REPORTED BY
NORMAN J CLEMENT RPH., DDS, NORMAN L.CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, BELINDA BROWN-PARKER, IN THE SPIRIT OF JOSEPH SOLVO ESQ., IN THE SPIRIT OF REV. C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., MBA., WILLIE GUINYARD BS., JOSEPH WEBSTER MD., MBA, BEVERLY C. PRINCE MD., FACS., LEROY BAYLOR, JAY K. JOSHI MD., MBA, ADRIENNE EDMUNDSON, ESTER HYATT PH.D., WALTER L. SMITH BS., IN THE SPIRIT OF BRAHM FISHER ESQ., MICHELE ALEXANDER MD., CUDJOE WILDING BS, MARTIN NDJOU, BS., RPH., IN THE SPIRIT OF DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS
‘A REPUBLICATION’
youarewithinthenorms.com
Julie Corcoran:
I can best describe DEA/DOJ actions as Diffusion of Responsibility…a soft genocide by a depraved mindset of murderers. No human suffering from an incurable disease has any effective non-narcotic option. They have taken away the lifeline of people with an incurable disease, their ability to stay alive, care for themselves, and control their diseases. DEA/DOJ uses the CDC grade structure based on low-quality evidence……They have failed to acknowledge these diseases don’t get better…. you will never be normal and they simply don’t care. They’ve screwed up and they know it,….however, it is much easier for them to double down on a lie
RACIAL BIAS IN PAIN ASSESSMENT AND TREATMENT RECOMMENDATIONS, AND FALSE BELIEFS ABOUT BIOLOGICAL DIFFERENCES BETWEEN BLACKS AND WHITES
aDepartment of Psychology, University of Virginia, Charlottesville, VA, 22904;
bDepartment of Family Medicine, University of Virginia, Charlottesville, VA, 22908;
cDepartment of Public Health Sciences, University of Virginia, Charlottesville, VA, 22908
1To whom correspondence should be addressed. Email: khoffman@virginia.edu.
Edited by Susan T. Fiske, Princeton University, Princeton, NJ, and approved March 1, 2016 (received for review August 18, 2015)
Author contributions: K.M.H., S.T., J.R.A., and M.N.O. designed research; K.M.H. and M.N.O. performed research; K.M.H. and S.T. analyzed data; and K.M.H., S.T., J.R.A., and M.N.O. wrote the paper.
Kelly M. Hoffman,a,1 Sophie Trawalter,a Jordan R. Axt,a and M. Norman Oliverb,c
SIGNIFICANCE
“The present work examines beliefs associated with racial bias in pain management, a critical health care domain with well-documented racial disparities. Specifically, this work reveals that a substantial number of white laypeople and medical students, and residents hold false beliefs about biological differences between blacks and whites and demonstrates that these beliefs predict racial bias in pain perception and treatment recommendation accuracy.
It also provides the first evidence that racial bias in pain perception is associated with racial bias in pain treatment recommendations. Taken together, this work provides evidence that false beliefs about biological differences between blacks and whites continue to shape the way we perceive and treat black people—they are associated with racial disparities in pain assessment and treatment recommendations.
Keywords: racial bias, pain perception, health care disparities, pain treatment
Black Americans are systematically undertreated for pain relative to white Americans. We examine whether this racial bias is related to false beliefs about biological differences between blacks and whites (e.g., “black people’s skin is thicker than white people’s skin”).
TO BE PROUD AND BRAVE
Study 1 documented these beliefs among white laypersons and revealed that participants who more strongly endorsed false beliefs about biological differences reported lower pain ratings for a black (vs. white) target.
Study 2 extended these findings to the medical context and found that half of a sample of white medical students and residents endorsed these beliefs. Moreover, participants who endorsed these beliefs rated the black (vs. white) patient’s pain as lower and made less accurate treatment recommendations. Participants who did not endorse these beliefs rated the black (vs. white) patient’s pain as higher, but showed no bias in treatment recommendations.”
Jklingenhofer WROTE:
“Thank you for speaking up on behalf of chronic pain patients and also acute pain patients. Unfortunately, another important side effect of this war on opioids is that surgical and post-surgical pain is being under-medicated by our doctors in hospitals, including some of our best hospitals in the country.
I am a chronic pain patient with a lifelong disease requiring many surgeries in my lifetime. I remember when the pain wasn’t managed well, the short period when it was given the importance of a vital sign, back to being under-medicated. I live in terror of having to have another surgery and have put off a needed surgery for well over a year now.“
TO BE SUDDENLY AFFLICTED
THE HARLEM WISDOM TABLE INTERVIEWS NORMAN J CLEMENT RPH DDS
The Criminalization of Medical Protocols
“A young man goes to the doctor complaining of severe pain in his back. He expects and trusts that a medical expert, his physician, will assess his pain and prescribe the appropriate treatment to reduce his suffering. After all, the primary goal of health care is to reduce pain and suffering. Whether he receives the standard of care that he expects, however, is likely contingent on his race/ethnicity. Prior research suggests that if he is black, then his pain will likely be underestimated and undertreated compared with if he is white (1–10).
TO BE FIGHTING MEDICAL APARTHEID
The present work investigates one potential factor associated with this racial bias. Specifically, in the present research, we provide evidence that white laypeople and medical students, and residents believe that the black body is biologically different—and in many cases, stronger—than the white body. Moreover, we provide evidence that these beliefs are associated with racial bias in perceptions of others’ pain, which in turn predict accuracy in pain treatment recommendations. The current work, then, addresses an important social factor that may contribute to racial bias in health and health care.”
