Racism in Pain Medicine: We Can and Should Do More

The long history of racism in the United States, including racist medical practices, has strongly influenced Black people’s perceptions health care delivery for generations. Unethical practices have included performance painful procedures without anesthesia on enslaved women by J. Marion Sims 1840s, Tuskegee study that intentionally withheld effective treatment from men with syphilis 1930s through 1970s, and sterilization performed consent (“Mississippi appendectomy”) as recently 1970s. Whereas these historical traumas highlight extreme cases, more salient is everyday leads to disparities distrust.1Bajaj S.S. Stanford F.C. Beyond Tuskegee—Vaccine distrust racism.N Engl J Med. 2021; 384: e12Crossref PubMed Scopus (82) Google Scholar Today, a public issue, physicians, we are oath bound provide just equitable all patients effect change when values fail be upheld.2Tyson P. Hippocratic today.https://www.pbs.org/wgbh/nova/article/hippocratic-oath-today/Date accessed: May 11, 2021Google Racism perpetuated implicit bias (also termed unconscious bias). Implicit negative evaluation person basis person’s race, gender, sexual orientation, or other factors occurs outside conscious awareness. Biases personal experiences, beliefs, accepted norms.3FitzGerald C. Hurst S. healthcare professionals: systematic review.BMC Med Ethics. 2017; 18: 19Crossref (706) Ignorance denial our biases makes it impossible address them. As humans, physicians like everyone else,3FitzGerald against been associated changes way communicate patients.4Mills A.M. Shofer F.S. Boulis A.K. Holena D.N. Abbuhl S.B. Racial disparity analgesic ED abdominal back pain.Am Emerg 2011; 29: 752-756Abstract Full Text PDF (62) Clinical visits less centered patient lower ratings interpersonal compared White visits.4Mills Physicians reported preferences over expressed views medically cooperative than patients.5Oliver M.N. Wells K.M. Joy-Gaba J.A. Hawkins C.B. Nosek B.A. Do physicians' African Americans affect clinical decision making?.J Am Board Fam 2014; 27: 177-188Crossref (73) When specifically looking at outcomes pain management, see similar results. In emergency departments, prescribed opioids acute rate matched chief concerns.4Mills Discrepancies prescriptions chronic therapies also identified Veterans Administration Medicaid payer databases, several retrospective cohort studies shown persistent underprescribing analgesics patients.6Burgess D.J. Nelson D.B. Gravely A.A. et al.Racial differences prescription opioid noncancer national sample veterans.J Pain. 15: 447-455Abstract (55) Scholar,7Ringwalt Roberts A.W. Gugelmann H. Skinner A.C. across provider specialties dispensed beneficiaries pain.Pain 2015; 16: 633-640Crossref (41) trainees, reflecting general population, can false beliefs about biologic between (eg, “Black feel pain”), this racial inaccurate diagnoses recommendations.8Hoffman Trawalter Axt J.R. Oliver assessment recommendations, biological blacks whites.Proc Natl Acad Sci U S A. 2016; 113: 4296-4301Crossref (736) anesthesiology medicine, use regional joint replacement surgery applied frequently underinsured.9Memtsoudis S.G. Poeran Zubizarreta N. Rasul R. Opperer M. Mazumdar Anesthetic orthopedic patients: there potential care?.Anesthesiology. 124: 608-623Crossref (29) This holds true implantation spinal cord stimulation postlaminectomy syndrome.10Missios Rahmani Bekelis K. Spinal stimulators: socioeconomic four US states.Neuromodulation. 17 (discussion 455-456): 451-455Crossref (15) Among occupational low injuries, incur costs their counterparts provided fewer interventions, surgery.11Tait R.C. Chibnall J.T. Andresen E.M. Hadler N.M. Management injuries: among Caucasians.Pain. 2004; 112: 389-396Abstract (39) Perceived discrimination results psychological distress, population–based demonstrated dose-response relationship distress pain.12Brown T.T. Partanen Chuong L. Villaverde V. Chantal Griffin Mendelson Discrimination hurts: development pain.Soc 2018; 204: 1-8Crossref (44) medicine specialists, must deeply aware ongoing patients. Because influence diagnosis decisions, start before move forward improve Scholar,13Blair I.V. Steiner J.F. Havranek E.P. Unconscious (implicit) disparities: where do go here?.Perm 71-78PubMed Pain Best Practices Inter-Agency Task Force Report Department Health Human Services14Cheng Rutherford Singh V.M. HHS Practice calls patient-centered individualized care.Pain 2020; 21: 1-3PubMed recognized affecting ethnic minorities called programs reduce disparities. Thus, moral professional obligation present harmful effects within specialty. Mahatma Gandhi said, “Action expresses priorities.” Tackling pervasive societal problem such daunting, but time act. Data suggest altered, opportunities exist which neuroscientific advances minimize translation into action. Beta blockers decrease subconscious during association testing, demonstrating autonomic nervous system bias.15Terbeck Kahane G. McTavish Savulescu Cowen P.J. Hewstone Propranolol reduces bias.Psychopharmacology (Berl). 