Elmo the Muppet, Carl Rogers, and Congruence

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

On January 29, 2024, a Muppet character from the US television show “Sesame Street” posted a friendly query on social media: “Elmo is just checking in! How is everybody doing?”

https://sesameworkshop.org/our-work/shows/sesame-street/sesame-street-characters/elmo-2/

Initial responses were cheery and light-hearted, but soon more than 20,000 readers responded “from the heart,” describing loneliness, financial and health struggles, depression, and more. It was quickly observed that Elmo (via his handler) seemed to be channeling psychologist Carl Rogers by responding with empathy and warm acceptance (aka unconditional positive regard).1,2

President Joe Biden echoed Elmo’s empathy and warm acceptance: “I know how hard it is some days to sweep the clouds away and get to sunnier days. Our friend Elmo is right. We have to be there for each other, offer our help to a neighbor in need, and above all else, ask for help when we need it. Even though it’s hard, you’re never alone.” Links to several mental health services were also posted.

What About Congruence?

In addition to empathy and warm acceptance, students of Rogerian counseling theory will notice that a third “pillar,” congruence, was not mentioned in news reports – partly because it is “inward work,” not readily observable:3

  • Persons who are congruent honestly understand their internal feelings and thoughts, which supports their ability to outwardly communicate empathy and warm acceptance to others.
  • On the other hand, persons who are incongruent do not honestly understand their internal feelings and thoughts, which may include unaddressed biases of any kind.4

Incongruence hinders our ability to communicate empathy and warm acceptance to persons associated with those biases, and efforts to do so come across as inauthentic.

When patients perceive inauthenticity, trust is difficult to establish – and as clinicians, we too are also aware when there is a disconnect, that at some level we “just don’t feel it for some reason.” The current call for increased awareness and management of implicit bias is consistent with the counseling principle of clinician congruence.5-7

Rogers’ Congruence Journey

It would not be unusual for helping professionals to miss the impact of unconscious / implicit bias on congruence – even Carl Rogers seemed to have overlooked it until rather late in his career. Crisp8 recently reported on two video recordings of Rogers’ therapy sessions with two different Black male patients, conducted 5 years apart. The first session from 1979 was described by peers as having a “therapist-centric perspective” (p. 223) with missed opportunities to respond with empathy to the client’s racism experiences and avoiding an exploration about their racial and cultural differences.

Subsequent experiences in cross-cultural workshops increased Rogers’ awareness of race-related issues and, as part of his commitment to ongoing examination of his unconscious assumptions, modified his definition of congruence to include an awareness of cultural diversity.9

His “reset journey” is perceptible in a second session recorded in 1984: “Rogers was confronted with a client whose difficulties with racism included Rogers himself being a white therapist… He communicated appreciation and respect for the client’s courage in speaking to him honestly, and for his rebellion against the racism in white America” (p. 230 ).

Conclusion

Congruence is obviously easy for Elmo, since he clearly doesn’t have a biased bone (or any bones!) in his body.  For the rest of us, it’s an ongoing project… just as with Carl Rogers.

“Personal development in terms of congruence is considered to be a lifetime process needing devoted commitment and active effort.”10

Salk Institute, La Jolla, California


References

  1. Rogers, C. A. (1961). On becoming a person. A therapist’s view of psychotherapy. Boston: Houghton and Mifflin Company
  2. Rogers, A. (1980). A way of being. Boston: Houghton and Mifflin Company.
  3. Sutanti, N. (2020) 1(2), 47-50 Understanding congruence in person-centred counselling practice: A trainee counsellor’s perspective. Journal of Professionals in Guidance and Counseling, 1(2), 47-50.
  4. Danvers A et al. (2018). Emotional congruence and judgments of honesty and bias. Collabra: Psychology, 4(1), 1-7.
  5. Apodaca, C. et al. (2022). Maybe they had a bad day: How LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out. Journal of the American Medical Informatics Association, 29(12), 2075–2082.
  6. Boysen, G. (2009). A review of experimental studies of explicit and implicit bias among counselors. Journal of Multicultural Counseling and Development, 37, 240-249.
  7. Hagiwara, N. et al. (2019). Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training. Patient Education and Counseling, 102, 1738-1743.
  8. Crisp, R. (2020). Carl Rogers’ reset with an African American client: a discussion. Person-Centered & Experiential Psychotherapies, 21(3), 220-234.
  9. Schmid, P. (2015). Person and society: towards a person-centered sociotherapy. Person-centered & Experiential Psychotherapies, 14(3), 217-235.
  10. Kaimaxi, D. & Lakioti, A. (2021). The development of congruence: A thematic analysis of person-centered counselors’ perspectives. Person-centered & Experiential Psychotherapies, 20(3), 232–249.

