Miles apart: Collective inequities in medical communication and decision-making.

Communication is essential to understanding the ways in which inequities occur in complex interaction-driven institutions. However, efforts to address disparities in healthcare communication overwhelmingly focus on interventions that address individual behavior. In-depth observation and interviews with physicians and patients' family members at four different hospitals' medical intensive care units (ICUs) demonstrated that structural elements, including the built environment, physician staffing, and the organization of care, contributed to institutional variation in communication and decision-making about life-sustaining treatments in medical ICUs. Structural elements combined to create emergent harms, resulting in collective inequity between the demographically distinct patient populations served at different institutions. I argue that well-intentioned and even effective interventions to address individual behavior are unlikely to address collective inequities and that addressing structural elements is essential to alleviating disparities in communication and decision-making and outcomes resulting from these interactions.