Burgess DJ (Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VAMC), van Ryn M
(University of Minnesota), Dovidio J
(Yale University), Matoka MC
(Center for Health Equity Research and Promotion (CHERP), Pittsburgh VAMC), Saha S
(Portland VAMC), Phelan S
(University of Minnesota), Roth C
(Minneapolis VAMC), Kerns R
Nonwhite patients are less likely than white patients to have their pain adequately treated. This study examined the influence of patient race and patient verbal and nonverbal behavior on physicians’ treatment decisions for chronic low back pain. The primary hypothesis was that physicians would be more likely to manifest racial bias when patients’ verbal and nonverbal behaviors behaved in a “challenging” manner that raised “red flags” about advisability of prescribing opioid analgesics.
We randomly assigned physicians to receive one of 8 versions of a paper-based, clinical vignette presented as a “photonovella”: serial photographs accompanied by a “script” depicting a male patient in a physician’s office, seeking relief for chronic low back pain. The 8 versions differed in terms of patient race (white vs. black), verbal behavior (“challenging” vs. “non-challenging”), and nonverbal behavior (confident vs. sad vs. angry). We employed a between-subjects factorial design and surveyed primary care physicians (N=382), randomly selected from the American Medical Association Physician Masterfile. The primary dependent measure was the surveyed physician’s decision as to whether (s)he would switch the patient to a higher dose or stronger type of opioid. Logistic regression was used to determine the effects of patient characteristics on physicians’ prescribing decisions.
There was a significant interaction between patient verbal behavior and patient race on physicians’ decisions to prescribe opioids (p=.02), which was counter to our hypothesis. Among white patients, physicians were more likely to state that they would switch to a higher dose or stronger opioid for patients exhibiting “non-challenging” (64.3%) versus “challenging” (54.5%) verbal behaviors (e.g., demanding a specific narcotic, exhibiting anger). However, for black patients, physicians were more likely to escalate treatment for patients exhibiting “challenging” behaviors (68.8%) compared to those exhibiting “non-challenging” behaviors (55.1%).
Patient race influenced physicians’ decisions about pain treatment, but the effect was modified by patient behavior.
Non-clinical factors such as patient race affect clinical decisions in complex ways. Better understanding of this complexity is needed to remedy the effect of racial bias on pain management and other clinical decision making.