Racial Bias in Pain Perception and Response: Experimental Examination of Automatic and Deliberate Processes

Racial disparities in pain treatment pose a significant public health and scientific problem. Prior studies have demonstrated that clinicians and nonclinicians are less perceptive of, and suggest less treatment for, the pain of African Americans relative to European Americans. Here we investigate the effects of explicit/implicit patient race presentation, patient race, and perceiver race on pain perception and response. African American and European American participants rated pain perception, empathy, helping motivation, and treatment suggestion in response to vignettes about patients' pain. Vignettes were accompanied by a rapid (implicit) or static (explicit) presentation of an African or European American patient's face. Participants perceived and responded more to European American patients in the implicit prime condition, when the effect of patient race was below the level of conscious regulation. This effect was reversed when patient race was presented explicitly. Additionally, female participants perceived and responded more to the pain of all patients, relative to male participants, and in the implicit prime condition, African American participants were more perceptive and responsive than European Americans to the pain of all patients. Taken together, these results suggest that known disparities in pain treatment may be largely due to automatic (below the level of conscious regulation) rather than deliberate (subject to conscious regulation) biases. These biases were not associated with traditional implicit measures of racial attitudes, suggesting that biases in pain perception and response may be independent of general prejudice.PerspectiveResults suggest that racial biases in pain perception and treatment are at least partially due to automatic processes. When the relevance of patient race is made explicit, however, biases are attenuated and even reversed. We also find preliminary evidence that African Americans may be more sensitive to the pain of others than are European Americans.     

Attentional bias to pain and social threat in pediatric patients with functional abdominal pain and pain-free youth before and after performance evaluation

This study investigated attentional biases for pain and social threat versus neutral stimuli in 54 youth with functional abdominal pain (FAP) and 53 healthy control subjects (ages 10 to 16 years). We assessed attentional bias using a visual probe detection task (PDT) that presented pain and social threat words in comparison to neutral words at conscious (1250 ms) and preconscious (20 ms) presentation rates. We administered the PDT before and after random assignment of participants to a laboratory stressor—failure versus success feedback regarding their performance on a challenging computer game. All analyses controlled for trait anxiety. At the conscious rate of stimulus presentation, FAP patients exhibited preferential attention toward pain compared with neutral stimuli and compared with the control group. FAP patients maintained preferential attention toward conscious pain stimuli after performance feedback in both failure and success conditions. At the preconscious rate of stimulus presentation, FAP patients’ attention was neutral at baseline but increased significantly toward pain stimuli after performance feedback in both failure and success conditions. FAP patients’ somatic symptoms increased in both failure and success conditions; control youth’s somatic symptoms only increased after failure. Regarding social threat, neither FAP nor control youth exhibited attentional bias toward social threat compared with neutral stimuli at baseline, but both FAP and control youth in the failure condition significantly increased attention away from social threat after failure feedback. Results suggest that FAP patients preferentially attend to pain stimuli in conscious awareness. Moreover, performance evaluation may activate their preconscious attention to pain stimuli.     

Cultural influences on neural basis of intergroup empathy

Cultures vary in the extent to which people prefer social hierarchical or egalitarian relations between individuals and groups. Here we examined the effect of cultural variation in preference for social hierarchy on the neural basis of intergroup empathy. Using cross-cultural neuroimaging, we measured neural responses while Korean and American participants observed scenes of racial ingroup and outgroup members in emotional pain. Compared to Caucasian-American participants, Korean participants reported experiencing greater empathy and elicited stronger activity in the left temporo-parietal junction (L-TPJ), a region previously associated with mental state inference, for ingroup compared to outgroup members. Furthermore, preferential reactivity within this region to the pain of ingroup relative to outgroup members was associated with greater preference for social hierarchy and ingroup biases in empathy. Together, these results suggest that cultural variation in preference for social hierarchy leads to cultural variation in ingroup-preferences in empathy, due to increased engagement of brain regions associated with representing and inferring the mental states of others.     

Do main caregivers selectively attend to pain-related stimuli in the same way that patients do?

