Results of the present study offer insights and patient-perspective recommendations for SDM in T2D care with medically underserved Black patients. On the basis of the views and perceptions of and the preferences for SDM among participants in our sample, humanistic communication should be a basic strategy for SDM.42 In the participants’ views, humanistic communication includes honest expression of empathy and rapport building; use of ice-breaker gestures such as humor, smiles, and handshakes; and a level-playing-field dynamic, in which the doctor talks with the patient, rather than at the patient. Making room for storytelling,43-45 a strategy that places medical information in a context that renders it meaningful and memorable, can overcome some of the cultural barriers to addressing emotional issues with Black Americans. Our findings also point to the need to prioritize a triadic SDM approach,46 whereby family members take substantial part in the decision making, over the classic dyadic SDM that involves just 2 participants, a patient and a clinician. Because the family often plays a central role in T2D management for Black individuals,47,48 more consideration and attention should be given to expanding SDM to a 3-way discussion.

Our findings also highlight which clinician behaviors to avoid. Impersonalized care and an autopilot communication mode are highly discouraged because they increase the patient’s mistrust of the clinician. Direct and open communication is preferred, perhaps even the blunt sharing of the difficulty experienced by the clinician to break the ice over any artificial robotic attempt to communicate. Finally, perhaps one of the most disturbing findings is related to lack of information sharing about T2D and care options. Information exchange is a basic principle in any SDM model and guidelines.30,31 However, information is not always shared with patients who are members of racial/ethnic minorities, and they often feel discouraged from asking questions.24,49,50 This leads to an unintentional disparity in offering and using SDM.26 Our quantitative results, measured by the SDM-Q-9, provide additional support. Whereas the overall score showed a good level of self-reported SDM, a detailed observation of the distributions of the 9 items showed lower levels for items addressing information sharing (item 3), elicitation of preferences (item 6), and deliberation (item 7).

As identified in our sample of Black Americans with T2D, our findings have higher-order implications for the need to address disparities in engagement methods, particularly in SDM research and clinical offerings for chronic conditions.24,26 According to the Purposeful SDM approach,51,52 common SDM tools assume universalism in patient-clinician communication; that each medical discussion uses the same communication principles regardless of diagnosis, patient, or setting. A recent systematic review of SDM tools found that common tools for T2D (ie, decision aids) focus on discussing medical options (risks and benefits) but neglect contextual factors, such as social determinants of health, race, ethnicity, culture, socioeconomic status, and racism, in health care.53 This situation is not unique to T2D; it is also observed in the context of other health conditions.54 This is a serious drawback of existing SDM tools,55 especially for Black Americans, who often experience high levels of the above-mentioned barriers.20,32,56,57 For example, Black patients with T2D reported that their need to share information and to be heard by their clinician exceeds mere symptom reporting and medical advice,18 which might explain the limited offering, use, and effectiveness of SDM and other communication tools among this group. In the field of mental health, for example, this weakness of SDM limits its dissemination, and some SDM interventions in mental health include additional factors, other than medical or clinical, that affect medical discussions.54,58-60 Therefore, there is an urgent need to expand SDM offerings and use for Black, Indigenous, and people of color (BIPOC), who could benefit the most from culturally sensitive SDM.

The present study has several strengths. First, we conducted it in primary care clinics that predominantly serve BIPOC. These clinics are part of a safety-net hospital that serves one of the most marginalized populations, which are often medically underrepresented in research, particularly in SDM research. Second, our team is diverse, and BIPOC and other minority members were involved throughout the study including during data collection, interpretation, analysis, and writing. Third, we used a formative qualitative approach that allowed us to gain in-depth insights into the perspectives, preferences, and views of the study participants.

Nonetheless, study limitations include the fact that participants were residents of Philadelphia; hence, our findings might not be generalizable to Black individuals with T2D living in rural areas and/or other US cities or to other ethnoracial groups. We did not document the number or length of appointments with primary care clinicians, which could affect SDM because a major barrier to good SDM is short appointment times.61 In addition, whereas we did not collect data on the gender, race, and ethnicity of the clinicians for each of the 32 participants, there were slightly more women than men clinicians in the participating clinics, and clinicians were overwhelmingly (>85%) White.

To summarize, addressing unconscious/conscious biases and differences in care delivery that lead to inequitable health outcomes is critical for the ability to move forward toward better health care for all. Our findings offer meaningful and needed insights into, and recommendations for, future use and adaptations to make SDM more valuable in the care of Black patients and other ethnoracial minorities. Future studies should focus on enhancing and adjusting current SDM tools and practices for marginalized communities that experience ineffective communication with their clinicians and worse health outcomes, and on developing new strategies for culturally sensitive and meaningful SDM. Taking into account clinician demographics, future research directions should also focus on the interaction of clinician-patient ethnicity and race on SDM and communication outcomes.