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

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

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

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

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

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


Implications: Checking Our Priorities

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

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

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

To the Ida Team…

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


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.


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.


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.

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.


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.


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 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


  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


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?”


  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 unrelated 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.


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.


  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.


  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/

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.

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

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.

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.

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