Despite increasing interest in the attentional biases of pain patients towards pain-related stimuli, there have been no investigations of whether the main caregivers of chronic pain patients also selectively attend to pain-related information. We compared the attentional biases to painful or happy faces of 120 chronic pain patients, 118 caregivers, and 50 controls. Analyses found that both patients and caregivers demonstrated biases towards painful faces that were not observed in control participants or to happy faces. Those patients and caregivers who were high in fear of pain demonstrated greater biases than those low in fear of pain, and the biases of the high-in-fear-of-pain group differed significantly from zero. When sub-groups of caregivers were compared, it was found that biases towards painful faces were not observed for those caregivers who accurately identified the level of pain the patient currently reported. In contrast, those caregivers who overestimated or underestimated the patients’ pain demonstrated biases that were significantly greater than zero. These results add to the growing weight of evidence suggesting that biases towards pain-related stimuli are observed in chronic pain patients, but that the nature of the stimuli is important. In addition, the results suggest that caregivers, particularly those who either under- or overestimate the level of pain that the patient reports, also demonstrate similar biases. Future research should investigate the links between caregivers’ biases and the way in which caregivers respond to pain.     

Manipulations of cognitive strategies and intergroup relationships reduce the racial bias in empathic neural responses

Social relationships affect empathy in humans such that empathic neural responses to perceived pain were stronger to racial in-group members than to racial out-group members. Why does the racial bias in empathy (RBE) occur and how can we reduce it? We hypothesized that perceiving an other-race person as a symbol of a racial group, rather than as an individual, decreases references to his/her personal situation and weakens empathy for that person. This hypothesis predicts that individuating other-race persons by increasing attention to each individual's feelings or enclosing other-race individuals within one's own social group can reduce the RBE by increasing empathic neural responses to other-race individuals. In Experiment 1, we recorded event related brain potentials from Chinese adults as they made race judgments on Asian and Caucasian faces with pain or neutral expressions. We identified the RBE by showing that, relative to neutral expressions, pain expressions increased neural responses at 128-188 ms after stimulus onset over the frontal/central brain regions, and this effect was evident for same-race faces but not for other-race faces. Experiments 2 and 3 found that paying attention to observed individual's feelings of pain and including other-race individuals in one's own team for competitions respectively eliminated the RBE by increasing neural responses to pain expressions in other-race faces. Our results indicate that the RBE is not inevitable and that manipulations of both cognitive strategies and intergroup relationships can decrease RBE-related brain activity.     

Impact of being primed with social deception upon observer responses to others’ pain

This study examined whether priming with social deception affects responses (pain estimates, self-reported sympathy, inclination to help) towards others’ pain. We further explored whether the priming effect is mediated by the valence of the patients (positive/negative), as indicated by the participants. First, participants (N = 55) took part in an ‘independent’ delayed memory study in which they read either a neutral text about the use of the health care system (neutral condition) or a text about its misuse (social deception condition). Second, participants watched videos of pain patients performing pain-inducing activities. Participants rated the patients’ pain, the sympathy felt for the patients, and the inclination to help the patients. Third, the participants re-estimated patients’ pain when patients’ self-report of pain was provided. Fourth, pictures of the patients were shown and participants indicated the valence of the patients (positive/negative). Results revealed no direct effect of priming with social deception. However, priming with social deception was related to less positive rating of the valence of the patients, that were related to lower ratings on pain and sympathy, and to larger discrepancies between the ratings of the patients and the observers. The results indicate that observers attribute less pain, feel less sympathy, and take patients’ self-reported pain intensity less into account when the patients are evaluated less positively, which is likely to occur when a cognitive scheme of social deception is primed.     