Replying to
“Lack of effective pain relief is harming millions of Americans. Racial bias exists in the health care field–it’s rampant. Kolodny is considered an expert. I hope the future sees him for what he is because the present values his killer instincts. War on Drugs is a war on people.“
TO BE MARGINALIZED
“Extant research has shown that, relative to white patients, black patients are less likely to be given pain medications and, if given pain medications, they receive lower quantities (1–10). For example, in a retrospective study, Todd et al. (10) found that black patients were significantly less likely than white patients to receive analgesics for extremity fractures in the emergency room (57% vs. 74%), despite having similar self-reports of pain.
WHITE RAGE:
This disparity in pain treatment is true even among young children. For instance, a study of nearly one million children diagnosed with appendicitis revealed that, relative to white patients, black patients were less likely to receive any pain medication for moderate pain and were less likely to receive opioids—the appropriate treatment—for severe pain (6).”
TO STOP THE IMPOSITION OF ILLEGAL BRITISH AND AMERICAN OPIUM INTO CHINA
Commissioner Lin Tse-hsu proceeded to Canton, seized vast stocks of opium and dumped the chests in the sea. This, plus a melee in which drunken sailors killed a Chinese villager, furnished the spark for the Opium War, initiated by Lord Palmerston, the British Prime Minister, and waged with determination to obtain full compensation for the opium. The Celestial Empire was humbled, forced to open five ports to foreign traders and to permit a British colony at Hong Kong.
“These disparities in pain treatment could reflect an overprescription of medications for white patients, underprescription of medications for black patients, or, more likely, both. Indeed, there is evidence that overprescription is an issue, but there is also clear evidence that the underprescription of pain medications for black patients is a real, documented phenomenon (1, 4).
For example, a study examining pain management among patients with metastatic or recurrent cancer found that only 35% of racial minority patients received the appropriate prescriptions—as established by the World Health Organization guidelines—compared with 50% of nonminority patients (4).”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/ Page 2 of 25
TO BE IMPRISONED
“Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Broadly speaking, there are two potential ways by which racial disparities in pain management could arise.
The first possibility is that physicians recognize black patients’ pain but do not treat it, perhaps due to concerns about noncompliance or access to health care (7, 8).
The second possibility is that physicians do not recognize black patients’ pain in the first place and thus cannot treat it. In fact, recent work suggests that racial bias in pain treatment may stem, in part, from racial bias in perceptions of others’ pain. This research has shown that people assume a priori that blacks feel less pain than do whites (11–17).”
TO HUMANIZE PAIN AND SUFFERING
“In a study by Staton et al. (14), for instance, patients were asked to report how much pain they were experiencing, and physicians were asked to rate how much pain they thought the patients were experiencing. Physicians were more likely to underestimate the pain of black patients (47%) relative to nonblack patients (33.5%). Of note, this research has also shown that racial attitudes, measured both implicitly and explicitly, do not predict racial bias in pain perception or treatment (11, 15, 18), with the exception of one study showing that implicit pro-white attitudes predicted physicians’ likelihood of recommending thrombolysis treatment (19). “
TO NOT BE AFRAID
“Racial bias in perceptions of pain (and possibly treatment) does not appear to be borne out of racist attitudes. In other words, it is likely not the result of racist individuals acting in racist ways. To date, then, it is unclear what beliefs account for disparities in pain assessment and treatment.
TO STOP ABUSING DRUG ABUSING DRUG USERS
Here, we examine the extent to which beliefs about biological differences between blacks and whites (e.g., beliefs that blacks have thicker skin than do white people or that black people’s blood coagulates more quickly than white people’s blood) are associated with racial bias in pain perception and treatment recommendations.”
TO EXPOSE THE DISPARITIES
“Beliefs that blacks and whites are fundamentally and biologically different have been prevalent in various forms for centuries.
In the United States, these beliefs were championed by scientists, physicians, and slave owners alike to justify slavery and the inhumane treatment of black men and women in medical research (20–25). In the 19th century, prominent physicians sought to establish the “physical peculiarities” of blacks that could “serve to distinguish him from the white man” (23). Such “peculiarities” included thicker skulls, less sensitive nervous systems, and diseases inherent in dark skin (20, 21, 23).”
TO FIGHT APARTHEID
“Dr. Samuel Cartright, for instance, wrote that blacks bore a “Negro disease [making them] insensible to pain when subjected to punishment” (20). Other physicians believed that blacks could tolerate surgical operations with little, if any, pain at all (22, 25). Well into the 20th century, researchers continued to experiment on black people based in part on the assumption that the black body was more resistant to pain and injury.
The military covertly tested mustard gas and other chemicals on black soldiers during World War II, and the US Public Health Service, in collaboration with the Tuskegee Institute, studied the progression of untreated syphilis in black men from 1932 to 1972.”
TO DEFILE HUMANITY
“Today, many laypeople, scientists, and scholars continue to believe that the black body is biologically and fundamentally different from the white body and that race is a fixed marker of group membership, rooted in biology (26–28). In fact, many people insist that black people are better athletes—stronger, faster, and more agile—as a result of natural selection and deliberate breeding practices during slavery (29–33).
Research suggests that people even believe that black people are more likely than white people to be capable of fantastical mental and physical feats, such as withstanding extreme heat from burning coals (17). These biological conceptions of race are only weakly if at all correlated with racial attitudes (27, 34). They are nonetheless consequential.
Research has shown that biological conceptions and related beliefs are associated with greater acceptance of racial disparities (27) and even racial bias
TO BE DEFILED
in pain perception (17). Indeed, in one study, white participants who believed black people can tolerate extreme heat more than white people can, for example, were more likely to think that black people feel less pain than do white people (17).”
TO SEEK OUT SCIENCE
“In the present work, we examine whether beliefs about biological differences are associated with racial bias in pain perception and treatment recommendations. Specifically, we test whether people— including people with some medical training—believe that black people feel less pain than do white people, and we test whether people with some medical training recommend fewer or weaker pain medications to black vs. white patients. In addition, the present work extends prior work in three important ways.
