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15 Articles in Volume 21, Issue #4
Advanced Practice Matters: Needs Assessment in Pain Management Training
Analgesics of the Future: Novel Capsaicin Formulation CNTX-4975
Ask the PharmD: How to Improve Medication Adherence in Chronic Pain Management
Behavioral Medicine: Applying Mindfulness-Based Stress Reduction for Comorbid Pain and PTSD
Case Report: Multimodal Management of Osteoarthritis
Commentary: The PCP's Role in Preventing Chronic Back Pain
Guest Editorial: Structural Racism in Pain Practice and How to Combat the “Hidden Curriculum”
Hypermobile Ehlers-Danlos Syndrome: An Update on Therapeutic Approaches for Pain Management
Male Clinicians as Allies in Women’s Leadership: What Your Female Peers Want You to Know
Meet the Women Changing Pain Medicine
Perspective: It’s Time to Advocate for Early Interventional Pain Management
Research Insights: Is Spinal Fusion Surgery Being Overused in Back Pain Care?
Tips from the Field: Treating Pain in an Under-Resourced State
Utilizing Music Therapy to Manage Chronic Pain
Woman to Woman: Leaders Share Advice for the Next Generation of Pain Medicine Clinicians

Guest Editorial: Structural Racism in Pain Practice and How to Combat the “Hidden Curriculum”

Pain management – from training to practice – is not immune to structural and institutional racism. It’s time for unconscious bias to bend toward cultural humility.

Medical education is not immune from perpetuating bias within its curriculum and clinical training. Such accounts are demonstrated when different perspectives are excluded from content, teaching is imbalanced or selective to only one interpretation of an issue, or stereotypes are assigned to specific groups at the cost of individual attributes or differences. The consequences of these unrecognized biases are positioned to enter professional practice, which has the potential to worsen health outcomes, exacerbate health disparities, and increase healthcare costs.1 This conditioning supports the notion of the “hidden curriculum” – a concept that has evolved as medical educators have come to understand and recognize great differences between what is taught and what is really being learned.2

The hidden curriculum can be broadly defined as the attitudes and values conveyed, most often in an implicit and tacit fashion, sometimes unintentionally, via the educational structures, practices, and culture of an educational institution.3 Research studies consistently recognize the persistent role of implicit and explicit biases in the healthcare setting, specifically among vulnerable populations such as racial and ethnic minorities, LGBTQ individuals, children, women, as well as people who are overweight, disabled, or considered to be experiencing behavioral health issues.

Research studies consistently recognize the persistent role of implicit and explicit biases in the healthcare setting, specifically among vulnerable and marginalized populations. (Image: iStock)


Racial Bias Exists in Pain Management, Too

Racial bias in pain management is well documented. There are studies revealing beliefs that Black patients have less sensitive nerve endings than white patients or that Black individuals have thicker skin than any other race and their blood coagulates more slowly. Further, some articles have claimed that Blacks generally experience less pain and thus need lower doses of – or often no – pain medication, and rarely need a narcotic. These ideas may sound absurd, and of course, none of them are valid. Yet almost half of the white medical students and residents in a 2016 University of Virginia study4 answered “true” to one or more of these false statements relating to pain assessment. The trainees were also more likely to report lower pain ratings for a Black patient versus a white patient in mock clinical exams.

Unconscious bias affects everyone in academic medicine and is not limited to your choice of specialty. Seasoned providers make similar biased decisions in professional practice. Several studies show Black patients are less likely to be given pain medications in comparison to their white counterparts, and, if given medication, they receive lower doses or quantities of the same.5

(See also, a discussion of disparities in pain management and a look at treating pain in under-resourced areas).

No one is exempt from bias. The reality is that we are all prone to making snap judgments about people based on stereotypes and “assumption-based” habits. It is our responsibility to make a conscious effort to avoid doing so.

The Need to Move Beyond Bias and Assumptions

Both for the individual and for the medical community at large, addressing quality health outcomes for all is an ongoing challenge. Fundamentally, it requires introspection and a mental shift to focus on differences beyond social constructs such as race and ethnicity, and to re-examine prevailing assumptions about the ways that healthcare is both taught and applied in the real world.

Change requires intentional integration of themes relating to cultural competence (knowledge, skills, and attitudes required to bridge cultural, ethnic, and linguistic gaps between patients and providers), cultural humility(a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic) and social determinants of health7 (circumstances in which people are born, grow up, live, work, and age, and the systems put in place to deal with illness shaped by economic circumstances, social policies, and political factors).

Medical education must also move upstream to create “structurally humble” physicians by incorporating structural competency in both undergraduate and graduate medical education. Structural competency8 builds upon existing cultural competency, cultural humility, and social determinants of health curricular efforts. A structural competency approach not only characterizes the epidemiology of racial health disparities but examines the structures that have created and sustain racial inequities (ie, structural racism).

