A few of you wrote me about the results of this study funded by the U.S. Department of Health and Human Services on the disparity in the pain management in the ER based on ethnicity. It's appalling.
The study, which analyzed treatments for more than 150,000 pain-related visits to U.S. hospitals between 1993 and 2005, found 23 percent of blacks and 24 percent of Hispanics received opioids compared with 31 percent of whites. Twenty-eight percent of Asians and other groups received opioids.– Differences in prescribing between whites and non-whites were greater among people with the worst pain. Among patients in severe pain, opioids were prescribed to 52 percent of whites, 42 percent of Hispanics and 39 percent of blacks.
– Blacks were prescribed opioids at lower rates than other groups for almost every type of pain-related emergency department visit, including back pain (33 percent for blacks versus 48 percent for whites), headache (22 percent versus 35 percent) and abdominal pain (20 percent versus 32 percent).
– Opioids were prescribed less often for blacks than whites for kidney stones (56 percent to 72 percent) and long bone fractures (45 percent to 52 percent).
– Non-opioid pain relievers, such as acetaminophen (sold as Tylenol), were prescribed more for non-whites (36 percent) than whites (26 percent).
This study is particularly timely since I've 1) been to the ER recently and 2) had gall bladder surgery last week. Both resulted in my receiving morphine while inpatient and pain-relieving opioid drugs for use at home. While I can't say that I experienced biased care and withholding of these medications because of my race, I have no doubt that implicit bias plays a role in denial of adequate medical pain management in many cases. I was simply fortunate.
I highly recommend Blender JulieWaters' diary on this, Medical care and racism: this is your war on drugs, which I noticed while working on this post. It gets to the heart of the third rail discussions that you all simply love to comment about — not.
This is about having a discussion about the spectrum of racism and bias, not accusing people of running around in a Klan Night Rider hood. People often head straight for the defensive zone there to make sure everyone knows they aren't "racist," when in fact this study proves that implicit bias has direct impact on minority health and well being. It's there, and it's dangerous.
And it's not a matter of whites shouldering all the blame for holding those biases. See after the jump.When talking about racism, it's easy to reduce it to the simplistic: to assume that everyone's racist to some degree and that while whites can act racist towards blacks, sometimes blacks are racist against whites as well. So let's get that out of the way first, by distinguishing between "small r" racism, which is personal racism: "I don't think I'd ever want to date a black man." "I lock my doors in that neighborhood." While problematic, occasional personal individual racism is not nearly as damaging as large-scale ("big R") institutional Racism, which is just intensely dangerous and is implemented nearly universally to the detriment of non-whites.
That doesn't leave anyone off the hook for providing inadequate health care, but this is a perfect example of misguided, misinformed attitudes affecting the health and welfare of individuals in dire pain based on preconceived notions about their ethnicity. This is a call for all of us to be honest about implicit bias.
"It's time to move past describing disparities and work on narrowing them," said Dr. Thomas L. Fisher, an emergency room doctor at the University of Chicago Medical Center who was not involved in the study. Fisher, who is black, said he is not immune to letting subconscious assumptions inappropriately influence his work as a doctor. "If anybody argues they have no social biases that sway clinical practice, they have not been thoughtful about the issue or they're not being honest with themselves," he said.
The study doesn't go into motivation for withholding adequate pain management, but one can assume some doctors believe blacks are more prone to abuse opioids, even though this flies in the face of the facts — blacks are the group least likely to abuse them.
While it's possible some doctors and nurses are doing this consciously, most do so because of the biases they hold based on the legacy of racism that permeates our culture. These medical professionals simply don't even think about whether they care for one group of patients differently than another. That doesn't make them evil, it merely means better ways to make health care providers more self-aware and diligent in doling out medical services based on the ailment, not the recipient's skin tone.
If you've ever been to the ER with kidney stones or a gall bladder attack, being denied adequate medication based on the biases of a health care provider is a sad commentary on our culture. Tossing someone non-opioid pain relievers on their way out of the ER, such as acetaminophen, simply won't cut it for either of the above woes.
I'm sure that differences in patient self-advocacy for requesting pain medication, also noted in the study press release, has some impact. It would be interesting to see statistics on how often minorities request additional pain medication or are aware that they should declare pain levels to the health care provider. I know I am always asked to rate my pain on a scale of 1-10. As I noted in an earlier post, my "10" is kidney stone pain, so I have a frame of reference.
If you want to examine your own implicit biases on race, gender, orientation, and all sorts of matters (and maybe you don't want to stomach it), you can try several out at Harvard's Project Implicit.
***
Alert -patient whining ahead: My incisions are healing well, btw, and most of the CO2 I was pumped up with for the operation is dissipating. I am still not able to sleep in any position other than my back, since side sleeping is excruciating and tummy sleeping is impossible (I’m a tummy sleeper).