First, it documents whether people with some medical training (medical students and residents who already treat patients) hold false beliefs about biological differences between blacks and whites in contemporary times.”
TO BE SCRAPPY, UNBOWED, AND DETERMINED
“Second, it tests whether these beliefs predict racial bias in perceptions of others’ pain and racial bias in the accuracy of treatment recommendations among a sample of white medical students and residents.
TO BRING OUT THE TRUTH
Third, it investigates whether racial bias in pain perception is related to racial bias in pain management. We focus on white participants given the historical context of black-white relations, particularly in the medical context (20–25). Analyses for nonwhite participants can be found in the SI Text for the interested reader.”
TO REMAIN INVISIBLE
“In two studies, we asked people to make judgments about another person’s pain. In study 1, we used a between-participants design in which laypeople were randomly assigned to rate the pain of either a black or a white target. In study 2, we used a within-participants design in which medical students and residents provided pain ratings and treatment recommendations for both a black and a white target. In addition to pain ratings, we measured beliefs about biological differences between blacks and whites using 15 items (e.g., black people’s skin is thicker than white people’s skin; see SI Text for the full list of items). We predicted that these beliefs would be associated with racial bias in pain perception.”
STUDY 1
In study 1, we first establish that individuals without medical training endorse beliefs about biological differences between blacks and whites and demonstrate that these beliefs are related to racial bias in pain perception.
TO SEEK FOOD FOR THOUGHT
We recruited 121 participants, 92 of whom met our a priori criteria (i.e., white, born in the United States, native English speakers). Participants gave informed consent in accordance with the policies of the Institutional Review Board (IRB) of the University of Virginia. Participants reported the amount of pain they would feel across 18 scenarios (e.g., “I slam my hand in a car door”; scale: 1 = not painful, 2 = somewhat painful, 3 = moderately painful, 4 = extremely painful) and were then randomly assigned to rate the pain of a gender-matched black or white target across the same scenarios.
TO SUFFER LOST
Participants also rated the extent to which 15 biological differences between blacks and whites are true or untrue on a six-point scale (1 = definitely untrue, 2 = probably untrue, 3 = possibly untrue, 4 = possibly true, 5 = probably true, 6 = definitely true; see Table 1 for a list of the items, and SI Text and Table S1 for additional descriptive information for the measure). Here, we report results using a composite averaging the false items about biological differences between the black body and the white body for each participant (α = 0.92). We provide analyses using all items in Table S2.
TABLE 1
Percentage of white participants endorsing beliefs about biological differences between blacks and whites
TO NOURISH OUR BODY AND SOUL
TO EXPRESS OUR INNER SELF
TO PASS ON GENERATIONAL WEALTH
TO SEEK HUMANITY
TO BE MISCHARECTERIZED
TO MAINTAIN YOUR DIGNITY
TO SEEK DELIGHT
TO INSTIIL FEAR
We next modeled the accuracy of treatment recommendations (coded as 1 = accurate, 0 = inaccurate) as a function of target race (as a repeated measure), false beliefs (as a between-participants measure), and their interaction, controlling for age, gender, and medical cohort. Once again, we found only the predicted interaction between target race and false beliefs [F(1,192) = 5.68, P = 0.018, !2 = 0.01;
Fig. 2B]. To decompose this interaction, we again conducted simple slope analyses on the difference score in treatment recommendation accuracy for the black vs. white target (white accuracy minus black accuracy; greater, positive scores indicate a greater likelihood of recommending an accurate treatment for a white vs. black target).
TO ENJOY THE PLEASURES OF LIFE
These analyses indicated that participants who endorsed more false beliefs (+1 SD) were less accurate in their treatment recommendations for the black target compared with the white target [β = 0.15, SE = 0.06, t(192) = 2.47, P = 0.014]. Conversely, participants who endorsed fewer false beliefs (−1 SD) did not differ in their treatment recommendation accuracy [β = −0.06, SE = 0.06, t(192) = −1.05, P > 0.250]. In other words, participants who endorsed more false beliefs about biological differences between blacks and whites showed a racial bias in the accuracy of their treatment recommendations. Participants who did not endorse such beliefs showed no bias in treatment recommendation accuracy.
TO FEED YOURSELF
We also examined the relationship between racial bias in pain perception and racial bias in treatment recommendation accuracy. We correlated racial bias in pain perception (white pain minus black pain) with racial bias in treatment recommendation accuracy (accuracy for white patient minus accuracy for black patient), covarying out age, gender, and medical cohort. This analysis revealed a significant and sizable positive correlation, such that greater racial bias in pain ratings was associated with greater racial bias in the accuracy of treatment recommendations (r = 0.46, P < 0.0001). As predicted, racial bias in pain perception is related to racial bias in the accuracy of treatment recommendations.
FOR THE LOVE OF FAMILY
Last, we conducted a mediation analysis to test whether racial bias in pain perception mediated theracial bias in treatment recommendation accuracy. When adding racial bias in pain assessment (whitepain minus black pain) to the model predicting racial bias in treatment recommendation accuracy, falsebeliefs was no longer a significant predictor [B = 0.05, SE = 0.04, F(1,191) = 1.22, P > 0.250,!2 = 0.01], whereas racial bias in pain perception continued to predict racial bias in treatment precommendation accuracy [B = 0.25, SE = 0.04, F (1,191) = 44.44, P < 0.0001, !2 = 0.19], suggesting mediation.
TO TREAT PAIN PATIENTS AS HUMAN BEINGS
GEORGE TENET MD
Study 2
Demonstrates that, similar to white laypersons in study 1, many white medical students and residents hold beliefs about biological differences between blacks and whites, many of which are false and fantastical in nature, and that these false beliefs are related to racial bias in pain perception. Furthermore, study 2 also reveals that white medical students and residents who endorsed false beliefs showed racial bias in the accuracy of their pain treatment recommendations.