“Be Sure To Establish Rapport with Your Patient” (gulp)

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

Student clinicians have a lot on their minds when they begin new clinical assignments. It’s possible that the exhortation to “establish patient rapport” registers as less important than accurate testing, proper use of technology, and precise documentation — and in the back of their minds, they may also be wondering, “What does ‘establishing rapport’ actually mean??”

Fifty years ago, an assistant professor in nursing1 asked the same question. “[Rapport] has become a cliché, an interpersonal bromide. We all know that it’s a good thing to have – but we’re not really sure what it is” (p. 70). Just recently, a scoping review2 determined that there was as yet no agreed-upon definition for rapport relative to healthcare. Elsewhere, however, “rapport” has been framed as a synonym for “therapeutic relationships”3 and described as “a positive, dyadic concept that comprises positive affect (liking), mutual attention, and coordination”(p. 1129).4

These descriptors are helpful, but the stressor point for students may be less about “what rapport is” and more about “how does one achieve it?”

Back to First Principles

This typical definition from Merriam-Webster for “rapport” (noun)…

a friendly, harmonious relationship, especially characterized by agreement or empathy that makes communication possible or easy

…reveals the clinical challenge: describing an existing relationship does not help us understand the process of establishing or building rapport.

“Rapport as process” starts off in an uncomplicated way. It includes familiar and natural behaviors: warm welcomes, conversations about patients’ lives and interests, giving warning before touching patients, and overall taking time to connect as human beings, as confirmed by patients themselves:

‘I used to teach people to drive cars … I would make sure, before I pulled up or picked anyone up, that I knew what their first name was, what their surname was, their date of birth and a little bit about them, before I’d even met them … No matter what you do, if you’re trying to create a bond or a – yeah, a bond will do – they’re the things you need to start with. Following on from that, you need to know the person’s needs … and their wants’(p. 7)5

[My clinician] was friendly and open, explained what was being done and seemed to understand me as an individual … answered my questions at an appropriate level when prompted…I always get a friendly welcome”(p. 198)6

What We May Not Notice: Unintended Hinderances

Less apparent to us are circumstances that hinder rapport-building, e.g.,

  • When patients sense awkwardness and avoidance (not receiving a warm welcome or eye contact; use of unexplained medical jargon)
  • When patients feel judged and uncared for (perceiving conscious or unconscious prejudice and disregard)2

These negative patient impressions resonate in the literature addressing discordant healthcare dyads. As discussed here, the term “discordant” does not mean that discord or friction or tension exists, but simply describes a dyad where differences exist with respect to:

https://www.tmc.edu/news/2019/10/best-intentions-wont-solve-implicit-bias-in-health-care/

  • Gender7-10
  • Age5,11-13
  • LGBTQ+ community14-19
  • Race20-24
  • Culture25,26
  • Socioeconomic status27-31

… plus intersections of these and other characteristics. Realistically, we should expect some degree of “dyadic discordance” on any given workday; more importantly, we should be aware that interpersonal differences could prompt behaviors influenced by unexamined implicit biases, resulting in those patient perceptions of awkwardness, avoidance, feeling judged and uncared for.

Discordance is Not Destiny

Working through rapport challenges: A lot to unpack

Implicit biases are part of the human experience, but are not irrevocable. Trainees might benefit from readings,32 discussions, role-playing, feedback about efforts, successes, struggles, and insights.

Of course, difficulties with patient rapport may also be related to shyness, insecurity, self-consciousness, under-preparedness, fear of failure… concerns that supervisors may refer to professional counselors.

Conclusion

A clinician’s ability to establish rapport cannot be taken for granted, and may actually require considerable attention. It may elude definition in research articles but in real-life clinic, we know that authentic patient rapport lays the groundwork for person-centered care.


