A new University of Virginia study suggests that many medical students and residents are racially biased in their pain assessment, and that their attitudes about race and pain correlate with falsely-held beliefs about supposed biological differences—like black people having thicker skin, or less sensitive nerve endings than white people—more generally.
The study highlights how a confluence of mistaken attitudes—about race, about biology, and about pain—can flourish in one of the worst possible places: medical schools where the future gatekeepers of relief are trained. And it illuminates what I’ve called the divided state of analgesia in America: overtreatment of millions of people that feeds painkiller abuse at the same time that, with far less public attention, millions of others are systematically undertreated. Think of it as a pain gap between the haves and the have-nots, along lines of class and race.
Unfortunately, the UVA findings are neither surprising nor fundamentally new. Back in the 1990s, two studies—one in an Atlanta emergency room, the other in Los Angeles—found that white patients being treated for long bone fractures were dosed more liberally than Latino patients in L.A., and more liberally than black ones in Atlanta. The authors put forward several possible explanations of the disparity: Perhaps patients in different groups expressed pain differently, or maybe caregivers interpreted pain differently in these groups, or perhaps nurses and doctors saw pain the same way across groups but just chose to remedy pain differently.
By the late 1990s, other studies found similar disparities in cancer care, where people receiving outpatient cancer care in places that mostly served minorities were three times more likely to be under-medicated with analgesics than patients in other settings. Speculation about the causes deepened: Perhaps inadequate prescribing for minority patients resulted from concerns about potential drug abuse, or maybe minority patients had more difficulty finding pharmacies that stocked opioid prescriptions, or again perhaps there was a cultural barrier in doctor-patient understanding and assessment. Into the 2000s, additional reports have confirmed the gap—again with no agreement about any single cause.
In a sense, the pain issue echoes other debates about race in America. We know there is a disparity; we know it is linked to racial discrimination somewhere or on some level, or even to institutional racism. But just as in racial bias in the law and policing, we struggle to put our finger on the one cause.
The truth is that there is no single cause for this disparity.
That said, the UVA study turns our gaze to one important place where race problems are manifest—medical training and physician perceptions. Medical students and residents learn precious little about race and social difference; but they also learn little about pain or about the fallacies of biological reasoning (for example, the false ideas apparently held by many in the UVA study that black blood coagulates more quickly than white blood). Given that such erroneous blood differences were once used to justify segregating the blood supply and to argue against racial integration (and that they seemed extinguished decades ago), their reappearance in the UVA study is especially shocking.
People in pain have remained a challenge for doctors. A noted Boston physician once said, “The relief of pain is obviously one of the main functions of physicians… Ironically, it is one of the things we do least well—partly because we don’t understand it.” That was in 1959. About 50 years later, a National Academy of Medicine report on pain concluded, “In medical education, pain generally has received little attention, which has contributed to the problem of undertreatment.”
Pain is not easy to measure objectively; a highly subjective experience, one person might complain about the same pain another would tolerate easily. Moreover, caregivers rely on subjective signs and personal judgments in deciding how bad your pain really is, and how aggressively to treat it.
Medical students often think health problems should have straightforward answers and easy solutions; chronic pain does not. If chronic pain is frustrating for patients, it is often unnerving for caregivers looking to provide a quick fix. Adding to the complexity are drug abuse concerns: Practitioners themselves can become resentful and fearful of the scrutiny they face for practicing compassionate pain care with potentially addictive drugs, and this takes its toll on the patient in need.
It is little wonder that medical students—trained in this atmosphere of fear, bias, skepticism, and too-little information—don’t understand pain, may allow a range of cultural judgments to shape diagnosis and care, and may also be quick to see the black person in pain as a drug abuse threat.
For years, black patients with sickle cell disease (a malady associated with African Americans and characterized by recurring pain episodes) have been on the front lines of this battle—a focal point in the struggle for proper compassionate care. In places where there is heightened concern over addiction, the sickle cell patient has been stigmatized as a complainer or drug-seeker. Their medical care has swung like a pendulum, shaped by the racial politics of the times and place—from more liberal recognition and care in the 1970s in some locales, to rising skepticism in more conservative times and places. In every context, however, physicians have been also on the front lines as gatekeepers to compassionate relief. As one sympathetic sickle cell physician once wrote, illustrating her patient’s plight, “Before you can get past the agony, you have to get a doctor to believe it’s real.”
The UVA study highlights a final, truly disturbing, problem in medical and science education—the way that false biological theories of racial difference and of blood can flourish in precisely the places they should not, and how damaging these false biological views can be.
In the UVA study, medical students saw imaginary biological differences across groups, black and white. Those mistaken beliefs shape their ideas about treating patients in pain differently. If students and residents act on these beliefs, the confluence of racial beliefs and differences in care would create new health disparities—adding to those that already afflict our society. Imagined biological differences thus become real social disparities. Those who should be gatekeepers of relief helping to reduce disparities may end up doing just the opposite.
A few years ago, the National Academy of Medicine report on unrelieved pain called for “a cultural transformation in the way pain is viewed and treated.” The UVA study highlights the continued urgency of that call, but it draws particular attention to the importance of doing a better job teaching the next generation of physicians—so that they can become part of the solution, rather than part of the problem.