Techniques for Clinical Practice: Communication Strategies for Black Patients with Serious Illness

To the Editor:

As our population continues to age, the prevalence of serious illness—“a condition that carries a high risk of mortality, negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments, or caregiver stress”¹ — is increasing. For patients with serious illness, communication with clinicians about which medical interventions align with their goals, values, and priorities has been shown to improve quality of life while reducing inappropriate healthcare costs.²

For Black patients, there are significant disparities in serious illness communication that require our urgent attention. Studies have shown that oncology clinicians spend less time discussing goals of care with racial/ethnic minority-group patients.³ Furthermore, as compared to White patients, Black patients report that clinicians listen and share information less, especially when there is not racial concordance between the patient and the provider.⁴ These disparities contribute to worse overall patient-reported satisfaction with medical care and health outcomes among Black patients.⁵ Furthermore, Black patients report that providers with pro-White implicit bias are less respectful and collaborative in clinical encounters.⁶

Overcoming barriers to serious illness communication for Black patients requires addressing both structural and interpersonal racism.^6–8 While we work to dismantle structural racism, clinicians have the power to reflect on their own implicit and explicit biases as a way to address aspects of interpersonal racism in serious illness communication. In this article, we review three communication techniques that can help clinicians evaluate their own biases and serve as tools for eliciting the perspectives of patients and caregivers. In proposing these techniques, we acknowledge that the experiences of Black patients are heterogeneous and influenced by racial/ethnic concordance, or more often discordance, with clinicians. Intersectional factors, including gender, sexual orientation, and socioeconomic status additionally impact the experiences of Black patients. Nevertheless, we believe the particular techniques we present here are broadly applicable in that they center patients’ diverse experiences and can be integrated into clinical practice.

Technique 1: Ask Questions about What is Most Important to Your Patients

We recommend that clinicians engage from a place of curiosity and ask specific questions about what is most important to patients. This technique is important to avoid making assumptions about our patients’ preferences, which may undermine our trustworthiness as partners in shared decision-making. Literature suggests, for example, that Black patients tend to prefer life-prolonging and aggressive medical care.⁹ Awareness of trends such as this one may lead to bias, impacting how we speak to a given patient before we know their individual preferences. If we take a moment to consider our own biases before stepping into the exam room, we have the opportunity to be curious about our individual patients and their experiences (Table 1).

Table 1.

Ask Questions about What is Most Important to Your Patients

Ask open-ended questions:	Avoid closed questions:	Why this matters:
“What is most important to you at this time in your life?’	“I imagine you want to live as long as possible and receive the next line of treatment. Is that right?”	Rather than making assumptions about next steps in your patients’ care, learn what is most important to them and help them achieve their goals.
“What are you most worried about?”	“You must be worried about being in the hospital for so long. We will work to get you home.”	Patients have different worries: being in the hospital may be hard for some and easier for others who have limited caregiver support. Patients may be most worried about pain or missing an important life event. Ask open-ended questions to explore those issues that are most important.
“What else should we know to best take care of you?”	“I plan to call the social worker and chaplain to offer support. Does that sound ok?”	Patients benefit from different forms of support. While some patients appreciate contact with the interdisciplinary team, others value one-on-one discussion with their primary provider or the involvement of their sibling or pastor. Ask patients directly how you can be most helpful.

Technique 2: Deliver Medical Information in a Value-Neutral Way to Build Trust

Clinicians may take for granted that the health system is basically benevolent and fundamentally has the patient’s best interest. However, for many patients, these assumptions are the opposite of their experiences—imagine a Black patient whose pain was inadequately treated in the past or whose loved one was denied a timely primary care appointment and ended up in the Emergency Department. Given a history of marginalization and mistreatment in the healthcare system, the delivery of medical information in a value-neutral manner without assumptions about how patients will respond to the serious news is crucial to build trust. The goal is to describe the medical facts without jargon or judgement. Clinician assumptions about patients’ goals, values, and preferences for medical care run the risk of further disenfranchising already marginalized populations (Table 2).

Table 2.

Deliver Medical Information in a Value-Neutral Way to Build Trust

Use value-neutral statements:	Avoid value-based statements:	Why this matters:
“After this stroke, your father will not be able to feed himself, talk, or walk. He will need skilled nursing care 24 hours per day.”	“After this stroke, your father will have an unacceptable quality of life and will be completely dependent for all of his needs.”	Quality of life is highly subjective and related to baseline function as well as values. Rather than making assertions about quality of life that can leave family members feeling at odds with the clinical team, allow patients and caregivers to share their thoughts.
“Antibiotics may extend your mother’s dying process. Unfortunately, they will not be able to make the cancer better.”	“Continuing to give your mother antibiotics will just prolong her suffering.”	Suffering is a value construct and, in many cultures, doing more to keep a person alive is respectful, not a cause of suffering.

Technique 3: Give Patients and Caregivers Multiple Opportunities to Ask Questions

Black patients and their caregivers are far less likely than White patients to ask questions during serious illness conversations.¹⁰ Addressing this striking disparity requires that clinicians make a deliberate effort to elicit questions that patients and their loved ones are reluctant to ask. Patients are hesitant for many reasons: they wonder whether they should have understood what was said or whether the clinician is listening to them. Even when we feel we have been clear in our communication, patients and families often walk away with an understanding that differs from what we meant to convey. At times, the emotional intensity of a piece of news interferes with patients’ and caregivers’ ability to digest information. By shifting the focus away from the clinician and to the patient, we can help overcome these barriers and address our patients’ concerns (Table 3).

Table 3.

Give Patients and Caregivers Multiple Opportunities to Ask Questions

Elicit Questions:	Avoid closing the door to questions:	Why this matters:
“What questions do you have?” (Wait 30 seconds) “That was a lot of information. I want to make sure that I explained clearly. What part of what we discussed do you want to go over again?”	“Any questions?” (Asked while already standing up and getting ready to finish the clinical encounter)	Patients and caregivers need multiple opportunities to ask for clarification and share concerns and questions. Answering questions in real-time has the potential to improve satisfaction and shared decision-making.

Conclusion and Future Directions:

Although we acknowledge that disparities in serious illness communication driven by both structural and interpersonal racism will require change over time, we hope that individual clinicians can put these communication techniques into practice immediately. In the wake of the COVID-19 pandemic, which laid bare disparities in health outcomes for Black patients, there is an urgent need to evaluate our own biases in clinical encounters. Although communication techniques are certainly not enough to address interpersonal racism, they are an actionable starting place for clinicians, which can offer patients the opportunity to share their experiences, adjust to serious news, and ask questions.