Photograph by Kevin A. Roberts
“How would you rate your pain on a scale of 1 to 10?” is a bit of a trick question. If you say you’re in excruciating pain—say, a 9—your doctor’s likely to assume the real level is lower. But if you minimize your pain, say it’s a 2 or 3, your doctor may well decide you’re in more pain than you’re willing to admit. “A colleague and I have done several studies on this,” says Raymond Tait, a psychologist who is currently vice president for research at Saint Louis University. “If you report low pain, the assumption is that your pain is higher, and vice versa.
“If there’s actual physical evidence of pain, though, the assessment bumps up,” he continues. “In most instances.”
Seventeen years ago, Tait was running a chronic-pain program at SLU. “Two people would come away with dramatically different conclusions about the same patient,” he recalls. “Chronic pain is to medicine what a Rorschach inkblot is to psychology: You project upon it your own attitudes, beliefs, and prejudices.”
He and John Chibnall, a SLU professor in neurology and psychiatry, started to pay specific attention to studies that suggested a racial bias in how chronic pain was assessed. Tait’s expertise was the psychology of pain; Chibnall brought strengths in research design and statistics. They decided to investigate assessment of one of the most debilitating sources of chronic pain: back injuries at work. That way, they could use Missouri’s workers’-comp database, in which everyone had the same insurance coverage and saw an assigned physician. The ground leveled, they could compare how much treatment the patients received, what kind of treatment they received, what disability rating (and therefore how much money) they were given, and their long-term outcome.
There was just one problem: In their early investigation of bias, Tait and Chibnall had found race to be a highly significant factor. And workers’-comp data in Missouri does not indicate the patient’s race.
“The argument would be, ‘Gee, we believe the provision of workers’-comp treatment is colorblind,’” says Tait. “That presumption, however, flies in the face of the truth. And not collecting the racial data means you can’t even ask the question.”
Tait and Chibnall decided to ask it anyway. They chose the three locations in Missouri with the highest African-American populations: the city of St. Louis, St. Louis County, and Kansas City’s Jackson County. Then they hired a health-research firm to call all 2,934 current workers’-comp patients in those areas. They wound up with almost 1,500 participants, more than 600 African-Americans and nearly 900 Caucasians.
The disability ratings that the black patients received were half as high, on average, as the ratings the white patients received. “Blacks got lower disability ratings and less treatment, with shorter treatment times, and they ended up worse-off physically in the long run,” Tait says.
Whites, meanwhile, were four times more likely to have surgery for their injuries. The frequency of surgery was 28 percent for whites, “possibly too high, given what we know about back-pain treatment,” Tait says, “and 7.8 percent for blacks, too low.”
“You get a higher disability rating if you have surgery,” Chibnall points out, “because presumably you were hurt worse. And that means you get paid more.”
Presumably, then, the white patients with high disability ratings should have suffered worse outcomes. Yet the black patients had more pain and less ability to function. “Disability rating predicts nothing,” Tait says. “The association between the rating and how they were doing two years out was zero.”
Chibnall looks over the top of his wire-rimmed glasses, his eyes dark blue and intense. “Wouldn’t you think something on which the whole edifice is based, the disability rating, would predict more than whether you are black or white?”
How can physicians disagree so consistently—with their patients and with each other—about one of the most important measures of health? Because chronic pain is invisible. The body acclimates to it over time, until it doesn’t even cause a spike in blood pressure. And there’s a natural tendency toward skepticism, especially when an individual stands to gain something—money, medication, time off, at the very least sympathy—by exaggerating the pain.
“The irony,” Tait says, “is that the people who report the highest levels of pain are the people most likely to have their pain discounted—even with evidence.” There are practical, if self-serving reasons: “The doctor who will then be charged with treating the pain has to feel convinced that this is a legitimate problem. And the higher the level of pain, the higher the bar, because they will require aggressive pain care.” Painkillers are dicey to prescribe, back surgeries are dicey to perform, and severe chronic pain is depressing to attempt to treat, because there’s often no way to fix it. “If the pain’s just a 3,” Tait says, “a pat on the head may be enough.”
Pain is a subjective experience: It varies by the hour, depending on people’s mood, their body’s resilience or fatigue, how hopeful or helpless they feel, how all-consuming the pain is, whether it’s sucked all meaning and joy from their lives. And as Chibnall and Tait soon realized, a medical professional’s assessment of pain is just as subjective. “Healthcare—especially in subjective conditions, like pain—is a social interaction,” Tait points out, “and it’s subject to social influences.”
