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It’s already difficult to find appropriate treatment for chronic pain. But a growing body of research shows that some groups are more likely than others to face diagnostic delays and undertreatment.
Physicians tend to “dismiss women’s pain a lot more than they do men’s,” says Penney Cowan, founder and chief executive of the American Chronic Pain Association. According to a 2014 online survey of more than 2,400 U.S. women with a variety of chronic pain conditions, 91 percent felt that the health-care system discriminates against female patients. Nearly half were told the pain was all in their head.
It’s also common, particularly for women with pelvic and menstrual pain caused by conditions such as endometriosis and fibroids, to be told their pain is just a normal part of being a woman, says Amy M. Miller, president and CEO of the Society for Women’s Health Research.
Evidence shows that women’s pain is also often less thoroughly investigated, especially initially, when the cause of pain is unknown. A 2008 study of nearly 1,000 patients in an urban emergency room found that women waited an average of 16 minutes longer than men to get medication when reporting abdominal pain and were less likely to receive it.
Other research has shown that clinicians are more likely to suggest psychosocial causes, such as stress or family problems, to female patients in pain — when they would order lab tests more frequently for a male patient with similar symptoms.
Studies also have shown that racial bias can affect how doctors assess and treat pain. In 2012, an analysis of 20 years of published research in the United States found that African American patients reporting pain were 22 percent less likely than white patients to get pain medication from their doctors. The gap was largest when the cause of the pain, such as back pain, was not immediately apparent.
Another study found that African American patients reported less-effective pain management than white patients. One factor in this, experts say, is that some health-care providers believe, falsely, that patients of color are more likely to abuse prescription painkillers.
Other research suggests that doctors — nationwide, about 72 percent are white — often underestimate the pain level of minority patients.
“A lot of work in the social sciences has shown that you’re more empathetic to people in your in-group than your out-group,” says Salimah H. Meghani, a lead author of the 2012 analysis and an associate professor at the University of Pennsylvania School of Nursing. “That’s a very well-studied phenomenon.”
Half of the hundreds of white medical students and residents surveyed for a 2016 study subscribed to at least one myth about supposed racial differences related to pain — such as believing that the nerve endings of black people were less sensitive than those of white people. The research found that those who believed in more myths were more likely to rate a black patient as having less pain and to undertreat accordingly.
Experts say the age of the patient also plays a role. Some physicians see pain as an inevitable part of the aging process; older patients often report that they are told, “What do you expect? You’re getting older.”
Pain is also frequently ignored in children, particularly among those too young to communicate effectively. A 2003 study in a pediatric emergency department found that more than half of the children younger than 2 with obviously painful injuries, such as broken bones and burns, were not given any pain medication at all.
Diane Talbert, an African American woman from a small town in Virginia, spent decades in pain despite repeatedly explaining her symptoms to about 10 doctors.
She has suffered from a severe case of psoriasis, a persistent skin condition, since she was a child. But when she experienced recurring shoulder pain and then hand swelling in her mid-20s, doctors didn’t take her seriously, she says. “They said it was all in my head.”
Over time, her pain worsened, and eventually she was unable to lift her arms over her head to get dressed in the morning. One doctor said she must be overreacting. As she got older, her symptoms were dismissed as signs of early menopause.
Finally, a rheumatologist took Talbert at her word and quickly diagnosed psoriatic arthritis, a painful autoimmune disease that affects about 15 percent of people with psoriasis.
Today Talbert, now 61, treats her psoriatic arthritis with the immunosuppressive drug Stelara, and she manages the residual pain with other medications.
Some disparities in pain treatment are because of implicit or unconscious biases, which may be amplified in the medical system, Meghani says. Overloaded health-care providers with little time to spend with patients may resort to taking shortcuts by falling back on stereotypes when making clinical decisions, she says.
Mark Rosenberg, a spokesman for the American College of Emergency Physicians, says ad hoc pain care is partially to blame. “Until recently, it was very subjective,” he says. “Standardizing pain management will go a long way in decreasing variability in treatment.”
Much of the research on these disparities comes from studies of acute pain. But the risk that stereotypes and biases will affect treatment decisions may be even greater when it comes to chronic pain.
Research has shown that health-care providers are more likely to believe patients’ self-reported pain levels when there is objective evidence of the pain’s cause. But in many chronic pain conditions, lab tests or imaging might not identify the cause of pain, or there’s no objective evidence of the pain at all.
“Since pain is subjective and relies on patients’ own testimony,” Meghani says, “disproportionately trusting the self-reports of some groups over others can result in discriminatory care.”
While there is greater awareness today that these disparities in pain treatment exist, there is little indication that they have begun to improve, Meghani says. Awareness alone will not solve the problem, she says, and neither will one-off empathy training sessions. “A lot of things need to change simultaneously for this deeply ingrained culture to change.”
Cowan says people with pain should not be deterred and should keep pushing to find providers who listen and offer treatment plans that work.
“Pain tends to take away our sense of self-esteem,” she says. “So many people blame themselves and take responsibility for the fact that they’re not getting better. When it comes to living with pain, we can’t be passive patients — we need to be active participants.”
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