but that is little more than role-playing, and it is not enough in the ruptured world we live in.

Radical empathy, on the other hand, means putting in the work to educate oneself and to listen with a humble heart to understand another’s experience from their perspective, not as we imagine we would feel. Radical empathy is not about you and what you think you would do in a situation you have never been in and perhaps never will. It is the kindred connection from a place of deep knowing that opens your spirit to the pain of another as they perceive it.”

Other People’s Shoes Don’t Fit Anyway

The consideration here has focused on cross-racial understanding, but needless to say applies to all human connections. Overall, if we want to understand another person’s perspective, it doesn’t help much to consider how we would feel about a situation. Since “putting ourselves in another’s shoes” is ineffective as a learning/understanding strategy, the metaphor needs to be abandoned.

Instead, “Take the other person’s shoes off: They don’t fit you, and they’re only going to give you blisters. Instead, just try asking them how they’re feeling — and more importantly, listen to what they tell you… If you want to know how someone is feeling or what they’re thinking, the single most effective method is simply to ask them” (Fiouzi, 2018).


References

Dubois, W.E.B. (1903). The souls of Black folk: The unabridged classic. Chicago, IL: A.C. McClurg & Co.

Eyal T, Steffel M, Epley N. (2018). Perspective mistaking: Accurately understanding the mind of another requires getting perspective, not taking perspective. Journal of Personality and Social Psychology, 114(4), 547-571. doi: 10.1037/pspa0000115

Fiouzi, A. (2018). “Putting yourself in someone else’s shoes” doesn’t work at all. 

Wilkerson I. (2020). Caste: The origins of our discontents. New York: Random House.

Cultural Humility, Part 3/4: Implicit Bias is a Cognitive Habit We Can Change

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

Should we complete a self-assessment on implicit bias such as the Implicit Association Test (IAT)? It’s a complicated question: the reliability and validity of the IAT has been established1,2 even as criticisms persist.3,4   And the uncomfortable prospective of finding out about our biases can keep us from considering the issue altogether….

Practically speaking, it may help us move forward by directly working with these “Key Characteristics of Implicit Bias” from the Kirwin Institute for the Study of Race and Ethnicity:

  • Implicit biases are pervasive.  Everyone possesses them, even people with avowed commitments to impartiality such as judges [and health care providers.]5
  • The implicit [unconscious] associations we hold do not necessarily align with our declared beliefs or even reflect stances we would explicitly endorse.6
  • Implicit biases are malleable.  Our incredibly complex brains not only formed implicit associations during our childhood years, but can also gradually unlearn those biases through a variety of debiasing techniques.7

The last point is our focus here: that is, techniques to help us unlearn implicit biases. The following debiasing practices are adapted from Blair et al.8 and Cox & Devine9 as a self-managed, evidence-based, habit-breaking intervention. Each step is intended to slow down our thinking, keep us in the moment, and increase our ability to override our unconscious reactions.

First, some “brain warm-ups,” also known as cognitive priming:

“Cognitive Priming”

  • Acknowledge that no one is bias-free.
  • Learn how implicit biases can impact health care outcomes (see “Resources” below).
  • Address rather than suppress uncomfortable feelings and thoughts associated with these insights.
  • Consciously affirm personal egalitarian goals.
    • Rationale: Affirming our goals and values eases our defensiveness and promotes patient trust10
    • Example of egalitarian goals: “People should be treated as equals, should treat one another as equals, should relate as equals, and enjoy an equality of social status”11

 Mindful Efforts During Clinical Encounters

  1. Think Before Acting:
    1. Individuation: Imagine what it would feel like to be in the position of a member of a different group. Actively see the person as an individual rather than a stereotype.12
    2. Perspective taking, i.e., “putting yourself in the other person’s shoes13
    3. Even better: perspective-getting
  2. During Clinical Encounters:
    1. As we listen: rather than jumping to stereotypical assumptions, ask ourselves what other possibilities might account for behavior? Keep in mind the complexity of people’s lives.
    2. As we build partnerships: if we are not doing so, strive to reframe the interaction as a collaboration between equals, rather than between a high-status person and a low-status person (recall egalitarian goals).
  3. Post-Encounter Reflection:
    1. Journaling, or discussion with like-minded peers or other positive peer support system.14
    2. New habits require continuous practice, feedback, and reflection before they become second nature.15, 16

Conclusion: Implicit Bias ≠ Destiny

Take-away #1: Implicit bias is a mental habit, and habits can be changed.

