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

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

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

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

Some Background:

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

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

from Institute of Medicine (2003), p. 200

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

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

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

IOM does stress requisite attitudes such as humility, as well as empathy, curiosity, respect, sensitivity, and awareness of outside influences. Advocates have indicated that the concept of cultural humility (Tervalon & Murray-García, 1998) has not been adequately emphasized, seeing this attribute as a fundamental premise to earning patient trust.

Characteristics of Cultural Humility

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

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

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

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

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

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


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

For more on Cultural Humility:

Part 2: Mitigating Racial Health Disparity with Patient-Centeredness

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

Part 4: Perspective-Getting/Radical Empathy


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

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

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

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

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

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

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

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

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

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

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

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

Patient Centered Care in Argentina

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

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

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

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

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

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

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

I Tell You What I Have Learned…

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

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

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

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

What Keeps Me Going…

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

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

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

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

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

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

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

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

PCC= Atención Centrada en el Paciente

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

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

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

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

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

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

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

Por lo tanto les cuento lo que he aprendido…

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

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

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

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

Io que me hace seguir adelante….

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

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

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

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

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

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

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

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

Responding to Patient Emotions is Part of Our Scope of Practice. What’s Hindering Us from Doing So?

Samantha Tai, PhD

Lecturer | Audiologist

The University of Melbourne

Victoria, Australia

Over the past couple of years, I’ve been asking our new audiology cohort, ‘What characteristics do you think makes a good audiologist?’ Often, there is a pause before a brave hand will come up to say ‘someone who cares about their patient’, another hand will pop up to say ‘someone knowledgeable, who knows a lot about ears’, another calls out ‘someone who is patient and really listens to the patient’, and then another ‘someone who makes the patient feel comfortable’. While the characteristic of being knowledgeable is often highlighted, the thing that baffles me is students’ intuitive recognition that interpersonal skills are a fundamental characteristic of being a good audiologist. Essentially, it comes down to how we make our patients feel.

In recent years, the scope of practice in the audiology profession has expanded from focusing on a site-of-lesion to a holistic, person-centred approach to hearing care (ASHA, 2018; AudA, 2013; BSA, 2016). That is, the role of an audiologist has moved away from simply being a technician who carries out audiological assessments, to a hearing professional who empowers and supports patients to self-manage their hearing loss. One of the fundamental elements of patient-centred care is the clinician’s ability to respond to patients’ emotions that have stemmed from their hearing loss. Audiologists who display empathy and acknowledge their patient’s emotions can make their patients feel their concerns are validated and help to reduce psychological distress (Ekberg et al., 2014; Poost-Foroosh et al., 2011). The emphasis on investing in the clinician-patient relationship is beginning to gain recognition in the audiologist’s scope of practice around the world. It falls under the professional guidelines as counselling on the psychosocial impact of the hearing loss (ASHA, 2018; AudA, ACAuD and HAASA, 2016; BSA, 2016).

Despite the aforementioned benefits, research has found that when our patients do open up and express their underlying concerns, both experienced clinicians and audiology students tend to miss these opportunities to acknowledge our patients’ emotions (Ekberg et al., 2014; Meyer et al., 2017; Tai et al, 2019). This can have a detrimental effect on the clinician-patient relationship and reduce the likelihood of the patient adhering to recommendations (Ekberg et al., 2014; Grenness et al., 2015). We know that limited acknowledgement or empathetic response is not because of a lack of care or preference for patient-centred care, so it raises the question, why does this deficit exist in our clinical practice?

What are the Current Barriers to Responding to Emotions in Audiology?

Can We Use Our Time Differently?

To put it simply, dealing with emotions is hard and several barriers hinder clinicians to adopt these practices in a clinical setting. To understand some of these barriers, we need to first recognize that traditionally, the audiology profession has placed a significant focus on diagnosing and managing the ‘site-of-lesion’. For instance, in a typical audiological appointment, we invest a majority of time assessing the hearing loss and only a limited time to collate all the relevant questions about the patient’s hearing and thoroughly explain the management options. Similarly, when discussing hearing aid options, audiologists are tasked with convincing the patient that hearing devices are beneficial, give a recommendation, perhaps perform an ear impression, and place an order. With the appointment duration set, clinicians and students alike may find themselves adopting a formulaic approach when communicating with patients, and missing opportunities to address patients’ emotional concerns.