However, yesterday was a horrid day. I’ve gone out a couple of times, and I’ve been terribly tired after even a short jaunt, particularly if I’ve eaten anything. I get winded quickly because two of the incisions seem to affect my diaphragm, so taking in air is constrained. Having food in there doesn’t help. Wearing pants hurts. Any pressure on my abdomen is unpleasant (I’ve been walking around in long nightgowns/nightshirts when at home), so when I do put on the pants to go out, it is an unwelcome restriction.
The worst part yesterday is that I got into a coughing jag and hurled and it felt like I was going to split my glued guts open. I was so sore afterwards that my whole body felt like it had been hit by a train, so I gave in and took meds, laid down, and somehow woke up 4 hours later as if no time had elapsed. [And these misguided health care folks in the ER are worried about black folks loading up on prescription pain killers? I want off of them ASAP — I can’t imagine the amount of laxative Rush Limbaugh had to take to counteract the massive amount of oxycontin he took for months and months. Is it just a coincidence why he ended up with cochlear implants? High consumption of oxy can kill ear hair cells and cause deafness. My wife Kate, who’s an audiologist, said he had to be on an ungodly amount for that to occur.]
This AM the pain seems to include my back flank (both sides), sort of where my kidneys are. Sigh. I know it’s still less than a week after surgery, but I’m tired of this already. At this rate I’ll sleep through the Iowa caucuses…
Kate had to go back to work today, so I have to attempt to be a good patient on my own. Her mom is flying in today to stay with us for a few days, and she’s going to take over the monitoring of me to make sure I stay out of trouble.
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Yeah, but there are also racial disparities in how medical people react to “patient self-advocacy.” My dad recently went to the emergency room for a kidney stone, and the triage person decided his pain wasn’t important and had him sit around for three hours, in agony. Finally, after spending three hours begging the triage nurse to get my dad looked at, my mom marched up, wrote down the person’s name, and said that if my father didn’t get some drugs in five minutes, she would find a way to make sure that the triage nurse lost her job. I don’t know what bullshit she made up: I think she may have claimed to be close friends with a leading malpractice lawyer. Anyway, my dad got his drugs within five minutes.
So here’s the thing. My parents are white and upper-middle-class. If any black person, or a white person who seemed less moneyed, threatened to the triage nurse, they’d probably get kicked out, rather than treated. And my hunch is that less-privileged people are less likely than my parents to issue threats and make demands, because they’re conscious of the possibility of bad consequences. Medical people expect deference from everyone, but they’re more willing to accept lapses in deference from some people. And they’re likely to construe furious black people as scary and threatening, I bet.
I’ve got more to say about this, but I’m visiting friends and am already being rude. Will say more later. This disparity in health care stuff is something I’ve thought a lot about, as a middle-class white person who receives care at a hospital that serves mostly working-class black people.
Yeah, but there are also racial disparities in how medical people react to “patient self-advocacy.” My dad recently went to the emergency room for a kidney stone, and the triage person decided his pain wasn’t important and had him sit around for three hours, in agony. Finally, after spending three hours begging the triage nurse to get my dad looked at, my mom marched up, wrote down the person’s name, and said that if my father didn’t get some drugs in five minutes, she would find a way to make sure that the triage nurse lost her job. I don’t know what bullshit she made up: I think she may have claimed to be close friends with a leading malpractice lawyer. Anyway, my dad got his drugs within five minutes.
So here’s the thing. My parents are white and upper-middle-class. If any black person, or a white person who seemed less moneyed, threatened to the triage nurse, they’d probably get kicked out, rather than treated. And my hunch is that less-privileged people are less likely than my parents to issue threats and make demands, because they’re conscious of the possibility of bad consequences. Medical people expect deference from everyone, but they’re more willing to accept lapses in deference from some people. And they’re likely to construe furious black people as scary and threatening, I bet.
I’ve got more to say about this, but I’m visiting friends and am already being rude. Will say more later.
Stuff like this always makes me feel so helpless. My study of history has led me to conclude that racism has done more to fuck things up in the U.S. than anything else, ever. It helps I suppose to educate ourselves and be aware of this sort of implicit bias (or whatever you want to call it) but I feel very frustrated because it seems to me that I have had only limited success, if any, in getting rid of it in myself. I still catch myself out thinking (sometimes even saying) stuff that rests on assumptions and what not that are racist.
I had an incision when I had gallblader surgery in the summer of ‘82. The cut was about 4-5 inches long. Since it was at a military teaching hospital, I know that half way through sewing me up, the surgeon passed the needle over to the young, just out of med school intern to complete the job as there is/was a noticeable difference in the sewing style. The lower half of the incision became infected and I wound up having to shower three times a day and swab my insides with iodine.
But far and away, the worst pain I’ve ever personally felt was the first time I sneezed without warning (a week after the surgery). I had sneezed before but had warning so was able to to brace myself.
