As if managing the broad spectrum of patient pain were not complex enough, results from an Indiana University-Purdue University Indianapolis study has found that patient race, provider bias and clinical ambiguity interact to influence providers’ assessment and treatment decisions. The researchers suggested that understanding these factors and their influence might be an important step toward improving patient care.
“Previous research has found that providers treat black and white patients differently whenever they have chronic pain,” said Adam T. Hirsh, PhD, assistant professor of psychology at the Indianapolis institution. “We’re interested in exploring why that may be. Is it simply because the patients differ in their race? Or are there other things at work here, too?”
To help tease out these possible factors, Dr. Hirsh and his colleagues studied 110 resident physicians who made pain assessment and treatment decisions for 12 computer-simulated patients. In each vignette, a patient presented with acute pain. Patient race (white or black) and clinical ambiguity (low or high) were manipulated across vignettes. The 110 participants also completed measures of implicit and explicit racial bias.
“The explicit measure asks people point-blank how they feel toward European American and African American patients,” Dr. Hirsh said. “The implicit measure gets at the more subtle forms of racial bias, which seems to be more prominent in contemporary society and may have a stronger effect on clinical care. Few people will outwardly say they dislike black or white people. But when you give them the implicit association test, a majority of people in the U.S. actually show an implicit preference for white rather than black people.”
As Dr. Hirsh reported in Tampa, Fla., at the 2014 annual scientific meeting of the American Pain Society (abstract 511), the sample demonstrated moderate to strong implicit bias favoring white patients over black patients, and indicated more explicit positive feelings toward whites than blacks. When analyzed separately, clinical ambiguity had a stronger influence on participants’ decisions than did patient race. However, when patient race and clinical ambiguity were examined together, an interesting picture emerged.
“We found an interesting interaction,” he explained. “Race mattered, but it mattered in a way that was tied to ambiguity. In the low back pain [high-ambiguity] conditions, black patients actually received higher pain intensity ratings and were more likely to be given an opioid, relative to whites. However, this effect reversed in the wrist fracture [low-ambiguity] situations, where white patients were given higher pain intensity ratings and more opioid medications than black patients.
“So race mattered, but it mattered according to ambiguity.”
Dr. Hirsh found it interesting that providers approached black patients the same way in both the wrist fracture and low back pain conditions. “So a different way of looking at this interaction is to say that providers gave black patients the same pain intensity ratings and opioid treatment regardless of their pain condition,” he explained, “whereas pain conditions seemed to influence providers’ treatment for white patients.
“Clearly the effect of race on treatment decisions is complicated,” he added. “It’s not always just black versus white. The context seems to matter, too; in our study, the clinical situation mattered. And that’s particularly important in pain management, because pain is not always a cut-and-dried situation.”
Although these results do not shed clear light on what influences providers’ decisions, they represent an important step in informing efforts to reduce disparities and improve pain care, Dr. Hirsh said.
“How do we solve this?” he asked. “First, we need to understand it better. More research allows for better-tailored solutions.”
Salimah H. Meghani, PhD, associate professor of nursing at the University of Pennsylvania, in Philadelphia, noted that 30 years of research has demonstrated that pain disparities are a very real phenomenon. “Dr. Hirsh’s study is important as it points to nuances in explaining these disparities, especially the critical role of ‘ambiguity’ in clinical decision making,” Dr. Meghani said. “The direction of some of the findings, however, is in contrast with our previous work.”
Indeed, a meta-analysis conducted by Dr. Meghani and her colleagues of analgesic treatment disparities in the United States (Pain Med 2012;13:150-174) found that black–white disparities were present for all types of pain, but were starkest for ambiguous pain types such as abdominal or low back pain. “The differences noted in Dr. Hirsh’s study may be related to the vignette nature of the study or that we don’t completely understand the relation between explicit and implicit bias,” Dr. Meghani explained. “However, the fact that white patients were given more high-intensity pain ratings and more opioid medications than black patients despite wrist fracture is consistent with our findings. This is concerning because treatment differences exist even when the cause of pain is readily verifiable.”
Identifying the genesis of these types of disparities is wound tightly into social processes, she added. “Research remains scarce on successful models for health [care] provider sensitization and education to overcome these disparities.”