Health providers' implicit racial bias negatively affects communication and patient reactions to many medical interactions. However, its effects on racially discordant oncology interactions are ...largely unknown. Thus, we examined whether oncologist implicit racial bias has similar effects in oncology interactions. We further investigated whether oncologist implicit bias negatively affects patients' perceptions of recommended treatments (i.e., degree of confidence, expected difficulty). We predicted oncologist implicit bias would negatively affect communication, patient reactions to interactions, and, indirectly, patient perceptions of recommended treatments.
Participants were 18 non-black medical oncologists and 112 black patients. Oncologists completed an implicit racial bias measure several weeks before video-recorded treatment discussions with new patients. Observers rated oncologist communication and recorded interaction length of time and amount of time oncologists and patients spoke. Following interactions, patients answered questions about oncologists' patient-centeredness and difficulty remembering contents of the interaction, distress, trust, and treatment perceptions.
As predicted, oncologists higher in implicit racial bias had shorter interactions, and patients and observers rated these oncologists' communication as less patient-centered and supportive. Higher implicit bias also was associated with more patient difficulty remembering contents of the interaction. In addition, oncologist implicit bias indirectly predicted less patient confidence in recommended treatments, and greater perceived difficulty completing them, through its impact on oncologists' communication (as rated by both patients and observers).
Oncologist implicit racial bias is negatively associated with oncologist communication, patients' reactions to racially discordant oncology interactions, and patient perceptions of recommended treatments. These perceptions could subsequently directly affect patient-treatment decisions. Thus, implicit racial bias is a likely source of racial treatment disparities and must be addressed in oncology training and practice.
In their article, "Physician as Partner or Salesman? Shared Decision-Making in Real-Time Encounters," Karnieli-Miller & Eisikovits raise important questions for us to consider about the process of ...shared decision-making (SDM) in a complex & high-stakes clinical setting (Karnieli-Miller & Eisikovits, 2009). The authors analyzed real-time pediatric encounters & interviewed physicians & parents to assess the extent to which physician practice reflects SDM principles. Results describe a variety of persuasive communication strategies used by physicians during treatment discussions, thus contributing valuable empirical data to further our understanding of treatment discussions. I have some concerns, however, about the conclusions drawn from the analysis. My concerns stem from the authors' use of language which implicitly suggests a bias against any physician use of persuasive strategies. The authors' interpretation of the data may indicate both a misapplication of qualitative methods & a misinterpretation of the principles of shared decision making. I disagree with the conclusion that, due to the inherent power imbalance in the physician-patient relationship, any use of persuasive communication by physicians during treatment discussions precludes a partnership. & therefore violates SDM principles. Copyright Elsevier Ltd.
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Background: Assessing patient-centered communication (PCC) is critical to improving quality patient-centered cancer care. While shown to be reliable and valid, most PCC measures ...were created by researchers, likely neglecting concerns of patients, families, and community members. PCC measures should be driven, in part, by the patient population of interest, especially given disparities in clinical communication. Our objective was to develop and validate a patient-informed PCC scale to assess cancer treatment discussions. Methods: As part of a larger study on communication and minority accrual to trials, we convened a panel of black and white cancer survivors, caregivers, and advocates. Panel members (n = 11) included 5 black and 3 white men and 1 black and 2 white women. Among them were 6 survivors and 5 caregivers. Panel members met regularly over six months to observe and discuss video-recorded treatment discussions between black and white men with prostate cancer and their physicians. Through an iterative process of generating and refining a list of physician communication behaviors they considered to be critical to PCC in a diverse patient population, they produced a list of 22 items, titled Patient-Informed Cancer Communication Scale (PICCS). We then applied the list as an observational scale to a set of video-recorded treatment discussions (n = 61) from the larger study. Trained raters applied the list and had acceptable inter-rater reliability. We used findings to determine constructs using scale development and factor analysis, then validated the scale through correlation with established scales. Results: We evaluated each item for content validity and feasibility. We divided some items that were assessing multiple attributes. The result was a 28-item scale. Using Classical Test Theory, we reduced the scale to 22 items. Using factor analysis, we identified five factors, including: 1. Treatment options (10 items a =.92); 2. Clinical relationship (6-items a =.92); 3. Prognosis and goals of treatment (2-items a =.79); 4. Explanations (2-items a =.43); and 5. Context (1-item). To validate, we correlated factors with two validated scales, one measuring physician PCC and the other patient active participation. Factor 1 was positively correlated with patient active participation ( r=.46; p=.003); Factor 2 with PCC ( r=.54, p. <.001); Factor 3 with patient active participation ( r=.48; p=.002); and Factor 5 with PCC ( r=.47, p=.002). The full PICCS scale was positively correlated with patient active participation ( r=.37, p=.02). PICCS Factor 4 was not correlated to the scales. Conclusions: This community-engaged research produced a reliable and valid patient-informed scale to assess PCC during cancer clinical interactions. Next steps include translating the findings by using PICCS to train physicians to communicate effectively in a diverse patient population.