Specifically, participants who endorsed more of these beliefs reported that a black (vs. white) target patient would feel less pain and they were less accurate in their treatment recommendations for the black (vs. white) patient. Although the effect sizes for these findings were not large (!2 = 0.03 and 0.04), the practical importance is significant: those endorsing more false beliefs rated the pain of a black (vs. white) patients half a scale point lower and were less accurate in their treatment recommendations 15% of the time.
TO SEEK ACCOUNTABILITY FOR JUSTICE AND FAIRNESS
In contrast to white medical students and residents who endorsed false beliefs, those who did not endorse (or endorsed fewer) false beliefs reported that a white (vs. black) target patient would feel less pain. This opposite bias perhaps reflects real-world differences, as previous work has shown that black patients tend to report greater pain than do white patients (7, 24, 42).
TO BE SILENCED,
This opposite bias could also reflect participants’ attempt to compensate for known racial disparities (see ref. 13 for a similar explanation). Of note, these medical students and residents did not exhibit a racial bias in treatment recommendations. In other words, endorsing fewer false beliefs was associated with the perception that whites feel less pain but not with insufficient treatment recommendations for white patients.
In contrast, endorsing more false beliefs was associated with perceptions that blacks feel less pain and a “commensurate” insufficient treatment recommendation for black patients. It thus seems that racial bias in pain perception has pernicious consequences for accuracy in treatment recommendations for black patients and not for white patients.
TO PASS ON GENERATIONAL KNOWLEDGE
Unexpectedly, shifts in racial bias as a function of false beliefs stemmed from shifts in perceptions of the white target and not the black target in study 2 (it stemmed from both shifts in perceptions of the white target and black target in study 1). Although perhaps counterintuitive, this pattern of results is consistent with research on intergroup bias demonstrating that discrimination often occurs due to ingroup favoritism rather than outgroup hostility (43).
In the present case, it is possible that shifts in perceptions of the white target (and not the black target) reflect this kind of bias; it is possible that these shifts reflect positive (empathic) cognitions about white in-group members rather than negative (callous) cognitions about black out-group members.
TO MAINTAIN THE RIGHT TO VOTE
Limitations of the present work offer avenues for future research. For practical reasons, we used survey methods to document medical students’ and residents’ beliefs and racial biases. Future work will need to test whether white and nonwhite medical personnel in more advanced stages of their career also hold beliefs about biological differences between blacks and whites, and if so, whether these beliefs have consequences for pain assessment and treatment in real medical contexts.
TO BE AN ELECTED OFFICIAL
Future work may also delve into the nature of the racial bias: whether it reflects ingroup favoritism rather than outgroup derogation. This distinction may be useful for the development of interventions. These limitations aside, studies 1 and 2 make at least three important contributions.
First, they provide the first evidence that racial bias in pain assessment is associated with racial bias in the accuracy of pain treatment recommendations.
Second, they reveal that a substantial number of white people—laypersons with no medical training and medical students and residents—hold beliefs about biological differences between blacks and whites, many of which are false and even fantastical in nature. To our knowledge, this is the first demonstration of medical personnel (students and residents with at least some medical training) endorsing such beliefs in modern times.
Third, the current studies demonstrate that these beliefs are associated with racial bias in perceptions of others’ pain. Interestingly, in study 2, that bias seemed to result from shifts in perceptions of the white target’s pain more so than perceptions of the black target’s pain, suggesting that perceptions of whites’ frailty may shape racial bias in pain perception as much, if not more, than perceptions of blacks’ strength.
TO BE PERCEIVED UPPIDTY AND ARROGANT
This last year marks the 30th anniversary of the landmark 1985 Report of the Secretary’s Task Force on Black and Minority Health—more commonly known as the Heckler Report—the first comprehensive documentation of racial disparities in health by medical experts. This report put a national spotlight on the pervasive racial inequities in health and issued a resounding call to eliminate health disparities.
Although this call was met with a surge in research efforts and substantial changes in medical programs, policy, and legislation, the ultimate goal of eliminating racial disparities remains elusive. Racial disparities in health and health care continue to be a problem in the United States, a point underscored by the US Department of Health and Human Services’ “clarion call to continue to take action toward ending health disparities” (minorityhealth.hhs.gov/Blog/BlogPost.aspx?BlogID=68).
The present work sheds light on a heretofore unexplored source of racial bias in pain assessment and treatment recommendations within a relevant population (i.e., medical students and residents), in a context where racial disparities are well documented (i.e., pain management). It demonstrates that beliefs about biological differences between blacks and whites—beliefs dating back to slavery—are associated with the perception that black people feel less pain than do white people and with inadequate treatment recommendations for black patients’ pain.
MATERIALS AND METHODS
Study 1.
Participants. We recruited a sample of 121 adults on Amazon’s Mechanical Turk in exchange for a small amount of money. As in previous work (15), we excluded participants who were not born in the United States or native English speakers, as well as participants who did not complete all of the relevant measures. We also excluded all nonwhite participants, given the historical context of black-white relations, particularly in the medical context (20–25). Our final sample consisted of 92 participants (28% female; Mage = 26.70, SD = 8.76).
Procedure and materials. Participants gave informed consent in accordance with the policies of the IRB of the University of Virginia. After consenting, participants were asked to provide their age and gender so the survey program could route the participant to a gender-matched target. They then rated the amount of physical pain they would feel across 18 scenarios and were randomly assigned to rate the pain of a gender-matched black or white target across the same 18 scenarios (SI Text). Next, participants completed a 15-item measure of beliefs about biological differences between blacks and whites that are true or untrue (see Table 1 and SI Text for a list of items and descriptive information).
To compose our conceptual variable of interest—false beliefs about biological differences between blacks and whites—we created an average rating of 11 of the items (α = 0.92; see bold items in Table 1 and see SI Text for additional information on the measure). All analyses were conducted using continuous measures of beliefs and pain ratings. After this measure, participants provided demographic information, including their race/ethnicity, nationality, and primary language. SI Text provides additional information on materials, methods, and results. Data and study materials are also available at https://osf.io/crxwa/.