In the long run, you will be far better off without the gallbladder though and the current inconvenience’s (and others upcoming as you adjust) are well worth the aggravation
As far as addiction and pain medication (I really don’t remember what they gave me), I’m pretty sure that there are a whole lot of white folks like me, who come from families with a lot of alcoholics/addictive personalities. Of course, that belies the assumptions shown in the ER which means I could likely go get some nice drugs and not be loooked at as a potential criminal.
Remember Edith Rodriguez, who died on the floor of the waiting room at King-Drew Medical Center here in Los Angeles? She died because the doctors and nurses assumed she was a drug seeker who was faking her pain.
Yikes, pain management is sufficiently FU’d without adding non-medical biases into the fray. Mind you, I have plenty of white family members who have over medicated because “if a doctor prescribes it it can’t be bad for you” or “if one is good, then two must be better.”
I feel for you on the sleeping angle, I’m a tummy sleeper but due to a flattened disk I had to learn to sleep on my side. Now I have to learn to sleep on my back because I ended up freezing a rib (that results in a pain that just keeps on giving, sheesh) from sleeping on my left side only. You would think that sleeping would come naturally but apparently you can actually do it wrong.
It is not surprising to find a racial element in the denial of pain meds, but it’s worth noting that the War on Some People’s Drugs has led to general undermedication of pain for everyone.
Why are we ignoring the possibility that minorities aren’t being denied medication but that whites might be getting too much? Whites are statistically more likely to abuse prescription medications than any other racial group. The current situation may be the result of systemic and long term overprescription of addictive substances.
Neither situation is pretty but there seem to be a number of assumptions being made here when all that’s been established is a correlation, not a causation.
WTF? I’ve been in for kidney surgery and kidney stones and I just couldn’t stand it without the vicodin. Give me the the mild opiate haze over trying to muddle by on toxic levels of acetomenophin.
Ouch. My commiserations, Pam. What a shitty way to spend the holiday.
Doctors can be pretty stinky about pain meds in general, in part because they’re intimidated by the DEA (no lie). Add racial prejudice to this equation, and it gets even uglier.
And of course lousy pain management translates pretty directly into more complications, shorter life expectancy.
I do wonder, though, how much of the difference is based on racist assumptions about whether the patient “deserves” or will abuse the drugs and how much on racist assumptions about whether the patient will be able to obtain/afford them. (Fer example, one of the illiberal, pandering things Howard Dean did as governor was to take oxycontin off the state formulary so that poor people couldn’t get good pain relief.)
Sorry to hear about your difficulties recovering. Ouch!
Speaking of pain, racism hurts, especially when you’re getting treated for painful medical conditions. It’s really a medical ethics issue that everyone get treated to the best of their providers’ ability– without discrimination. The study also speaks to the problems with healthcare in general– if you can afford care in the first place, what kind of a ridiculous slap in the face is it to arrive and not even get the relief that other (mostly white people, in the same class who can afford what passes for quality medical care) people believe they’re *paying* for? Getting our wallets out of the system is one part of the solution, and getting bias out of the heads and hands of practitioners is another.
Wow, I could play around on that Project Implicit page all day.
“Why are we ignoring the possibility that minorities aren’t being denied medication but that whites might be getting too much? Whites are statistically more likely to abuse prescription medications than any other racial group. The current situation may be the result of systemic and long term overprescription of addictive substances.”
I can’t speak for all causes of pain and their treatment regimens, but it is a well known fact that when it comes to many pain-causing conditions, such as cancer, American medical professionals tend to under-prescribe pain medications, not over-prescribe.
There is a huge cultural bias against opiates in general (which tend to be the most effective analgesics), tracing back over the last 50-75 years, and combined with the government’s War On Drugs, many doctors are fearful of prescribing the most effective pain medications.
So while you have high-profile abusers like Rush “Pills” Limbaugh who make a lot of press being prescription junkies, there are a huge number of people who are suffering horribly because they are unable to get access to the medications (or adequate doses) they need to properly treat their pain…
Damn, I’m sorry to hear about the coughing thing - I can sympathize, having (AFAIK) cracked my sternum in that accident six weeks ago and *still* having pain from sneezing/laughing etc, tho’ not (anymore) incapacitating. No insurance, ergo no doctor, so toughed out w/alleve and whiskey.
I would say tho’ that the painkiller stuff is evil, that this is the nature, of what evil is - utterly banal, all around us, and therefore invisible.
