59 Years and Counting

By Maia Beaulieu

After decades of fighting, The Civil Rights Act of 1964 ended segregation and granted rights to African Americans, yet nearly 60 years later, we still see explicit and implicit injustice embedded in our political, educational, and social structures. An often overlooked consequence of racial injustice is health care. In the United States, Black women are three times more likely to suffer death due to pregnancy complications than their White counterparts (Centers for Disease Control and Prevention). Out of all racial and ethnic groups, African Americans have the highest cancer death rates (Kaiser Family Foundation), and as of 2019, 9-12 grade Black females were 60% more likely to attempt suicide than their non-Hispanic White peers (Office of Minority Health). Need I go on? 

“Of all the forms of inequality, injustice in health is the most shocking and inhumane.”

-Martin Luther King Jr.

The ample and seemingly endless evidence of physical and mental health care disparities between Black and White individuals are no coincidence. The primary culprit for such incongruencies is often connected to how physicians communicate with their Black patients. Yet, as the U.S. healthcare system stands today, we see inadequate support to help physicians meet the needs of their Black patients.

In The Presence 5 for Racial Justice Framework for anti-racist communication with Black patients, Brown-Johnson et al. (2022) sought to identify communication practices that can help clinicians better support their Black patients. Through human-centered design and community-based research, Brown-Johnson et al. analyze qualitative data from interviews of 112 participants, including Black patients, clinicians, and nonmedical professionals. They note that Black patients often describe their physicians’ communication practices as condescending, lacking empathy, and making assumptions of poor behavior and low socioeconomic status. This inhibits patient-physician trust development which, in turn, discourages use of preventative health care, thus potentially hurting long term health, most notably for low-income Black women.

Despite this awareness, there is currently no widespread structure that explicitly encourages anti-racist communication. However, there are some instances of such at the clinical-level; several leadership teams across the country have added discussion of current events that could impact Black patients during their morning huddles, and saw positive results. In regards to the educational-level, some medical schools have added anti-bias curricula to standard training. Although a step in the right direction, these approaches fail to recognize the nuances of individual identity. 

The Presence 5 for Racial Justice Practices Framework (P5RJ) ventures to mitigate disparities by implementing anti-racist communication practices in both medical education and within clinics by encouraging the following practices to promote racial equity in health care.

Prepare with Intention guides practitioners to reflect on their own implicit an explicit biases. During the interviews, patients recommended intentional self awareness, mindful interaction, and extra attention to diseases known to disproportionately strike Black patients, such as sickle cell anemia and diabetes. The primary concern raised by clinicians is the difficulty to prepare with intention under the fast paced nature of the medical system.

Listen Intently and Completely suggests patient-focused listening and attention to verbal and nonverbal cues – especially those which may imply impacts to a patient’s health due to racism. One research participant highlighted the importance of a physician “coming in warm and [asking]… ‘What’s going on?’ ” with compassion, and sitting down to be eye level with the patient. Another recalled their appreciation when their physician “actually sat there and wanted to know what happened, what [their] story was.” Clinicians echoed that these barriers to connection could be mitigated by allocating more time with each patient.

To Connect with the Patient’s Story addresses negative experiences and inquire about a patient’s life without making biased assumptions. One interviewee recalled the safety they felt when their physician asked for their trust “as if she was saying ‘I know, in the African American community, y’all have a hard time trusting physicians.’ ”

Agree on What Matters Most pulls patients to the forefront of their treatment plan, as it encourages clinicians to make medical plans with patients, addressing their specific goals. Part of this is avoiding biased assumptions by explicitly asking their priorities. With this, it is important to build trust with “affirmation and reaffirmation that the clinician-patient relationship extends beyond the visit,” thus improving long term health outcomes.

Exploring Emotional Cues is to clarify emotions and look out for signs of racial trauma. To help patients through this, P5RJ suggests trauma-informed care practices. An interviewee expressed their desire for a physician to ask “Where’s your mind at?” and explained that “sometimes [Black patients] have to hold in how [they] feel because [they] don’t want to seem like [they] want sympathy.” The interviewee continued on, expressing that “ we just want to vent because we’re… exhausted from second hand pain. Although it didn’t happen to us, it did happen to someone of our color, just because of our color… it’s painful.” 

P5RJ offers a framework to implement teachings that would support self-accountability and allyship phrasing in communication. These are two concepts that are severely underutilized even within health equity discourse. Additionally, Brown-Johnson et. al recommend networking between clinics and specialty clinicians to increase support and access for Black patients and improve team-based treatment based on community need. One limitation of this article is the tendency to lump all “Black” people into one category, while the best care would be tailored to each identity, culture, and community circumstance. For example, a 2019 meta-analysis found that in a community with prevalent diabetes issues, team-based, diabetes-focused care accessibility “reduced blood glucose and diastolic blood pressure among low-income Black patients” more so than if the condition were only treated with a single physician. Additionally, team-based care contributes to a warmer handoff to mental health specialists who may be able to help with patient mental health and environmental circumstances, including those pertaining to racism.

The generational trauma inflicted on Black individuals is too significant to ignore, yet many of us do not understand the extent of its impact. By implementing the P5RJ Framework, physicians will be able to build awareness of their own biases, be more knowledgeable of current events, and be better equipped to build a trusting relationship with Black patients. It is crucial that clinicians do their part; however, systemic, institutional level change must occur to better support clinicians in their growth. Brown-Johnson et al. echo clinician input that the pace of visits is far too fast to be conducive to necessary trust and connection building practices. Proposed solutions are system-level changes to readdress reimbursement policies that would allow visit extensions for complex patients, prioritization of continuity of care, emphasis of team-based care, and the implementation of P5RJ Framework to foster a more equitable care.

This framework can be expanded in several ways to focus on specific Black identities, rather than a catch-all approach. Not only is this framework promising for care racial identities, but further research can also find applications for LGBTQ+ identities and pediatrics. For physicians to have the resources to support their Black patients, training and system-level change needs to occur using frameworks such as P5RJ to improve public health.

59 years and counting. Systemic racism, structural prejudice, and social bias threaten the lives of every Black person in America. We cannot let time act as an ally to injustice any longer.