Targeting Bias to Reduce Disparities in End of Life Care: Clinician Communication Behavior in Simulated Patient Encounters Study
Phase: NA
Conditions: Terminal Illness, Critical Illness
Sponsor: Montefiore Medical Center

Title:  Targeting Bias to Reduce Disparities in End of Life Care
NCT05165888
IRB#:  2021-12898
IRB Approval Date:  01/20/2026
IRB NUMBER: 2021-12898
IRB APPROVAL DATE: 01/20/2026

Protocol #
Protocol 
January 18, 2025
PI: Elizabeth Chuang, MD, MPH
Targeting Bias to Reduce Disparities in End of Life Care: Clinician Communication 
Behavior in Simulated Patient Encounters (BRiDgE-Sim)
Significance
Scope of the problem: 
US adults over 65 are more racially diverse than ever, and this trend will continue. The 
number of older Black Americans is projected to reach 12 million or 12% of older adults by 
2060.1 Although the growth of palliative care has improved the quality of end-of-life care over 
the past two decades,2 racial and ethnic minority patients have not fully benefitted from these 
advances. There are well-documented disparities in access and uptake of palliative care and in 
the quality and intensity of end-of-life care.3-5 These inequalities affect many minority groups, 
each with its unique history, language and culture that may influence the underlying 
mechanisms of disparities. The current proposal focuses on Black Americans who experience 
disparities that are deeply rooted in complex historical and present-day interactions with the 
health care system.6,7 Black patients receive more intensive care and are less likely to use 
hospice at the end of life.8-15 Their family members are more likely to report poor quality care 
and decisional regret.3,4,16,17
Mechanisms underlying disparities in quality of end-of-life care
Patient and family factors: 
Behavioral, attitudinal, cultural and knowledge differences between Black and White 
patients and family members have been proposed as explanatory mechanisms. Black patients 
have lower rates of completion of advance directives, which only partially explains differences in 
end-of-life treatments that they receive.13,18-28 Studies suggest that there may be differences in 
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preferences for life-sustaining treatment between racial groups.20,25,29-33  However, the absolute 
differences in these studies were small, and the majority of Black patients preferred comfort 
care at end-of-life.20,21,27,33-37 When Black patients are presented with adequate information, their 
choices do not differ from those of White patients.38 While some studies found racial differences 
in patient and family factors such as religiosity, discomfort discussing death, preferences, health 
literacy and distrust,18,21,39-41 studies were often inconclusive and sometimes 
contradictory.22,24,27,35,42-46 In qualitative studies, Black Americans were open to discussing end-
of-life treatment options and limiting life-sustaining treatment in terminal illness.42,47 These 
proposed cultural and attitudinal barriers may be stereotypes, rather than true impediments to 
quality end-of-life care.48 Regardless of population variations in preferences, clear presentation 
of options is the standard of care and essential for providing goal-concordant care tailored to the 
values and beliefs held by individuals.49
Healthcare systems factors: 
Patient race is not only a marker of shared social identity and beliefs. It is also a proxy 
for unequal access to resources and systemic racism.50,51 Systems factors including geographic 
distribution of resources play a role in quality of end of life care.15,52 
Clinician factors: 
There is a major gap in knowledge regarding clinicians’ contributions to end-of-life 
disparities.4,32,45 The National Institute on Minority Health and Health Disparities has identified a 
key research priority of exploring health care systems factors at the interpersonal level of the 
patient-clinician relationship.53,54 The majority of physicians are White, and only 4% are Black.55 
Patient-physician racial discordance is associated with decreased quality of communication.56 
Quality of communication explained a significant portion of the variance in decisional regret 
among Black family members.17 Clinician communication during racially discordant encounters 
is an important and modifiable factor in end-of-life care disparities.5,44,57-65
The wide dissemination of studies indicating that Black patients and their families prefer 
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Protocol #