Take-away #2: Changing habits is not easy, but our egalitarian goals (treating all persons as equals) can serve as “the better angels of our nature” (U.S. President Abraham Lincoln’s 1861 Inaugural Address).

Take-away #3: Readers will immediately recognize that each strategy described above is fully consistent with patient-centered communication and audiologic counseling. The goal remains the same: to communicate our commitment to making a personal connection, earning trust, and developing a partnership.


Resources

Cornell University Graduate School/UCLA Office of Diversity, Equity, and Inclusion: Implicit Bias Video Series

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.

Kirwan Institute for the Study of Race and Ethnicity, The Ohio State University


How to Outsmart Your Own Unconscious Bias

How Racism Makes Us Sick

The Problem with Race-Based Medicine


 

 

 

White, A., (2019). Seeing patients: A surgeon’s story of race and medical bias (2nd ed.). Cambridge, MA: Harvard University Press.

 

 


For More on Cultural Humility:

Part 4: Perspective-Getting/Radical Empathy


References

  1. Greenwald, A.G., et al. (1998). Measuring individual differences in implicit cognition: the implicit association test. Journal of Personality and Social Psychology, 74(6), 1464–80.
  2. Greenwald, A.G., et al. (2009). Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. Journal of Personality and Social Psychology, 97(1), 17–41.
  3. Arkes, H.  & Tetlock, P. (2004). Attributions of implicit prejudice, or “Would Jesse Jackson ‘Fail’ the Implicit Association Test?” Psychological Inquiry, 15(4), 257 278. DOI: 1207/s15327965pli1504_01
  4. Meissner F., & Rothermund K. (2015). A thousand words are worth more than a picture? The effects of stimulus modality on the Implicit Association Test. Social Psychological and Personality Science, 6(7), 740-748. doi:1177/1948550615580381
  5. FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(19).  DOI 10.1186/s12910-017-0179-8
  6. Chapman, E., et al. (2013). Physicians and implicit Bias: How doctors may unwittingly perpetuate health care disparities. Journal of General Internal Medicine, 28(11), 1504–10. DOI: 10.1007/s11606-013-2441-1
  7. Devine, P., et al. (2012). Long-term reduction in implicit race bias: A prejudice habit-breaking intervention. Journal of Experimental Social Psychology, 48, 1267-1278.
  8. Blair, I., et al. (2011). Unconscious (implicit) bias and health disparities: Where do we go from here? The Permanente Journal, 15(2), 71-78.
  9. Cox, W., & Devine, P. (2019). The prejudice habit-breaking intervention: An empowerment-based confrontation approach.  In R. Mallett & M.J. Monteith (Eds.), Confronting prejudice and discrimination: The science of changing minds and behaviors(pp. 249-274). London, UK: Academic Press.
  10. Moskowitz, G & Li, P. (2011). Egalitarian goals trigger stereotype inhibition: A proactive form of stereotype control. Journal of Experimental Social Psychology, 47, 103-116.
  11. Stanford Encyclopedia of Philosophy. (n.d.).
  12. 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.
  13. Todd, A.R., & Galinsky, A.D. (2014): Perspective-taking as a strategy for improving intergroup relations: Evidence, mechanisms, and qualifications. Social and Personality Psychology Compass, 8, 374–387. DOI: 10.1111/spc3.12116
  14. Sukhera, J., et al. (2018). Adaptive reinventing: implicit bias and the co‑construction of social change. Advances in Health Science Education, 23, 587-599.doi: 10.1007/s10459-018-9816-3
  15. Byrne, A., & Tanesini, A. (2015). Instilling new habits: Addressing implicit bias in healthcare professionals. Advances in Health Science Education, 20,1255-1262. DOI 10.1007/s10459-015-9600-6
  16. Monteith,M.J., et al.  (2009). Schooling the cognitive monster: The role of motivation in the regulation and control of prejudice. Social and Personality Psychology Compass, 3, 211–226.