In alignment with the audiology culture, the audiology curriculum was developed to foster students’ diagnostic and technical skills in accordance with the scope of practice. Until recently, counselling skills were absent or minimally integrated into the audiology curricula. Consequently, the lack of formal training means that graduates need to learn counselling skills, including how to respond appropriately to patients’ emotional concerns, on the job. Some clinicians are natural communicators with an innate ability to pick up patient cues and respond empathetically. Honestly, I wouldn’t classify myself as a natural communicator and perhaps there are those of you out there who can relate. I’m sure there are clinicians out there who do not feel comfortable addressing our patient’s emotions because there is
an underlying fear that we might make them feel worse. Without further upskilling or training in counselling skills, experienced clinicians may be unaware of the benefits of acknowledging patient emotions, resulting in the provision of suboptimal hearing care to patients. And through no fault of their own, the missed opportunities to invest in the client-patient relationship may be observed by new graduates or students on clinical placements, who will miss a valuable lesson on how to build a therapeutic relationship.

So What Can We Do to Improve This?

As audiologists, we carry the responsibility to do what’s right by our patients. Although there are things we can’t control such as our educational past or the culture of our workplace, there are plenty of things that are within our control.

Firstly, we need to recognize the way we interact with our patients carries a significant effect on our patient’s hearing outcome. This includes whether they understand their hearing loss, to whether they take your advice about getting an MRI to investigate their asymmetrical hearing loss, or getting and wearing their hearing devices. When we tell our patients they have a hearing loss, we often forget that we’re delivering bad news. On the surface, our patients may be putting on a brave face as they try to listen intently as we describe the circles and crosses on the graph (FYI, sometimes it’s best not to show patients the audiogram). We lose sight that our patients are trying to decipher how their hearing loss will impact their relationships, hobbies, work and perhaps their self-image. If we understand the emotional toll our patients are experiencing due to their hearing loss, then we are more inclined to try and support them through it.

Secondly, we need to critically and honestly examine our own clinical practice and identify any areas that need improvement. In this piece, we’ve focused on acknowledging patient emotions, but it also extends to other areas in our practice. One method is the use of self-reflective practice where we take a couple of minutes after each appointment to reflect on what went well and what can be improved. Bringing the focus back to addressing patient emotions, we may find that when we recognize and acknowledge our patient’s emotional concerns, he/she starts opening up and we have developed a better rapport. Conversely, we may have noticed a missed opportunity when our patient seemingly joked about early retirement because he can’t carry out his normal work duties. Both scenarios are wonderful opportunities for professional growth and life-long learning.

Finally, we need to invest in ourselves to improve the deficits in our clinical practice. There are many established teaching frameworks available that outlines the key elements of patient-centred communication. For instance, the Calgary Cambridge Guides (Kurtz et al., 1996), or the Four Habits (Krupat et al, 2006) are examples of evidence-based frameworks in medicine that can be translated to an audiological setting. There are also free training resources from the Ida Institute that provides counselling tools for experienced clinicians and students. If other work colleagues are interested in some upskilling, in-house case discussions can include communication strategies to counsel patients in different scenarios. There may even be opportunities for peer learning by observing your colleague’s appointment. Be creative!


American Speech-Language-Hearing Association. (2018). Scope of Practice in Audiology.  [Accessed October 18, 2018]

AudA, ACAud, & HAASA. (2016). Scope of Practice for Audiologists and Audiometrists, (September), 1-23. [Accessed October 18, 2018]

Audiology Australia. (2013). Professional Practice Standards – Part A Clinical Operations.  [Accessed March 29, 2016]

British Society of Audiology. (2016). Practice Guidance: Common Principles of Rehabilitation for Adults in Audiology Services.  [Accessed January 17, 2017]

Ekberg, K., Grenness, C., & Hickson, L. (2014). Addressing patients’ psychosocial concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiology, 23(3), 337–350.

Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2015). Communication patterns in audiologic rehabilitation history-taking: Audiologists, patients, and their companions. Ear and Hearing, 36(2), 191–204.

Krupat, E., Frankel, R., Stein, T., & Irish, J. (2006). The Four Habits Coding Scheme: Validation of an instrument to assess clinicians’ communication behavior. Patient Education and Counseling62(1), 38-45.

Kurtz, S. M., & Silverman, J. D. (1996). The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Medical Education, 30(2), 83–89.

Meyer, C., Barr, C., Khan, A., & Hickson, L. (2017). Audiologist-patient communication profiles in hearing rehabilitation appointments. Patient Education and Counseling100(8), 1490–1498.

Poost-Foroosh, L., Jennings, M. B., Shaw, L., Meston, C. N., & Cheesman, M. F. (2011). Factors in client-clinician interaction that influence hearing aid adoption. Trends in Amplification, 15(3), 127–139.

Tai, S., Barr, C., & Woodward-Kron, R. (2019). Towards patient-centred communication: An observational study of supervised audiology student-patient hearing assessments. International Journal of Audiology, 58(2), 97-106.

Yoga Principles and Audiologic Counseling

Kirsten Ellis, BA(Hons) MSc
Southend University Hospital
NHS Foundation Trust

In Yoga, we are encouraged to minimise distractions. Now, I am speaking from a student’s point of view, as I certainly don’t possess the in-depth knowledge that my dear yoga teachers do. When laying in Savasana (the prone relaxation pose at the end of a class, and sometimes at the beginning) we are reminded that there are no distractions, there is nothing else we need to do at that moment apart from being present in the space. Often easier said than done!So to my surprise, when relaxing in Savasana one evening and listening to the teacher guide us through meditation, she reminded us that we were there for ourselves, we had no expectations on us at that time, and that this was a safe space for us to just “be.”

“Don’t bring your story.” – The Breakthrough

On hearing this my mind lit up (probably much to the disappointment of my yoga teacher) – how can this be carried over into our counselling?  The clinical ego wants us to bring our “story” to each appointment.  It tells us to reassure the patient that we know best, that our experiences and training (our story) are how we can best manage someone seeking help.

Additionally, in a more literal sense we don’t want to belittle our patients’ experiences by comparing them to our own. How often have we felt disheartened at being told “I know how you feel,” or “I’ve been though that, it’s not so bad”?

To truly listen, we shouldn’t bring our story to the appointment. By releasing our story and subsequent distractions, we can truly be present to listen.

The Yogi and the Clinician

My yogi has helped me work through what feels uncomfortable, or through a busy state of mind to find peace in the present moment. When we are truly listening, are we also not working to find peace within ourselves to be fully present for the person in front of us?

I’ve often found myself in the midst of what I would feel is a difficult conversation, trying to push my clinical ego aside and allowing my patient to just talk. For me, this echoes working through what I feel is uncomfortable, allowing my patient to work through vulnerability to achieve a sense of calm (not necessarily a conclusion) in the appointment.

What are we doing to be self-aware, and how are we responding to this state?

To summarise my thoughts, I am reminded of a recent patient who attended for a review of his hearing aids. On the outside, one would assume he was a patient who could not hear well, felt his hearing had changed, and that an update was needed. However, once he came and took a seat, his body language communicated some further inner turmoil.

He confessed that he had been mishearing and forgetting important dates, the most recent being his daughter’s landmark birthday celebration. I let him talk. With tears in his eyes, he told me that he had sought an appointment at his GP for an assessment for dementia. My clinical ego wanted me to reassure him, and tell him everything is fine and to push on with the appointment. But instead, we sat and explored his concerns. We asked each other questions and we sat through conversation and silences that were uncomfortable for the both of us.  We came to an agreement that we would get his hearing aids as good as they can be for his dementia assessment, so that we can face things confidently with our heads held high.