Study 2.
Participants. We recruited cohorts of first-, second-, and third-year medical students from a large public university, who completed the study online during class sessions. We also recruited medical residents from multiple sites, who completed the study online at their convenience. The sample included 418 participants (first years, n = 134; second years, n = 133; third years, n = 117; residents, n = 34); we had no set sample size, but rather collected data from as many participants as we were able to obtain. As in previous work (15), we excluded participants who were not native English speakers and/or American because the racial bias in pain perception is likely a cultural phenomenon.
Including these participants in our analyses does not change the pattern of results. We again excluded nonwhite participants given the historical context of black-white relations, particularly in the medical context (20–25). The final sample consisted of 222 participants (first years, n = 63; second years, n = 72; third years, n = 59; residents, n = 28; 48% female; Mage = 25.18, SD = 2.66). Some participants did not report age, gender, and/or race/ethnicity and thus degrees of freedom vary across analyses.
Procedure and materials. Participants gave informed consent in accordance with the policies of the IRB of the University of Virginia. After consenting, participants were asked to provide their age and gender so the survey program could route the participant to gender-matched targets. Participants then read two mock medical cases about a black and a white patient. They were asked to estimate the pain of each patient and to make a recommendation to treat the patient’s pain.
Next, participants were asked to provide demographic information and to complete the same measure of beliefs about biological differences between blacks and whites as in study 1, averaging the 11 false items to create a measure of false beliefs (α = 0.92). Last, participants responded to debriefing questions about the study and then were debriefed in person (medical students) or read an electronic debriefing (medical residents). SI Text provides additional information on materials, methods, and results. Data and study materials are also available at https://osf.io/crxwa/.
SI TEXT
All study materials and data can be freely and openly accessed online at https://osf.io/crxwa/.
Study 1: Laypersons Without Medical Training (Method and Materials). Participants gave informed consent in accordance with the policies of the IRB of the University of Virginia. After consenting, participants were asked to provide their age and gender so the survey program could route the participant to a gender-matched target.
They then rated the amount of physical pain they would feel across 18 scenarios (e.g., “I slam my hand in a car door,” “I cut myself with a sheet of paper”) using a four-point scale (1 = not painful, 2 = somewhat painful, 3 = moderately painful, 4 = extremely painful). Participants were then randomly assigned to rate the pain of a gender-matched black or white target across the same 18 scenarios.
Next, participants completed a 15-item measure of beliefs about biological differences between blacks and whites that are true or untrue on a six-point scale (1 = definitely untrue, 2 = probably untrue, 3 = possibly untrue, 4 = possibly true, 5 = probably true, 6 = definitely true; see list of items and descriptive information below and Table 1). Of the 15 items, 4 were true, including 3 items pertaining to disease and morbidity (e.g., blacks are less likely to contract spinal cord diseases); 11 items were false statements about blacks and whites (e.g., black people’s blood coagulates more quickly than white people’s blood), and of these, 8 were in the direction of black strength and white frailty (see the previous example) and 3 were in the direction of white strength and black frailty (e.g., whites have a better sense of hearing compared with blacks).
To compose our conceptual variable of interest—false beliefs about biological differences between blacks and whites—we created an average rating of the 11 false items
(α= 0.92; see bold items in Table 1). Note that one item about racial differences in bone density is tricky; bone strength is strongly associated with lifestyle and diet, and research on racial group differences in bone density and its relationship to fracture risk is mixed. For example, a recent review of the literature on ethnic differences in bone health concluded that there are numerous factors that are crucial to consider when investigating bone strength between racial groups and that bone density alone cannot account for fracture risk (44). Given this mixed evidence, we exclude this item from our composite.
We report results using the false beliefs composite, but we provide descriptive information and analyses using a composite of all items in Tables S1 and S2. Both composites yielded similar patterns of results. All analyses were conducted using continuous measures of false beliefs and pain ratings. After this measure, participants provided demographic information, including their race/ethnicity, age, nationality, and primary language. See Table S3 for correlations between covariates (age, gender, self- ratings of pain) and pain ratings.
Study 2: Medical Students and Residents
Method.
Procedure and materials. Participants completed the study through Qualtrics, an online survey program. With the help of faculty and administrators at a medical school, we were given permission to conduct the study with medical students during classroom sessions. Each cohort completed the survey in the same classroom, but on separate dates.
A white experimenter provided a link to the study, and participants who chose to participate completed the study online. To recruit medical residents, a faculty member of the medical school and coauthor sent the survey link to other faculty to be distributed to residents, who voluntarily completed the study online at their convenience.
Participants gave informed consent in accordance with policies of the IRB of the University of Virginia. After consenting, participants were asked to provide their age and gender so the survey program could route the participant to gender-matched targets. Participants then read two mock- medical cases about a black and white patient.
They were asked to estimate the pain of each patient and to make a recommendation to treat the patient’s pain. Next, participants were asked to provide demographic information. Table S3 provides correlations between covariates (age, gender, self-ratings of pain, medical cohort) and dependent measures.
They then answered questions regarding the subjectivity and difficulty of estimating others’ pain (e.g., “How subjective are these types of pain assessments?”), followed by the same measure of beliefs about biological differences between blacks and whites as in study 1. Last, participants responded to debriefing questions about the study and then were debriefed in person (medical students) or read an electronic debriefing (medical residents).
Medical cases. Participants read two mock medical cases about a gender-matched black patient and white patient (the order of patient race and the medical case was counterbalanced across participants); one case referenced an ankle fracture and the other case referenced a kidney stone. Each case was formatted similarly to real medical and mock cases with which students and residents are familiar.
