Addressing Bias and Disparities in Pain Management

The DEI Shift's mission is to create a podcast series on diversity, equity, and inclusion (D.E.I.) in medicine that sparks discussion and provides practice-changing data and stories for a physician, student, allied health professional, and health care leader audience. Listeners will be able to gain useful information to improve their practices and environments, to gain empathy, cultural competency, and humility, and to learn more about emerging D.E.I. concepts. The DEI Shift will discuss issues related to gender, race, sexuality, religion, ability, socioeconomics, and so much more.

Course Director and Senior Producer: Dr. DJ Gaines

Co-Hosts: Dr. Candace Sprott

Guest: Dr. Amber Brooks

Production Assistants: Alex Babakanian, Clara Baek, Likitha Aradhyula

Addressing Bias and Disparities in Pain Management" features Dr. Amber Brooks, a board certified anesthesiologist and comprehensive pain management physician. This episode examines the management of acute and chronic pain, focuses on bias that can manifest in treating those with chronic pain and how physicians and members of the health care team can address disparities in groups that have been historically marginalized..

Learning Objectives:

• Define Acute Pain and Chronic Pain
• Describe different biases that can manifest in treating those with chronic pain
• Summarize some of the ways we can address disparities in groups that have been historically marginalized, such as those with limited English proficiency and Sickle Cell Disease
• Explain how a mobile phone intervention can be used to address disparities in populations with limited transportation

[00:00-01:08] Introduction

• Introduction to co-hosts and episode
• ACP Pain Management Learning Series

[01:22-02:28] Introduction to Guest

• Dr. Amber K. Brooks, a board certified anesthesiologist and comprehensive pain management physician

[02:28-04:27] Step in Your Shoes

• Dr. Brooks shares about her travel experience to Addis Ababa, Ethiopia which sparked her interest in addressing disparities in pain management

[04:36-05:30] Definition of Acute Pain and Chronic Pain 

• Dr. Brooks defines acute pain and chronic pain
  • Acute pain: associated with trauma, surgery, etc. Usually lasts a few weeks but  less than 3 to 6 months
  • Chronic pain: pain that extends beyond the normal tissue healing process, usually greater than 3 to 6 months and is present on most days
• Learn more about the continuum of pain throughACP Pain Management Curriculum, Module 1

[05:30-12:02] Common Bias Seen in Pain Management

• Because of the subjective nature of pain, it is common for bias to form towards patients with chronic pain
• In trainees, a common way unconscious bias presents is calling someone a “challenging patient,” which is often learned through the hidden curriculum
• This can also be called confirmation bias, where we interpret data and information based on our own beliefs. It is important we leave room for the patient to tell their story so we minimize bias.
• Bias can also be transmitted through the Electronic Medical Record, so we should be mindful of how we describe patients in our notes
• Candace references an article from 2015 where medical students held misconstrued facts about black patients, such as higher threshold for pain and thicker skin
• We must hold each other accountable about our implicit bias as this is the only way to recognize our own biases and properly address them

[12:03-20:18] Multimodal Approach to Chronic Pain

• A multimodal approach to chronic pain is critical as it address pain from multiple angles, including sleep, mood and physical activity
• Use of non-opiate medications that target both pain and mood, physical therapy and referral to a pain specialist are some examples of a multimodal strategy.
• It is crucial that we spend time listening, establish rapport, trust, and expressing empathy towards our patient’s experience as this helps strengthen the patient-doctor relationship in groups placed at increased risk of disparities.
• The ACP Pain Management Hub has additional resources on how to employ a multimodal approach

[20:19-23:02] Disparities Seen in Patients with Chronic Pain

• Dr. Brooks commonly sees a lack of referrals to a pain specialist for patients suffering from chronic pain
  • Medical mistrust is  a contributing factor. This article helps provide some further learning on this important topic
• In low socioeconomic neighborhoods, there may be disparities in different types of pain medications that are stocked in their pharmacies when compared to other neighborhoods