2012; 222: 419-424Crossref (81) Similarly, cognitive training techniques induce cortical neuroplastic improved attention, compassion, perspective-taking, used empathic abilities.16Valk S.L. Bernhardt B.C. Trautwein F.M. al.Structural plasticity social brain: differential after socio-affective mental training.Sci Adv. 3: e1700489Crossref (115) We propose systematic, “inside-out” antiracism approach (Figure) starts community extends society. serve an example because both stand-alone specialty integrated so many fields (adult pediatric, inpatient outpatient, chronic, surgical medical). such, recommendations nearly specialties. Medical school faculty should begin identifying make education antiracist. Some schools adapted curricula deliberately systemic biases. However, advocate continuing throughout graduate subspecialty well capture practicing management possible. Effective does not involve high levels cost, although investment likely worthwhile. Antiracism include voluntary, trainees faculty. Introduced 1998, Association Test (Project Implicit) validated, computer-based test evaluates perspectives toward various categories measuring speed participant sorts concepts.17Greenwald A.G. McGhee D.E. Schwartz J.L. Measuring individual cognition: test.J Pers Soc Psychol. 1998; 74: 1464-1480Crossref (7020) attending perpetuates staff trainees. Hearing comments greater students, favorable contact improvement subsequent testing.18van Ryn Hardeman Phelan S.M. al.Medical School experiences 3547 students: Student CHANGES report.J Gen Intern 30: 1748-1756Crossref (161) leaders clinics educational programs, duty demonstrate traits hope will emulate. Without knowledge acceptance own biases, unqualified teach equality tomorrow’s physicians. With proper training, avoid maladaptive techniques, recognize act prejudice. Simple strategies (Table 1) integral part residents fellows approaches potentially bias-based responses Training run counter one’s exposure interaction highly respected accomplished people.20Blair malleability automatic stereotypes prejudice.Pers Psychol Rev. 2002; 6: 242-261Crossref (738) Scholar,21Dasgupta Greenwald On attitudes: combating prejudice images admired disliked individuals.J 2001; 81: 800-814Crossref (798) ScholarTable 1Strategies Reduce BiasStrategyExampleStereotype replacementBe consciously stereotype response.Counterstereotype imagingVisualize opposing stereotype.IndividuationLearn situation history.Perspective takingTemporarily adopt someone else’s perspective.Increasing individuals different groupsExpand network events diverse attendees.Partnership buildingFocus collaboration.Data Institute Healthcare Improvement.19Institute ImprovementHow bias.2017http://www.ihi.org/communities/blogs/how-to-reduce-implicit-biasDate Open table new tab found strategy changing associations prejudices,22Hagiwara Kron F.W. Scerbo M.W. Watson G.S. A call grounding translational frameworks.Lancet. 395: 1457-1460Abstract (40) few examined impact explicit behaviors outcomes. Still, important first step ultimate goal reducing medicine. Several authors noted challenges implementing inconsistent methods differing motivations institutions.22Hagiwara Scholar,23Sukhera Watling framework integrating recognition professions education.Acad 93: 35-40Crossref (77) view practice addressing key component effective, evidence-based medicine.22Hagiwara Understanding necessary impactful learning how take perform physical examination, disseminating building scientific evidence favor its professionals. Although efforts level, wide prevalence institutions passively support structures. These systems, probably intentionally, still result inequitable allocation resources worsen care. For example, 2019, algorithm widely hospitals insurers identify needing complex reportedly was designed “race blind.”24The Lancet Digital HealthThere no thing race health-care algorithms.Lancet Health. 2019; 1: e375Abstract (3) factor algorithm, total were included, result, assigned falsely complexity scores they had If field aims all, actively existing structures settings may tacitly put disadvantage. lenses diversity, inclusion, equity.25US Housing Urban DevelopmentDiversity inclusion definitions.https://www.hud.gov/program_offices/administration/admabout/diversity_inclusion/definitionsDate 3 components diversity step. Diversity refers range group differences, enrich workplace environment enhance patient’s experience. Promoting clinicians, staff, critically specific actions taken setting. interviewers learn shapes impressions influences assessing residency program applicants, recommended American Colleges.26Association CollegesBest conducting interviews.https://www.aamc.org/media/44746/downloadDate awareness shed light why organization, leadership, clients ways 2). Depending characteristics practice, diversification talent pipeline, consultation third-party