more aggressive end-of-life care may result in stereotyping Black patients as less receptive to 
discussing other end-of-life options.66-69 These beliefs may increase clinician anxiety when 
suggesting more comfort-oriented options to Black patients and families. However, given that 
the literature is equivocal and absolute differences are small, the assumption that a Black 
patient will prefer aggressive care will most often be false. My research has shown that in an 
urban medical center, Black patients were more likely to be referred for specialty-level palliative 
care (Figure 1), but less likely to have a documented goals-of-care discussion initiated by the 
primary team (Figure 2).70 This finding suggests that clinicians perceive goals of care 
discussions to be more complex for Black patients, necessitating specialty referral. Other 
studies have shown that even when these conversations occur, clinicians are less likely to share 
prognostic information with Black patients,71 and are more likely to include inflated survival 
estimates when speaking with Black compared to White patients.72 End-of-life conversations are 
less likely to result in goal-concordant care for Black compared with White patients.36 Possible 
explanations for these differences include implicit bias,73 as well as explicit beliefs.68,74 Cooper et 
al. have developed a theoretical model outlining the contribution of relationship-centered care to 
health disparities.75 Figure 3 shows the importance of implicit associations and explicit 
stereotypes in a version of this model modified to highlight the centrality of communication to 
relationship-centered care and its relation to quality of end-of-life care. Stereotypical beliefs 
hinder development of true knowledge of the patient by shortcutting around knowledge-
gathering communication. Implicit attitudes decrease the quality of communication affecting 
partnership, respect, affiliation and trust. 
Patients who are acutely deteriorating in the inpatient setting are particularly vulnerable 
to clinician bias because high cognitive load, stress, little prior knowledge of the patient, clinical 
uncertainty and time constraints accentuate the effects of bias.76-80 Clinicians who lack specific 
end-of-life communication training may have more stress when engaged in these challenging 
discussions. Given current and projected severe shortfalls in the palliative care workforce,81,82 it 
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Community and social environment: employment and educational opportunities, neighborhood 
and work conditions, healthcare infrastructure
Patient
Beliefs, Preferences, 
Values, Implicit 
Attitudes, Role 
Orientation
Clinician
Beliefs, Preferences, 
Values, Implicit 
Attitudes, Role 
Orientation
Shared understanding of prognosis, treatment options, 
and patient/family goals of health care
Disparities in Quality 
of End of Life Care
Relationship-Centered Care:
Partnership, Respect, Affiliation, 
Knowledge, Trust, Concordance
Verbal and Nonverbal 
Communication
is critical to address bias in all clinicians caring for the seriously ill to avoid widening disparities 
over time. Reduced access to quality communication could explain some of the increased use 
of aggressive care and reduced quality of end-of-life care for Black patients.83
Bias and Communication: 
Implicit bias refers 
to unconscious, 
automatic positive or 
negative attitudes. 
Clinicians rarely mention 
race and ethnicity as 
barriers to 
communication, 
suggesting that they are 
unable to name these barriers due either to the implicit nature of the bias or to social desirability 
bias in reporting.63,84,85 The Implicit Association Test (IAT) demonstrates unconscious racial bias 
among clinicians.86-95 Implicit bias predicts patient ratings in domains critical to quality end-of-life 
care including interpersonal treatment, communication and trust.96 Physician implicit bias results 
in poor communication patterns, and poor patient-doctor relationships.73,89,97-102 Implicit racial 
bias has been linked to more verbal dominance, less positive affect, visit length and patient-
centeredness.99 A single study showed unconscious differences in nonverbal communication 
with Black patients while communicating bad news regarding terminal illness.73 Some 
physicians do express explicit beliefs regarding Black patients’ “resistance” to hospice care.66 It 
is unknown whether explicit stereotypes about end-of-life preferences influence communication 
behavior.