Cultural Humility, Part 2/4: Mitigating Racial Health Disparity with Patient-Centeredness

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

Relatively poorer health outcomes among racial and ethnic minorities have been documented in depth, for instance by the Institute of Medicine (2003) and the Journal of Racial and Ethnic Health Disparities. Reasons are understandably complex (National Academies of Science, Engineering and Medicine, 2017), but here we will focus on the clinician-patient dyad, communication styles, and clinical relationships.

When clinicians and patients are of the same race – racial concordance – disparities are less likely to occur (Cooper et al., 2003; Shen et al., 2018) although the evidence is mixed (Meghani et al. 2009; Rand & Berger, 2019). The more urgent concern is the documented consequences of racial discordance, wherein the clinician and patient are of differing races. As just one example, Cooper et al.’s (2012) results from racially discordant clinical appointments included more clinician verbal dominance, less patient-centered dialogue, lower patient positive affect, and poorer patient ratings of care – none of which support patient trust and acceptance of treatment recommendations (Dovidio et al., 2008; Zolnierek & DiMatteo, 2009).

Clinical Disparities: Not Inevitable

Racially discordant clinical encounters have been shown to be influenced by clinician bias (Maina et al., 2018; Schaa et al., 2015). Since up to 90% of audiologists in the United States are White (Tittle et al., 2020), we can expect a high likelihood of racially discordant clinical encounters in most areas of the country.

While we come to grips with implicit bias, audiologists can also draw upon the research indicating that clinicians can still strive for concordance within a racially discordant dyad.  “Concordance” as used here, per Pryce et al. (2018) means “an agreed plan between clinician and patient, replacing terms such as ‘adherence’ or ‘compliance’ with their connotations of authority led care… These discussions rely on rapport and trust in the clinical relationship” (p. 631).

Street et al. (2018) describe the impact of rapport-building, trust-earning discussions from data collected from 214 physician-patient consultations. Their study concluded that:

“Perceived personal similarity is associated with higher ratings of trust, satisfaction, and intention to adhere. Race concordance is the primary predictor of perceived ethnic similarity, but several factors affect perceived personal similarity, including physicians’ use of patient-centered communication.” (emphasis added) (p. 198)

In other words, when providers employed patient-centered communication in racially discordant consultations, they achieved cross-racial concordance: their patients were more active participants in the clinical encounters, were more satisfied with their care, expressed greater trust, and had a stronger intention to follow recommendations when their physicians were more informative and supportive.

Chu et al. (2019) recently reported similar outcomes, concluding: “Providers who are skilled in informing, showing respect, and supporting patient involvement could overcome perceived issues of being racially discordant with their patients and establish a connection with the patient that contributes to greater patient satisfaction” (emphasis added)(p. 5).

Establishing Connections

How encouraging to learn that racial discordance does not inevitably result in disparities in health care! Many factors are beyond an audiologist’s control, but at minimum, we can continue to increase our efforts to establish connections. Shen et al’s (2018) systematic review (consistent with seminal writings by Stewart et al., 2014) recommends focusing on the following skills, addressed in several essays on this web forum:

Communication Quality/Listening, Responding to Emotions

Talk Time Ratio

Information-Giving

Patient Participation

Participatory Decision-Making

Patient-Centeredness: Just the Beginning

The best patient-centered communication skills could still mask an audiologist’s implicit biases. A subsequent entry explores evidence-based interventions to help us understand and address these personal issues. For now, let us develop pathways to cross-racial concordance and share our journeys with the profession.