Moderation is our friend…dammit…
Had a long talk with a doctor friend of mine about his work in the emergency room. We were talking about diagnosing people and how that happens (I was working on a computer/video simulation of a diagnosis in an ER). What struck me as significant (but not him) is how large a proportion of an ER doctor’s time and training is spent trying to figure out which ER patients are actually drug abusers scamming the system to get legal drugs to feed their illegal habits. I wanted to talk about how good doctors as opposed to bad doctors begin the process of figuring out what is wrong with sick people from the moment the doctor walks in the room, before they order tests. He wanted to talk about how experienced doctors screen out fakers (first) before they get to diagnosing the really sick people. I pointed out that the legal system (the war on drugs) is actually forcing doctors to be police and waste their time “detecting” who deserves medical care and who doesn’t. Why not just give drug addicts the drugs they want and kick them out of the ER satisfied so you could spend your time trying to figure out whether patient X has appendicitis or patient Y has a tumor? He’d never thought of it that way. The war on drugs and the struggle of the DEA to prevent doctors from writing scrip for phony patients or being scammed by drug addicts for narcotics that they don’t “need” has put an extra layer between the doctor and the sick person–suspicion. And that suspicion of wrong doing by the patient, all patients, is heightened by class and race issues and by the doctor’s own experience of the community he serves. Everyone remember the case of the obese african american woman who was *arrested* for disorderly conduct in the ER and then *died of a perforated ulcer* as she was being taken out to the police car? That example, which to most of us stood out for its absurdity (the nurses and doctors of that hospital didn’t trust the woman’s self reported pain and refused to take her seriously. They treated her pain and fear as “disorderly.”) struck my (very nice) doctor friend as *perfectly reasonable* considering the number of times in his career that drug addicts and other scam artists have tried to trick him into prescribing pain meds. The whole system of illegality cputs doctors and nurses and ER’s on the front line of preventing sick, addicted, and disorderly and dangerous people fromg etting something they want. Shifting the burden away from clinics and allowing addicts to determine how much of their own poison they want to take would mean that patients in hospitals and er’s wouldn’t have to all be put under suspicion. Its a terrible system and it makes racism and classism and sexism a component part of its functioning because those are the actual diagnostic tool used to separate “needy” patients from “faking” addicts.
aimai
Had a long talk with a doctor friend of mine about his work in the emergency room. We were talking about diagnosing people and how that happens (I was working on a computer/video simulation of a diagnosis in an ER). What struck me as significant (but not him) is how large a proportion of an ER doctor’s time and training is spent trying to figure out which ER patients are actually drug abusers scamming the system to get legal drugs to feed their illegal habits. I wanted to talk about how good doctors as opposed to bad doctors begin the process of figuring out what is wrong with sick people from the moment the doctor walks in the room, before they order tests. He wanted to talk about how experienced doctors screen out fakers (first) before they get to diagnosing the really sick people. I pointed out that the legal system (the war on drugs) is actually forcing doctors to be police and waste their time “detecting” who deserves medical care and who doesn’t. Why not just give drug addicts the drugs they want and kick them out of the ER satisfied so you could spend your time trying to figure out whether patient X has appendicitis or patient Y has a tumor? He’d never thought of it that way. The war on drugs and the struggle of the DEA to prevent doctors from writing scrip for phony patients or being scammed by drug addicts for narcotics that they don’t “need” has put an extra layer between the doctor and the sick person–suspicion. And that suspicion of wrong doing by the patient, all patients, is heightened by class and race issues and by the doctor’s own experience of the community he serves. Everyone remember the case of the obese african american woman who was *arrested* for disorderly conduct in the ER and then *died of a perforated ulcer* as she was being taken out to the police car? That example, which to most of us stood out for its absurdity (the nurses and doctors of that hospital didn’t trust the woman’s self reported pain and refused to take her seriously. They treated her pain and fear as “disorderly.”) struck my (very nice) doctor friend as *perfectly reasonable* considering the number of times in his career that drug addicts and other scam artists have tried to trick him into prescribing pain meds. The whole system of illegality cputs doctors and nurses and ER’s on the front line of preventing sick, addicted, and disorderly and dangerous people fromg etting something they want. Shifting the burden away from clinics and allowing addicts to determine how much of their own poison they want to take would mean that patients in hospitals and er’s wouldn’t have to all be put under suspicion. Its a terrible system and it makes racism and classism and sexism a component part of its functioning because those are the actual diagnostic tool used to separate “needy” patients from “faking” addicts.
aimai
Family and friends have been going through these sorts of things lately. My grandmother was in severe pain for the couple weeks before she died, including after having her lower leg amputated. They were incredibly reluctant to prescribe IV opiods even though those were the only things that alleviated the pain and allowed her to rest (she was lucky my mother, a former nurse, was there to advocate for her).
We were talking about that the other day, and about increasing the drip a little for those in terminal pain….