My general feelings once the appointment ended were that because of our interaction and agreement, we were both fully self-aware, in a compassionate environment that allowed for vulnerability (Hanson, 2009). Upon further reflection, I was struck by the parallels of Rogers’ (1961) three conditions of person-centered counselling: congruence with self, unconditional positive regard, and empathic understanding – all essential audiologic counselling skills. Of the three conditions, the foundational skill of self-awareness/congruence with self seems to generate almost no interest among audiologists.

So let’s start, shall we? Let’s develop a professional version of the prone relaxation pose Savasana – and breathe.


Hanson, J. (2009). Self-awareness revisited: Reconsidering a core value of the counseling profession. Journal of Counseling & Development, 87(2), 186-193.

Rogers, C. (1961). On becoming a person.  Boston: Houghton Mifflin.

Can Patient Autonomy and Patient-Centered Care Co-Exist?

Kris English, PhD

Professor Emeritus

The University of Akron

The concept of patient autonomy is a fundamental right in today’s health care system (Bernstein, 2018). Per Walter and Ross (2014), classic textbooks teach us that “autonomy is all about individualism and the rights of patients to make decisions without paternalistic interference” (p. S18).  It is such a strongly held concept that, overall, we are likely left with the impression that respect for autonomy apparently “obliges clinicians to tell patients about health care options, then stand back and abide by their choices” (emphasis added)(Enwistle et al., 2010, p. 741).

While protecting and empowering patients, the principle of patient autonomy might give an audiologist pause. When the standard definition of patient autonomy isolates the patient as decision-maker and ignores the influence of the clinician, how do we provide patient-centered care? If we are expected to “stand back and abide,” then PCC conversations such as shared decision-making would be inappropriate. If these two principles — patient autonomy and PCC — are at odds, how do we reconcile the values each principle represents?

A Bright Idea: Expand the Definition

The tension between these two concepts has not gone unnoticed. In the 1980’s, bioethicists saw the need to revisit the narrow “self-sufficient” version of patient autonomy – not to limit patient rights but also to include the clinician. The point was made that “in the clinical setting, perhaps more than in any other, patients are not self-sufficient, and an expanded definition of autonomy is required to preserve their sense of self-governance and the ability to assume the responsibility of making choices” (emphasis added)(Tauber, 2005, p. 123).  Incorporating the basic tenets of autonomy within a relational context came to be known as relational autonomy.

Relational Autonomy in Audiology

Mackenzie and Stoljar’s (2000) description of relational autonomy will resonate with audiologists:

Relational autonomy perspectives are premised on a shared conviction that persons are socially embedded and that agents’ identities are formed within the context of social relationships and shaped by a complex of intersecting social determinants, such as race, class, gender, and ethnicity.

And a comparison of clinic variables is certainly consistent with patient-centered audiologic counseling (from Wilson & Ross, 2014):

Treading Carefully

Needless to say, patients vary in their comfort level with autonomy of any kind. Variables include patient education levels, age, the nature of decisions being considered, and the type and severity of health concerns.  Cultural differences must also be considered: in many societies, patients and families prefer health care providers to assume a paternal role, and prefer a different balance between personal autonomy and the involvement of the family in decision-making (Tauber, 2005).

So… Can Patient Autonomy and Patient-Centered Care Co-exist?

Yes — as long as we evolve with the field of bioethics.

  1. We can recognize that the classic definition of patient autonomy serves the patient well but inadvertently (and unhelpfully) overlooks the role and impact of the clinician.
  2. We can mindfully define ourselves as practitioners of relational autonomy: always honoring patient choice and agency, within a relationship-based context.

And in all likelihood, even though the terminology may not be familiar, audiologists already practice relational autonomy. We already understand how patient choice and agency is integrated into patient-centered care and shared decision making. One indicator: the communication and interpersonal skills involved in relational autonomy are already represented in audiologic counseling.


Bernstein. (2018, May). Take control of your health (exert your patient autonomy). Harvard Medical School, retrieved December 27, 2019.

Entwistle, V., et al. (2010).  Supporting patient autonomy: the importance of clinical relationships. Journal of General Internal Medicine, 25, 741–745.