Discounting pain in the absence of medical evidence is explained by negative evaluation of the patient

This study investigated the effect on observer responses of the presence/absence of information about medical evidence for pain and psychosocial influences on the patient’s pain experience. Additionally, the moderating role of the patient’s pain expressions and the mediating role of the observer’s belief in deception and evaluation of the patient was examined. Sixty-two participants were presented with videos of 4 patients, each accompanied by a vignette describing the presence or absence of both medical evidence for the pain and psychosocial influences on the patient’s pain. Participants estimated patients’ pain and rated their own sympathy and inclination to help; they re-estimated patients’ pain when the patient’s self-report of pain was provided. Finally, participants evaluated each patient as positive or negative and the likelihood that the patient was feigning pain. Participants gave lower ratings on pain, sympathy, and help when medical evidence was absent. Further, in the presence of psychosocial influences, participants took patients’ self-reported pain less into account. Next, only for patients expressing high-intensity pain, information about both medical evidence and psychosocial influences was taken into account. Finally, the observer’s evaluation of the patient and his/her belief in deception fully, respectively partially, explained the effect of medical evidence. The results indicate that discounting pain in the absence of medical evidence may involve negative evaluation of the patient. Further, the patient’s pain expression is a moderating variable, and psychosocial influences negatively impact the degree to which patients’ self-reports are taken into account. The results indicate that contextual information impacts observer responses to pain.     

Review article: Implicit bias towards Aboriginal and Torres Strait Islander patients within Australian emergency departments

Aboriginal and Torres Strait Islander peoples continue to suffer adverse experiences in healthcare, with inequitable care prevalent in emergency settings. Individual, institutional and systemic factors play a significant part in these persisting healthcare disparities, with biases remaining entrenched in healthcare institutions. This includes implicit racial bias which can result in stereotyping of racial minorities and premature diagnostic closure. Furthermore, it may contribute to distrust of medical professionals resulting in higher rates of leave events and hinder racial minorities from seeking care or following treatment recommendations. The aim of this review is to analyse the effect of implicit bias on patient outcomes in the ED in international literature and explore how these studies correlate to an Australian context.     

Racial and Ethnic Disparities in Pain Management in the United States

PURPOSE: To critically examine research on racial and ethnic disparities in pain management with a focus on who has been studied, the magnitude of disparities, and potential explanations for those disparities. DESIGN: A systematic literature review. Articles included were reports of original research in which at least two racial or ethnic groups were compared on adequacy of pain management. METHODS: Review of research articles published between 1990 and 2004 with the primary aim of identifying the influence of race or ethnicity on pain management in the US. Databases were CINAHL, Medline, and Pubmed. Relevant articles were categorized by pain type. Effect sizes were calculated where sufficient data were provided. FINDINGS: Studies were focused on Blacks or African Americans, Whites or non-Hispanic Whites, Hispanics, and Asians. Terms for describing these groups were neither well defined nor consistently used within and across studies. Disparities in pain management were reported in relation to minority status, but the magnitudes of these disparities were mostly small. CONCLUSIONS: Greater clarity and consistency are needed in the use of the terms race, ethnicity, and minority. Groups were treated as if they were homogeneous, and details were lacking about whether subgroups of different races or ethnicities had been studied. Although reported disparities in pain management were small, they were consistent. Further research is needed to examine differences within groups and to explain possible reasons for disparities across groups.     

Potential influence of nurses’ implicit racial bias on maternal mortality

Stark disparities persist in maternal mortality and perinatal outcomes for Black and other birthing people of color, such as Native Americans, and their newborns compared to White people in the United States. An increasing body of research describes the phenomenon of implicit racial bias among providers and how it may affect communication, treatment decisions, the patient care experience, and health outcomes. This synthesis of literature reviews and distills current research on the presence and influence of implicit racial bias among nurses as it may relate to maternal and pregnancy-related care and outcomes. In this paper, we also summarize what is known about implicit racial bias among other types of healthcare providers and interventions that can mitigate its effects, identify a gap in research, and recommend next steps for nurses and nurse researchers.     

