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.

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.

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.

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.


Shared Decision-Making Requires Counseling Skills


Kris English, PhD

Professor Emeritus

The University of Akron


“Nothing About Me Without Me”

For more than 20 years, patient-centered care (PCC) has been defined by the slogan “Nothing about me without me” (Quinlan, 2018). These five words represent years of effort by a grass-roots movement that demanded an end to a “doctor knows best” culture and the establishment of an informed and participatory role for patients.

The Institute of Medicine (2001) has defined patient-centeredness as “Care that is respectful and responsive to individual patient preferences, needs and values, ensuring patient values guide all clinical decisions” (p. 3)  Patient preferences, patient values: we can usually glean these perspectives during our intake consultations, but how do we use them to guide clinical decisions?  This question brings us to a feature of PCC called shared decision-making, defined as “the conversation that happens between a patient and their healthcare professional to reach a health care choice together.” These conversations require advanced counseling skills: active listening, empathy, respect for patient autonomy, a willingness to share control, the ability to find common ground.

Not Yet a Practice Norm in Audiology

Based on our literature to date, shared decision-making (SDM) is almost an orphan topic, although a few tools – decision aids – have been developed to guide balanced discussions through hearing care options and choices (e.g., Laplante-Lévesque et al., 2010; Pryce et al., 2018). While the profession continues to explore SDM, we need to appreciate now how this process can drastically change our clinical conversations.

On the surface, SDM seems straightforward. As described by Alston et al. (2014):

  • The clinician shares information with the patient about test results and treatment options
  • The patient explores and shares with the clinician his/her preferences regarding these options, and
  • After discussion, clinician and patient reach a mutual decision about subsequent treatment.

This template assumes the clinician welcomes and supports SDM. Unfortunately, our available evidence suggests this assumption is not a given (e.g., Ekberg et al, 2015; Grenness et al., 2015). Our limited research has also only focused on decisions related to hearing aid acceptance and options. However, there are other SDM opportunities in an audiology appointment, and these could be easily overlooked.

Example: SDM and HA Orientation

Consider the moment when hearing aids are first fitted. If only from habit, our interactions could disregard patients as decision-makers and rely on directives and advice-giving.  For example:

Standard Instructions? Shared Decision-Making (SDM)
You will need to wear these new hearing aids at home and every other possible environment before your next appointment. Our best practices recommend listening with hearing aids as much possible. What would that look like for you? Are there specific situations you’d like to start with? What would be a manageable target of hours of use per day?
It’s normal to dislike the sound of your voice, but you will get used to it. Let’s start by giving it a little time. How many days would you like to try to get comfortable with your voice? After that trial period, call or email and let me know how you’re doing.
You’ll realize that what you thought was “people mumbling” is really your hearing impairment. Earlier you mentioned “people mumbling.” Are you interested in testing those impressions?  It’d help me confirm if these devices are helping. Your observations would be invaluable.
You will still have problems in noise. It’s unavoidable. It’s quiet here now, but let’s anticipate noisy situations. What might those be in your life? …I have some brochures on easy communication strategies. If they fit your situation and you have an opportunity to try them out, let’s talk about it next time.

A student exercise: How do these comments differ? How might a patient respond/react to each, and why? What counseling/communication skills do you recognize? These essays provide some relevant background:


The point of the slogan “Nothing about me without me” is to include the patient in every decision, not just the obvious one (for audiology) regarding amplification. Ultimately, each patient is “an autonomous decision-maker” (Pryce et al., 2018, p. 638); if patients do not participate in hearing aid management decisions, they may decide to do nothing. Even without decision aids, we can use counseling skills to develop shared decisions now.

Acknowledgement: My appreciation to Ida Institute for sharing helpful materials.


Alston, C. et al. (2014). Shared decision-making strategies for best care: Patient decision aids. Institute of Medicine.

Ekberg, K., Grenness, C., & Hickson, L. (2015). Addressing patients’ social concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiology, 23, 337-350.

Institute of Medicine. (2001). Crossing The Quality Chasm: A New Health System For The 21st Century. National Academies Press, Washington, DC.

Grenness, C., Hickson, L., Laplante-Lévesque, A., Meyer, C., & Davidson, B. (2015).  The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations. Journal of American Academy of Audiology, 26(1), 36-50.

Laplante-Lévesque, A. et al. (2010). Factors influencing rehabilitation decisions of adults with acquired hearing impairment. International Journal of Audiology, 49, 497-507.

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

Quinlan, C. (2018, April 25). “Nothing about me without me”—20 years later.  Retrieved May 12, 2019.


David Luterman, D.Ed.

Professor Emeritus

Emerson College, Boston MA

The American Speech-Language-Hearing Association (2018) has delineated two aspects of counseling as within the scope of practice of audiologists: information and personal adjustment. The information aspect of counseling is relatively easy for audiologists to manage as it fits comfortably within the medical model of service delivery and also fits the expectation of clients.

The personal adjustment aspect, on the other hand, often presents difficulty; it means encountering clients on a psychosocial level involving their emotions and in this realm, audiologists often feel a lack of training (Meibos et al., 2017). The discomfort in psychosocial counseling is reflected in several studies: Ekberg, Grenness, and Hickson (2014) analyzed the clinical interactions between audiologists and 63 elderly hearing aid clients. They found that audiologists did not address the clients’ social and emotional needs but continued in content based communication. Cienkowski and Saunders (2013) examined the communication of audiologists during hearing aid fittings, and found that over 66% of the communication was content based. They also concluded that clients would benefit greatly if audiologists became more comfortable with personal adjustment counseling.