The cases contained a brief description of the patient and the medical issue, physical examination notes (e.g., vital statistics, description of patient’s physical presentation), and imaging or laboratory results. For example, in one case, the patient described her/his injury as resulting from slipping on a step and feeling her/his ankle “crack.”
The physical examination notes contained such observations as the swelling, range of motion of the ankle, and lack of bone protrusions, as well as the patient’s temperature, heart rate, height, and weight. The case also included X-ray results confirming a fracture.
We manipulated the critical factor—patient race—in two ways. We included a stereotypically black or white patient name at the top of the medical case (black names: Taneisha, Kiesha, Darnell, Jermaine; white names: Hannah, Katelyn, Brett, Connor).
We also indicated the ostensible race of the patient in the case information, denoting that the patient was either a Caucasian female/male or an African- American female/male. Each participant received one medical case about a black patient and one medical case about a white patient; thus, the patient race was our within-subjects factor.
Pain ratings and treatment recommendation accuracy. After reading each medical case, participants were asked to rate how much pain they thought the patient would be experiencing on a traditional 11-point medical scale (0 = no pain; 1; 2 = mild pain; 3; 4 = moderate pain; 5; 6 = severe pain; 7; 8 = very severe pain; 9; 10 = worst possible pain). They were then asked to provide a free response for the type of pain medication they would recommend for the patient’s pain.
In any medical case, the accurate treatment for pain is based on both objective factors (e.g., imaging, laboratory results) and subjective factors (e.g., patient’s self-reported symptoms and pain). To determine the appropriate treatment for our two specific cases, we provided 10 experienced physicians with both medical cases and asked them to indicate what they would recommend for pain management.
The majority of physicians reported that they would prescribe a narcotic (e.g., opiate, oxycodone, tramadol) for both the fracture case (9 of 10 physicians) and the kidney stone case (8 of 10 physicians).
Moreover, these physician recommendations align with World Health Organizations’ (WHO) guidelines for the treatment of acute pain (45). Accordingly, we dummy coded participants’ treatment recommendations as being accurate (coded as 1) or inaccurate (coded as 0).
See below for a list of representative responses and their respective codings. Of note, observations where participants wrote “I don’t know” (or something similar) were coded as missing because it is unclear how to interpret such responses. However, coding these as inaccurate does not change the pattern of results.
TO REPUDIATE CDC UNSCIENTIFIC OPIOIDS GUIDELINES AS JUNK SCIENCE
Beliefs about biological differences between blacks and whites. Participants completed the same 15-item measure of beliefs about biological differences between blacks and whites from study 1 (see Table 1 for the percentage of participants by a medical cohort who endorsed each). We again created a false beliefs composite of 11 of the 15 items (α = 0.92).
Here, we again report results using the false beliefs composite, but we provide descriptive information and analyses using a composite of all of the items in Tables S1 and S4; this composite yielded similar patterns of results. All analyses were conducted using continuous measures of false beliefs and pain ratings, except for the dummy-coded treatment recommendation accuracy measure.
Julie Corcoran:
“I can best describe DEA/DOJ action as Diffusion of Responsibility…a soft genocide by a depraved mindset of murderers. No human suffering from an incurable disease has an effective non-narcotic option. They have taken away the lifeline of people with an incurable disease, their ability to stay alive, care for themselves, and control their diseases. DEA/DOJ uses the CDC grade structure based on low-quality evidence……They have failed to acknowledge these diseases don’t get better…. you will never be normal. They screwed up it and they know it, however, it is much easier for them to double down on a lie“
Additional items. Because this study was conducted during class times for students, we were required to include an educational component with reflection questions about pain assessment. Participants were asked to indicate “How subjective are these types of pain assessments?” and “How difficult was it to estimate the pain of another person?” on a five-point scale (1 = not at all, 2 = a little bit, 3 = somewhat, 4 = very, 5 = extremely), as well as a dichotomous yes/no question: “Can doctors and patients ever provide ‘accurate’ pain ratings?”
Participants were also given the chance to provide open-ended responses to each of these items. These items were not relevant to the variables of interest and were thus not included in our analyses. They are, however, accessible online for the interested reader.
Results.
Additional analyses. Of note, one could argue that first-year students’ lack of experience in medical training may be unduly influencing the treatment recommendation accuracy findings. However, the pattern of results does not change when removing first-year students [F(1,147) = 5.50, P = 0.020, !2 =0.01 (target race × false beliefs interaction)].
Readers may also be interested in analyses for nonwhite participants (Asian, n = 43; black, n = 21; biracial, n = 28; Hispanic/Latino, n = 11; other, n = 3). When examining the same models for nonwhites, there were no effects for pain ratings or treatment recommendation accuracy (P > 0.250).
Beliefs about biological differences between blacks and whites measure. INSTRUCTIONS: In this part, you will be given a list of statements regarding race and health. Some of these statements are true, while others are not. Please read each statement and rate the extent to which you believe it is true, from Definitely Untrue to Definitely True.
Scale: 1 = Definitely untrue, 2 = Probably untrue, 3 = Possibly untrue, 4 = Possibly true, 5 = Probably true, 6 = Definitely true.
- On average, Blacks age more slowly than Whites.
- Black people’s nerve-endings are less sensitive than White people’s nerve-endings.
- Black people’s blood coagulates more quickly–because of that, Blacks have a lower rate of hemophilia than Whites.
- Whites, on average, have larger brains than Blacks.
- Whites are less susceptible to heart disease like hypertension than Blacks.
- Blacks are less likely to contract spinal cord diseases like multiple sclerosis.
- Whites have a better sense of hearing compared with Blacks.
- Black people’s skin has more collagen (i.e., it’s thicker) than White people’s skin.
- Blacks, on average, have denser, stronger bones than Whites.
- Blacks have a more sensitive sense of smell than Whites; they can differentiate odors and detect faint smells better than Whites.
