Communication for Equity in the Service of Patient Experience: Health Justice and the COVID-19 Pandemic

Health professionals are responding to the coronavirus disease 2019 (COVID-19) pandemic with Herculean effort and a desire to provide high quality care for all. As is true with any intervention, one size does not fit all. Differences matter. Communicating across differences is a complex skill set that is necessary for high quality care.

Reports in print and online media indicate disparate outcomes for patients who identify as Black/African American, Native, and Latinx (1). Long-standing inequities are at the root of these disparities. For example, Black and Latinx communities have fewer options for working from home and higher rates of diabetes than other racial/ethnic groups, factors that are associated with higher risk of infection and greater mortality (2,3). In Chicago, “Black residents accounted for 72% of deaths from COVID-19 complications in the city and 52% of positive tests for the coronavirus, despite making up only 30% of the city’s population, according to the city’s public health agency”(4). Additionally, a diversity of language preferences impacts health care at a time when conversations about prevention, treatment, and advanced directives are vital.

Communication that fosters equity is essential in mitigating interpersonal bias (5). Importantly, this does not exempt the reader from the responsibility of remedying structural inequities within health care institutions and society at large. We also acknowledge that no document, regardless of how well-meaning, could fully address the needs of health care team members in recognizing and mitigating interpersonal bias during this pandemic.

Here, we offer a brief guide that may improve patient engagement across differences. The authors recognize that health care workers possess a wide range of awareness and expertise. For those who are new to this work, we hope to offer practical tools for communication that can mitigate interpersonal bias. For those with greater awareness of bias, we hope this guide will serve as a reminder of the importance of consistently applying these tools in times of crisis. Health care providers have displayed bravery in this pandemic. We are hopeful that this courage will extend to a willingness to engage in more effective communication to mitigate disparate COVID-19 outcomes.

Be Aware

Human beings rapidly judge situations as safe or unsafe, discriminatory or fair. Health care workers’ appearance, age, gender, ethnicity, and skin color may influence patients’ reactions which can be recognized and addressed immediately in rapport building (6,7).

Good morning Mrs. Sofia, I’m Dr. Niraj. We met yesterday in the Emergency Department. You’ve seen many staff members and I wanted to remind you who I am behind this mask. It’s good to see you again.

For language discordance, begin by immediately addressing the person’s language needs and offer through the interpreter:

I wish that I spoke your language. I’m grateful to have an interpreter helping me.

“Fast thinking” increases implicit bias—an unconscious process that values certain groups over others. Implicit bias is not a moral failing; it is a consequence of socialization (8). Cultural humility, a key aspect of personal awareness, includes critical self-reflection, awareness of personal biases, and advocacy in holding institutions accountable for equity (9). In high stakes decision-making, thinking critically with others how bias may be affecting decision-making is recommended.

Let’s think about the composition of our team and what we know about the patient. What might we be missing? How might bias be present in our assessments and recommendations?

Earn Trust

Patients and family members with whom clinicians have little or no previous relationship need significant attention to trust. Trusting clinician–patient relationships are associated with greater treatment adherence and perceived quality of services (10). Earning trust may require additional efforts with patients who identify as members of marginalized groups, and who may have developed adaptive strategies to navigate bias, including but not limited to mistrust and skepticism of the health care system. Even in time-pressured environments, establishing rapport is critical. Consider eye contact, sitting when possible, sharing both your role and a brief professional narrative with the patient.

Pleasure to meet you, though I’m sorry it’s under the circumstances that you have a fever. Mrs. James, I’m Dr. Williams. I’m a family doctor and I’ve worked at Elmwood Hospital for 4 years. I find great meaning in my work.

Consider directly addressing trust.

This is our first meeting, and I know trust takes time. I want to earn your trust.

Empathy is Excellence

Empathic statements—“caring out loud”—made in response to emotional cues are associated with shorter, and presumably more effective, visits and are important in facilitating communication across differences (11). Patients and families who have experienced bias, discrimination, and violence have seen few people in power hold their needs in high regard (12). The COVID-19 crisis affords us the opportunity to demonstrate compassion and advocacy for those who are navigating racism, homophobia, xenophobia and other “isms.” Statements that convey partnership, legitimize emotions, and explicitly convey respect are necessary in every visit. For patients who are mistrustful, frustrated or angry, a series of open-ended questions and empathic responses may help individuals feel heard and may also give time for clinicians to reflect critically on the equity of their recommendations.

Mrs. Smith. It sounds like you feel you are being treated differently because you are not being offered COVID testing. Is that how it feels? I have time to hear your thoughts and concerns.

Respond to Cues and Acknowledge Reality ARTfully

Often patients and family members will not address bias directly, but may offer clues in the form of frustration, disengagement, and questions about how testing and treatment decisions are made (13). These clues often generate discomfort in clinicians and staff, and defensiveness is a natural reaction, but an alternative is to see these reactions as an invitation to engage immediately, honestly, and compassionately.

Ask: “You mentioned celebrities who have had testing and I noticed everyone you mentioned is white. How much do you think race has to do with who gets tested?”

Respond with Empathy: “You’re right, race matters a lot. You might think I don’t care as much about your health and your concerns because I’m recommending you stay at home and monitor your symptoms instead of getting a COVID test today. Is that how it feels to you?”

Teach: “I would imagine this has been a difficult and disappointing visit for you today. I often think I’m being clear, but sometimes I’m not clear. Would you tell me what you understand about the plan going forward? I’m devoted to helping you know when to come back to the Emergency Department.”

Exemplary patient experience requires attention to relationships and trust, and results in improved safety, quality, and patient satisfaction. During the COVID-19 pandemic, quality care for those who suffer is the goal, but suffering has not been equally distributed for patients. Marginalized communities have long histories of confronting injustice, and long-standing health disparities bear witness to those bitter realities (14). Our current health care crisis has tragically and disparately affected these groups (15,16).

Committing additional resources to assess and advance patient experience for marginalized groups is long overdue, and the COVID-19 pandemic makes clear the moral and ethical responsibility of health care workers and institutions to seize opportunities for substantive improvement. Health care has always involved human struggle, uncertainty, and loss, and this is true now more than ever. Compassionate, high quality communication in health care for all is at another crossroads.