Had a long talk with a doctor friend of mine about his work in the emergency room. We were talking about diagnosing people and how that happens (I was working on a computer/video simulation of a diagnosis in an ER). What struck me as significant (but not him) is how large a proportion of an ER doctor’s time and training is spent trying to figure out which ER patients are actually drug abusers scamming the system to get legal drugs to feed their illegal habits. I wanted to talk about how good doctors as opposed to bad doctors begin the process of figuring out what is wrong with sick people from the moment the doctor walks in the room, before they order tests. He wanted to talk about how experienced doctors screen out fakers (first) before they get to diagnosing the really sick people. I pointed out that the legal system (the war on drugs) is actually forcing doctors to be police and waste their time “detecting” who deserves medical care and who doesn’t. Why not just give drug addicts the drugs they want and kick them out of the ER satisfied so you could spend your time trying to figure out whether patient X has appendicitis or patient Y has a tumor? He’d never thought of it that way. The war on drugs and the struggle of the DEA to prevent doctors from writing scrip for phony patients or being scammed by drug addicts for narcotics that they don’t “need” has put an extra layer between the doctor and the sick person–suspicion. And that suspicion of wrong doing by the patient, all patients, is heightened by class and race issues and by the doctor’s own experience of the community he serves. Everyone remember the case of the obese african american woman who was *arrested* for disorderly conduct in the ER and then *died of a perforated ulcer* as she was being taken out to the police car? That example, which to most of us stood out for its absurdity (the nurses and doctors of that hospital didn’t trust the woman’s self reported pain and refused to take her seriously. They treated her pain and fear as “disorderly.”) struck my (very nice) doctor friend as *perfectly reasonable* considering the number of times in his career that drug addicts and other scam artists have tried to trick him into prescribing pain meds. The whole system of illegality cputs doctors and nurses and ER’s on the front line of preventing sick, addicted, and disorderly and dangerous people fromg etting something they want. Shifting the burden away from clinics and allowing addicts to determine how much of their own poison they want to take would mean that patients in hospitals and er’s wouldn’t have to all be put under suspicion. Its a terrible system and it makes racism and classism and sexism a component part of its functioning because those are the actual diagnostic tool used to separate “needy” patients from “faking” addicts.
aimai
OK, I give up, I had a great post and as far as I know I didn’t use any forbidden words like blank, or blank, but it seems to have been swallowed up. If it appears three times I beg everyone’s pardon.
aimai
“My dad recently went to the emergency room for a kidney stone, and the triage person decided his pain wasn’t important and had him sit around for three hours, in agony”
I hear a lot of this stuff from people who don’t know what “triage” means or how it works. The idea is that you assess everyone who comes in to see who needs care the most urgently. Somebody who was shot or stabbed or badly wounded in a car accident gets to skip the line and have treatment NOW to save their life. Someone suffering a painful but not life-threatening condition will have to wait until the really urgent cases are seen to. Basically the nurse’s train of thought is, “kidney stones, OK, he’s not gonna die if he has to wait till after we take care of this kid with a possibly fatal brain injury…” People going to the ER for routine complaints or pain management are usually last in line, because their conditions are the least urgent.
Why does nobody get this? I know it’s hard to be patient when you’re in terrible pain, but almost everyone I know who’s ever been to the ER for something non-fatal has bitched about this (usually for wait times that aren’t excessive, either).
Oh, and regarding the article itself, I have to say that talking to my mom, who is a nurse in an ER in the rural south, it is obvious to me that the reason for the disparity is due to prejudices held by individuals administering care. A black person who comes to my mother’s ER for pain management is going to either be seen as a junkie inventing complaints to score some painkillers, or someone who probably isn’t going to be able to pay their bills (and you’d be surprising how much that assumption affects your care).
Another contributing factor is that people who go to the ER for pain management are often seen by ER staff to be in the wrong place — that’s something you’re supposed to see your regular doctor about, or the specialist treating you for the thing causing the pain. NOT the emergency room. I think this is difficult for lay people to understand, and it’s probably not a fair bias for the providers to hold. But it’s out there.
Aimai, it just happened to me, too. Ah, c’est la vie…
i don’t argue with the statistics, but yes, i’d be interested to know how insurance plays into this, and whether it’s maybe not just one part of the larger mess that is pain management.
anecdotally: my brother (white, insured, middle class) was unable to get adequate painkillers when he was hospitalized for leukemia. (not that leukemia is marked by pain, but the surgeries to implant IV ports and the many, many spinal and bone marrow biopsies WERE). the nurses mentioned a prevailing ethos of “no more than we absolutely have to”, for fear of creating dependency and bringing down the DEA’s wrath. Sucks.
Lizzie,
First, you just reminded me it’s time to make some coffee.
But, I think you raise two very important points: state regulation and the insurance industry. I think part of the issue is how the regulatory mechanisms produced by those two institutions intersect in the moment of care giving and what types of pain management take place. The “no more than necessary” is both a cost issue and medical regulation issue (”let’s not use the more heavily regulated opiod”).
None of these decisions are based in patient care or pain management, but are instead driven by institutional imperatives. There’s something very wrong with this equation.
Now, add the usual institutionalization of white supremacy (or privilege if you prefer), as well as other class-based issues, and I think we’ve got a model that explains a lot of what’s going on.