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Protocol #
Bias Mitigation: 
Evidence-based strategies have been developed to reduce effects of implicit bias,103 but 
few have been systematically tailored to gaps in care and measured for effectiveness in the 
clinical setting. There is limited evidence to support specific strategies to reduce the effects of 
clinician bias on clinical care.104 Strategies that focus only on making clinicians aware of their 
biases are unlikely to reduce their effects in the long term without providing them with specific 
strategies to overcome them.67,105,106 A strategy based on transformational learning theory and 
incorporating critical reflection, guided dialogue, perspective taking exercises, role plays and 
strategy development has been successfully used with medical students.107 
Aims/Objectives:
The aim of this study is to assess the effects of clinician racial bias on end-of-life 
communication and to develop interventions to reduce the effects of implicit bias on quality of 
clinician communication. There are two study objectives: (1) Establish which communication 
behaviors in the end-of-life setting are most affected by clinician implicit racial bias and explicit 
stereotyping. (2) Pilot a theory-driven intervention to improve clinician communication and 
reduce disparities in quality end-of-life care. These objectives will be met in two study phases.
Methods/Design:
Phase 1:
Methods: 
(1) I will develop a case depicting a hospitalized 72-year-old with lung cancer and sepsis 
due to pneumonia on high-flow nasal cannula with my mentorship team of experts in palliative 
medicine and critical care. I will design a clinical encounter with the caregiver to discuss goals of 
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Protocol #
care. 2) The caregiver encounter will be piloted with critical care and hospitalist physicians at 
Montefiore to ensure realism and achieve standardization.108 Black standardized caregivers will 
be recruited from the pool of actors used by the Einstein Clinical Skills Center. (3) Standardized 
caregivers will be trained in the use of a communication assessment tool.109 (4) 50 physicians 
will be recruited to participate in a videotaped high-fidelity simulation of the encounter. The 
session will be followed by a 1-hour communication skills training to allow participants to earn 
continuing medical education (CME) credit. (5) Immediately after the simulation subjects will 
complete the IAT and a questionnaire probing for attitudes about race and end-of-life care along 
with demographic questions. We will assess training needs by adapting a previously developed 
questionnaire measuring physicians’ self-identified serious illness communication training needs 
by incorporating questions about bias mitigation skills.110 The IAT is publicly available here: 
https://implicit.harvard.edu/implicit/selectatest.html.
COVID-19 Concerns:
The Clinical Skills Center will be holding in-person simulations with standardized patients 
for the purposes of medical education starting in May 2021. The simulations in this study will not 
begin until after that time and will involve less risk than typical simulations because they will not 
entail a physical examination of the standardized caregiver. Actors and participants will be 
equipped with personal protective equipment including surgical masks. Trainers and participants 
in the training session will be required to wear provided surgical masks and remain six feet apart 
during the training sessions. If COVID-19 state or institutional guidelines prohibit these types of 
encounters at the time the simulations will be launched, the simulations and training will be 
adapted to a virtual format and nonverbal behavior coding will be adjusted. These changes will 
be submitted to the IRB as an amendment. 
Study population: 
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IRB APPROVAL DATE: 01/20/2026

Protocol #
We will recruit intensivists, oncologists, emergency medicine physicians and hospitalists, 
including resident and fellow trainees in those specialties. Physician subjects will be recruited 
face-to-face by the PI, through departmental email blasts and emails to contacts of the study 
team. Physicians will complete a screening questionnaire to exclude those that do not routinely 
encounter hospitalized patients with a life expectancy of less than one year. Potential subjects 
will be asked about the frequency and timing of previous communication and bias training. 
Physicians practicing Hospice and Palliative Medicine will be excluded because of their 
extensive prior training in communication. 
Data collection: 
Encounters will be videotaped. The amount of time the physician and standardized 
caregiver speak will be recorded. A five-point verbal communication rating scale will be used to 
rate physician (1) informativeness, (2) supportiveness, and (3) partnership-building and a 
modified version of the Nonverbal Accommodation Analysis System (NAAS).89,111 The NAAS will 
be modified to include physical distance and open/closed body language which were shown to 
be important in serious illness encounters.73 Verbal communication will also be analyzed from 
transcripts of the videotaped encounters. Coded verbal communication will be categorized as 
data gathering, emotion talk, partnership building, biomedical topics and decision-making 
content. Videos and transcripts will be coded in the secure Dedoose™ qualitative data coding 
software. An extra passcode will be added for a second layer of data security.
