Putting Non-Verbal Communication Under a Lens: An Examination of the Dynamic Interplay of Patient-Provider Interactions Between Black Patients and non-Black Physicians

Discordant and ineffective communication between patient and provider are critical factors contributing to the healthcare disparities observed amongst Black patients.¹ Shorter visit times, less rapport-building behaviors and statements, and lower participatory decision making are unfortunate characteristics of patient-physician interactions for Black patients in racially discordant pairs.^1,2 A study by Cooper et al. demonstrated that Black patients in racially discordant physician encounters experienced shorter visit times and generally rated their physicians as less participatory compared to concordant pairings.³ Similarly, Cene et al. reported that visit lengths were shorter among Black patients seeking care for their hypertension and that patient race had a larger impact on the communication quality of their physician than patient blood pressure control.² These ineffective communication pairings widen the disparate gaps in the care of Black patients and negatively influence their outcomes.^2-6 It has been reported that Black patients experience poorer quality communication marked by decreased participatory decision making, information giving, and patient participation compared to their white counterparts. Moreover, there is no robust literature indicating that white patients receive lower quality care or perceive worse communicative interaction in discordant patient-physician dyads compared to Black patients.¹

A clear link between patient-centered communication and patient trust in their physician has been made in the literature.^7,8 As a result, it has been suggested that these poor-quality interactions contribute to the lower post-visit trust in physicians that Black patients report.^1,9 In a study comparing pre- and post-visit patient reported trust in physician, Gordon et al. found similar expectations between Black and white patients prior to their visit. However, trust in physician significantly decreased for Black patients after their visit, as they reported their racially discordant physicians’ communication was less informative, less partnering and less supportive.⁹ Overtly or implicitly held race-related attitudes among physicians contribute to differences in information exchange and ultimately treatment recommendations between Black and white patients, especially with regard to cancer treatment and pain management.^10,11 Thus, the seemingly modifiable nature of patient-provider communication, and particularly provider-related communication techniques, make them an attractive focus for research and ultimately intervention in the realm of healthcare inequalities.

Thus, it is with keen interest that we read the important work pertaining to patient-provider communication reported by Hamel et al. in this issue of Cancer. The authors document and categorize the non-verbal interactions of Black patients with breast, colorectal, or lung cancer, and their non-Black oncologists during treatment discussions. In turn, they offer insight and a framework in which to operationalize non-verbal cues and behaviors exhibited in racially discordant patient-provider interactions; they assert that their findings may be used to improve communication quality. The authors succeed in pinpointing non-verbal behaviors that promote convergence and divergence between Black patients and their non-Black oncologists from one time point to the next. Moreover, they demonstrate that nonverbal behaviors such as physician gaze, physician laughter and physician smile, which show convergence, promote desired similarity between the patient and provider as well as mutual closeness.

While the focus of prior studies has been on coding non-verbal patient and provider behaviors and correlating them with patient reported satisfaction and communication, Hamel et al. document the strength of these behaviors on subsequent non-verbal behaviors. With this, the authors highlight the importance of understanding the dynamic interplay that is implicit in any communicative exchange, which is unaddressed in other studies.

The findings of this work provide insights into possible mechanistic practices that can be adopted to influence the exchange of information moment to moment in racially discordant patient-physician pairs. However, the article does not provide an examination of patient-reported sentiments of participatory decision making and overall satisfaction in dyads exhibiting convergent behavior. Inclusion of this type of information would provide a patient-oriented corollary to better understand the effect that these behaviorally convergent encounters have on a patient’s perspective of the affective tone of the interaction. Within this context, future endeavors in this realm should seek to examine the impact of behavioral convergence on patient-oriented outcomes such as partnership building and patient participatory decision making, as well as clinical outcomes. The inevitable goal of work within this area must center on the delivery of equitable healthcare in which communication serves as an important means of rendering that care. The tools for this are simple, well documented and readily available.¹² Yet, racial biases remain an ever-present barrier for Black patients.¹³ Solutions to eradication of these biases within the healthcare system are complex and require concerted efforts on a large scale likely both at the individual and national level.¹⁰ While it is important that non-Black physicians receive training in recognizing bias and racism within the medical system, as well as confronting their own racial biases, the medical system and society as a whole would greatly benefit from a directed and purposeful increase in the recruitment, retention and promotion of Black medical students and physicians in all specialties. Only until the moniker of “under-representation” is eliminated will we see a dramatic change in the quality of the patient-physician dyad. The growing literature and research directed at examining the interactions between racially discordant patient-provider pairs with a discerning eye are of particular value as they are a means of illuminating our understanding of how the healthcare system interacts with Black patients at its most basic unit, the patient-doctor exchange.