References

  1. Travelbee J. (1963). What do we mean by rapport? American Journal of Nursing,63(2), 70–72.
  2. English W. et al. (2020). The meaning of rapport for patients, families, and healthcare professionals: A scoping review. Patient Education and Counseling, 105, 2-14.
  3. Norfolk T et al. (2007). The role of empathy in establishing rapport in the consultation: A new model. Medical Education, 41, 690-697.
  4. Henry S. et al. (2017). Associations between thin slice ratings of affect and rapport and perceived patient-centeredness in primary care: Comparison of audio and video recordings. Patient Education and Counseling, 100, 1128-1135.
  5. Orgin R. et al. (2020). The inter-relationship of diversity principles for the enhanced participation of older people in their care: A qualitative study. International Journal of Equity in Health, 19:16.
  6. Potter M. et al. (2003). The physiotherapy experience in private practice: The patients’ perspective. Australian Journal of Physiotherapy, 49, 195-202.
  7. Choudhury A. et al. (2020, October). Impact of gender on doctor-patient communication and emotion: Exploratory analysis. 2020 IEEE International Symposium on Systems Engineering (ISSE)(pp. 1-10)
  8. Gross R. et al. (2008). The association of gender concordance and primary care physicians’ perceptions of their patients, Women & Health, 48(2),123-144.
  9. Schieber AC et al. (2014). Do gender differences affect the doctor–patient interaction during consultations in general practice? Results from the INTERMEDE study. Family Practice, 31(6), 706-713.
  10. Wallis J. et al. (2022). Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surgery, 157(2), 146-156.
  11. Elliot M. et a. (2022). The hospital care experiences of older patients compared to younger patients. Journal of the American Geriatrics Society, 70, 3570-3577.
  12. Gilbert D., Hayes E. (2009). Communication and outcomes of visits between older patients and nurse practitioners. Nursing Research, 58(4), 283-293.
  13. Stewart M. et al. (2000). The influence of older patient-physician communication on health and health-related outcomes. Clinics in Geriatric Medicine, 16(1), 25-36.
  14. Balik C. et al. (2020). A systematic review of the discrimination against sexual and gender minority in health care settings. International Journal of Health Services, 50(1), 44-61.
  15. Bonvicini K. (2017). LGBT healthcare disparities: What progress have we made? Patient Education and Counseling, 100, 2357-2361.
  16. Joudeh L. et al. (2021). “Little red flags”: Barriers to accessing health care as a sexual or gender minority individual in the rural southern United States—A qualitative intersectional approach. Journal of  the Association of Nurses in AIDS Care, 32(4), 467–480.
  17. Malta M. (2023). LGBTQ+ health: Tackling potential health-care professionals’ bias. Nature Review Disease Primers
  18. McDowell M et al. (2020). Strategies to mitigate llinician implicit bias against sexual and gender minority patients. Psychosomatics, 61(6), 655-661.
  19. Sabin J. et al. (2015). Health care providers’ implicit and explicit attitudes toward lesbian women and gay men. American Journal of Public Health, 105(9), 1831-1841.
  20. Cuevas A., et al. (2016). African American experiences in healthcare: “I always feel like I’m getting skipped over.” Health Psychology, 35(9), 987-995.
  21. Hajiwara N. et al. (2017). Physician racial bias and word use during racially discordant medical interactions. Health Communication, 32(4), 401-408.
  22. Knoebel R. et al. (2021). Treatment disparities among the Black population and their influence on the equitable management of chronic pain. Health Equity, 5(1), 596-605.
  23. Mhaimeed N. et al. (2023). Shared decision making with black patients: A scoping review. Patient Education and Counseling, 110, 107646
  24. 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. 
  25. Berlin A. et al. (2010). Watchfully checking rapport with the primary child health care nurses – A theoretical model from the perspective of parents of foreign origin. BMC Nursing, 9(14).
  26. Pérez-Stable J, El-Toukhy S. (2018). Communicating with diverse patients: How patient and clinician factors affect disparities. Patient Education and Counseling, 101, 2186-2194.
  27. Davies J. et al. (2023). The association between socioeconomic position and the symptoms and concerns of hospital inpatients seen by specialist palliative care: Analysis of routinely collected patient data. Palliative Medicine, 37(4), 575-585.
  28. Mercer M, Watts G. (2007). The inverse care law: Clinical primary care encounters in deprived and affluent areas of Scotland. Annals of Family Medicine, 5(6), 503-510.
  29. Rowley J. et al. (2021). The impact of poverty and deprivation at the end of life: A critical review. Palliative Care and Social Practice, 15, 1-19.
  30. Xesfingi S, Vozikis A. (2016). Patient satisfaction with the healthcare system: Assessing the impact of socioeconomic and healthcare provision factors. BMC Health Services Research, 16:94
  31. Yuan Y. (2021). Public satisfaction with health care system in 30 countries: The effects of individual characteristics and social contexts. Health Policy, 125, 1359-1366.
  32. Vela M. et al. (2002). Eliminating explicit and implicit biases in health care: Evidence and research needs. Annual Review of Public Health, 43, 477-501.

