Improving Health Equity and Addressing Bias in Pain Management

Laura M. Cascella, MA, CPHRM

Bias in healthcare is a persistent issue, both at an institutional and individual level. The downstream effect of this problem is evident in negative outcomes and health disparities for various populations. In particular, issues of bias have been noted in research focusing on variances in pain management. Studies have shown that:

• Racial and ethnic minority patients are less likely than white patients to receive any pain treatment or adequate pain treatment.
• Women are less likely than men to be treated aggressively for pain, and they wait longer to receive treatment for acute pain.
• Patients who have a history of substance abuse are more likely to be viewed as drug-seekers and, as a result, not given adequate pain treatment.
• Factors such as patients’ ages, incomes, and educational levels can affect how providers make decisions about pain management.¹

Addressing and managing bias is a multistep process that involves defining the problem and understanding its consequences, recognizing barriers and challenges that enable bias, and developing organizational-level and provider-level mitigation strategies.

Defining Bias and Understanding Its Consequences

Although the term “bias” often conjures perceptions of overt discrimination, the reality is more complex. Research suggests that much of the bias in pain management — and healthcare for that matter — is implicit rather than explicit (that is, it operates at a subconscious level).² Cognitive processes, learned stereotypes, and ingrained beliefs can be automatically triggered during clinical assessment, reasoning, and decision-making.

An AMA Journal of Ethics article about combating racial bias in pain management explains that “most individuals who are biased are unaware of their biases, and, if given the choice, would not consciously harm others.”³ The author also notes that healthcare providers are likely not aware of personal or institutional-level biases operating within the healthcare system.

Understanding that bias in pain management often is unintentional might feel relieving, but it doesn’t diminish the very real and concerning consequences. Failure to treat pain or poorly treated pain can interfere with how patients recover from illnesses and procedures, which can potentially cascade into numerous patient safety and financial consequences, such as increased morbidity, preventable hospitalizations and readmissions, and liability exposure. Bias in pain management also may lead to misdiagnosis, unnecessary patient suffering, mistrust of healthcare providers, communication lapses, and failure to provide patient-centered care.⁴

Recognizing Factors That Enable Bias

Recognizing bias in pain management is challenging, but addressing it might be even more difficult for various reasons. Foremost, pain is complicated and subjective, which can “open the floodgates to the impact of bias.”⁵ Unlike other conditions and symptoms, such as hypertension or tachycardia, pain cannot be quantified or measured. The subjectivity surrounding pain is reinforced by individual thresholds for pain — two patients who have the same injury might interpret and rank their pain very differently.

Also, because much of the bias in pain management is implicit — and because discrimination runs counter to the ideals of health equity and just culture — healthcare institutions and providers might be reluctant to consider whether they are contributing to this problem.

Even when the problem is recognized, it can be difficult to root out because, as The Joint Commission explains, “stereotypes and prejudices resist change, even when evidence fails to support them or points to the contrary. . . . Studies show people can be committed to egalitarianism, and deliberately work to behave without prejudice, yet still possess hidden negative prejudices or stereotypes.”⁶

Developing Mitigation Strategies

Researchers have studied and proposed a variety of techniques to reduce bias in pain management, and many healthcare organizations and providers are taking steps to acknowledge and address this problem. Developing a two-fold approach that includes organizational-level and provider-level strategies is a prudent method for tackling this challenging issue.

Organizational-Level Strategies

An organizational commitment to implement policies and procedures that address bias in pain management can help elevate the importance of equity in healthcare and reinforce a just culture. Some strategies that have been recommended at the organizational level include:

• Administering the Implicit Association Test (IAT) to assess subconscious feelings, attitudes, and thoughts among providers that may contribute to stereotypes and bias in treatment decisions. Although this test isn’t infallible, UpToDate notes that “IAT remains widely accepted as a good approximation of unconscious biases.”⁷
• Periodically surveying providers and staff members to better understand how they perceive the organization’s policies and actions related to improving diversity and addressing discrimination. Make sure a mechanism is in place that allows workers to provide anonymous feedback.
• Developing and consistently using a protocol to investigate reports of discrimination or unfair policies and practices.
• Supporting workforce training that raises awareness about bias and health disparities and teaches strategies that promote health equity.
• Leveraging data capabilities to (a) monitor and compare patient treatment and outcomes by race, gender, and socioeconomic indicators and (b) implement quality improvement initiatives.
• Providing constructive feedback and offering innovative solutions at various levels (e.g., by department, care unit, staff role, or individual) to address issues of bias.
• Establishing accountability and expectations relative to implementing techniques to reduce bias and improve quality of care.
• Devising strategies to address the burden of high cognitive workload, which may result in providers defaulting to automatic reasoning and decision-making processes that are vulnerable to bias.
• Promoting diversity, empathy, and understanding throughout the organization via methods such as intergroup and equal-status contact, team building, positive association, and counter-stereotype exposure.⁸