- Whites have more efficient respiratory systems than Blacks.
- Black couples are significantly more fertile than White couples.
- Whites are less likely to have a stroke than Blacks.
- Blacks are better at detecting movement than Whites.
- Blacks have stronger immune systems than Whites and are less likely to contract colds.
False beliefs about biological differences between blacks and whites.
False beliefs are listed as items 1, 2, 3, 4, 7, 8, 10, 11, 12, 14, and 15.
Representative responses and codings for treatment recommendations. If participants mentioned both a narcotic and a nonnarcotic, their response was coded as a 1. Participants who wrote responses such as “I don’t know” were coded as missing. One could argue for coding these responses as inaccurate (0); doing so does not change the pattern of results. Given the uncertainty in interpreting these types of responses, we decided to err on the more conservative side of marking these observations as “missing” rather than “inaccurate.”
1 = narcotic (accurate).
Opioids
Opiates
Hydrocodone Morphine
Vicodin
Prescription pain killers Fentanyl
Dilaudid
0 = all others (inaccurate).
Tylenol Anti-inflammatory NSAIDS Acetaminophen OTC pain meds None
Ice pack Lidocaine
ACKNOWLEDGMENTS
We thank Laurie Archbald-Pannone and Mary Kate Worden for help and support recruiting medical students; Tim Wilson for helpful comments on this manuscript; and Jennifer Doleac, Derek Ford, Isaac Mbiti, and Jay Shimshack for providing advice regarding data analyses.
FOOTNOTES
The authors declare no conflict of interest.
†We counterbalanced the order of target race (black, white) and medical case (kidney stone, ankle fracture) across participants. Preliminary analyses revealed that the order of target race and medical case did not moderate the effects, and we thus exclude them from our models for parsimony. Including them does not change the pattern of results.
‡We present analyses using ordinary least squares (OLS) regressions. For the continuous pain measure in study 2, we provide the mixed-effects model for comparison in Table S5. For binary outcomes, such as treatment recommendation accuracy in study 2, logistic or OLS regressions are appropriate and produce similar results.
The OLS regression is our preferred specification because interpretation requires weaker functional form assumptions than a linear dependent variable model (35) and provides unbiased, reliable estimates of a variable’s average effect (36–40). However, because the outcome is binary, some may prefer a logit and/or probit specification; we provide these specifications in Table S6.
§This analysis also revealed that medical cohort was a significant predictor of both pain ratings and treatment recommendation accuracy irrespective of patient race [F(1,211) = 38.79, P < 0.0001 and F(1,192) = 8.08, P = .005, respectively]. As participants progressed in their training from first-year students through residents, they rated the targets as feeling more pain and they were more accurate in their treatment recommendations.
This finding is interesting given the common perception that medical training hardens physicians to others’ pain and suffering (see ref. 41 for a review). At least in our sample, people with more medical training were actually more, not less, sensitive to others’ pain. Perhaps in the present sample, as more senior medical students and residents gained “hands-on” experience on the medical wards and witnessed patients in pain, they perceived greater pain for the scenarios we provided—both of which would be extremely painful. In addition, it is perhaps not surprising that treatment recommendation accuracy was higher among more senior students, as additional training and experience should yield greater accuracy.
The medical cohort did not moderate the interaction between target race and false beliefs for pain ratings or treatment recommendation accuracy (Fs < 1). We thus included the medical cohort as a covariate and not as a moderator of the target race × false beliefs interaction term in all of our analyses.
This article is a PNAS Direct Submission.
Data deposition: Data and materials are available through the Open Science Framework, https://osf.io/crxwa/.
This article contains supporting information online at www.pnas.org/lookup/suppl/doi:10.1073/pnas.1516047113/- /DCSupplemental.
FOR NOW, YOU ARE WITHIN
THE NORMS
REFERENCES
1. Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: Causes and consequences of unequal care. J Pain. 2009;10(12):1187–1204. [PubMed] [Google Scholar]
2. Bonham VL. Race, ethnicity, and pain treatment: Striving to understand the causes and solutions to the disparities in pain treatment. J Law Med Ethics. 2001;29(1):52–68. [PubMed] [Google Scholar]
3. Cintron A, Morrison RS. Pain and ethnicity in the United States: A systematic review. J Palliat Med. 2006;9(6):1454–1473. [PubMed] [Google Scholar]
4. Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya KJ. Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med. 1997;127(9):813–816. [PubMed] [Google Scholar]
5. Freeman HP, Payne R. Racial injustice in health care. N Engl J Med. 2000;342(14):1045–1047. [PubMed] [Google Scholar]
6. Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr. 2015;169(11):996–1002. [PMC free article] [PubMed] [Google Scholar]
7. Green CR, et al. The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain Med. 2003;4(3):277–294. [PubMed] [Google Scholar]
8. Shavers VL, Bakos A, Sheppard VB. Race, ethnicity, and pain among the U.S. adult population. J Health Care Poor Underserved. 2010;21(1):177–220. [PubMed] [Google Scholar]
9. Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press; Washington, DC: 2013. [Google Scholar]
10. Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11–16. [PubMed] [Google Scholar]
11. Dore RA, Hoffman KM, Lillard AS, Trawalter S. Children’s racial bias in perceptions of others’ pain. Br J Dev Psychol. 2014;32(2):218–231. [PubMed] [Google Scholar]
