We acknowledge that these skills don’t address social determinants more broadly. But we felt that racism is important enough to call out specifically as a skills focus. As before, we welcome your feedback, ideas, and contributions. Thank you!

(Principle: mistrust is often expressed nonverbally—we call these mistrust cues)

What the patient does or says What the clinician says
Gestures that say ‘I don’t really want to be here’ such as closed posture, folded arms, stern glances, or eye rolls “It looks as if you might have something on your mind. Is it something that might help me understand your situation better?”

 

 
“I am concerned that I am not being told everything about COVID”.

 

 

 “There is a lot of information out there, and some of it is not factual. Let’s start with your most important concerns. Your trust is important to me.”

 

 

(Principle: naming racism explicitly show that you recognize that it exists)

What the patient does or says What the clinician does and says
Patient recounts something they have seen in the news about how COVID affects black people, e.g. “I have read that black people are more impacted by COVID.”  “I have read that also. Are you concerned that racism may be involved?” A follow-up: “What does racism look like from your perspective?” 
Patient describes an instance where a family member had a negative outcome with care, e.g, “My aunt did what they told her to do, but still ended up in the hospital.” “Anybody would be concerned about that. I would be concerned too. What happened?… Do you think she was being treated differently because of her background?” 

(Principle: acknowledging racism explicitly can build trust)

What the patient does or says What the clinician does and says
Patient describes frustration or lack of engagement with health care, e.g., “I went to the emergency room but they didn’t really do anything.”  “I have heard from other black patients that they have had negative experiences with health care that make it hard to trust the medical system. I realize that racism exists in medical care. How much has it affected you?” 
Patient describes frustration with a clinician, e.g. “That doctor did not seem to listen to me.” “That sounds frustrating. I acknowledge that we clinicians don’t always listen well, and sometimes racism is involved. I want to do what I can to help you get the care you need.” 

(Principle: allow the patient to describe what they would like before you jump in.)

What the patient does or says What the clinician does and says
Patient voices interest in their own health, e.g. “I have been trying to take care of myself.”  “I am glad to hear that you take care of yourself. How could we work together on your health?”
Patient voices understanding of recent diagnostic tests (after clinician has explained them). “Ok, what do I need to do?” “I’m going to explain a plan that would be the best treatment for your medical condition. Then I want to hear your thoughts and concerns about the plan because we can customize it for you.” And: “Please don’t hesitate to ask for clarity on the words I use. We medical people sometimes speak in another language. My goal is to help you in the best possible way.” 

(Principle: cultural norms may involve decisions by an extended social group, rather than an individual)

What the patient does or says What the clinician does and says
After hearing the treatment recommendation, the patient says “I’ll think about that.” “Many of my patients want to include someone from their family or faith or community in medical decisions, and I welcome that. If there is someone that you want to bring into this discussion, we can do that.”