Physician implicit attitudes and stereotypes about race and quality of medical care

BACKGROUND: Recent reports speculate that provider implicit attitudes about race may contribute to racial/ethnic health care disparities. OBJECTIVES: We hypothesized that implicit racial bias exists among pediatricians, implicit and explicit measures would differ and implicit measures may be related to quality of care. RESEARCH DESIGN: A single-session, Web survey of academic pediatricians in an urban university measured implicit racial attitudes and stereotypes using a measure of implicit social cognition, the Implicit Association Test (IAT). Explicit (overt) attitudes were measured by self-report. Case vignettes were used to assess quality of care. RESULTS: We found an implicit preference for European Americans relative to African Americans, which was weaker than implicit measures for others in society (mean IAT score = 0.18; P = 0.01; Cohen's d = 0.41). Physicians held an implicit association between European Americans relative to African Americans and the concept of "compliant patient" (mean IAT score = 0.25; P = 0.001; Cohen's d = 0.60) and for African Americans relative to European Americans and the concept of "preferred medical care" (mean IAT score =-0.21; P = 0.001; Cohen's d = 0.64). Medical care differed by patient race in 1 of 4 case vignettes. No significant relationship was found between implicit and explicit measures, or implicit measures and treatment recommendations. CONCLUSIONS: Pediatricians held less implicit race bias compared with other MDs and others in society. Among pediatricians we found evidence of a moderate implicit "perceived patient compliance and race" stereotype. Further research is needed to explore whether physician implicit attitudes and stereotypes about race predict quality of care.     

Exploring Empathic Space: Correlates of Perspective Transformation Ability and Biases in Spatial Attention

Separate lines of research have noted recruitment of parietal cortex during tasks involving visuo-spatial processes and empathy. To explore the relationship between these two functions, a self-other perspective transformation task and a task of spatial attention (line bisection) were administered to 40 healthy participants (19 women). Performance on these tasks was examined in relation to self-reported empathy. Rightward biases in line bisection correlated positively with trait-level self-reported empathic concern, suggesting a left hemisphere mediation of this prosocial personality trait. Unexpectedly, speed of perspective taking in the self-other transformation task correlated negatively with empathic concern, but only in women, which we interpret in light of gender differences in empathy and strategies for egocentric mental transformations. Together, the findings partially support the commonalities in visuo-spatial attention, perspective-taking and empathy. More broadly, they shed additional light on the relationship between basic cognitive functions and complex social constructs.     

Racial and Ethnic Disparities in Pain: Causes and Consequences of Unequal Care

The purpose of our review is to evaluate critically the recent literature on racial and ethnic disparities in pain and to determine how far we have come toward reducing and eliminating disparities in pain. We examined peer-reviewed research articles published between 1990 and early 2009 that focused on racial and ethnic disparities in pain in the United States. The databases used were PubMed, Medline, Scopus, CINAHL, and PsycInfo. The probable causes of minority group disparities in pain are discussed, along with suggested strategies for eliminating pain-related disparities. This review reveals the persistence of racial and ethnic disparities in acute, chronic, cancer, and palliative pain care across the lifespan and treatment settings, with minorities receiving lesser quality pain care than non-Hispanic whites. Although health and health care disparities attract local, state, and federal attention, disparities in pain care continue to be missing from publicized public health agendas and health care reform plans. Ensuring optimal pain care for all is critically important from a public health and policy perspective. A robust research program on disparities in pain is needed, and the results must be successfully translated into practices and policies specifically designed to reduce and eliminate disparities in care.PerspectiveThis review evaluates the recent literature on racial and ethnic disparities in pain and pain treatment. Racial and ethnic disparities in acute pain, chronic cancer pain, and palliative pain care continue to persist. Rigorous research is needed to develop interventions, practices, and policies for eliminating disparities in pain.     

Depression and Pain in Asian and White Americans With Knee Osteoarthritis

Few studies have examined the underlying psychosocial mechanisms of pain in Asian Americans. Using the biopsychosocial model, we sought to determine whether variations in depression contribute to racial group differences in symptomatic knee osteoarthritis pain between Asian Americans and non-Hispanic white Americans. The sample consisted of 100 participants, including 50 Asian Americans (28 Korean Americans, 9 Chinese Americans, 7 Japanese Americans, 5 Filipino Americans, and 1 Indian American) and 50 age- and sex-matched non-Hispanic white Americans with symptomatic knee osteoarthritis pain. The Centers for Epidemiologic Studies Depression Scale was used to assess symptoms of depression, and the Western Ontario and McMaster Universities Osteoarthritis Index and the Graded Chronic Pain Scale were used to measure clinical pain. In addition, quantitative sensory testing was used to measure experimental sensitivity to heat- and mechanically-induced pain. The results indicated that higher levels of depression in Asian Americans may contribute to greater clinical pain and experimental pain sensitivity. These findings add to the growing literature regarding ethnic and racial differences in pain and its associated psychological conditions, and additional research is warranted to strengthen these findings.