Inclusion Needs to Start in Medical School

Fulfilling this promise inevitably broadens understanding of diversity, equity, and inclusion (DEI). Medical schools are pivotal to acknowledging that curricula enhancements, research opportunities, and training in public health, population health science, and health equity have a discernable impact.

As science advances, new treatment options and approaches will emerge. What will not change is an individual’s ability ­­– and responsibility – to impart dignity to others, to demonstrate compassion in a time of vulnerability, to act ethically, and to help others in need. Inclusivity in learning and clinical environments is also necessary to sustain such desires and influences engagement, satisfaction, recruitment, and retention.9

See also, how the language of pain matters.

Measuring Diversity, Equity, and Inclusion

Diversity, equity, and inclusion (DEI) is crucial to every aspect of academic medicine and must operate as a priority and core institutional strategy – permeating all aspects of learning, policies, and practices. Leaders and faculty are critical influencers and are well-positioned to serve as change agents by embracing, engaging, and openly acknowledging that diverse people, perspectives, and backgrounds do not compete with excellence, but instead drive it.

Creating a culture and climate that values diversity and inclusion will help support this shift.4,10

How is that achieved? Professional development, education, policy, and practice are all key pillars. The objective is to create an atmosphere that fosters belonging, respect, and value for all and encourages engagement and connection throughout the institution and community.11

Focus on your institution’s culture, climate, and mindsets. Diversity can move from the periphery to a core principle of your institution when excellence is considered in optimal patient care delivery, research, or education. Leaders must carefully examine teaching, learning, training, and levels of satisfaction from all served by the institution. For example, consider these questions:

Are residency program graduates working only in suburban areas, not rural or other underserved areas?

Do our leaders or students reflect the demographics of the populations served?

Is the value of basic science weighed more than translational, population health, community-based, or comparative effectiveness research? 

Are faculty appointment, promotion, and tenure processes fair?

Are expectations different for women or minority faculty, staff, and students compared to those from dominant groups?

Ensure that DEI efforts are measuring success in the right ways. The process of trying to create a diverse, equitable, and inclusive environment can often bring with it a different kind of pain for marginalized individuals or underrepresented minorities working in healthcare. For example, consider the “minority tax” – extra responsibilities placed on minority faculty in the name of diversity. Too often, underrepresented minority faculty are often disproportionately represented in institutional diversity efforts, illustrating the disparity that exists in this area.12

Note that this disparity is evident in many areas, such as racism or bias in the promotion process; feelings of isolation, invisibility, or exclusion; inadequate numbers and shortage of effective mentors; and increased clinical responsibility loads and lack of time for scholarly activity.

These factors support forms of institutional racism – accepted practices within an organization that can, usually unintentionally, create barriers to leadership opportunities and advancement for underrepresented minorities. Well-meaning administrators with limited understanding of DEI may view it as simply checking a box, filling quotas, or accepting others as “less than.” It is much more than that.

Avoid “Tokenism” of the Underrepresented Minority in Medicine

For the individual underrepresented minority (URM) in medicine, this presents an additional challenge to what is already a difficult path. Across disciplines and during all stages of life, URMs of all backgrounds unavoidably serve in “ambassador roles” for their races and ethnicities. They are often the “only” in the class or committee, asked to represent “all” their race13 on any given issue. Not only does this put the individual in an unfair (and unrealistic) position, but it also limits their ability to express their individual strengths and leadership qualities.

This is where factors like key performance indicators, an accountability framework, and other data-driven approaches to advancement help level the playing field and create more equitable learning, clinical, and work environments.

See more on disparities in the medical field with a focus on mental health care in marginalized populations on our sister clinical site, Psycom Pro.


Practical Takeaways: Removing Structural Racism in Pain Practice

Accountability, transparency, and real investments in DEI can go a long way toward keeping an institution on track. Strategies may include:

  • reviewing curriculum to detect bias
  • instituting policies, practices, and procedures that address and correct bias, harassment, and discrimination
  • regularly surveying students, faculty, and staff about the culture
  • hosting frequent town halls with leadership to discuss successes, challenges, and opportunities of existing or potential DEI initiatives
  • increasing networking and mentoring opportunities while avoiding marginalizing or “othering” individuals
  • being open to new ideas

Remember, too, that diversification of the student body, faculty, or professional staff is not the endpoint, nor is the implementation of even the most robust of programs, seminars, and training. All of these are tools that can be harnessed to advance equitable opportunities for professionals in medicine and – as an end goal – health equity for all patients.

In the end, no policy or mandate can make it happen. To paraphrase Dr. Martin Luther King Jr: The ultimate solution to the equality or race problem lies in the willingness of men and women to obey the unenforceable.

The end to this pain lies within you.

*This article is based in part on a presentation given by the authors at the 2020 American College of Rheumatology (ACR Convergence) annual meeting.

Last updated on: July 8, 2021
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Tips from the Field: Treating Pain in an Under-Resourced State
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