“Nonverbals” Can Convey Implicit Bias

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.


  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.

Serving Persons Who Are Refugees or Immigrants

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.


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.

Addressing DEI Early in the AuD Curriculum

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.
Class # Topics
1 Attitudes towards communication in clinic. Discuss concerns centered around communication as students enter clinic for the first time. Ask students to provide suggestions on how to address these concerns.
2, 3 Communication basics. How to introduce oneself, make eye contact, arrange seating in the clinic. Verbal, non-verbal behaviors: clear speech, tone, posture, facial expressions, especially when providers and patients are wearing masks during COVID-19 pandemic.
4 Listening. Students complete an inventory of their communication style and listening. Consider questions such as, “What kinds of people do I relate to the most/least?” or “Do I bring issues from my personal life into my educational/professional work?”
5 Emotional responses to hearing loss. How to ask questions to facilitate discussion, build rapport with patients. Attend to what patient is saying, especially psychosocially and/or emotionally, instead of solely focusing on technology aspects.
6, 7, 8 Age differences. Considerations for children, adolescents, adults of all ages; generational differences; families. Discuss age differences (in any direction) between student and supervisor; contrast communication behaviors between student and patients of varying ages.
9 Patient advocacy. Audiologist as advocate, supporting patients to acknowledge their hearing loss, seeking help as needed. Compare audiologist’s duties to patient expectations.
10 Cultural and linguistic diversity. Ethical, legal topics related to diversity, including race and ethnicity, gender, sexual orientation, religion, age, etc.
11 Diverse populations. What practices are inclusive, create a welcoming clinical environment? (E.g, asking for preferred name and/or pronouns on intake forms; being mindful of student dress codes)
12 Assessment/rehab with diverse populations. Legal requirements, audiologists’ scope of practice documents. How to interact, modify appointments for diverse populations. Avoid generalizations and stereotypes of cultures, genders, generations, disabilities, etc.
13, 14 Difficult situations. Role play scenarios related to microaggressions among students, patients, supervisors. Present guidelines for reporting these behaviors, how they will be addressed in a timely/sensitive manner.


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.

Counseling Cannot Be Colorblind

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

Most White adults in the United States (~70%) describe themselves as “colorblind” to race.1 For non-US readers, the term means that the color of a person’s skin does not matter in today’s society, and is communicated by statements such as “I don’t see race, I only see the human race.”2,3

Colorblind racial ideology (CBRI) is meant to overrule any impression of prejudice4 even as it distances the speaker from the lived experiences of people of color.5,6 In all fairness, it might also intend to express a sincere desire to support a more just society.

However, even when based on good intentions, racial colorblindness is at odds with audiology counseling principles. Following are three fundamental difficulties:

1. A Colorblind Stance Lacks Honesty

The position “I don’t see race” is factually not true. Neurological research indicates that when we look at an unfamiliar person, the first detail we see is race, right before gender and age.8,9 Furthermore, when we pretend not to see the primary characteristic of another human being, that person will likely sense our false front. For example, Apfelbaum et al7 found that Black patients were suspicious of Whites who adopted a colorblind racial perspective, leading them to conclude that a White person who avoids acknowledging race is a racist. Counseling in audiology requires us to communicate with honesty, not cause suspicion and distrust.10,11

2. A Colorblind Stance Inhibits Empathy

Per Iacoboni,12 “When we see someone else suffering or in pain, neurons help us to read her or his facial expression and actually make us feel the suffering or pain of another . . . and this is the foundation of empathy (p. 5)… [but] if an individual relates to a CBRI, he or she will first reduce a person who is different to an object and then not see that an actual person is in pain” (p. 187). In other words, one’s “personhood” is not acknowledged: If you don’t see my race, you don’t see me.” Tettegah13 describes this dynamic as a racial empathy gap. Counseling in audiology requires us to connect with empathy, not create distance by objectifying patients.

3. A Colorblind Stance is Associated with Health Care Disparities

Racial healthcare disparities have long been associated with implicit bias, and implicit bias is related to racial colorblindness.14,15,16 In a representative study, Dovidio et al.6 reported, “White physicians generally perceive themselves not only as nonprejudiced and color-blind… but also, based on their responses to the IAT (Implicit Association Test), harbor negative implicit racial biases toward Blacks” (p. 1523). In comparison, counseling in audiology is intended to optimize outcomes, not contribute to disparities.

Lack of honesty, inhibited empathy, disparate outcomes … a colorblind racial ideology can undermine our best intentions. What to do? Since problems cannot be solved by pretending they don’t exist, we are challenged to face and contend with the barriers that colorblindness creates.

Counteracting Colorblindness

One of life’s truisms is that people don’t change unless they feel a sense of discomfort with the status quo.18 If committed to changing our position from colorblindness to race-consciousness,19 consider these suggestions:

1. Reflect / Study / Discuss with Friends. If we have identified with colorblind racial ideology, the starting point is to ask ourselves what we mean by it. Of course we see race, so what do we mean when we say we don’t? Somewhere along the way, did we absorb the message that “not seeing color” was a virtue?17 Why has it been described as an unexamined form of racism?20  What are we really allowing ourselves to be blind to? These questions are not easy, but discussions based on reading materials, guest speakers, and other learning opportunities with like-minded friends can help. When ready to move ahead, even while still uncomfortable, at least the next step is a familiar one in audiology counseling….