(Oh, and while we’re at it, inadequate pain medication actually runs a higher risk of addiction, because you can get away with much lower doses when you keep ahead of the curve. Once the pain is established, it’s much harder to beat back.)
What MikeEss said in response to Thomas. Anyone who could think that U.S. doctors generally overmedicate any group is not paying attention, knows nothing about pain management, and/or has some Neanderthal ideas about “toughing out” pain. Sorry if I sound pissy about this issue but I’ve had back problems and such ideas really anger me.
The prejudice against painkillers in the U.S. is, in part, rooted in the fundie love of suffering.
I wonder if more black people get tagged with “drug seeking behavior” on their medical chart than white people, because after that happens it’s pure hell trying to get painkillers from any doctor … I got tagged as a drug seeker after having 2 separate pain related medical conditions in 1 year (that was one shitty year!) since then I’ve found it almost impossible to get prescription pain killers when needed. This would make the whole racism angle even worse because all it takes is one doctor to think “this black guy is probably doing it for the drugs” and you get put on a pretty permanent no drugs list.
DeadMan
Thanks for blogging this (especially considering how miserable you’re feeling!); when I read this last night, I was spluttering angry. Knew that you’d do it justice!
I have no doubt that alot of the reason that my little sister was able to obtain so many Rxs for hydrocodone, darvocet, etc the last 20 years of her life was a combination of her background and appearance- she was a petite white woman who was an RN for years. After she was disabled on-the-job, she underwent multiple shoulder surgeries, then later worked as a pharmacy rep for a “Big Pharma” company throughout the country for awhile. She also had a major personality disorder and was a master manipulator.
In the last year of her life, she created almost a dozen excuses to obtain more meds from various clinics and ERs. And if the Drs refused, she threatened lawsuits. She even bragged, while high on Darvocet and laughing, how she scared one resident in an ER, threatening to call the local TV stations- he gave her the meds to get her out of there!
She denied to the end that she had a problem, because “her meds were all legally prescribed”. My family’s answer to Rush Limbaugh is what my Charlie called her, and he was right. I hate who she was as an adult, yet mourn my baby sister from our childhood.
While I’m not blind to how horrible drug abuse is, I also feel that the medical community was also partially culpable. Yes, she manipulated the system. But had she been a minority, I doubt that she would have gotten away with it all.
It is not surprising to find a racial element in the denial of pain meds, but it’s worth noting that the War on Some People’s Drugs has led to general undermedication of pain for everyone.
IIRC, at one point the DEA was investigating a lot of oncologists because they were prescribing “too many” pain meds for their terminal cancer patients. I can see investigating a dermatologist for prescribing a lot of pain meds, but there are some specialties like oncology where the doctor is going to be prescribing a lot of pain meds as a matter of course.
After my knee surgery, I had to switch meds because Vicodin makes me vomit uncontrollably (a lovely thing to find out at 4 am while you’re on crutches), and I’m sure someone somewhere in the DEA made a note that I must be a “drug seeker” because I got two separate prescriptions for two different meds written within a week.
May I make a recommendation to folks? If at first your comment does not immediately appear, just be patient instead of immediately writing the same thing a second or third time. Sometimes, for the protection of the blogger, ALL comments go into moderation and have to be manually released.
For myself, even if I assume that I have not used any forbidden words, I go on about my business then check back later to see if my comment is now visible. It saves me the time of writing the same info two or three times and saves everyone else from having to read it two or three times.
YMMV.
Several of the comments are making me wonder if there’s a certain amount of selection bias in the ER. IIRC, white people are more likely than blacks or Latinos to have a regular doctor, so drug-seeking white people can do it in the privacy of a doctor’s office. Meanwhile, people who are stuck getting their medical care end up in the ER, including drug-seekers who would be in doctor’s offices if they were white. So because most of the drug-seekers in the ER tend to be black or Latino, the medical personnel assume that must be the profile for most drug-seekers, even though that’s not at all the case.
Doesn’t explain why Asians are undermedicated for pain, though.
I’ve also noticed that these sorts of posts get fewer comments, and I think you’re right about the “third rail” thing. I don’t know about the rest of the Pandagon community, but I just wanted to say that I really appreciate the work you put in to writing about these issues and exposing us to issues like this one that we might never have thought about. You do really important work here, and you do it really well.
I’m really glad your surgery went okay and I hope you make a full recovery very soon. Keep up the great work!
It’s interesting for me to read this stuff about pain management in the US, since my Dad does pain management here in Canada. He’d probably be under close scrutiny, if not arrested, if he was in the US, and he’s very, very careful about prescriptions. Of course he has some drug addict patients, but he monitors them closely, and will not let them have more than a day’s worth of meds at any time. He’s also got a lot of patients who became addicted to illegal drugs because of the pain. Dad’s attitude is that he’ll give them the medication they need, so long as they stop taking stuff he doesn’t prescribe. He’s been pretty successful. He uses a canniboid pill for a lot of patients, and has been able to get them off marijuana-if anyone tells you marijuana should be legal to treat pain, tell them that’s bullshit. The canniboid compounds you can get in pill form are just as effective for pain, and don’t carry the risks that smoking pot does.