Objectives
The aim of this cross-sectional study was to apply a novel software to measure and compare levels of nonverbal synchrony, as a potential indicator of communication quality, in video ...recordings of racially-concordant and racially-discordant oncology interactions. Predictions include that the levels of nonverbal synchrony will be greater during racially-concordant interactions than racially-discordant interactions, and that levels of nonverbal synchrony will be associated with traditional measures of communication quality in both racially-concordant and racially-discordant interactions.
Design
This is a secondary observational analysis of video-recorded oncology treatment discussions collected from 2 previous studies.
Setting
Two National Cancer Institute-designated Comprehensive Cancer Centers and another large urban cancer center.
Participants
Participants from Study 1 include 161 White patients with cancer and 11 White medical oncologists. Participants from Study 2 include 66 Black/African-American patients with cancer and 17 non-Black medical oncologists. In both studies inclusion criteria for patients was a recent cancer diagnosis; in Study 2 inclusion criteria was identifying as Black/African American.
Main outcome measures
Nonverbal synchrony and communication quality.
Results
Greater levels of nonverbal synchrony were observed in racially-discordant interactions than in racially-concordant interactions. Levels of nonverbal synchrony were associated with indicators of communication quality, and these associations were more consistently found in racially-discordant interactions.
Conclusion
This study advances clinical communication and disparities research by successfully applying a novel approach capturing the unconscious nature of communication, and revealing differences in communication in racially-discordant and racially-concordant oncology interactions. This study highlights the need for further exploration of nonverbal aspects relevant to patient-physician interactions.
e13684 Background: Clinical trials are often terminated due to insufficient accrual, with only about 6% of patients enrolling into a trial. Trial enrollment rates are even lower for Black patients. ...In 2021, we began recruitment for a clinic-based behavioral trial testing the effectiveness of a health equity communication intervention designed to address patient cancer treatment cost concerns. This study involves patients and providers completing surveys before and after a video-recorded clinical interaction. We are implementing this study at a NCI-designated comprehensive cancer center in Detroit, Michigan, a city with a majority Black population. Based on findings that most patients agree to participate in a trial if they are eligible and invited, we set a sample goal of 50% Black and 50% White patients. We used evidence-based strategies and lessons from our previous work, including having a diverse staff and building trusting relationships with provider and patient participants. As we begin the final year of recruitment, we consider what suggestions we can offer teams seeking to recruit a diverse patient sample to trials. Methods: We based our strategies on evidence that racially concordant (same racial group) clinical dyads have better communication quality than racially discordant (different racial group) dyads, and that medical mistrust is greater among Black patients than among White patients. First, we hired and trained a team that includes Black and White members, and encouraged them to take leadership roles. Second, we built trust with providers, staff, and patients. Procedures involve discussing the study with providers and their staff, recruiting providers as participants, and screening patients for eligibility. We recruit patients in-person in the clinic or by phone. Patients who provide oral consent are later met in person to collect written consent. Results: We achieved a consent rate of 52% across 4 clinics; our sample includes 86 (61%) Black patients and 55 (39%) White patients, which reflects the demographics of our patient population. We attribute our success to critical aspects of our protocol. First, recruitment of providers as participants helps capture the attention of and builds trust with patients. Second, we have a flexible recruitment approach. Once potential participants are screened, we can approach them in person or by phone. Third, our team composition reflects the patient population we hope to recruit. Last, we have the support of a diverse group of medical student team members in terms of race, gender, and age who provide additional recruitment support. Conclusions: Our strategies, based on scientific literature, helped achieve our goal of recruiting a sample that reflects racial diversity in our patient population. These and similar strategies can be adapted for other trials with the goal of achieving clinical trial recruitment equity. Clinical trial information: NCT04766190 .
•We examined the influence of a QPL on patient/companion-oncologist information exchange.•Patients identified most QPL questions as important, especially those related to side effects and patient ...experience.•The QPL did not increase the information oncologists provided, but increased patients/companions prompting for information.•Findings suggest QPLs can make oncology interactions more interactive.
Question Prompt Lists (QPL) increase patient active participation in oncology interactions, but questions remain regarding how QPLs influence patient-oncologist information exchange. We examined how a QPL influenced information exchange during oncology interactions with African-American patients.