Another questionnaire will be administered at the end of the training. We will ask 
physicians to rate their experiences with different educational modalities presented in the 
training session, such as feedback from observed encounters, communication drills and role-
plays. Open-ended questions will be used to gather formative information that the researchers 
may not have considered. This questionnaire will be distributed at the end of the communication 
skills training.
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Outcome measures: 
The primary endpoint will be verbal dominance (ratio of clinician to patient speaking time 
with a ratio of >1, meaning that the clinician dominated the discussion). Empirical evidence links 
this communication measure to implicit bias and to patient-centered communication outcomes.99 
Secondary endpoints will include duration of the communication encounter, verbal 
communication ratings, nonverbal communication behaviors coded with the NAAS and 
standardized caregiver ratings. Inter-rater reliability will be reported using Kappa values. 
Analysis plan: 
Bivariate associations of communication scores with IAT scores will be estimated with 
Pearson or Spearman rank correlation coefficients depending on the distribution of the data. 
Generalized linear models (GLM) will be fit to the data to assess the associations of the IAT and 
racial attitudes with primary and secondary communication outcomes, while controlling for 
potential confounding variables including clinician age, gender and specialty. The identity link 
will be used in the GLM for continuous communication outcomes. Subgroup analysis will be 
performed in Asian, Black and Hispanic physicians if there are sufficient numbers in these 
groups to assess heterogeneity of the associations by race.
Power analysis: 
The target sample size of 50 participants would have >80% power to detect a minimum 
correlation between IAT score and verbal dominance of ρ ≥ 0.38 using a two-sided hypothesis 
test of a single correlation with a significance level of 0.05. This correlation is similar in 
magnitude to associations observed in prior studies; B=11.0 in one study and r = 0.32 in 
another.112  
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Phase 2:
Methods: 
This is a communication training session based on a culturally-based program 
developed with rural, southern Black patients and families by Dr. Ronit Elk113 and modified for 
an urban, northern population. A strategy of bias mitigation successfully used with medical 
students will be adapted for practicing clinicians using results of phase 1. This strategy is based 
on transformative learning theory and incorporates critical reflection, guided dialogue, 
perspective taking exercises, role plays and strategy development.107 In this study, a virtual 
reality (VR) experience (https://michigan.it.umich.edu/news/2023/07/31/education-and-
awareness-in-vr-new-experience-illustrates-the-effects-of-racial-discrimination/) will be used as 
the disorienting dilemma to spark the process of transformative learning. This brief experience 
embodies the participant in the experiences of an African American man over his life course. It 
is aimed to engender empathy and perspective taking. Following the VR experience, 
participants will debrief with the facilitator in small groups, discuss how implicit bias impacts the 
clinical encounter, brainstorm bias mitigation techniques and role-play strategies to mitigate bias 
in the clinical encounter. If specific communication behaviors are found related to bias and 
stereotyping in phase 1, these will be discussed and targeted using these techniques. 
Otherwise, these techniques will be used to address racial bias generally. The intervention will 
be incorporated within the communication training session. 
Design: 
Clinicians will be randomized 1:1 
to the active intervention or a 
control communication training without bias mitigation techniques. Allocation concealment will 
be in place to ensure the individual enrolling the subject into the study has no a priori knowledge 
• 25 Subjects 
Communication Training Only
• 25 Subjects 
Communication + Bias Training
50 Subjects 
Pre-Intervention 
Standardized 
Clinical Encounter: 
50 Subjects 
Post-Intervention 
Standardized 
Clinical Encounter
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of group assignment. Block randomization will occur with randomly mixed block sizes of 2, 4, 
and 6. The allocator (research assistant) will hide block size from the executer (PI) in order to 
prevent the executor from predicting the next assignment. Randomization will be carried out by 
having a piece of paper that has the phrase “Intervention (Communication + Bias)” or “Control 
(Communication only)” placed inside an opaque envelope. The outside of the envelopes will be 
labeled with the sequence number. After a subject has been enrolled into the study and 
consented, the next sequence numbered envelope on the stack will be opened to determine the 
study group that the subject will enter.