Cross-Racial Concordance, COVID-19 Era


For more on Cultural Humility:

Part 4: Perspective-Getting/Radical Empathy


References

Chu, J., et al. (2019). The effect of patient-centered communication and racial concordant care on care satisfaction among U.S. immigrants. Medical Care Research and Review. Online ahead of print. doi: 10.1177/1077558719890988

Cooper, L. et al. (2003). Patient-centered communication, ratings of care, and concordance of patient and physician race. American College of Physicians, 139, 907-915.

Cooper, L. 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(5), 979-987.

Dividio, J., et al. (2008). Disparities and distrust: The implications of psychological processes for understanding racial disparities in health and health care. Social Science and Medicine, 67, 478-486. doi: 10.1016/j.socscimed.2008.03.019

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.

Maina, I.W. et al. (2018) A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science in Medicine, 199, 219-22. doi: 10.1016/j.socscimed.2017.05.009.

Meghani, S., et al. (2009). Patient–provider race-concordance: does it matter in improving minority patients’ health outcomes? Ethnic Health, 14(1), 107-130. doi:10.1080/13557850802227031

National Academies of Science, Engineering and Medicine. (2017). Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/24624.

Pryce, H., et al. (2018). Shared decision-making in tinnitus care – An exploration of clinical encounters. British Journal of Health Psychology, 23, 630–645. doi:10.1111/bjhp.12308

Rand, L., & Berger, Z. (2019). Disentangling evidence and preference in patient-clinician concordance discussions. AMA Journal of Ethics, 21(6), S505-S512.

Schaa, K, et al. (2015). Genetic counselors’ implicit racial attitudes and their relationship to communication.  Health Psychology, 34(2), 111-119. doi:10.1037/hea0000155.

Shen, M., et al. (2018). The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. Journal of Racial and Ethnic Health Disparities, 5(1), 117-140. doi:10.1007/s40615-017-0350-4

Stewart, M., et al. (2014). Patient-centered medicine: Transforming the clinical method. Abington, UK: Radcliffe Medical Press.

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.doi: 10.1370/afm.821

Tittle, S., Berry, S., Lewis, J & DeBacker, J.R. (2020). The count starts here: The 2020 audiology student census. Audiology Today, 32(4), 52-56.

Zolnierek, K.B., & DiMatteo, M.R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47, 826–834. doi:10.1097/MLR.0b013e31819a5acc

 

Counseling with Cultural Humility, An Introduction: Part 1/4

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

Audiologists committed to patient-centered counseling are well aware of the importance of humility. As C.S. Lewis once said, “Humility is not thinking less of yourself, it’s thinking of yourself less” – as is our goal in each patient encounter. By word and deed, we communicate respect for the patient’s lived experience, and strive for partnership and service to the patient’s needs, rather than expecting compliance/obedience.

The concept of cultural humility takes us a step further. Communication with patients different than ourselves — by race, ethnicity, socioeconomic status, age, religion, gender, sexual orientation, occupation, abilities – can be inherently complicated. Although not a comfortable idea to consider, we must accept the possibility that we could unintentionally contribute to these complications, potentially resulting in a failure in patient care.

Some Background:

In 2003, the Institute of Medicine (IOM) published a 780-page report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” In reviewing potential sources of disparity in the United States, including historical segregation and underrepresented minorities in health care settings, the authors included a variable that audiologists can immediately address: our cross-cultural/cross-racial communication skills.

The relationship between communication skills and patient outcomes is succinctly summarized by the figure below:

from Institute of Medicine (2003), p. 200

IOM’s recommended intervention for ineffective communication across race and culture is a familiar one: provide pre-service coursework and in-service training in cultural communication skills. Accordingly, accredited audiology programs in the US are now required to integrate cultural competence into their curricula (Accreditation Commission for Audiology Education, 2016; Council on Academic Accreditation, 2019).

