Physician Awareness of Demographic Influences on Pain Treatment Decisions Can Impact Care Delivery

While past studies suggest variability in physicians’ chronic pain treatment decisions based on patients’ sex and race — such as conclusions that female and black chronic pain patients receive less treatment compared to their respective male and white counterparts — few have considered the degree of providers’ self-insight into the influence of such demographics on their treatment decisions.

To investigate the topic, Hollingshead, Matthias, Bair, et al., launched a mixed methods study, “Variability in Pain Treatment Decisions and Provider Self-Insight,” examining how 20 medical trainees at an academic medical center made treatment decisions for 16 computer-simulated patients with manipulated sex and race who all presented chronic lower back pain with no contraindications. The trainees — 65 percent females and 35 percent males; 65 percent white, 20 percent Asian, 5 percent black, 5 percent Hispanic, and 5 percent Middle Eastern — then rated the extent to which nine factors, including patient sex and race, influenced their likelihood to prescribe opioids or antidepressants, recommend physical therapy, or provide a referral to a pain specialist for each patient profile.

The results of that quantitative study indicated that “four participants used sex as a significant cue when making opioid treatment ratings; specifically, one trainee gave higher opioid ratings to female (virtual humans) and three trainees gave higher opioid ratings to male (virtual humans),” while “trainees made significantly higher antidepressant ratings for white patients than black patients,” according to the authors of the study poster presented at the American Pain Society’s 32nd Annual Scientific Meeting, held May 8-13, 2013, in New Orleans, LA.

More importantly to the researchers, 13 participants reported using patient sex and/or race while making their treatment ratings, and 11 participants demonstrated awareness of the influence of those demographics on their chronic pain treatment decisions.

After completing the quantitative analysis, the researchers conducted individual qualitative interviews with the participants up to eight weeks later to discuss the factors that impacted their treatment decisions. They discovered that the participants demonstrated some awareness of the influence of patient demographics on their ratings, and that the self-aware trainees engaged in more discussion about tailoring and individualizing chronic pain treatments based on patients’ sex and race.

For example, one “aware” participant told the researchers “if there are studies that show … women work better with certain medications than men, then if there’s evidence that backs it up, I’d be willing to try it,” while another “aware” participant said “I feel like women maybe are just more sensitive in how they rate their pain (because) it’s a little more rare to have a guy rating his pain as high as a woman would.”

According to the authors of the poster, “these findings suggest providers’ decision-making awareness influences their care of diverse patients, and early intervention may improve pain management and help reduce pain treatment disparities for all patients.” However, Hollingshead said her initial research on the topic of intervention shows a short-term one — such as verbally informing physicians about their use of patient sex and race in treatment decisions — causes providers to utilize those patient demographics more, and a follow-up study awaiting grant funding will assess the effectiveness of a more long-term intervention.