Participants will be videotaped during high-fidelity simulations of encounters with 
caregivers described in phase 1, before and after receiving the intervention or control. The 
intervention and simulations will take place in one half-day workshop.
COVID-19 Concerns:
The Clinical Skills Center will be holding in-person simulations with standardized patients 
for the purposes of medical education starting in May 2021. The simulations in this study will not 
begin until after that time and will involve less risk than typical simulations because they will not 
entail a physical examination of the standardized caregiver. Actors and participants will be 
equipped with personal protective equipment including surgical masks. Trainers and participants 
in the training session will be required to wear provided surgical masks and remain six feet apart 
during the training sessions. If COVID-19 state or institutional guidelines prohibit these types of 
encounters at the time the simulations will be launched, the simulations and training will be 
adapted to a virtual format and nonverbal behavior coding will be adjusted. These changes will 
be submitted to the IRB as an amendment. 
Study population and Recruitment: 
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Protocol #
A new group of intensivists, oncologists, emergency medicine physicians and 
hospitalists will be recruited including resident and fellow trainees in those specialties. Physician 
subjects will be recruited face-to-face by the PI, through departmental email blasts and emails to 
contacts of the study team. As in phase 1, physicians will complete a screening questionnaire to 
exclude those that do not routinely encounter hospitalized patients with a life expectancy of less 
than one year. Potential subjects will be asked about the frequency and timing of previous 
communication and bias training. Physicians practicing Hospice and Palliative Medicine will be 
excluded because of their extensive prior training in communication. 
Data collection: 
Encounters will be videotaped. We will use the five-point verbal communication rating 
scale and nonverbal communication behaviors coded with the NAAS during the standardized 
encounter as described in phase 1 above.111,114  A research assistant who did not participate in 
the training sessions and is blinded to participant group will code communication behaviors.  
Subjects will complete the IAT and the questionnaire described in phase 1 immediately after the 
first encounter.
Outcome measures: 
Subjects will complete an on-line questionnaire at the close of the session with Likert-
type questions on the usefulness and acceptability of the training program and self-efficacy with 
cross-cultural communication. In addition, the questionnaire will include the cognitive and 
affective empathy portions of the Interpersonal Reactivity Index. For participants in the active 
group only, several questions will assess the illusion of ownership of the virtual body in the VR 
experience. An open-ended text box will invite feedback. The primary efficacy endpoint will be 
verbal dominance (ratio of clinician to patient speaking time during the encounter with a ratio of 
>1 meaning that the clinician dominated the discussion).99 Secondary endpoints will include 
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verbal and nonverbal communication and encounter duration. Inter-rater reliability for the 
communication scores will be reported using Kappa values. 
Analysis plan: 
Initially, the mean change in verbal and nonverbal communication scores pre- and post-
intervention will be evaluated within each intervention arm using paired t-tests or Wilcoxon tests 
if the data are not normally distributed. To assess whether communication scores improved 
more in the bias mitigation treatment compared with communication training only control, a 
generalized linear model will be fit to the data with post-intervention score as the outcome, and 
pre-intervention score and intervention arm as the main effects. In addition, we will investigate 
whether pre-intervention level of bias modifies the effect of bias mitigation training, e.g., those 
with more bias will have a greater difference in improvement between the intervention and 
control group, by including in the model an interaction term between IAT score and treatment 
group on communication scores. A positive interaction will indicate that implicit bias as 
measured by the IAT modifies the effect of treatment group on communication score. With 25 
subjects per intervention arm, the study will have 80% power to detect an effect size of 0.8 
between groups in pre-post change in communication scores with a two-sided Type 1 error rate 
of 5%.  While this is considered a large effect size according to Cohen’s criteria, we would like 
emphasize that this is a pilot study in which the primary goal is to assess feasibility and to 
generate preliminary data on the effect of the proposed communication training intervention for 
clinicians to mitigate the effects of implicit bias. 
