Differences in Physicians' Verbal and Nonverbal Communication With Black and White Patients at the End of Life

Abstract

Context: Black patients are more likely than white patients to die in the intensive care unit with life-sustaining treatments. Differences in patient- and/or surrogate-provider communication may contribute to this phenomenon.

Objectives: To test whether hospital-based physicians use different verbal and/or nonverbal communication with black and white simulated patients and their surrogates.

Methods: We conducted a randomized factorial trial of the relationship between patient race and physician communication using high-fidelity simulation. Using a combination of probabilistic and convenience sampling, we recruited 33 hospital-based physicians in western Pennsylvania who completed two encounters with prognostically similar, critically and terminally ill black and white elders with identical treatment preferences. We then conducted detailed content analysis of audio and video recordings of the encounters, coding verbal emotion-handling and shared decision-making behaviors, and nonverbal behaviors (time interacting with the patient and/or surrogate, with open vs. closed posture, and touching the patient and physical proximity). We used a paired t-test to compare each subjects' summed verbal and nonverbal communication scores with the black patient compared to the white patient.

Results: Subject physicians' verbal communication scores did not differ by patient race (black vs. white: 8.4 vs. 8.4, P-value = 0.958). However, their nonverbal communication scores were significantly lower with the black patient than with the white patient (black vs. white: 2.7 vs. 2.9, P-value 0.014).

Conclusion: In this small regional sample, hospital-based physicians have similar verbal communication behaviors when discussing end-of-life care for otherwise similar black and white patients but exhibit significantly fewer positive, rapport-building nonverbal cues with black patients.

Keywords: Communication; disparities; provider behavior; race; terminal care.

Conflict of interest statement

Disclosures

None of the authors have financial conflicts of interest relevant to the current work.

Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Figures

Fig. 1

Images used to code nonverbal communication behaviors. This illustrates the angles of the two cameras in each simulation room. The left panel shows the camera mounted on the wall behind the surrogate to the left of the patient. The right panel shows a view from a camera mounted on the wall across from the foot of the patient’s bed.

Fig. 2

Illustration of several measures of nonverbal communication. The physician to the left is standing >12″ from the patient body’s lateral most plane (each tile 12″), is standing at the knee while the actor/wife of the patient is at the chest (evident by the arm rail and patient’s posture/flexion at the hip) and touching the bed. The physician is using closed body language (chart in front of body between himself and the patient) and is looking at the patient (although this information is obscured by the de-identifying box over the subject’s face).