Can a “Patient Dignity Question” Mitigate Heathcare Inequities? Part 1/2

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

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

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

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

Dignity

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

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

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

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

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

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

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

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

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

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

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

 

References

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

Can a “Patient Dignity Question” Mitigate Healthcare Inequities? Part 2/2

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

Part 1 began with the observation that addressing healthcare inequities requires vigilance, specifically with attention to the topic of relational dignity. Chochinov1 points out, “Although the literature on dignity is sparse, it shows that ‘how patients perceive themselves to be seen’ is a powerful mediator of their dignity” (p. 184). To “be seen” or to “feel seen” are familiar phrases that describe recognition from another person, referred to in Part 1 as relational dignity.2

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

Some Background

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

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

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

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

Proposal: Pose the PDQ…

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

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

Concerned about saying the question accurately?  We could:

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

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

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

Conclusion

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

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

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


References

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

Ida Institute’s Legacy: Person-Centeredness

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

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

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

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

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

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

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

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

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

 

Implications: Checking Our Priorities

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

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

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

To the Ida Team…

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


References

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

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

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

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

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

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

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

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

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

Supporting Student Counseling Skills via Self-Efficacy

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

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

Positioning the Learner to Take the Lead

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

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

A Recent Application

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

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

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

A Secondary Benefit

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

Conclusion

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

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


References

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

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

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

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

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

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

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

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

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

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

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

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

The “What Matters to You?” Movement

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

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

NHS Scotland Guide for Patients

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

Trying Something New

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

20190304-WMTY-Guide.pdf

An Additional Consideration: Racial Equity

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

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

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

Conclusion

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

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


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

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

References

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

Clinician Presence: Now.Here.This.

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

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

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

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

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

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

Conclusion

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


References

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

Timeless Boundary Guidance and An Update: Screenings

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

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

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

1989: Key Concepts

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

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

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

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

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

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

The 2020’s: What We Now Also Talk About

When the classic “boundaries” article was published, audiologists in the US lacked professional autonomy and were not expected or prepared to address whole-person care.3 At the time, some activities were rightly considered beyond our boundaries, for instance collecting information on related medical problems, following up on observations of chronic feelings of unhappiness, or screening for patient safety concerns. But things change…

In the mid 1990’s, the Audiology Doctorate (AuD) was established as the entry level degree in the US. A primary goal of the advanced degree was to align our profession with changes in healthcare overall: i.e., to prepare students to serve as full members of coordinated healthcare teams. These days, we may likely find ourselves broaching/being broached about topics other than hearing and balance but still relevant to patient health and safety. Audiologists now inquire about medications that may adversely interact with hearing and balance4-7 and are typically required by law to intervene with a referral when we perceive indications of self-harm or suicide ideation.8 Institutions and states require us to report concerns about child and elder abuse.9,10 Other developments include screening for vision problems,11,12 cognitive and memory concerns,13-15 depression,16-19 and childhood bullying20 – of course not to diagnose but to assume responsibility for overall patient health and safety, and direct those concerns to relevant support systems. And although not directly related to our care, of course we will listen and support patients who are coping with a death in the family and similar life experiences. Person-centered care has replaced disease- or disorder-centered care.

Conclusion

Clearly our “what we talk about” boundaries have expanded. Our counseling skills are as essential in these endeavors as with any topic related to audiology. Sensitivity, careful listening, preparedness … we “stay in our lane” while keeping our full attention on the patient-as-person.


References

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

“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.

References

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