experts, provision markedly closer dismantling institutional racism.Table 2Strategies Improving Within PracticeExamine recruiting hiring résumé review, interview process).Comprehensively assess culture attitudes race.Identify leading employee turnover.Establish positions authority responsible guiding tracking progress diversity.Review patient-marketing practices.The develop foster mentorship sponsorship employees.Data Wilson.27Wilson B.M. Engaging diversity: best create inclusive work environment.https://digitalcommons.pepperdine.edu/etd/689Date each setting strive inclusivity supporting employees sense belonging acceptance. Furthermore, organization perceived commitment employees’ mission intention remain organization. improving minority groups, extended entire office staff. Other members team measure baseline levels, histories, examinations, conduct follow-up visits. much data consider diagnosing treating conditions collected members. At any point process, decisions based prejudice, misinformation, held member unintentionally negatively Given number clinician-patient interactions, strong case made promoting protocols procedure standardized order sets. perfect, protocolized removes some decision-making subject bias, established setting, Many organizations, Improvement, need safety “people merely encouraged change; action needed.”28Institute ImprovementDevelop safety.http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspxDate physician antiracist culture. challenging, suggested Improvement pertinent task 3).Table 3Strategies Establish Culture SafetyStrategyExampleCreate reporting system.•Empower speak up bias.•Train “upstanders” (someone who takes witnessing intolerance) instead bystanders.•Allow nursing report discuss microaggressions, inconsistencies due fear repercussion.Involve initiatives.•Patients vital gained only perspective.•360° evaluations operating room environments communication threaten safety.Designate officers, event response teams, officers.•Create dedicated teams monitor introduce policy findings.•Team expertise efficient feedback team.•Ensure underrepresented expected fairly compensated efforts.Data Improvement.28Institute Even properly addressed, leadership roles services equitable. Equity fair opportunities,29University MichiganDefining DEI: equity inclusion.https://diversity.umich.edu/about/defining-dei/Date equal chance influence. Institutions responsibility promote egalitarianism creating goals advancing candidates roles. It reflects prepare candidate pools. Goals planning lead action, metrics accountability. One metric percentage top 10, 50, 100, 200 non-White department, even division. filling 40 100 prioritize “emerging” “ready now” immediate contenders leadership. All search, advancement, committee undergo annual committees set minimum groups. Committees implement principles meetings. First, leader sets tone emphasizing everyone’s viewpoint valued. Second, receive speaking time, interruption. Third, unanimous mandate allows single dissenting heard, considered, discussed, prejudice.30Mendelberg T. Karpowitz C.F. Oliphant T.B. Gender inequality deliberation: unpacking black box interaction.Perspect Politics. 12: 18-44Crossref (56) intensive, allow wield opportunity. Professional societies represent patients, government agencies, industry. Societies representation boards, conference faculty, appointments, meeting chairs, attendees, Awards, grants, scholarships, advancement reviewed carefully ensure groups overlooked consideration, plans implemented necessary. Table 4 lists equity, societies.Table 4Strategies Promote Diversity, Equity, Inclusion SocietiesPromote junior nationally.Review pay workload inconsistencies.Journal editors recruit URM reviewers editors.For education, topics prioritized risk significant harm if addressed.Grant welcome applicants.Professional accountable dues-paying members.Meeting chairs review panel speaker proposals commit avoiding all-White panels.Planning diverse.URM, minority.Data Silver.31Silver J.K. leaders: ending gender workforce ethical imperative.http://sheleadshealthcare.com/wp-content/uploads/2018/10/Be_Ethical_Campaign_101418.pdfDate URM, minority. discussion device companies decide trained innovative technology turn trains others, especially evident pain. Pharmaceutical sponsor major meetings presentations, select fund site investigator.32Tau Shochat Gafter-Gvili Amir E. Shepshelovich D. Undisclosed financial conflicts interest drug trials published influential journals: study.Mayo Clin Proc. 94: 2272-2276Abstract (5) industry known, representatives studied detail, representative satisfaction unclear. Our primary quality life Patients never suboptimal Acknowledging taking break down barriers steps eliminating patients.33The Henry Kaiser Family FoundationNational survey I: doctors care.https://www.kff.org/wp-content/uploads/2002/03/national-survey-of-physicians-part-1.pdfDate By upholding efficient, low-cost better next generation help end