Over the last several decades we’ve learned a lot about the role of bias in the way that individuals are treated in the healthcare setting. Race and ethnicity, gender, sexual identity and orientation, disability status or special health care needs, geographic location (rural and urban) can all have a dramatic impact on the type and quality of health care we receive.
As we dive into this topic, there are a couple of key concepts we need to discuss. The first is the concept of Health Disparity. What do we mean when we say health disparity? According to Healthy People 2020 (1) a health disparity is defined as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” Understanding where and how these health disparities exist is the first step to addressing them. Disparities include information like: Among working-age US adults, over 40% of low-income and non-Hispanic Black adults have untreated tooth decay (2); From 1999 through 2015, both rural and urban all-cause mortality rates decreased, but decreases were greater in urban areas, which increased the disparity for all-cause age-adjusted mortality between rural and urban regions of the U.S. (3) Hispanic/Latino and Black/African-American women have higher rates of cervical cancer than women of other racial/ethnic groups(4). These are just a few examples that illustrate the type of health disparities that exist.
Now let's turn our attention to health CARE disparities which looks at the treatment that people receive and how race and ethnicity, gender, sexual identity and orientation, disability status or special health care needs, geographic location impact the type and quality of care that individuals receive. A health care disparity typically refers to differences between groups in health insurance coverage, access to and use of care, and quality of care (5). Where health disparities are often related to systemic issues outside of the healthcare system or basic access to the health care system, health care disparities are related to differences in care that emerge from biases and prejudice, stereotyping, and uncertainty in communication and clinical decision making and three main mechanisms are offered in producing these discriminatory patterns: 1) bias (or prejudice) against minorities; 2) greater clinical uncertainty when interacting with minority patients; and 3) beliefs (or stereotypes) held by the provider about the behavior or health of minorities (6). An example of a health care disparity is illustrated by a study conducted by Schulman et al. (1999), which looked at physician recommendation for management of chest pain. The study found that found that physicians were less likely to recommend cardiac catheterization procedures for women and African Americans, suggesting that they were 40% less likely to be recommended for catheterization than for whites and men. This is one of many examples where various forms of bias or discrimination enter the clinical encounter.
Now let's turn our attention to issues related to chronic pain and how bias or discrimination can affect the treatment and management of pain. Pain is often referred to as an invisible disability. There is no objective measure of pain and there is a wide degree of variability in how individuals experience pain. This means there is a LARGE degree of clinical uncertainty (see mechanism 3 above) that creates a significant opportunity for possible bias and discrimination as the physician must rely on the subjective reports of the patient and in turn make a subjective decision about the credibility of the report and how to treat the condition. To illustrate this concept let’s look at a meta analysis conducted by Morales and Yong (2020) looking at literature on disparities within the treatment of chronic pain in the United States published between January 2000 and June 2020 (7). Many findings of disparity were identified, too many to discuss them all, but a few examples include: For a diagnosis of nonmalignant chronic pain Hispanic patients were less likely to receive opioids than were non-Hispanic patients; Patients with private health insurance were less likely to be prescribed opioids than were patients with Medicare coverage; Among adults with chronic abdominal pain treated in outpatient clinics, Blacks were less likely to be prescribed opioids; Rural patients were more likely to be prescribed opioids than were nonrural patients; Rural Blacks were less likely to receive physical therapy than were urban Blacks.
What this study illustrates is the complex mechanisms of how heath disparity interacts with bias and discrimination to create the very real effect of treatment disparity, especially in areas as subjective as pain management. The point of this is to highlight the complexity of making treatment decisions in chronic pain conditions. When making treatment decisions regarding chronic pain it’s important to remember the strong potential for bias.
Editor's Note: For more info on the topic, check out this month's Spotlight on Chronic Pain
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Jeff Mann, Psy.D., is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences.
6: Institute of Medicine 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/12875
7: Mary E Morales, MD, R Jason Yong, MD, MBA, Racial and Ethnic Disparities in the Treatment of Chronic Pain, Pain Medicine, Volume 22, Issue 1, January 2021, Pages 75–90, https://doi-org.usu01.idm.oclc.org/10.1093/pm/pnaa427