Data Management/Analysis:
∆ y = α + β0 (Tx) + β1(IAT) + β2(Tx x IAT) + ε1, where ∆ y = change in communication score, Tx = treatment group
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Communication behavior codes and data from the questionnaires and IAT stored on 
Montefiore’s secure Box drive and will only be accessible by members of the research team. 
Video recordings will be stored on a password-protected hard drive accessible only to the 
research team.
Risks/Benefits:
Potential risks: This research poses two main risks to subjects: 1) emotional distress 
and 2) risk to privacy. There may be some emotional distress caused by learning about one’s 
unconscious racial biases. Emotional distress may also result from passive deception; subjects 
will not be told that racial bias is the focus of the study until after the intervention. Privacy risk 
arises because racial biases may be considered sensitive information about the subject.
Adequacy of Protection Against Risks
Recruitment and Informed Consent: All subjects will be recruited by the PI through 
departmental email blasts, emails to contacts of the study team and departmental faculty 
meeting presentations. The consent process will take place in the Clinical Skills Center on the 
prior to the standardized patient encounter. Subjects will be informed of their right to participate 
or discontinue participation at any time without jeopardizing their employment, professional 
position or relationships with colleagues. Copies of the signed consent form will be given to the 
subject and placed in the subject’s research folder in a locked file drawer in an office in the PI’s 
office expressly designed for this purpose. 
Incomplete disclosure of information during the consenting process: Subjects will be 
informed that they are participating in a study exploring physician cognition, cognitive biases 
and communication behavior. They will be informed that study participation includes completion 
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of an on-line instrument after the standardized patient encounter. They will not be told during the 
consent process that implicit racial bias and stereotyping are the focus of the study.
Incentives: Incentives have been chosen to provide a counterbalance to the opportunity costs 
of participating by offering continuing medical education (CME) credits for attending physician 
participants. Given that CME credits can be obtained in many ways, this incentive is not to be 
enough to be coercive. Since resident and fellow participants are unable to use CME credits 
during training, they will be offered a $50 gift card to compensate them for their time.
Protections against risks: Personal identifiers not be collected in the on-line 
instrument; instead a unique study ID will be assigned to each participant. Video recordings will 
be maintained in a password protected digital folder on a hard drive in a locked office. This 
database of coded communication scores will be stripped of participant identifiers as soon as all 
data is collected, and a file linking the study ID and patient identifiers will be kept in a separate, 
password protected digital folder.
Debriefing: After completion of the on-line bias measurement instrument, the subjects will be 
shown a debriefing statement including full disclosure of the aims of the study and the intent to 
examine the relationship between implicit racial bias and stereotyping and communication 
behavior. This statement will include a reminder that they may discontinue participation at any 
time and request that their data be removed from the dataset without penalty. The PIs contact 
information will be provided.
Potential Benefits of the Proposed Research: Subjects are not expected to directly 
benefit from this research. 
Importance of the knowledge to be gained: The information from this study will provide 
knowledge about the role of implicit bias and stereotyping in communication behaviors that have 
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profound effects on the quality of end of life care for black patients. It will also inform efforts to 
mitigate the effects of this bias in future studies.
Necessity of withholding information in the consent process: Withholding of complete 
information from the consent process is only acceptable if there is no reasonably effective 
alternative to achieve the goals of the research. In this case, knowledge of the intent to study 
implicit racial bias is likely to affect the way physicians communicate in the standardized patient 
encounter, thus invalidating the results of the study.
Figures:
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IRB APPROVAL DATE: 01/20/2026

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IRB NUMBER: 2021-12898
IRB APPROVAL DATE: 01/20/2026

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IRB NUMBER: 2021-12898
IRB APPROVAL DATE: 01/20/2026

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IRB NUMBER: 2021-12898
IRB APPROVAL DATE: 01/20/2026

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IRB NUMBER: 2021-12898
IRB APPROVAL DATE: 01/20/2026

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IRB NUMBER: 2021-12898
IRB APPROVAL DATE: 01/20/2026