The continuum of skills for cultural competence have been typically listed as awareness, knowledge, sensitivity, and competency (IOM, 2003). However, even before the IOM publication, concerns have been expressed about the limitations of this model:

  • The focus of attention is only on “the other” (i.e., reading about, seeking to understand a range of cultures) as a disengaged object of study, which could reinforce an unintended power differential (Foronda, 2020).
  • The continuum does not typically emphasize self-awareness or personal change/growth, thereby overlooking the impact each clinician personally has on a clinical encounter, including unrecognized biases and prejudices.
    • As an example, Isaacson (2014) describes course outcomes indicating her students perceived themselves as culturally competent, even as their journal reflections revealed many “blind spot” negative stereotypes.
  • The word “competency” can imply an endpoint, comparable to mastering tympanometry (i.e., once mastered, the learner moves on to new challenges) rather than life-long learning (Tervalon & Murray-García, 1998).
  • Cultural competence also implies “that the healthcare professional has an a priori understanding of the person’s culture before engaging with the patient” (Isaacson, 2014, p. 252).

IOM does stress requisite attitudes such as humility, as well as empathy, curiosity, respect, sensitivity, and awareness of outside influences. Advocates have indicated that the concept of cultural humility has not been adequately emphasized, seeing this attribute as a fundamental premise to earning patient trust.

Characteristics of Cultural Humility

  • A life-long commitment to cultural competence (no endpoint)
  • Assuming no expertise in another’s culture
  • Self-reflection, awareness of our own assumptions and prejudices
  • Acting to redress the imbalance of power inherent in clinician-patient relationships
  • A lack of superiority about one’s own cultural background and experience (Borkan et al., 2008; Foronda, 2020; Hook et al, 2013).

We can safely say that cultural humility is profoundly consistent with the principles of audiologic counseling – in fact, it might seem exactly the same. But we should not be complacent. We may be unaware that our self-perception as patient-centered clinicians may be at odds with a patient’s impressions.

A tool called the Cultural Humility Scale (Hook et al., 2013) was created to measure those impressions. This patient report rates positive and negative behaviors on a 1-5 scale within the context of a person’s cultural background.  (Negative behaviors are highlighted.)

from Hook & et al., (2013), p. 366

If we received patient scores of 4 or 5 from the highlighted negative items, we would be devastated. These impressions are not what we intend to convey – but that is precisely the point. We might not realize that an unconscious behavior (an implicit bias) caused a negative reaction (Chapman et al., 2013; Devine, 1989). White et al. (2018) indicate that “Decades of research in social cognitive science show that hidden biases operating largely below the scope of human consciousness influence the way we see and treat others even when we are determined to be fair and objective” (p. 34).

No one is immune from implicit bias. That said, we can learn about and understand our implicit biases in order to manage them. To cross-check our self-perceptions about bias and prejudice, we can explore tools such as an online 10-minute test called the Race Implicit Association Test, view a 12-minute TED talk on implicit bias and discuss it with a colleague, and/or consider the wide range of learning opportunities offered by White et al. (2018, see Appendix).

Conclusion

In all humility, let us appreciate that cross-cultural communication skills do not have an endpoint. Rather, as Campinha-Bacote (2011) suggests, let us think of our pathway as forward steps in awareness, knowledge, sensitivity, and becoming competent throughout our lifetimes.

For more on Cultural Humility:

Part 2: Mitigating Racial Health Disparity with Patient-Centeredness

Part 3: Implicit Bias is a Cognitive Habit We Can Break

Part 4: Perspective-Getting/Radical Empathy


References

Accreditation Commission for Audiology Education. (2016). Accreditation standards for the Doctor of Audiology (AuD) program.

Borkan, J., et al. (2008). Toward cultural humility in health care for culturally diverse Rhode Island. Medicine and Health/Rhode Island, 91(12), 361-364.

Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 5.

