Patients from ethnic minorities seen in emergency rooms are relatively undertreated for pain, according to a new study (Annals of Emergency Medicine 2000;35:11-6, 77-81).
Doctors at Emory University School of Medicine, Atlanta, Georgia, conducted a retrospective analysis of the medical charts of 217 patients who had presented with long bone fractures to a single urban emergency department over 40 months.
Of the total, 127 patients were black and 90 were white. The patients had similar injuries and similar complaints of pain. Overall, 43%of the black patients received no pain medication whereas only 26% of white patients went untreated for pain.
This is the second study to uncover a racial bias in the prescribing of pain relief. An earlier study conducted by the same authors at the University of California School of Medicine in Los Angeles found that Hispanic patients were also less likely to receive adequate pain relief in the emergency room.
Commenting on the research, Dr Knox Todd, lead author of the latest report, said: “Patient ethnicity affects decision making, independent of objective clinical criteria.” He implied that the racial bias in offering analgesia is not due to differences in pain assessment by physicians or in its reporting by patients. Ingrained racial stereotypes may insidiously and unconsciously make their way into medical practice.
In an accompanying editorial Dr Marcus Martin of the University of Virginia said that his clinical experience suggested that ethnic differences in pain tolerance and expression existed and that pain relief is sometimes withheld because doctors feared drug seeking and substance misuse behaviours in subsets of patients.
Some patients may also be viewed as histrionic and less deserving of pain relief. The manner in which an injury was sustained also plays a part in the prescription of pain relief. For instance, patients who are injured during police fights or during drunken brawls may be considered less deserving of pain relief than those injured during skiing accidents. He called for additional studies to be performed to see if some patients act in a manner that appears less convincing than others, causing physicians to disbelieve their complaints of pain.
Dr Knox and colleagues are calling for standardised criteria for pain assessment to eliminate the racial bias. They concluded: “Efforts to alter pain management practice may be more successful using interventions that target administration of medications and standardise pain assessments, including using clinical guidelines that couple pain ratings with specific recommendations for analgesic use.”
In another accompanying editorial, Dr Louis Goldfrank, director of the New York University School of Medicine's emergency medicine training programme, called for an “affirmative action approach” to solving racial bias.
Figure.
AP PHOTO/GEORGE NIKITIN
A patient waits for emergency treatment in Kaiser Hospital, California. Will she get less pain relief than a white patient?