As many doctors, nurses and other health workers have joined protests against systemic racism, research has shown that racial bias is pervasive in health care, perhaps most apparent in the assessment and treatment of pain.
The strongest evidence of this comes from a clinical setting commonly requiring surgery – acute appendicitis. Not only are there clear racial disparities in pain relief provided even in this acute condition, but they are found even for treatment of children.
In a national study that included almost a million emergency room visits, black children in severe pain from acute appendicitis had just one-fifth the odds of receiving opioid painkillers compared with white children, even after adjusting for other factors.
The disparity may reflect that doctors were less likely to trust their black patients, particularly because the study also showed no difference in the prescription of non-opioid painkillers by race. Another study confirmed that racial disparities in opioid prescription are greater in conditions with fewer objective findings, such as migraine or back pain, which depend on a patient’s own assessment, as opposed to say a bone fracture, which shows up on an X-ray.
But another study suggests that broader racist myths about black people and pain might also be at play here. During slavery times, violence against enslaved black people was justified by a supposed greater tolerance for pain, and a ludicrously false belief that they had thicker skin. The study, from 2016, found a third of 222 white medical students and residents surveyed held that false belief. And those respondents, the study found, were also less likely to perceive the intensity of black patients’ pain and recommend appropriate treatment.
Because the appraisal of pain remains entirely subjective, confined exclusively to the eye of the beholder, a doctor or nurse’s ability to accurately assess and respond to a patient’s suffering is heavily dependent on empathy, the process that allows us to understand and share another person’s emotional state. Empathy is seen as an evolutionarily promoted phenomenon: Watching someone else wince in pain after, say, they grab a hot pan, may help us not make the same mistake. Being sensitive to others’ feelings allows us to form cohesive societies. In fact, brain imaging studies show that there is considerable overlap in the brain circuits that feel one’s own pain and those that react to the pain of others.
There is a rich body of research showing that we feel another’s pain most acutely when we feel like they are part of the same group: when they support the same soccer team, adhere to the same religion – and, many studies shows, belong to the same race. And given that only 5 percent of American physicians and 6 percent of nurses are black, the majority of black patients are treated by clinicians of a different race.
This racial intergroup bias in empathy is ubiquitous, but researchers have performed small, carefully planned experiments showing that it is not insurmountable. Overcoming racial intergroup bias in empathy could be central not just to achieving equity in pain management, but throughout medical care and society at large.
Simply living together and interacting with people of other races is associated with increases in empathy. The longer Chinese immigrants to Australia had lived in their new country, the more they were in everyday contact with white Australians, the more empathy toward their pain they exhibited.
A key factor that mediates implicit bias is that people emphasize the differences between people from other races rather than what unites them. A process called individuation training nudges people to focus on other people as individuals and on their unique traits and characteristics rather than which group they belong to. In one experiment, focusing on how much pain people from other races were feeling rather than the color of their skin increased the empathetic response generated, eliminating intergroup bias.
Another reason driving bias is the feeling of otherness generated by groups different from one’s own. In this same experiment, a biased response to the pain of other races was eliminated when they were included as part of the individual’s team in a mock game.
Training physicians to be more empathetic, particularly toward people of other races, may be an effective tool at closing the racial gap in pain relief. An empathetic physician can have a real impact on their patients’ well-being. In one study of nearly 3,000 adult patients from 2017, patients with chronic pain who rated their doctors as more empathetic experienced greater pain relief.
Last year, a former associate dean of curriculum at the Perelman School of Medicine at University of Pennsylvania wrote an op-ed in the Wall Street Journal decrying that “at ‘woke’ medical schools, curricula are increasingly focused on social justice rather than treating illness.” However, as this current moment has made clear, medical schools need to be doing more to train their graduates in overcoming the medical consequences of social injustice and bias. Nowhere is this more apparent than how they treat the person in pain.
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Warraich is a cardiologist at VA Boston Healthcare System, Brigham and Women’s Hospital and Harvard Medical School. He is also author of “State of the Heart: Exploring the History, Science, and Future of Cardiac Disease.”