[23:03-25:22] Ways Disparities Manifest for Marginalized Patients whose English is not Their First Language

• There is an assumption that Hispanic and Latina women traditionally do not want epidurals during labor, but this may be due to language barriers
• Systems-level strategies such as mitigating language barriers and optimizing care coordination can address disparities in this populations
• This article describes the results of a language-concordant educational program about epidurals for Hispanic women
• Certified Medical Interpreters are crucial for our patients to understand the risk and benefits of pain management, even if we think they speak ‘good enough’ English
• This article discusses the impact medical interpreters have in talking about palliative services to patients with limited English proficiency

[25:23-32:23] Addressing Disparities Seen in Those with Sickle Cell Disease

• It is vital that we increase communication between the hematologist, inpatient physicians and other members of the care team
• Dr. Brooks implemented a care plan for patients suffering with an acute sickle cell pain crisis which decreased hospital length of stay and readmission rates
• We must be mindful that patients express their pain in different ways. Someone may appear ‘comfortable’ but could be experiencing severe pain. One of the largest pitfalls is not listening to patients and letting them tell you their experiences of what works and what doesn’t work for them.

Asking open-ended questions is essential. Students and trainees may be in the best position to spend time and present a more complete story from the patient’s perspective

[32:34-36:23]  Steps We Can Take to Dismantle Bias Towards Patients with Chronic Pain

• Hold each other accountable towards addressing each others bias and be open if you are on the receiving end of that feedback
• Step outside of your comfort zone and experience something outside of your lived experience can help you better relate to patients
• If you are at an institution that may lack resources, advocate for those resources by referencing known evidence based interventions  including how they can improve cost and outcomes

[36:32-39:35] How Mobile Phone Interventions Can Address Disparities

• Dr. Brooks shares with us one of her mobile phone interventions to help address disparities in geriatric patients with obesity suffering from chronic pain
• Here is another mobile phone intervention that her group implemented
• Given the recent pivot towards tele-medicine, these interventions are timely and can help address and decrease these disparities

[39:36-41:55] Take Home Points from Dr. Brooks

• All of us have an obligation to our patients and to one another to call each other out respectfully when something is not right
• Important to listen to our patient and let them share their lived experiences
• Dr. Brooks also references an educational series on teaching pain management and bias to trainees

[41:57-43:36] Closing

• Website: www.thedeishift.com
• Twitter/Instagram: @TheDEIShift
• Theme Music: www.chrisdingman.com

Special thanks to  Dr. Tammy Lin, Dr. Tiffany Leung, Dr. Pooja Jaeel, Dr. Maggie Kozman, Alex Babakanian, Clara Baek, Likitha Aradhyula, Cheryl Ruston, Clare Sipler, and

Dr. Davoren Chick for helping to make this project possible.

Contributors

Candance Sprott, MD, MBA, FACP – host

Dirk Gaines, MD, ACP Member – course director and senior producer

Amber K. Brooks, MD - guest

Alexandra Babakanian – production assistant

Likitha Aradhyula – production assistant

Clara Baek – production assistant

Tammy Lin, MD, MPH, FACP - staff
Stock: Abbott Laboratories, AbbVie, Inc., Gilead Sciences, Inc., Sanofi US Services, Inc.

Reviewers

Tiffany Leung, MD, MPH, FACP
Independent Contractor: PlushCare, Inc.

Tammy Lin, MD, MPH, FACP - staff
Stock: Abbott Laboratories, AbbVie, Inc., Gilead Sciences, Inc., Sanofi US Services, Inc.

Relevant financial relationships appear in italics below each individual’s name. All financial relationships have been mitigated. All others have nothing to disclose or no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Release Date: January 20, 2022

Expiration Date: January 20, 2025

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the DEI Shift.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for 0.75 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to .75 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz.  To claim CME credit and MOC points you must achieve a minimum passing score of 66%.  You may take the quiz multiple times to achieve a passing score.