Chapman, E., et al. (2013). Physicians and implicit bias: How doctors may unwittingly perpetuate health care disparities. Journal of General Internal Medicine, 28,1504–1510.

Council on Academic Accreditation. (2019). Standards for accreditation of graduate education programs in audiology and speech-language pathology.

Devine, P.G. (1989). Stereotypes and prejudice: Their automatic and controlled components. Journal of Personal Social Psychology, 56(1), 5–18.

Foronda, C. (2020). A theory of cultural humility. Journal of Transcultural Nursing, 31(1), 7-12.

Hook, J. N., et al. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology, 60, 353–366.

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.

Isaacson, M. (2014). Clarifying concepts: Cultural humility or competency. Journal of Professional Nursing, 30(3), 51-258.

Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125,

White, A., et al. (2018). Self-awareness and cultural identity as an effort to reduce bias in medicine. Journal of Racial and Ethnic Health Disparities, 5, 34–49.

Patient Centered Care in Argentina

Abi Nardi
Licenciada en Fonoaudiología
Óptica contactóloga
Especialista en Audiología
Villa Dolores, Cordoba, Argentina

I am licensed to practice audiology and language therapy, a career path that takes 5 years to complete plus the final thesis in my country, Argentina. After graduating I dedicated myself to the area of audiology.

I have worked in a very prestigious hospital in a big city, and currently work in a smaller city, in a private practice and municipal clinics, knowing different social, emotional and economic realities, where each person goes through similar pathologies in different ways.

In my family I grew up learning to see the “patient” as a person first. My mother is an optometrist, and she always listened to her patients, showing me how to learn about each as persons first and what they contribute, before their pathologies.

However, in my years of the University I didn´t have, not even half a semester, a subject that taught me to LISTEN, CARE and ACCOMPANY a patient. Conversely I had the ones that taught me to carry out and understand tests, know pathologies and ways to solve them, from a purely scientific approach. I am obviously grateful because it is necessary to incorporate these topics and they are the basis of an audiologist’s college career.

But in my country it´s normal to attend patients within a certain time and try to unilaterally resolve the conditions — without remembering the environment, social, economic and emotional level of each person.

After gaining some experience, I needed to know a little more every day, to update me and learn. One day I found this website, got to know Kris English and through her the IDA Institute. I had been trying to provide patient-centered care for years in a disorganized way and without given it a name. I also had no coworkers interested in PCC, until now.

I Tell You What I Have Learned…

Person Centered Care (PCC) is a practice that is difficult to understand. It moves us from a structured job, or rather a traditional one, which is what we have been taught to exercise in a unidirectional way. I have learned that PCC proposes a more complex, dynamic professional exercise; we must be adaptable to what our patients are expressing and we must discover what they value. It means getting more involved in each consultation, paying extra attention to each situation that occurs in the meeting, managing to understand all aspects of our patient life.

There are situations that we cannot control, such as the culture where we live, that of our work, economic tools, our educational past, but nevertheless there many other situations that we can control.

I never spent hours explaining an audiogram, I have never been only theoretical; I always went further, observing whoever chose me as an audiologist, LISTENING to what he has to say, without asking closed questions, allowing freedom to express oneself. I know that it’s a unique experience each patient brings to their hearing loss, since for each one it means something different, having different thoughts, feelings and experiences according to how this loss is affecting him in his life.

Recognizing that the way we interact with our patients has a significant effect in the auditory result means we see the importance of how to build a therapeutic relationship. And so we can position ourselves as clinicians, where we not only explain options, but we must also work with the goals and values of our patients, situating ourselves with EMPATHY. We help them  chart a path with a plan appropriate to what we believe best for them, according to what they explicitly and implicitly propose to us in their narratives.

What Keeps Me Going…

I will never forget a patient who entered the consultation, referred by a colleague, who described him as a patient who didn’t accept his diagnosis: profound bilateral sensorineural hearing loss.