“Whole Person Care”

mind + heart

In actual practice, however, there should be no distinction between the informational aspect of counseling and the emotional component. There is considerable research evidence indicating that clients do not retain much content after a diagnostic evaluation (Margolis,2004; Martin, 1990) and the reason for the low retention of content is directly related to their anxiety level (Kessels, 2003). We know this on an experiential level: when we are emotionally upset, our cognitive ability becomes limited. Our brain goes into fight or flight mode and if we try to read something we can read the words, but they do not connect in the brain; we are essentially in our right brain. What this means: if we do not address the emotions of our clients, then information will not be processed. Therefore, to be effective as clinicians, we need to address both content and personal adjustment.

Personal adjustment counseling is often not addressed because it is lacking in training programs (Wicker et al., 2018), and it feels professionally risky to practicing audiologists because there is a lack of structure and no clear guidelines. The primary experience of our clients is grief. They have lost the life they thought they would have, and this is a painful loss. At heart we need to be grief counselors.

In emotion based counseling, clients’ primary need is to be listened to non-judgmentally, not made to feel better. This is a hard concept for professionals to acquire, as our assumed  mandate is to fix, and in the personal adjustment realm the fix is not apparent. Our clients are not emotionally disturbed; they are emotionally upset, which is appropriate to their life situation. The conventional response to someone who is upset is to try to make them feel better. The two favorite strategies are to instill hope (“Cochlear implants will make him normal”) or use positive comparisons (“It could be worse. He could have cancer, be deafer, etc.”).

Neither strategy is effective because it invalidates the client’s emotional pain. Now they feel guilty because they are still upset, and their feeling are stifled. We need to give our clients permission to grieve by listening to them and validating their feelings. We are not putting the feelings in, just giving them permission to be expressed and validated. The notion we need to convey to our clients is that feelings just are; you never have to be responsible for how you feel. Behavior which stems from feelings can be judged as self-enhancing or not. This notion builds in emotional safety for our clients, giving them the permission to express their deep and painful feelings. We have to do nothing but listen and validate and not try to fix or cheer up. I have found that clients self-limit in their emotional expression, and they have their own capacity to make themselves feel better. Embracing painful feelings is the first step in healing. And when this begins to occur, emotions settle down and clients can begin to absorb information.  We cannot damage clients by listening and validating their feelings. Giving them information when they are not ready for it can be overwhelming and often diminishes their self-esteem.

Boundaries and Referrals

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Difficult Conversations: Talking About Stigma

Kris English, PhD

Professor Emeritus

The University of Akron

Audiologists observe the impact of stigma on hearing loss (HL stigma) on a regular basis, and yet we haven’t addressed it much as a counseling issue.  HL stigma can be a complicated experience: for many patients, developing hearing loss can itself be stigmatic (associated with negative stereotypes of aging). And as we know, the added prospect of hearing aids can compound the stigma further. Recent research (David et al. 2018) supports this long-standing observation: that hearing aids can be “central to the stigmatic experience,” which is why we need to attend to “the importance of these devices for psychological wellbeing” (p. 133).

From a counseling perspective, we have to acknowledge that HL stigma has negative power and should be addressed. Stigma has been consistently found to impede help-seeking (e.g., Gagné et al., 2011; Heijnders & van der Meij, 2006; Wallhagen, 2009), so our challenge is to address it openly and therapeutically. This article will provide a basic background regarding the development of stigma, and suggestions on how to address stigma in clinic.

Stigma Develops in Stages

Corrigan et al. (2006) describe stigma development as a socially-constructed three-stage process:

1st stage: Stereotype Awareness, wherein we are aware of society’s negative beliefs about a health condition or disability: My grandmother says all of her friends are losing their hearing. She says they always seem confused, and she doesn’t enjoy their company anymore.

2nd stage: Stereotype Agreement, wherein we concur and endorse these negative beliefs, developing our own prejudice: When I visited my grandmother, I could see why she doesn’t enjoy her friends these days. They are in their own world and have no idea what anyone else is talking about.

3rd stage: Self-Congruence or Self-Stigma, wherein we internalize society’s negative attitudes and apply them to ourselves, risking adverse effects on self-concept and personhood: I am having the same hearing problem my grandmother used to complain about.  It’s so humiliating.

The final stage – self-stigma – includes self-rejection, a belief in a diminished self, and shame, wherein an individual feels “disqualified from full social acceptance” (Goffman, 1963, p. 9). Weiss et al. (2006) describes self-stigma as a “hidden burden” – our challenge is to help patients discuss that burden and perhaps free oneself from it.

Rosenstock, 1974

Our take-away: as described above, stigma is a belief, which in itself presents a challenge. Because of our scientific base, audiologists don’t pay much attention to beliefs, but we should. After all, common objections to hearing devices – the impact on self-image and self-identity, cosmetic sensitivity, the certainty of social rejection – are beliefs, not facts.  We may be familiar with The Health Belief Model (Rosenstock, 1974), created as a means to predict health-promoting behaviors (e.g., Saunders et al., 2013), but it has yet to impact clinical practices.

Preparing Ourselves

Before we respond to a patient’s perception of stigma, we must be comfortable talking about it. For instance, we may worry about the “elephant in the room” phenomenon: should we “go there?”  We may think that talking about it will increase a patient’s self-stigma, yet if we don’t talk about it, we can be fairly sure it will not resolve on its own.

As applied to audiologic counseling, we aim to help patients consider changing their negative beliefs about hearing loss and hearing help (Clark & English, 2019). Consider the following dialogue: how did the audiologist help the patient transcend stigma and move forward?

A Self-Stigma Conversation

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