Empathy, Interrupted


Kris English, PhD

Professor Emeritus of Audiology

University of Akron


Scene: Audiology Clinic

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

Audiologist: I understand why that would worry you.

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

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

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

Shift or Support?

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

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

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

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

Worth Evaluating

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

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

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

There is No “I” in “Empathy”

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

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


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


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

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

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

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

Kris English, PhD

Professor Emeritus of Audiology

University of Akron

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

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

Address Patients by a Title and Their Last Name

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

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

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

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

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

The patient decides when using a first name is acceptable

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


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

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


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

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

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

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

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

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

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

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

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

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

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

Unlocking Assumptions re: “Others’ Shoes”

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

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

“Radical Empathy”

(p. 386)

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

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

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

Other People’s Shoes Don’t Fit Anyway

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

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


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

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

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

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

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

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

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

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

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

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

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

“Cognitive Priming”

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

 Mindful Efforts During Clinical Encounters

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

Conclusion: Implicit Bias ≠ Destiny

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

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

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


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

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

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

How to Outsmart Your Own Unconscious Bias

How Racism Makes Us Sick

The Problem with Race-Based Medicine




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



For More on Cultural Humility:

Part 4: Perspective-Getting/Radical Empathy


  1. Greenwald, A.G., et al. (1998). Measuring individual differences in implicit cognition: the implicit association test. Journal of Personality and Social Psychology, 74(6), 1464–80.
  2. Greenwald, A.G., et al. (2009). Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. Journal of Personality and Social Psychology, 97(1), 17–41.
  3. Arkes, H.  & Tetlock, P. (2004). Attributions of implicit prejudice, or “Would Jesse Jackson ‘Fail’ the Implicit Association Test?” Psychological Inquiry, 15(4), 257 278. DOI: 1207/s15327965pli1504_01
  4. Meissner F., & Rothermund K. (2015). A thousand words are worth more than a picture? The effects of stimulus modality on the Implicit Association Test. Social Psychological and Personality Science, 6(7), 740-748. doi:1177/1948550615580381
  5. FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(19).  DOI 10.1186/s12910-017-0179-8
  6. Chapman, E., et al. (2013). Physicians and implicit Bias: How doctors may unwittingly perpetuate health care disparities. Journal of General Internal Medicine, 28(11), 1504–10. DOI: 10.1007/s11606-013-2441-1
  7. Devine, P., et al. (2012). Long-term reduction in implicit race bias: A prejudice habit-breaking intervention. Journal of Experimental Social Psychology, 48, 1267-1278.
  8. Blair, I., et al. (2011). Unconscious (implicit) bias and health disparities: Where do we go from here? The Permanente Journal, 15(2), 71-78.
  9. Cox, W., & Devine, P. (2019). The prejudice habit-breaking intervention: An empowerment-based confrontation approach.  In R. Mallett & M.J. Monteith (Eds.), Confronting prejudice and discrimination: The science of changing minds and behaviors(pp. 249-274). London, UK: Academic Press.
  10. Moskowitz, G & Li, P. (2011). Egalitarian goals trigger stereotype inhibition: A proactive form of stereotype control. Journal of Experimental Social Psychology, 47, 103-116.
  11. Stanford Encyclopedia of Philosophy. (n.d.).
  12. Burgess, D., et al. (2007). Reducing racial bias among health care providers: Lessons from social-cognitive psychology. Journal of General Internal Medicine, 22, 282-287.
  13. Todd, A.R., & Galinsky, A.D. (2014): Perspective-taking as a strategy for improving intergroup relations: Evidence, mechanisms, and qualifications. Social and Personality Psychology Compass, 8, 374–387. DOI: 10.1111/spc3.12116
  14. Sukhera, J., et al. (2018). Adaptive reinventing: implicit bias and the co‑construction of social change. Advances in Health Science Education, 23, 587-599.doi: 10.1007/s10459-018-9816-3
  15. Byrne, A., & Tanesini, A. (2015). Instilling new habits: Addressing implicit bias in healthcare professionals. Advances in Health Science Education, 20,1255-1262. DOI 10.1007/s10459-015-9600-6
  16. Monteith,M.J., et al.  (2009). Schooling the cognitive monster: The role of motivation in the regulation and control of prejudice. Social and Personality Psychology Compass, 3, 211–226.

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

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

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

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

Clinical Disparities: Not Inevitable

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

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

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

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

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

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

Establishing Connections

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

Communication Quality/Listening, Responding to Emotions

Talk Time Ratio


Patient Participation

Participatory Decision-Making

Patient-Centeredness: Just the Beginning

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

Cross-Racial Concordance, COVID-19 Era

For more on Cultural Humility:

Part 4: Perspective-Getting/Radical Empathy


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

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

Cooper, L. et al. (2012). The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health, 102(5), 979-987.

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

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

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

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

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

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

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

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

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

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

Street, R. et al. (2008). Understanding concordance in patient-physician relationships: Personal and ethnic dimensions of shared identity. Annals of Family Medicine, 6(3), 198-205.doi: 10.1370/afm.821

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

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


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

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

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

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

Some Background:

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

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

from Institute of Medicine (2003), p. 200

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

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

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

IOM does stress requisite attitudes such as humility, as well as empathy, curiosity, respect, sensitivity, and awareness of outside influences. Advocates have indicated that the concept of cultural humility (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.

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.

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. https://www.audiology-counseling.com

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.