We sat down… no one spoke for a  minute, we just looked at each other, waiting for the other to speak…when suddenly he said to me: “ How comfortable I have felt for a moment, where nobody told me what to do or how, just waited for me to decide to speak…Now I´m going to tell you…”, Then I asked a few questions, since my patient described himself without questionnaires. And I asked myself: profound hearing loss? Without any testing? It turned out to be a patient with a wrong diagnosis.

That encounter occurred in 2019, and since then I have treated eight patients sent by him.

This is where, through PCC, I can fully appreciate what to do with this information and how to take advantage of it. Today I feel supported, accompanied, on track, I found academic training on the subject, I found those who gave it a “frame”

I Know that it’s in me and in every professional who wants it, the ability to respond to the emotions that derive from the hearing loss of our patients.

With these insights, I try to encourage colleagues to get involved and soak up this knowledge that is very simple to implement but complexly difficult to apply, especially if we don’t manage to deconstruct our way of looking the traditional clinician-patient relationship.

I understand the added value that we can achieve, but the structures of traditional education don’t put in value, hence it’s difficult to see and adopt it. The important thing is that if we manage to move from the traditional approach and adopt this way of working, we’ll quickly see that benefits are found for both parties: we manage to improve the patient’s health and we as professionals will have fidelity on their part. The idea of ​​building loyalty to our patients, listening to them, making them feel at ease beyond getting involved in their problems and trying together to reach the best possible option for their condition. Simply by using the responsible practice of PCC.

Here is the future of our way of working effectively, responding to the global need of each person.

PCC= Atención Centrada en el Paciente


Abi Nardi
Licenciada en Fonoaudiología
Óptica contactóloga
Especialista en Audiología
Villa Dolores, Cordoba
Argentina

Soy Licenciada en Fonoaudiolgía, una carrera que lleva 5 años de cursado más la tesis final en Argentina,  mi país.  Luego de graduarme me dediqué al área de audiología.

He trabajado en un Hospital muy prestigioso en una gran Ciudad,  actualmente trabajo en una ciudad más pequeña, en un consultorio particular y en Dispensarios Municipales, conociendo diversas realidades sociales, emocionales y económicas, donde cada persona atraviesa de manera muy diferente  la misma o similares patologías.

En mi familia crecí aprendiendo a ver al “paciente” como una persona ante todo, mi mamá siempre se involucró y escuchó a sus pacientes (en el área visual), demostrándome así que cada uno es uno y lo que trae, antes que las patologías.

Sin embargo en mis años de estudio no tuve, ni medio semestre, una materia que me enseñara como ESCUCHAR, ATENDER y  ACOMPAÑAR a un paciente, por el contrario  si tuve las que me enseñaron a realizar y comprender estudios,  conocer patologías y maneras de resolverlas, desde un enfoque netamente científico. De las cuales obviamente estoy plenamente agradecida, porque es necesario incorporarlas y son la base de la carrera.

Por lo tanto, en mi país es normal atender pacientes en un tiempo determinado e intentando resolver de manera unilateral las afecciones. Pero sin recordar entorno, nivel social, económico y emocional  de cada persona.

Ahora que la experiencia incomoda, ya que cada día debo conocer más, actualizarme y aprender; me encontré con una gran referente en un tema que nunca dejó de movilizarme y sigue haciéndome perder el sueño.  Aquí conocí a Kristina English y  a través de ella a IDA Institute y  a esta práctica que llevo años utilizando, de manera desorganizada y  sin haberle puesto nombre. Sin  colegas con quienes  pudiera compartir. Hasta ahora.

Por lo tanto les cuento lo que he aprendido…

PCC Atención Centrada en el Paciente, es una  práctica que cuesta un poco comprender, ya que nos corre de un trabajo estructurado, o más bien tradicional que es lo que nos han enseñado, a ejercer de una manera unidireccional. Siendo que PCC plantea un ejercicio profesional más complejo, dinámico; adaptable a lo que nuestros pacientes van expresando y nosotros debemos ir descubriendo. Debiendo estar más involucrados en cada consulta, poniendo atención extra a cada situación que se presente en el encuentro, logrando comprender todos los aspectos de la vida de cada paciente.