We’ve discussed the American situation, and he thinks that most doctors, and the DEA, don’t realize that dependancy is not the same thing as addiction, and being dependant on pain medication is no different that being dependant on insulin. You don’t tell a diabetic to suck it up stop taking insulin. People who are dependant on pain medication may be taking huge quantities, but that is what is needed to function-they don’t get high. The DEA doesn’t seem to get that the doses for someone with long-term pain will be higher than those for people just on the medication for post-surgical pain.
Good post. Its scary how doctors are bullied into not providing pain medication even when its needed. Its worth pointing out that this is even beginning to happen in rural, poor white areas due to the Oxy Contin (”Hillbilly Heroin”) panic.
It’s interesting for me to read this stuff about pain management in the US, since my Dad does pain management here in Canada. He’d probably be under close scrutiny, if not arrested, if he was in the US, and he’s very, very careful about prescriptions. Of course he has some drug addict patients, but he monitors them closely, and will not let them have more than a day’s worth of meds at any time. He’s also got a lot of patients who became addicted to illegal drugs because of the pain. Dad’s attitude is that he’ll give them the medication they need, so long as they stop taking stuff he doesn’t prescribe. He’s been pretty successful. He uses a canniboid pill for a lot of patients, and has been able to get them off marijuana-if anyone tells you marijuana should be legal to treat pain, tell them that’s bullshit. The canniboid compounds you can get in pill form are just as effective for pain, and don’t carry the risks that smoking pot does.
We’ve discussed the American situation, and he thinks that most doctors, and the DEA, don’t realize that dependency is not the same thing as addiction, and being dependant on pain medication is no different that being dependant on insulin. You don’t tell a diabetic to suck it up stop taking insulin. People who are dependant on pain medication may be taking huge quantities, but that is what is needed to function-they don’t get high. The DEA doesn’t seem to get that the doses for someone with long-term pain will be higher than those for people just on the medication for post-surgical pain.
Considering the history of the control of “illegal” drugs, which only started in the 20th century as a response to a panicked public fearing rampaging Marijuana- (and cocaine-) crazed Hispanics and Blacks (the later in response to the Jazz culture that started during the first decades of the century), I guess it’s not too hard to see a direct line to a general (and unfair) suspicion that people of color are more likely to be abusers. The public perception that illegal drugs are a POC problem as well (also unfair) just makes it worse.
Racism turns up in the most “interesting” places…
This thread is very moderation-prone. But that’s a GOOD thing…
Wow. When I lived in France a few years ago one of my friends warned me that when I went in to see doctors to make sure they knew I was an American because there’s some kind of bias there wherein doctors thought that Africans could take pain better than native French people and therefore under treated pain in black folks. I was sort of dumbfounded to hear this.
Looks like the French aren’t alone.
When I lived in France a few years ago one of my friends warned me that when I went in to see doctors to make sure they knew I was an American because there’s some kind of bias there wherein doctors thought that Africans could take pain better than native French people and therefore under treated pain in black folks. I was sort of dumbfounded to hear this.
It was a pretty common belief 20 or 30 years ago, and I don’t think it’s quite died off.
Sick as it sounds, I think it’s along the lines of “animals don’t feel pain the way humans do.” IOW, Africans aren’t really human, so they don’t feel pain the way real humans (like white people) do, so you don’t have to give as much medication.
Ick. I feel dirty even having typed that.
I’m as black as the Ace of Spades and I got Vicodin for my back this Sunday. Of course, they talked to me like I was 8 years old until they saw that I’m a lawyer for a medical research institution.
There’s a doctor who writes for the New Yorker, almost always really interesting stuff, though I can’t recall his name right now. Anyway, he had a piece a few months ago about decision making in the ER and the role that underlying biases play in the decisions doctors make. I can’t recall if he explicitly talked about race and pain management. But he had examples of how bias affects stuff as supposedly scientific as diagnoses (doctors ideas about what “types” of patients get what “types” of diseases) and ways doctors can be more self-aware and really more scientific in how they do their jobs and provide better care and save more lives.
First, Pam get your MD to write a Rx for an abdominal binder. It should help with coughing/sneezing.
Second, while I haven’t read the study, I think we need to keep in mind, as a general rule, that data on Rx patterns for pain meds in the ER need to be interpreted with caution.
For example, for people with the worst pain, or pts with abdominal pain the ER doc would not be prescribing any pain meds; it would be the consult doc (from a different service, surgery, ob/gyn, etc) who’d do that. So other factors–like private vs. service pt.; transfer from the ER to another service–could play a role.