Mackenzie, C, & Stoljar, N. (Eds.).(2000). Relational autonomy: Feminist perspective on autonomy, agency, and the social self. New York, NY: Oxford University Press.

Tauber, A. (2005). Patient autonomy and the ethics of responsibility. Cambridge, MA: MIT Press.

Walter, J., & Ross, L. (2014). Relational autonomy: Moving beyond the limits of isolated individualism. Pediatrics, 33(Suppl 1), S18-S23.

New Year’s Resolution, 2020: Notice More Clues



Kris English, PhD

Professor Emeritus

The University of Akron

A Conversation Overheard in Clinic:

New Patient:  My bridge party friends roll their eyes when my friend Mary joins us. Her hearing aids don’t help her and we have to shout at her all afternoon. I think my hearing is getting as bad as hers.

Audiologist: Feel free to give her my number, I could probably adjust her aids.


The attentive reader will immediately spot a communication mismatch (Clark & English, 2019). The patient was dropping a clue regarding her own hearing, but as professional problem-solvers, we can find it hard to resist the fixable problem. As a consequence, the audiologist didn’t notice that the patient used an indirect opening to discuss her own worries. (Fortunately, her next attempt was quite direct and everyone was back on track.)

The Challenge of Indirect Comments: Easy to Miss

This patient’s indirect approach is likely more common than not. For instance, Adams et al. (2012) recorded 79 patients’ encounters with 27 physicians, and identified 190 patient emotional-state comments. Of these, 58% were indirectly stated (e.g., “that’s the hardest part”).

From their evaluation of 116 clinical conversations, Levinson et al. (2000) provide an instructive dialogue with an indirect — and missed — clue:

“Most often, emotional clues were embedded in a biomedical examination (e.g., during pauses in measurement of blood pressure). Typically, such clues were raised indirectly when the conversation touched on an emotional issue…

Physician: Your blood pressure is looking good; 140 over 70, pretty good.

Patient: My sister was in a car accident 4 weeks ago, and she’s been…

Physician: How’s she doing?

Patient: She’s staying with me, she’s doing better, she gets dizzy a lot.

Physician: Dear me, any neck injuries?

Patient: I know they checked her, and they said it’s OK” (p. 1024).

Why Indirect?

We can certainly understand the indirect approach: patients may feel embarrassed, or worry about what will happen if they put their thoughts into words. They may not be sure they can trust their clinician with personal disclosures. We “test the waters” like this ourselves, to determine if a communication partner is attentive and receptive.

Understanding the reasons for indirectness is a start; if we hope to be helpful, we also need to notice the clues.

“Try to Be One of Those People…”

An achievable goal for the New Year might be to channel our inner Sherlock Holmes and be more alert to patient clues. As Charon (2017) puts it, “Henry James’s dictum to novelists, ‘Try to be one of those people on whom nothing is lost’ … can also be said to listeners” (p. 166).

A Note to Preceptors and Clinical Instructors

For those who supervise students, consider this assignment: keep a journal or log of patient comments, organized as direct or indirect clues, to determine the proportion of each over a period of time. Learning objectives: (1) Demonstrate attention to patient concerns; (2) Demonstrate “close listening” skills relative to patient concerns; (3) Demonstrate journaling/reflection skills (a recommended practice for professional growth per Schön, 1987).

If learning outcomes are fruitful, please consider submitting a report! Contact Kris: [email protected]


Adams, K., et al. (2012). Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotion in hospital admission encounters. Patient Education and Counseling, 89, 44–50.

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.

Clark, J., & English, K. (2019). Counseling-infused audiologic care (3rd ed.). Cincinnati OH: Inkus Press.

Levinson, W., et al. (2000). A study of patient clues and physician responses in primary care and surgical settings. JAMA, 284(8), 1021-1027.

Schön, D. (1987). Educating the reflective practitioner. San Francisco: Jossey-Bass.

