Indiana University-Purdue University Indianapolis (IUPUI) / Chronic pain is a common and costly health condition for children. Previous studies have documented racial and gender disparities in pain care for adults, with women and racial minorities receiving poorer pain assessment and treatment. Providers contribute to these disparities when their pain-related decision-making systematically varies across patient demographic groups. Little is known about racial and gender disparities in children with chronic pain, or the extent to which providers contribute to these disparities. In a sample of 129 medical students (henceforth referred to as ‘providers’), Virtual Human (VH) methodology and a pain-related version of the Implicit Association Test (IAT) were used to assess the effects of patient race/gender and provider implicit racial/gender attitudes on providers’ pain assessment and treatment decisions for children with chronic pain. Findings indicated that, in the context of abdominal pain, providers rated Black patients as more distressed (mean difference [MD]=2.33, p<.01, SE=.71, 95% CI=.92, 3.73) and as experiencing more pain-related interference in daily activities (MD=3.14, p<.01, SE=.76, 95% CI=1.63, 4.64) compared to White patients. Providers were also more likely to recommended opioids for Black patients’ pain compared to White patients (MD=2.41, p<.01, SE=.58, 95% CI=1.05, 3.76). Female patients were also perceived to be more distressed by their pain (MD=2.14, p<.01, SE=.79, 95% CI=.58, 3.70), however they there were no differences in treatment recommendations based on patient gender (all ps>.05). The sample reported implicit attitudes that men and Black Americans were more pain-tolerant than their demographic counterparts; however, pain assessment and treatment decisions were not related to these implicit attitudes. This study represents a critical step in research on pain-related disparities in pediatric pain. Future studies are needed to further elucidate specific paths through which the pain experience and consequent treatment differ across racial and gender groups.

<p></p><p> Compared to White and high socioeconomic (SES) patients, Black and low SES patients are less likely to receive adequate pain care, including receiving fewer analgesic medications. Providers may, inadvertently or not, contribute to these disparities in pain care via biased decision-making. Prior work suggests there is a complex relationship in which race and SES uniquely and interactively affect providers’ clinical decisions, but few studies have examined the influence of patient race and SES simultaneously on providers’ pain-related decisions. Furthermore, previous studies suggest that providers’ attitudes about race and SES influence their clinical decisions. The present study examined the influence of patient race and SES and providers’ implicit and explicit attitudes about race and SES on providers' pain-related decisions. Four hundred and seven medical residents and fellows made pain assessment (interference and distress) and treatment (opioids, opioid contracts, and workplace accommodations) decisions for 12 computer-simulated patients with chronic back pain that varied by race (Black/White) and SES (low/high). Subjects completed Implicit Association Tests to assess implicit attitudes and feeling thermometers to assess explicit attitudes about race and SES. Repeated measures ANOVAs indicated that patient race and/or SES had main effects on all pain-related decisions and had interaction effects on providers’ ratings for interference, distress, and workplace accommodations. Providers’ implicit attitudes about race and explicit attitudes about race and SES predicted their pain-related decisions, but these effects were not consistent across all decisions. The current study highlights the need to examine the effects of patient race and SES together, along with providers’ implicit and explicit attitudes, in the context of pain care. Results inform future work that can lead to the development of evidence-based interventions to reduce disparities in pain care.</p><br><p></p>

Chronic pain is a common and costly health condition for children. Previous studies have documented racial and gender disparities in pain care for adults, with women and racial minorities receiving poorer pain assessment and treatment. Providers contribute to these disparities when their pain-related decision-making systematically varies across patient demographic groups. Little is known about racial and gender disparities in children with chronic pain, or the extent to which providers contribute to these disparities. In a sample of 129 medical students (henceforth referred to as ‘providers’), Virtual Human (VH) methodology and a pain-related version of the Implicit Association Test (IAT) were used to assess the effects of patient race/gender and provider implicit racial/gender attitudes on providers’ pain assessment and treatment decisions for children with chronic pain. Findings indicated that, in the context of abdominal pain, providers rated Black patients as more distressed (mean difference [MD]=2.33, p<.01, SE=.71, 95% CI=.92, 3.73) and as experiencing more pain-related interference in daily activities (MD=3.14, p<.01, SE=.76, 95% CI=1.63, 4.64) compared to White patients. Providers were also more likely to recommended opioids for Black patients’ pain compared to White patients (MD=2.41, p<.01, SE=.58, 95% CI=1.05, 3.76). Female patients were also perceived to be more distressed by their pain (MD=2.14, p<.01, SE=.79, 95% CI=.58, 3.70), however they there were no differences in treatment recommendations based on patient gender (all ps>.05). The sample reported implicit attitudes that men and Black Americans were more pain-tolerant than their demographic counterparts; however, pain assessment and treatment decisions were not related to these implicit attitudes. This study represents a critical step in research on pain-related disparities in pediatric pain. Future studies are needed to further elucidate specific paths through which the pain experience and consequent treatment differ across racial and gender groups.<br>