12. Hoffman KH, Trawalter S. Assumptions about life hardship and pain perception. Group Process Intergroup Relat. 2016 doi: 10.1177/1368430215625781. [CrossRef] [Google Scholar]
13. Mathur VA, Richeson JA, Paice JA, Muzyka M, Chiao JY. Racial bias in pain perception and response: Experimental examination of automatic and deliberate processes. J Pain. 2014;15(5):476– 484. [PMC free article] [PubMed] [Google Scholar]
14. Staton LJ, et al. When race matters: Disagreement in pain perception between patients and their physicians in primary care. J Natl Med Assoc. 2007;99(5):532–538. [PMC free article] [PubMed] [Google Scholar]
15. Trawalter S, Hoffman KM, Waytz A. Racial bias in perceptions of others’ pain. PLoS One. 2012;7(11):e48546. [PMC free article] [PubMed] [Google Scholar]
16. Wandner LD, Scipio CD, Hirsh AT, Torres CA, Robinson ME. The perception of pain in others: How gender, race, and age influence pain expectations. J Pain. 2012;13(3):220–227. [PMC free article] [PubMed] [Google Scholar]
17. Waytz A, Hoffman KM, Trawalter S. A superhumanization bias in Whites’ perceptions of Blacks. Soc Psychol Personal Sci. 2014;6(3):352–359. [Google Scholar]
18. Haider AH, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306(9):942–951. [PMC free article] [PubMed]
[Google Scholar]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/ Page 23 of 25
Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites 7/8/21, 5:47 AM
19. Green AR, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–1238. [PMC free article] [PubMed] [Google Scholar]
20. Cartwright SA. Report on the diseases and physical peculiarities of the Negro race. New Orleans Med Surg J. 1851;7:691–715. [Google Scholar]
21. Guillory JD. The pro-slavery arguments of Dr. Samuel A. Cartwright. La Hist. 1968;9:209–227. [PubMed] [Google Scholar]
22. Pernick MS. A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America. Columbia Univ Press; New York: 1985. [Google Scholar]
23. Tidyman P. A sketch of the most remarkable disease of the negroes of the southern states. Phila J Med Phys Sci. 1826;12:306–338. [Google Scholar]
24. Trawalter S, Hoffman KM. Got pain? Racial bias in perceptions of pain. Soc Personal Psychol Compass. 2015;9(3):146–157. [Google Scholar]
25. Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Doubleday; New York: 2006. [Google Scholar]
26. Prentice DA, Miller DT. Psychological essentialism of human categories. Curr Dir Psychol Sci. 2007;16(4):202–206. [Google Scholar]
27. Williams MJ, Eberhardt JL. Biological conceptions of race and the motivation to cross racial boundaries. J Pers Soc Psychol. 2008;94(6):1033–1047. [PubMed] [Google Scholar]
28. Morning A. The Nature of Race: How Scientists Think and Teach About Human Difference. Univ of California Press; Berkeley, CA: 2011. [Google Scholar]
29. Hoberman JM. Darwin’s Athletes: How Sport Has Damaged Black America and Preserved the Myth of Race. Houghton Mifflin Company; New York: 1997. [Google Scholar]
30. Hughey M, Goss DR. A level playing field? Media constructions of athletics, genetics, and race. Ann Am Acad Pol Soc Sci. 2015;661(1):182–211. [Google Scholar]
31. Sailes GA. In: The African American Athlete: Social Myths and Stereotypes. African Americans in Sports: Contemporary Themes. Sailes GA, editor. Transaction Publishers; New Brunswick, NJ: 1998. pp. 183–198. [Google Scholar]
32. Hall RE. The ball curve: Calculated racism and the stereotype of African American men. J Black Stud. 2001;32(1):104–119. [Google Scholar]
33. Price S. Whatever happened to the White athlete? Sports Illustrated. 1997;87(23):30–55. [Google Scholar]
34. Jayaratne TE, et al. White Americans’ genetic lay theories of race differences and sexual orientation: Their relationship with prejudice toward Blacks, and gay men and lesbians. Group Process Intergroup Relat. 2006;9(1):77–94. [PMC free article] [PubMed] [Google Scholar]
35. Angrist JD, Pischke J-S. Mostly Harmless Econometrics: An Empiricist’s Companion. Princeton Univ Press; Princeton, NJ: 2009. [Google Scholar]
36. Allison PD. Comparing logit and probit coefficients across groups. Sociol Methods Res. 1999;28(2):186–208. [Google Scholar]
37. Baetschmann G, Staub KE, Winkelmann R. Consistent estimation of the fixed effects ordered logit model. J R Stat Soc [Ser A] 2015;178(3):685–703. [Google Scholar]
38. Greene WH. 2002 The bias of the fixed effects estimator in nonlinear models. Working paper EC- 02-05 (New York University, New York) Available at people.stern.nyu.edu/wgreene/nonlinearfixedeffects.pdf. Accessed October 17, 2015.
39. Hellevik O. Linear versus logistic regression when the dependent variable is a dichotomy. Qual Quant. 2009;43(1):59–74. [Google Scholar]
40. Mood C. Logistic regression: Why we cannot do what we think we can do, and what we can do about it. Eur Sociol Rev. 2010;26(1):67–82. [Google Scholar]
41. Neumann M, et al. Empathy decline and its reasons: A systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009. [PubMed] [Google Scholar]
42. Klonoff EA. Disparities in the provision of medical care: An outcome in search of an explanation. J Behav Med. 2009;32(1):48–63. [PubMed] [Google Scholar]
43. Greenwald AG, Pettigrew TF. With malice toward none and charity for some: Ingroup favoritism enables discrimination. Am Psychol. 2014;69(7):669–684. [PubMed] [Google Scholar]
44. Zengin A, Prentice A, Ward KA. Ethnic differences in bone health. Front Endocrinol (Lausanne) 2015;6(24):24. [PMC free article] [PubMed] [Google Scholar]
45. Medecins Sans Frontieres 2013 Clinical guidelines: Diagnosis and treatment manual for curative programmes in hospitals and dispensaries: Guidance for prescribing. Available atapps.who.int/medicinedocs/documents/s17078e/s17078e.pdf. Accessed February 23, 2016.
Articles from Proceedings of the National Academy of Sciences of the United States of America are provided here courtesy of National Academy of Sciences