Listening and Ethics

Kris English, PhD

Professor Emeritus

The University of Akron

Like most health care professions, Audiology is guided by codes of ethics (e.g., by the American Academy of Audiology). Although codes of ethics are essential, they are not immutable. Over time, ethics evolve in response to new information and new insights (Calman, 2004). For instance, 40 years ago, it was not unusual – and considered ethical – to fit one hearing aid on a patient with a bilateral hearing loss without much thought. What changed? Initially, our knowledge base: we learned about neural plasticity and the effects of acoustic stimulation counteracting neural atrophy. This new knowledge then changed our practices, which then affected our ethical understanding of unilateral HA fittings.

Importantly, our codes of ethics tend to be broadly stated and do not single out specific changes in thinking. It’s up to us to interpret our codes of ethics in light of new evidence and accepted best practices (Palmer, 2012). Borrowing from the field of narrative medicine (Charon, 2017), we can consider this interpretative process as a type of “close reading,” defined as the thoughtful, critical analysis of text in order to develop deeper understanding (Moss et al., 2015).

What Else Has Changed?

We also now know a great deal more about patient-centered care (PCC) (e.g., Stewart et al., 2014), especially the primacy of “close listening” to patients’ stories (Irving & Charon, 2017). Like hearing aid practices, PCC as an evidence-based practice is usually not explicitly reflected in codes of ethics. However, a “close reading” of our ethics strongly suggests, as a predicate, the need to closely/fully listen and understand our patients’ narratives. “Close listening” is essential if we are to ethically provide services with compassion and meet our patients’ best interests.

Close listening to patient stories involves narrative competence, defined as “the fundamental human skill of recognizing, absorbing, interpreting, and being moved to action by the stories of others” (Charon, 2017, p. 126). Depending on our backgrounds in counseling, this concept may be obvious but we shouldn’t assume so; as Charon notes (supported by abundant evidence), “Despite the range of sources and skills bent toward the effort to improve clinical listening, patients continue to complain that their doctors don’t listen to them” (p. 158).  One reason might be that “close listening” has not been recognized as an ethical practice.

 Listening as an Ethical Practice

A close reading of our ethics texts leads us to appreciate the ethical implications of listening (or not listening) to our patients.  If we don’t fully absorb patient narratives, we are less likely to be “moved to action” toward personalized and comprehensive care. Promoting “close listening” (in the context of PCC) as an ethical practice warrants review and discussion within the profession.


Calman, KC. (2004). Evolutionary ethics: Can values change? Journal of Medical Ethics, 30, 366-370. doi: 10.1136/jme.2002.003582

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.

Irvine, C. & Charon, R. (2017). Deliver us from certainty: Training for narrative ethics. In R. Charon, et al., The principles and practices of narrative medicine (pp. 110-133)NY: Oxford University Press.

Moss, B. et al. (2015). A close look at close reading: Teaching students to analyze complex texts. Alexandria, VA: ASCD.

Palmer, C. (2012). Ethics of best practice. In Teri Hamil (Ed.), Ethics in audiology: Guidelines for ethical conduct in clinical, educational, and research settings (2nd ed.)(pp. 237-245. Reston, VA: American Academy of Audiology.

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

Can We Be Person-Centred and Sell Hearing Aids?

Anna Pough, BA MSc

Hearing Therapist Audiologist

British Society of Hearing Aid Audiologists

Everything we do in our hearing care consultations must have a purpose. Given our daily time crunch, it is a true challenge to purposefully apply person-centred practices such as shared decision making, ownership and rapport – and simultaneously work with the realities of the retail imperative. We need to support the person in the purchase and use of a product that no one wants, all the while working with barriers of stigma, bereavement of selfhood, and limited understanding of hearing instrument technology.

These responsibilities take up a lot of “bandwidth,” and it can be very tempting to resort to habits, shortcuts and routines. Hence the question: can we be person-centred and also sell hearing aids?  Following are three ways we can answer with YES.