Strategies for successful conduct of research with low-income African American populations

Health disparities among racial and ethnic minorities are associated with poor health outcomes. African Americans bear a disproportionate amount of the burden of health disparities. The elimination of health disparities among the nation's racial and ethnic groups requires immediate action that the health care community cannot accomplish in isolation. Eliminating health disparities calls for new and non-traditional partnerships across diverse sectors of the community that include research initiatives using culturally competent and participatory action methodologies. While there is much evidence documenting health disparities in racial and ethnic groups, there is little evidence of successful interventions that address health disparities in African Americans. Furthermore, there is little direction for successful strategies for recruiting African Americans for participation in health disparities research. This article addresses important factors to consider when conducting research with low income African Americans based on the authors' research experience in health promotion and cancer detection and prevention. Strategies for successful conduct of research with low income African American populations are offered.     

The influence of anchoring on pain judgment

Context

Research on decision making suggests that a wide range of spontaneous processes may influence medical judgment.

Objectives

We considered an easily accessible strategy, anchoring and insufficient adjustment, which might contribute to health care professionals’ miscalibration of patients’ pain.

Methods

A sample (n = 423) of physicians, nurses, medical students, and nursing students participated in a computerized task that showed 16 vignettes featuring fictitious patients reporting headache. In the experimental condition, participants were asked to evaluate the severity of the patient’s pain before and after knowing the patient’s rating. In the control condition, participants were shown all information about the patient at the same time and were required to make judgments in a single stage.

Results

When participants could express an initial impression before knowing the patient’s rating, they fully anchored to their initial impressions in almost half of the responses. Moreover, even among those who revised their initial impression, the extent of the revision was often insufficient. Greater anchoring was associated with patients’ ratings that were higher than the participants’ initial impression. Finally, we provided evidence that anchoring increased pain miscalibration. We discuss our findings in terms of their contribution to the understanding of the cognitive processes involved in pain assessment.

Conclusion

When estimating patients’ pain intensity, observers are driven by anchoring, a rule of thumb that might have pernicious consequences in terms of unwarranted overreliance on initial impressions and insufficient revision in light of relevant disconfirming evidence. Taking this heuristic into account might foster accurate pain assessment and treatment.     

Cognitive Biases in Children and Adolescents With Chronic Pain: A Review of Findings and a Call for Developmental Research

Cognitive biases that emphasize bodily harm, injury, and illness could play a role in the maintenance of chronic pain by facilitating fear and avoidance. Whereas extensive research has established attention, interpretation, and memory biases in adults with chronic pain, far less is known about these same biases in children and adolescents with pain. Studying cognitive biases in attention, interpretation, and memory in relation to pain occurring in youth is important because youth is a time when pain can first become chronic, and when relationships between cognitive biases and pain outcomes emerge and stabilize. Thus, youth potentially offers a time window for the prevention of chronic pain problems. In this article, we summarize the growing corpus of data that have measured cognitive biases in relation to pediatric pain. We conclude that although biases in attention, interpretation, and memory characterize children and adolescents with varying pain experiences, questions regarding the direction, magnitude, nature, and role of these biases remain. We call for independent extension of cognitive bias research in children and adolescents, using well powered longitudinal studies with wide age ranges and psychometrically sound experimental measures to clarify these findings and any developmental trends in the links between cognitive biases and pain outcomes.