What they needed to know was why certain factors, like race, cause providers to systematically underrate pain in some people and overrate it in others. So they wrote a series of hypothetical scenarios, describing the patients’ characteristics and self-reported pain, and asked physicians and med students to rate the pain.
Other studies echoed what they found: One researcher hired actors to simulate chest pain; another study focused on cancer pain. Consistently, a patient’s race had an effect on physicians’ assessments.
“Stereotyping is probably what’s going on,” says Tait. “If you have a pain complaint from someone who is a minority, almost unconsciously, you require more information that demonstrates validity.”
Class evokes a similar bias. When Tait and Chibnall looked at the amount of treatment given to the back-injury patients, less money was spent on the African-Americans, but less was also spent on patients of low socioeconomic status in general, regardless of race. “Some people would say it’s all socioeconomic and has nothing to do with race,” Chibnall observes. “But we were able to tease that apart multiple times, to show that it’s not one or the other—it’s both.”
Six years after injury, more blacks were on disability, unable to return to work. Yet they had lower disability ratings—thus presumably lesser injuries—than the whites. Were they faking disability? “[Social Security Disability Insurance] is not exactly a gold mine,” Chibnall points out dryly. “And at the time of injury, 95 percent were fully employed.”
Tait’s attention was caught by another six-year finding: People who had retained an attorney because they were dissatisfied with their care ended up reporting more pain and lower function. “One explanation is perceived injustice,” says Tait. “Also, the treatment for persistent back pain is often not curing it, but managing it, and to do that you have to be able to work collaboratively with your providers. If you feel like you are getting shafted…” you can’t trust the provider and relax, so you’re more stressed, and your pain’s worse.
“There are very negative stereotypes about workers’ comp,” says Tait, “and about people with back pain. If you are black, you’ve got back pain, and you got hurt at work...”
Complicating matters, he and Chibnall also found blacks “more likely to report pain at higher levels than whites,” Tait adds. Maybe it’s cultural—emotional expressiveness. Maybe there are genetic differences in pain thresholds and receptors. Or maybe they’re trying to make sure somebody hears them.
They don’t yet know what Tait and Chibnall learned: The more patients emphasize the pain’s severity, the more likely it is to be discounted.
The solution would be to eliminate all bias and then find an objective way to measure pain’s severity. “We all wish you could just poke somebody’s head in a scanner and say, ‘Malingering,’ ‘Pain at the level of 4,’ or ‘Pain at the level of 8,’” Chibnall says. “People have tried. The data are mush.” Even brain scans are too variable to be helpful.
Medical education’s the next best hope—but at most schools, says Tait, there’s about an hour’s worth of pain education across four years of study. Meanwhile, “the data suggest that with every passing year of medical school, the students’ empathy declines,” Tait says. “In fact, there are pretty good data that suggest the more experience the doctor has, the more likely the doctor will estimate pain lower. We also have data saying that surgeons estimate pain at lower levels than internists, we believe because they’re used to seeing people in terrible pain.”
In one study, Chibnall and Tait gave physicians a series of reports on a patient. “Over time, with each new piece of information, the individual physician’s judgments are very consistent,” Chibnall says. “But if you compare the physicians to each other, the rate of agreement is zero—with the same patients.”
At a conference of the Midwest Pain Society, he recalls, “a guy stood up and said, ‘I can explain everything you are talking about. Those people did not comply with treatment.’”
The problem’s not confined to the medical profession; even spouses and friends can be dismissive if they grow weary of a loved one’s complaints. “Humans are exquisitely attuned to social-exchange issues,” Chibnall observes. “If you are claiming something that gets you out of a lot of stuff and makes you a pain in the butt, and nobody can see it, touch it, or feel it, we are instantly suspicious.”
“The tendency,” Tait says, “is for people not to appreciate how debilitating pain can be until they experience it. Then they say, ‘Whoa! This is really bad! I’m depressed, I can’t sleep, I don’t want to eat, I can’t have sex, I’m having trouble working…’”
Tait and Chibnall now have 18 studies based on their original workers’-comp research, published over 17 years in an array of journals. “We want to tie those findings together in a coherent package that can be immediately appreciated,” Tait says, “and see if we can also come up with some guides for action.
“It would be nice to do something that would force people to pay attention.”