YES: Begin with Carl Rogers’ Concept of “Person-Centredness”

Psychological therapy was initially based on the professional’s didactic perspective of how therapy should be undertaken and how success would be measured. Rogers was a radical thinker and changed this perspective. He believed that genuine meaningful therapeutic change would only occur when certain core clinician behaviors were applied: empathy, unconditional positive regard (acceptance) and congruence (being genuine)(Rogers, 1961). Specifically:

  • The clinician should work alongside the client as an equal partner in the therapeutic intervention;
  • By building on ‘unconditional positive regard’ and ‘empathy,’ the client is supported to recognize and acknowledge their own behaviours and responses through ‘congruence’ from the therapist;
  • A person’s own life experience provides the basis for their own standards of living in the real world, and influences their acceptance of therapy.

Rather than the therapist controlling the clinical interaction, Rogers explicitly addressed the issue of power and challenged the presumption of expertise. When he was described as “giving power back to the patient,” he insisted on clarifying: “It is not that this approach gives power to the person; it never takes it away” (Rogers, 1977, p. xii).

His theories developed further through psychological research and have become a cornerstone of most current interventions. [Read more about the Rogerian approach here.]

YES: Review Maslow’s Hierarchy of Needs

Abraham Maslow and Carl Rogers were both considered founders of a humanistic approach to psychology.  Maslow’s now-classic pyramid-shaped model (“hierarchy of needs”) reflects five states, starting with the need for sustenance, procreation, and existence, and then for safety and security. When these needs are met, relationships become important, leading to a need to be liked, respected, and to have a place in the group, which allows us to have an identity or self-actualisation; we can be who we choose to be. He later amended and addressed some concerns about this model, but as a concept it remains a useful visual tool.

If we accept that behaviours are based on these needs being met or not met, then we can place Rogerian principles of acceptance, congruence and empathy within this hierarchy as being integral to function within a “normal” life. In other words, a person-centred approach is positioned within the concept of having a “normal life” and being valued as “normal.”

By understanding better where the concept of person-centred services originated, we can appreciate the work required to maintain its principles in our day-to-day practice. By being congruent, empathic and by practicing real reflective listening, we can help people move from denying they have a hearing problem to purchasing and wearing hearing instruments – in effect, achieving a degree of self-actualization by improving a “self” problem. [Read more about Maslow’s theories here.]

YES: Remember that “Change is Hard” – But Achievable

Providing support as recommended by Rogers, and helping a person advance along Maslow’s stages, involves change — which can make people feel uncomfortable, insecure, and off-balance. And yet, people do change, and the process is often described by the Transtheoretical Model (TTM) (Prochaska and DiClemente, 1983). Developed in the 1980s, this construct helps therapists help their clients understand how and why they behave as they do, and how they could change.  TTM is a combination of several ideas examining change and influence, habit and acceptance, and describes the progression through various elements, each having their own response.  Anyone who has used the Ida Institute Motivational Tools, or anything similar, will recognise these stages of change pathway as the foundational model. [Read more about TTM here.]

Applying Theory to Practice

These models and theories can be directly contextualized to hearing healthcare and the consultation process. I began this piece by stating that everything we do in the consultation process must have a purpose. Each element of the consultation process must have a solid theoretical and clinical rationale, but embedded within this, each element also should also have a clear commercial perspective.

  • The decision to attend the hearing assessment should be rewarded with value within that person’s concept of worth, value and self esteem. They should be able to recognise the empathy and positive regard we as Audiologists afford them.
  • They should feel that their time and effort to attend the appointment is worth their while. This implies consequently that our time and effort as audiologists and therapeutic partners, are valuable too. This is a value construct and is a commercial transaction, even if no money has passed between us at this point. People have begun to think about the relationship in a transactional manner: they give us their time, and in return we give them information, advice and professional expertise. This has a tangible value. We go further to establish the need for our expertise, services and, in time, amplification products.
  • We ask open questions, eliciting answers where we actively listen, noting salient clues about attitudes, behaviours, needs and expectations which we reflect back, thereby demonstrating empathy. We gather commercially pertinent information in a non-judgmental manner about communication difficulty, domestic and work relationship conflicts, and the relative importance of those communication ecologies.
  • The consultation process should also allow us to understand the person’s place on their own cycle of the stages of change. This will help us to support and frame their expectations, work with them to acknowledge and/or accept their hearing loss, and build the desire to make a shared decision to purchase hearing amplification where that’s the most appropriate solution.