Hay situaciones que no podemos controlar, como la cultura donde vivimos, la de nuestro trabajo, herramientas económicas, nuestro pasado educativo;  pero  sin embargo hay muchas otras que sí. Por ejemplo yo nunca pasé horas explicando un audiograma, nunca he sido solo teórica; siempre fui más allá, observando a quien me elige como audióloga, ESCUCHANDO qué tiene para decir, sin llenar de preguntas cerradas, dejando libertad a expresar. Observando.

Conociendo que es una experiencia única la que cada paciente trae (pudiendo presentar similares o iguales patologías) ante una pérdida auditiva; ya que para cada uno significa algo distinto, teniendo pensamientos, sentimientos y experiencias diferentes según cómo esta pérdida le esté afectando en su vida.

Reconociendo  que la forma en que interactuamos con nuestros pacientes tiene un efecto significativo en el resultado auditivo del mismo, es cuando debemos ver la importancia de cómo construir una relación terapéutica. Y así lograr situarnos como clínicos, donde no solo explicamos opciones,  sino que debemos trabajar con los  objetivos y valores de nuestros pacientes, situándonos con EMPATÍA. Logrando  diagramar un camino con un plan adecuado a lo que creemos mejor para ellos, de acuerdo a lo que nos plantean explícita e implícitamente en sus narraciones.

Io que me hace seguir adelante….

Nunca olvido un paciente que entró a la consulta (derivado por una colega, quién lo describió como paciente que no aceptaba su diagóstico: hipoacusia neurosensorial bilateral profunda).

Luego de saludarnos, nos  sentamos… nadie habló por un minuto, solo nos miramos, esperando uno al otro para que hablara… cuando de repente me dijo: “qué a gusto me he sentido por un momento, donde nadie me dijo qué hacer ni cómo, solo me espero a que me decidiera a hablar… Ahora te voy a contar…”, luego realicé pocas preguntas, ya que mi paciente se describió solo sin necesidad de cuestionarios. Y me pregunté: ¿Hipoacusia profunda? Sin haberle realizado siquiera un estudio. Resulto ser un paciente con diagnóstico equivocado desde su narración hasta las pruebas realizadas posteriormente.

Siguiendo con este caso, en lo que fue del año 2019,  he atendido a ocho pacientes enviados por él.

Aquí es donde a través de PCC logre valorar al máximo qué hacer con esa información y cómo aprovecharla. Hoy me siento respaldada, acompañada, encaminada, encontré formación académica sobre el tema, encontré quienes le dieron un “encuadre”.

Sabiendo que está en mí y en cada profesional que así lo desee, la capacidad para responder a las emociones que derivan de la pérdida auditiva de nuestros pacientes.

Con esto intento animar a colegas a involucrarse y empaparse en este conocimiento que es muy sencillo de implementar pero complejamente difícil de acceder si no logramos desestructurar nuestra manera de mirar al clínico-paciente tradicional.

Entendiendo el valor agregado que podemos lograr, pero que las estructuras de la educación tradicional no ponen en valor, de allí que cuesta verlo y adoptarlo. Lo importante es que si logran correrse de lo tradicional y adoptar esta manera de trabajo, verán rápidamente que se encuentran beneficios para ambas partes. Ya que logramos mejorar la salud del paciente y nosotros como profesionales tendremos fidelidad por parte de ellos. Aquí me paro,  la idea de fidelizar a nuestros pacientes, escucharlos, hacerlos sentir a gusto más allá de involucrarnos en su problemática e intentar juntos llegar a la mejor opción posible para su afección. Sencillamente utilizando la práctica responsable de PCC.

Aquí está el futuro de nuestra manera de trabajar eficazmente, respondiendo a la necesidad global de cada persona