Examining Potential Implicit Bias in Oncologist-Patient Communication (CONNECT): Protocol for an Observational 2-Site Study

Abstract

Background: Compared with White patients, minoritized patients (Black and Hispanic patients) have a higher incidence of advanced solid cancers and have a higher mortality. These patients also report poor patient-centered communication and worse pain assessment and management. Although many factors contribute to these disparities, physician implicit bias may be a contributing factor.

Objective: The primary goal of this study is to evaluate the role of implicit bias among oncologists and examine the impact on racial or ethnic differences in objective assessments of communication with minority patients with advanced cancer.

Methods: To accomplish this goal, we plan to recruit 65 oncologists and 325 patients (5 patients per oncologist) with advanced solid cancer from ambulatory cancer clinics within the diverse settings of the Mount Sinai Health System in New York City and the Duke University Health System in Durham, NC. We audio record patient-oncologist encounters during a postimaging visit, with 3 encounters for each of the patients. We will analyze the recorded visits and compare the patient-centered communication content of these conversations. Immediately after the recorded visit (no more than 2 weeks later, in order to minimize recall bias), patients are required to complete a follow-up survey to evaluate patient-centered outcomes. A 3-month follow-up survey is used to assess pain levels and control, use of analgesics, and psychological distress. A 6-month follow-up survey is used to assess psychological distress. We administer the Implicit Association Test to oncologists to assess their level of implicit bias toward patients who identify as Black or Hispanic after we finish recording patient encounters.

Results: Funding from the National Cancer Institute was received in March 2021. Patient and oncologist recruitment began in March 2022. We have recruited all 65 oncologists in the study, and patient recruitment is ongoing. The study team plans to continue to enroll patients until March 2025. As of December 2024, we have enrolled 245 patients. We expect to publish the findings in October 2026.

Conclusions: In this paper, we outline the study methods, describe the development of a codebook to assess pain conversations being used to evaluate primary and secondary outcomes, and discuss challenges and lessons learned throughout the study.

International registered report identifier (irrid): DERR1-10.2196/66086.

Keywords: audio-recorded encounters; communication; oncologist-patient communication; oncology.