Provider-Level Strategies

At the individual level, debiasing techniques generally focus on situational awareness, self-perception, and reflective practice. Some strategies that have been recommended at the provider level include:

• Participating in training to improve situational awareness and better understand metacognition. This type of training may help providers think critically about their thought processes and how biases can affect thinking and reasoning.
• Using techniques such as cognitive forcing functions, which are strategies designed to help practitioners self-monitor their decisions and avoid potential lapses in clinical judgment.
• Learning and implementing skills such as perspective-taking, emotional regulation, and partnership-building to reduce bias and promote empathy, positive feelings, and patient-centered care.
• Working toward a better understanding of cultural beliefs, attitudes, and values that affect various patient populations. The U.S. Department of Health and Human Services’ Think Cultural Health website offers numerous educational resources for different provider types and care settings.
• Using techniques and methods to assist in cross-cultural communication, break down health literacy barriers, and improve provider–patient communication. Examples of such techniques and methods include motivational interviewing, the LEARN model, the explanatory model, the RESPECT model, and the teach-back method.
• Consciously making an effort to see each patient as a unique individual rather than applying stereotypical characteristics, and respecting their personal values, experiences, preferences, and expressed needs.
• Identifying situations that might increase the likelihood of stereotyping or making biased decisions. Acknowledging these situations can help improve overall awareness and understanding.
• Using clinical pathways, adhering to established standards of care, and practicing evidence-based medicine.
• Adhering to the ethical principles of autonomy (patients’ right to make decisions about their healthcare), beneficence (making decisions and taking actions that will benefit patients), nonmaleficence (making decisions and taking actions that will not harm patients), and justice (treating patients fairly and equally according to their situations).⁹

In Summary

The aforementioned strategies show promise in confronting the pervasive issue of bias in pain management, but more research is needed to identify new solutions, determine best practices, and evaluate the feasibility of introducing various techniques into clinical practice. However, with appropriate and ample organizational support, education and training, cognitive resources, self-awareness, and ongoing research, the healthcare community has reason to be optimistic about overcoming disparities in pain management and treatment.

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¹ Campbell, C. M., & Edwards, R. R. (2012). Ethnic differences in pain and pain management. Pain Management, 2(3), 219–230; Drwecki, B. B. (2015, March). Education to identify and combat racial bias in pain treatment. AMA Journal of Ethics, 17(3), 221–228; Fassler, J. (2015, October 15). How doctors take women’s pain less seriously. The Atlantic. Retrieved from www.theatlantic.com/health/archive/2015/10/emergency-room-wait-times-sexism/410515/; Paulson M. R., Dekker, A. H., & Aguilar-Gaxiola, S. (2007, September). Eliminating disparities in pain management. The Journal of the American Osteopathic Association, 107(9 Suppl 5), ES17–20; University of Rochester Medical Center. (2013, June 26). Socioeconomic status plays major role in opioid pain control. Retrieved from www.urmc.rochester.edu/news/story/3868/socioeconomic-status-plays-major-role-in-opioid-pain-control.aspx

² Drwecki, Education to identify and combat racial bias in pain treatment.

³ Ibid.

⁴ Keller, A. (2016, August 24). What every nurse needs to know about pain management. Daily Nurse. Retrieved from http://dailynurse.com/what-every-nurse-needs-to-know-about-pain-management/; The Joint Commission. (2016, April). Quick safety: Implicit bias in healthcare. Retrieved from www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-23-implicit-bias-in-health-care/

⁵ Brooks, K. (2017, May 17). Doctors must be honest about their own biases when treating people in pain. Stat. Retrieved from www.statnews.com/2017/05/17/bias-undertreatment-pain/

⁶ The Joint Commission, Quick safety: Implicit bias in healthcare.

⁷ Bryant, A. (2022, January 28). Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases. UpToDate. Retrieved from www.uptodate.com/contents/racial-and-ethnic-disparities-in-obstetric-and-gynecologic-care-and-role-of-implicit-biases

⁸ The Joint Commission, Quick safety: Implicit bias in healthcare; Drwecki, Education to identify and combat racial bias in pain treatment; Tropp, L. R., & Godsil, R. D. (2015, January 23). Overcoming implicit bias and racial anxiety. Psychology Today. Retrieved from www.psychologytoday.com/blog/sound-science-sound-policy/201501/overcoming-implicit-bias-and-racial-anxiety

⁹ Ibid; Croskerry, P., Singhal, G., & Mamede, S. (2013). Cognitive debiasing 2: Impediments to and strategies for change. BMJ Quality & Safety, 22(Suppl 2), ii65–72; Bernhofer, E. (2011, October 25). Ethics and pain management in hospitalized patients. The Online Journal of Issues in Nursing, 17(1). Retrieved from www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No1-Jan-2012/Ethics-and-Pain-Management.html

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