Indiana University-Purdue University Indianapolis (IUPUI) / Compared to White and high socioeconomic (SES) patients, Black and low SES patients are less likely to receive adequate pain care, including receiving fewer analgesic medications. Providers may, inadvertently or not, contribute to these disparities in pain care via biased decision-making. Prior work suggests there is a complex relationship in which race and SES uniquely and interactively affect providers’ clinical decisions, but few studies have examined the influence of patient race and SES simultaneously on providers’ pain-related decisions. Furthermore, previous studies suggest that providers’ attitudes about race and SES influence their clinical decisions. The present study examined the influence of patient race and SES and providers’ implicit and explicit attitudes about race and SES on providers' pain-related decisions. Four hundred and seven medical residents and fellows made pain assessment (interference and distress) and treatment (opioids, opioid contracts, and workplace accommodations) decisions for 12 computer-simulated patients with chronic back pain that varied by race (Black/White) and SES (low/high). Subjects completed Implicit Association Tests to assess implicit attitudes and feeling thermometers to assess explicit attitudes about race and SES. Repeated measures ANOVAs indicated that patient race and/or SES had main effects on all pain-related decisions and had interaction effects on providers’ ratings for interference, distress, and workplace accommodations. Providers’ implicit attitudes about race and explicit attitudes about race and SES predicted their pain-related decisions, but these effects were not consistent across all decisions. The current study highlights the need to examine the effects of patient race and SES together, along with providers’ implicit and explicit attitudes, in the context of pain care. Results inform future work that can lead to the development of evidence-based interventions to reduce disparities in pain care.

Indiana University-Purdue University Indianapolis (IUPUI) / Compared to people who are White and have high socioeconomic status (SES), those who are Black and have low SES are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making—there is compelling evidence that providers are influenced by patient race and SES when making pain treatment decisions. According to the dual process model, people are more likely to be influenced by demographic stereotypes, including implicit beliefs, when they are under high cognitive load (i.e., mental workload). One stereotype belief relevant to pain care is that Black and low SES people are more pain tolerant. Aligned with the dual process model, providers who are under high cognitive load and have strong implicit beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments to them. To test this hypothesis, I recruited physician residents and fellows (n=120) to make pain treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the providers were randomized to the high cognitive load group in which they were interrupted during the decision task to make conversions involving hypertension medications for another patient. Remaining providers completed the task without being interrupted. Providers’ implicit beliefs about race and SES differences in pain tolerance were measured with two separate Implicit Association Tests (IATs). Multilevel modeling indicated that providers recommended stronger medications to low than high SES patients (OR=.68, p=.03). There was also a significant interaction between patient SES and cognitive load (OR=-.56, p=.05) and a trending interaction between patient race and cognitive load (OR=1.7, p=.07). Under low cognitive load, providers recommended more pain treatments to high SES (vs. low SES) and Black (vs. White) patients, but under high cognitive load, providers recommended more pain treatments to low SES (vs. high SES) patients and equivalent treatment to Black and White patients. There were no three-way interactions between patient demographics (race or SES), cognitive load, and providers’ implicit beliefs (race-pain or SES-pain IAT scores). However, there was a trending interaction between patient race and race-pain IAT scores (OR=2.56, p=.09). Providers with stronger implicit beliefs that White people are pain sensitive and Black people are pain tolerant recommended more pain treatments to White patients and fewer pain treatments to Black patients. Lastly, there was a trending effect that providers with stronger implicit beliefs that high SES people are pain sensitive and low SES people are pain tolerant recommended stronger medications in general (OR=13.03, p=.07). Results support that provider cognitive load is clinically relevant and impacts clinical decision-making for chronic pain for racially and socioeconomically diverse patients. Future studies are needed to further understand the impact of cognitive load on providers’ pain care decisions, which may inform evidence-based interventions to improve pain care and reduce disparities.

<p>Compared to people who are White and have high socioeconomic status (SES), those who are Black and have low SES are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making—there is compelling evidence that providers are influenced by patient race and SES when making pain treatment decisions. According to the dual process model, people are more likely to be influenced by demographic stereotypes, including implicit beliefs, when they are under high cognitive load (i.e., mental workload). One stereotype belief relevant to pain care is that Black and low SES people are more pain tolerant. Aligned with the dual process model, providers who are under high cognitive load and have strong implicit beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments to them. To test this hypothesis, I recruited physician residents and fellows (n=120) to make pain treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the providers were randomized to the high cognitive load group in which they were interrupted during the decision task to make conversions involving hypertension medications for another patient. Remaining providers completed the task without being interrupted. Providers’ implicit beliefs about race and SES differences in pain tolerance were measured with two separate Implicit Association Tests (IATs). Multilevel modeling indicated that providers recommended stronger medications to low than high SES patients (OR=.68, p=.03). There was also a significant interaction between patient SES and cognitive load (OR=-.56, p=.05) and a trending interaction between patient race and cognitive load (OR=1.7, p=.07). Under low cognitive load, providers recommended more pain treatments to high SES (vs. low SES) and Black (vs. White) patients, but under high cognitive load, providers recommended more pain treatments to low SES (vs. high SES) patients and equivalent treatment to Black and White patients. There were no three-way interactions between patient demographics (race or SES), cognitive load, and providers’ implicit beliefs (race-pain or SES-pain IAT scores). However, there was a trending interaction between patient race and race-pain IAT scores (OR=2.56, p=.09). Providers with stronger implicit beliefs that White people are pain sensitive and Black people are pain tolerant recommended more pain treatments to White patients and fewer pain treatments to Black patients. Lastly, there was a trending effect that providers with stronger implicit beliefs that high SES people are pain sensitive and low SES people are pain tolerant recommended stronger medications in general (OR=13.03, p=.07). Results support that provider cognitive load is clinically relevant and impacts clinical decision-making for chronic pain for racially and socioeconomically diverse patients. Future studies are needed to further understand the impact of cognitive load on providers’ pain care decisions, which may inform evidence-based interventions to improve pain care and reduce disparities.</p> <p>  </p>