Data were self-reports and video recordings from a parent study testing the effects of a QPL in the outpatient clinics of two urban cancer hospitals. In this secondary analysis, we investigated which QPL questions patients identified as ones they wanted to ask their oncologists, how frequently patients/companions used patient active participation statements to seek information related to each QPL question, whether oncologists provided QPL-related information unprompted or prompted by patients/companions, and how frequently patients’ QPL-related information needs were addressed or unaddressed.
The QPL influenced information exchange by increasing patients’ and companions’ (if present) prompting for QPL-related information from their oncologists. Patients/companions most often prompted for QPL-related information about side effects and patient experience.
This study builds on prior research on QPL interventions by expanding the object of study to information exchange and by analyzing patients’ information needs.
This research demonstrates that a QPL supports patient/companion participation in oncology consultations by making information exchange more interactive.
In this study, the authors investigate how medical ideology and physician professional identity are socially constructed during morning report, a formal teaching conference considered to be a ...cornerstone of medical education. Analysis of transcripts from 20 meetings reveals physician identity is developed through ideological discourse that produces and reproduces systems of domination that privilege scientific medicine and marginalize humanistic approaches. Findings indicate how, in a socialization context uniquely focused on discourse, communication functions to construct a professional identity grounded in the principles of the biomedical model. Although medical residents deviate from traditional ideology by articulating the voice of the lifeworld, faculty physicians counter these moves by asserting the voice of medicine. The authors draw conclusions regarding identity formation and the socialization practices of medical education.
Active surveillance (AS) is recognized as a reasonable treatment option for low-risk localized prostate cancer (LPC) but continues to be chosen by a minority of men. To date, limited data are ...available regarding reasons why men with low-risk LPC adopt AS.
The aim of this study is to better understand conceptualizations, experiences and reasons why men with low-risk LPC and their partners adopt AS.
We conducted five focus groups (FGs), three among men with low-risk LPC who had chosen AS and two with their partners. FGs were video/audio recorded, transcribed and analysed using qualitative thematic analysis.
A total of 12 men and 6 partners (all women) participated in FG discussions. The most common reasons for choosing AS were seeing the LPC as 'small' or 'low grade' without need for immediate treatment and trusting their physician's AS recommendation. The most common concerns about AS were perceived unreliability of prostate specific antigen, pain associated with prostate biopsies and potential cancer progression. Partners saw themselves as very involved in their husbands' treatment decision-making process, more than men acknowledged them to be. Multiple terms including 'watchful waiting' were used interchangeably with AS. There appeared to be a lack of understanding that AS is not simply 'doing nothing' but is actually a recognized management option for low-risk LPC.
Emphasizing the low risk of a man's LPC and enhancing physician trust may increase acceptability of AS. Standardizing terminology and presenting AS as a reasonable and recognized management option may also help increase its adoption.
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Background: High-quality, patient-centered communication is not experienced equitably across patient populations, likely contributing to healthcare disparities. Question Prompt Lists (QPL) ...improve patient active participation and other aspects of patient-physician communication in diverse populations and settings. This descriptive, single-arm study assessed the implementation and patient perceptions of a previously-developed, evidence-based QPL, the ASQ brochure, across a network of oncology clinics providing care in a diverse population across Michigan. Methods: The QPL was revised in collaboration with community and physician stakeholders. Implementation was assessed through the reach, adoption, and efficacy domains of the RE-AIM framework. Eligible patients had a cancer diagnosis and were scheduled for a first appointment with an oncologist at any of eight participating clinics. All participants received the ASQ brochure and completed three surveys: one at baseline, one immediately before their appointment, and one following their appointment. Surveys assessed sociodemographic characteristics; communication-related outcomes (knowledge, self-efficacy in interacting with physicians, trust in physicians, distress); and perceptions of the ASQ brochure. Analyses included descriptive statistics and univariable and multivariable linear mixed-effects models. Results: Reach: A total of 81 patients participated with a consent rate of 68.3%. Self-identified racial/ethnic groups were representative of the population served by the clinic network (72.4% white, 21.0% black, 3.7% American Indian/Native Alaskan, and 1.2% Mexican/Hispanic). Adoption: All eight invited clinics participated and recruited patients. Efficacy: All outcomes improved significantly, with no significant differences by clinic site or patient race. Patient perceptions of the ASQ brochure were overwhelmingly positive. Conclusions: The implementation of the ASQ brochure was successful in this oncology clinic network providing care to a diverse patient population. Findings suggest this simple, evidence-based communication intervention should be implemented widely in similar clinical contexts.
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