As Audiologists, we must maintain an ethical and congruent relationship with the people with whom we work. Understanding the theoretical foundations of a person-centred approach enables us to be effective and efficacious in our relationships, within the parameters of the commercial reality of the retail imperative.


Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–96.

Prochaska, J. & DiClemente, C. (1983) Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390–395.

Rogers, C. (1961). On becoming a oerson. Boston: Houghton Mifflin

Roger, C. (1977). Carl Rogers on personal power. NY: Delacort Press.


Challenge: Staying Patient-Centered While Taking Electronic Notes. Solution: Signposting

Kris English, PhD

Professor Emeritus

The University of Akron

An ongoing challenge in today’s health care system is managing computer use during patient encounters. Documenting each appointment is essential, but it can also disrupt our goal of providing patient-centered care (Ratanawongsa et al., 2016). In their literature review, Duke et al. (2013) noted that “the first minute of the consultation is often taken up with interacting with the computer rather than the patient” (p. 362), and that “patients worldwide express one major concern about computers in the office – the fixation of the physician’s eyes on the computer screen” (p. 359).

To manage the potential conflict between maintaining patient relationships and electronic records, let’s consider a relatively simple communication skill called signposting. The following definitions of signposting will resonate, since they are already routine practices in audiologic practice:

  • “A signpost is an explicit statement used to inform your patient what you are about to say or do. Signposts are often used to transition or change directions during a consultation. It makes clear to the patient what is going to happen” (Center for Health Care Communication, n.d.)
  • “Signposting progresses from one section to another using transitional statements; may include rationale for next section” (Silverman et al., p. 111)

Less routine might be the application of signposting while entering electronic notes:

  • “Signposting (telling the patient what you are doing as you transition to the computer) will signal that you are making a shift but still attending to his or her needs. Reading back what you have written, and then looking at your patient, also demonstrates active listening” (Duke et al., p. 362)

Applying a Familiar Skill to a New(ish) Situation

Even if not familiar with the term, audiologists “signpost” throughout an appointment: “Now that we’ve chatted about your concerns, let’s have you step into our testing booth …. That’s it for the testing portion. Let’s step into this area and talk about the results,” and so on. Like providing a roadmap, signposting reduces uncertainty and anxiety.

Applying the signposting skill to computer use includes these steps::

  1. “Introducing the computer” – “Our office uses an electronic medical record so I will occasionally need to type in information.” This process is no longer a novel experience to most patients, but mentioning it early provides the courtesy of a “heads up.”
  2. As needed, clearly signal any shifts from patient-focused to computer-focused moments by changes in posture, focus of visual attention, and a brief explanation such as, “I should summarize our chat so far in your record. This will take about a minute.”
  3. When done, either read what was typed to the patient (for transparency and accuracy checks) OR verbally indicate task completion as well shifting away from the screen, removing hands from the keyboard and mouse, and again facing the patient to re-establish eye contact and our undivided attention.

Importantly, signposting can involve both verbal and non-verbal cues.

Knowing the Name of a Skill Can Increase Its Use

Clinicians may not have known the name of a communication skill they already use, but to paraphrase Ursula LeGuin, “To know the name of a thing is to have power over it.” Signposting is a relatively straightforward patient-centered communication skill, but when it comes to computer use, applying it might require mindfulness as we break old habits and establish new ones. How will we teach ourselves the application of this important skill?  How will we monitor our efforts?


Center for Health Care Communication (n.d).  Signposting: An effective communication skill!

Duke P, Frankel R, & Reis S. (2013). How to integrate the electronic medical record and patient-centered communication into the medical visit: A skills-based approach. Teaching and Learning in Medicine, 25(4), 358-365.

Ratanawongsa N, Barton J, et al. (2016). Association between clinician computer use and communication with patients in safety-net clinics. JAMA Internal Medicine,176(1),125-128. doi:10.1001/jamainternmed.2015.6186

Silverman J., Kurtz S, & Draper J. (2013). Skills for communicating with patients (3rded.). Boca Ratan: CRC Press.