2. Reframe: shift our perspective, language, thinking, viewpoints — in other words, work to disrupt our colorblind belief systems. We can reframe objectified, stereotypical perceptions to genuinely “see race” and see persons in front of us in full humanity. Engaging our social intelligence would serve us well. Deeply listening to patients’ stories creates a two-way connection: the speaker experiences the gratifying, trusting-building feeling of being seen and heard, while helping the listener overcome the power of stereotypes.21

3. View and share this 2019 TED talk: The Problem with Racial Colorblindness by Philip Mazzocco, author of “The Psychology of Racial Colorblindness” (2018).

4. Use a standardized treatment guideline as often as possible.22 For example, the APSO Hearing Aid Fitting Standard for Adult and Geriatric Patients23 has the potential to reduce the impact of colorblindness on treatment decisions by minimizing or eliminating unconscious clinical discretion.24 The more audiologists can provide consistent standards-based care overall, the better, especially considering increased calls to address healthcare disparities.

Conclusion: Only we can change what we “see.” As with breaking any habit, working out how to override a “colorblind habit” takes conscientious effort, but the work will keep us aligned with audiologic counseling principles.

Grundini / Ikon Images


  1. Hartmann, D. et al. (2017). Colorblindness as identity: Key determinants, relations to ideology, and implications for attitudes about race and policy. Sociological Perspectives, 60(5):866-888.
  2. Burke, M. (2019). Colorblind racism. Cambridge, England: Polity Press.
  3. Neville, H. et al. (2016). Introduction: Has the United States really moved beyond race?  In H.A. Neville, M.E., Gallardo, and D.W. Sue (Eds.), The myth of racial color blindness: Manifestations, dynamics, and impact (pp. 3-21). Washington, DC: American Psychological Association.
  4. Crenshaw, K. et al. (Eds.) (2019). Seeing race again: Countering colorblindness across the disciplines. Oakland, CA: University of California Press.
  5. Bonilla-Silva, E. (2014). Racism without racists: Color-blind racism and the persistence of racial inequality in the United States (4th ed.). Lanham, MD: Rowman & Littlefield.
  6. Dividio J.F. et al. (2015). Color-blindness and commonality: Included but invisible? American Behavioral Scientist, 59(11),1518–1538.
  7. Apfelbaum, E.P. et al. (2008). Seeing race and seeming racist? Evaluating strategic colorblindness in social interaction. Journal of Personality and Social Psychology 95(4), 918–32.
  8. Amadio, D. M. et al. (2014).  The neuroscience of prejudice and stereotyping. Nature Reviews/Neuroscience, 15, 670-682.
  9. Ito, T.A., & Urland, G.R. (2003). Race and gender on the brain: Electrocortical measures of attention to the race and gender of multiply categorizable individuals. Journal of Personality and Social Psychology, 85, 616-26
  10. Cooper, L. A. 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.
  11. McGhee, H. (2021, May). Why saying “I don’t see race at all” just makes racism worse.
  12. Iacoboni, M. (2008). Mirroring people. New York, NY: Farrar, Strauss & Giroux.
  13. Tettegah, S. (2015). The good, the bad, and the ugly: Color-blind racial ideology and lack of empathy. In H.A. Neville, M.E., Gallardo, and D.W. Sue (Eds.), The myth of racial color blindness: Manifestations, dynamics, and impact (pp. 175-190.). Washington, DC: American Psychological Association.
  14. Apfelbaum, E.P. et al. (2012). Racial color blindness: Emergence, practice, and implications. Current Directions in Psychological Science, 21(3) 205–209.
  15. Penner, L, & Dovidio, J. (2016). Racial color-blindness and Black-White health care disparities. In H.A. Neville, M.E., Gallardo, and D.W. Sue (Eds.), The myth of racial color blindness: Manifestations, dynamics, and impact (pp. 275-293). Washington, DC: American Psychological Association.
  16. Richeson, J. A. & Nussbaum, R.J. (2004). The impact of multiculturalism versus color-blindness on racial bias. Journal of Experimental Social Psychology, 40, 417–423.
  17. Lipsitz, G. (2019). Sounds of silence: How race neutrality preserves white supremacy. In Crenshaw, K. et al. (Eds.), Seeing race again: Countering colorblindness across the disciplines (pp. 23-51). Oakland, CA: University of California Press.
  18. Knowles E., et al. (2009). On the malleability of ideology: Motivated construals of color blindness. Journal of Personality and Social Psychology, 96(4), 857–869.
  19. Tatum, B.D. (2017). Why are all the Black kids sitting together in the cafeteria? 20th anniversary edition. New York: Basic Books.
  20. Neville, H., et al. (2013). Color-blind racial ideology: Theory, training, and measurement implications in psychology. American Psychologist, 68(6), 455–466.
  21. Charon, R. (2017). Close reading: The signature method of narrative medicine. In R. Charon, et al., The principles and practices of narrative medicine (pp. 157-179). NY: Oxford University Press.
  22. Parsons S. (2020). Addressing racial biases in medicine: A review of the literature, critique, and recommendations. International Journal of Health Services, 50(4),371-386.
  23. Audiology Practice Standards Organization. (2021). S2.1: Hearing aid fitting standards for adult and geriatric patients.
  24. Goldin, C., & Rouse, C. (2000). Orchestrating impartiality: The impact of “blind” auditions on female musicians. The American Economic Review, 90(4), 715-741.

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.


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).


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.


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.”


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.”


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.)


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).


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.


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


  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.