Assessment and Treatment Recommendations for Pediatric Pain: The Influence of Patient Race,Patient Gender,and Provider Pain-Related Attitudes

Previous studies have documented that racial minorities and women receive poorer pain care than their demographic counterparts. Providers contribute to these disparities when their pain-related decision-making systematically varies across patient groups. Less is known about racial and gender disparities in children with pain or the extent to which providers contribute to these disparities. In a sample of 129 medical students (henceforth referred to as "providers"), Virtual Human methodology and a pain-related version of the Implicit Association Test (IAT) were used to examine the effects of patient race/gender on providers’ pain assessment/treatment decisions for pediatric chronic abdominal pain, as well as the moderating role of provider implicit pain-related race/gender attitudes. Findings indicated that providers rated Black patients as more distressed (mean difference [MD] = 2.33, P < .01, standard error [SE] = .71, 95% confidence interval [CI] = .92, 3.73) and as experiencing more pain-related interference (MD = 3.14, P < .01, SE = .76, 95% CI = 1.63, 4.64) compared to White patients. Providers were more likely to recommend opioids for Black patients than White patients (MD = 2.41, P < .01, SE = .58, 95% CI = 1.05, 3.76). Female patients were perceived to be more distressed by their pain (MD = 2.14, P < .01, SE = .79, 95% CI = .58, 3.70) than male patients, however there were no gender differences in treatment recommendations. IAT results indicated that providers held implicit attitudes that Black Americans (M = .19, standard deviation [SD] = .29) and males (M = .38, SD = .29) were more pain-tolerant than their demographic counterparts; however, these implicit attitudes did not significantly moderate their pain assessment/treatment decisions. Future studies are needed to elucidate specific paths through which the pain experience and care of children differ across racial and gender groups.PerspectiveProviders’ pain assessment (ie, pain distress/pain interference) and treatment (ie, opioids) of pediatric pain differs across patient race and to a lesser extent, patient gender. This study represents a critical step in research on pain-related disparities in pediatric pain.     

Recruitment and entrance of participants into a physical activity intervention for hypertensive African American women

Decreasing health disparities between White Americans and racial/ethnic minority populations is a public health priority. An ongoing inability to attract sufficient numbers of African Americans and other people of color to participate in research studies is a major barrier to accomplishing this goal. Participation of racial/ethnic minorities in intervention studies is especially critical to the development of appropriate strategies to promote health among these populations. This article examines the effectiveness of preintervention meetings as well as interactions between African American research team members and potential participants as recruitment strategies. Intersections between recruitment and health promotion are also addressed.     

The impact of patients’ gender,race, and age on health care professionals’ pain management decisions: An online survey using virtual human technology

Background

Previous literature indicates that biases exist in pain ratings. Healthcare professionals have been found to use patient demographic cues such as sex, race, and age when making decisions about pain treatment. However, there has been little research comparing healthcare professionals’ (i.e., physicians and nurses) pain decision policies based on patient demographic cues.

Methods

The current study used virtual human technology to examine the impact of patients’ sex, race, and age on healthcare professionals’ pain ratings. One hundred and ninety-three healthcare professionals (nurses and physicians) participated in this online study.

Results

Healthcare professionals assessed virtual human patients who were male and African American to be experiencing greater pain intensity and were more willing to administer opioid analgesics to them than to their demographic counterparts. Similarly, nurses were more willing to administer opioids make treatment decisions than physicians. There was also a significant virtual human-sex by healthcare professional interaction for pain assessment and treatment decisions. The sex difference (male > female) was greater for nurses than physicians.

Conclusions

Results replicated findings of previous studies using virtual human patients to assess the effect of sex, race, and age in pain decision-making. In addition, healthcare professionals’ pain ratings differed depending on healthcare profession. Nurses were more likely to rate pain higher and be more willing to administer opioid analgesics than were physicians. Healthcare professionals rated male and African American virtual human patients as having higher pain in most pain assessment and treatment domains compared to their demographic counterparts. Similarly the virtual human-sex difference ratings were more pronounced for nurses than physicians. Given the large number of patients seen throughout the healthcare professionals’ careers, these pain practice biases have important public health implications. This study suggests attention to the influence of patient demographic cues in pain management education is needed.