Third, I think the assumption that a doctor’s personal beliefs (some doctors believe blacks are more prone to abuse opioids) play an important role in who does or does not get a Rx for pain meds is incorrect. No matter what your personal prejudices might be, you still have to take a history and examine the pt. You don’t determine drug seeking behavior just by looking at a pt.
When I lived in France a few years ago one of my friends warned me that when I went in to see doctors to make sure they knew I was an American because there’s some kind of bias there wherein doctors thought that Africans could take pain better than native French people and therefore under treated pain in black folks. I was sort of dumbfounded to hear this.
Exactly what I was going to say. Except without the France part.
I really do think that this is not only about the War on (some groups of people who use some) drugs, but also about perceptions about strength, weakness, and pain tolerance. I think there is a widespread and unconscious belief in American culture (inherited from the ideology of slavery, where it was made explicit by pro-slavery “scientists” of the time) that black people can naturally bear greater burdens and suffer less pain than whites. It’s sick that it’s still with us, but you see it sometimes in sports commentary and in images of “strong black men” and “strong black women” that come up again and again. It goes hand in hand with the belief that they’re more physical and less intellectual than whites.
I have two, possibly stupid questions.
1. Does the effect remain if you control for economic status of the individual patient?
2. Does the effect remain if you control for individual hospitals? I.E. is it possible that regardless of race you are more or less likely to get pain meds depending on which ER you visit?
Basically it really does sound like doctors are differentially offering pain meds based on race, but I’m curious whether they’ve excluded the possibility that these figures really are just byproducts of deeper systemic inequalities in America. I.E. is it possible that the effect you’re actually seeing here is that the more financially well-off go to nicer hospitals and therefore are more likely to be offered pain meds there?
Sheesh, knowing how hard it has been for me (an educated, insured, white woman) to get adequate pain meds when they were really warranted, I can’t imagine how much pain must go untreated for people of color or those without insurance.
A few years back, I had to complain and refuse to leave and go up two levels of authority before I could get something prescribed for 4 broken ribs + 3 separated from the cartilige (fell in the old claw-foot cast-iron bathtub, slamming my chest down onto the side of the tub. I am Miss No-Slip Bath Mat Advocate now!). They wanted me to just take Tylenol. It’s not like I could just “stay off of” the injury or anything, as breathing is sort of a required ongoing activity. Finally finally I got some Vicodin.
Interesting that as I read this now, I am dealing with a new pain issue. The muscles in the left side of my back are so tight that moving at all hurts. I have tried heat, cold, ibuprofen, professional massage, epsom salt baths, muscle relaxing creams, all to no avail — the pain waxes and wanes, but never goes away entirely. This is a new thing for me and not traceable to an identifiable injury. When I couldn’t even get out of bed a couple days ago, my girlfriend offered to take me to the hospital, and I said “Are you kidding? To sit in an uncomfortable chair for 10 hours and probably get nothing of value out of it? I’ll just stay here in bed on my heating pad, thanks.” Moving a little better today, but still hurts a lot, so I give up, I have to go for professional medical care. I may just need some serious muscle relaxants, and wonder if I’m going to be able to get them. I have an appointment with my regular private doctor Friday afternoon, so I think my chances are fairly good. But I wish I didn’t feel like I have to play it cool and not seem too eager, even though I am indeed EAGER AS HELL TO END THIS DAMN PAIN THAT’S SO AWFUL AND CONSTANT THAT I JUST WANT TO CRY!!!
Beth- is it up along the shoulder? I recently had the left side of my body go into excruciating pain and it was diagnosed as rotator cuff tendonitis needing pain killers, anti-inflammatories and a referral to a physiotherapist. He put me through some very painful paces and then laid me on my back and popped my 1st rib back into place. Pain left like magic. Took a few more visits to teach the muscle systems that it wasn’t coming back and I have full range of painfree movement back. See your doctor and check out a good physiotherapist- it was worth every penny I paid.
Third, I think the assumption that a doctor’s personal beliefs (some doctors believe blacks are more prone to abuse opioids) play an important role in who does or does not get a Rx for pain meds is incorrect. No matter what your personal prejudices might be, you still have to take a history and examine the pt. You don’t determine drug seeking behavior just by looking at a pt.
Really, no doctor ever makes that determination just by looking? Ever?
And yet that’s exactly what the doctors at King/Drew did with Edith Rodriguez, even when she started vomiting blood on the floor of the ER. The nurse in charge finally decided that Rodriguez was making too much of a fuss and called the cops. Rodriguez died as they were hauling her out to the patrol car.
You can say what should happen in an ideal world with a good doctor, but “should happen” and “does happen” are two very different things, especially in a busy inner-city emergency room.
I tend not to like sharing personal anectdotes because individual experiences are rarely indicative of wider trends; hence, “I’m black and I got Vicodan” and “I’m white and my doctor would only give me Tylenol.”
In any event, I think this experience is relavant. A couple of years ago, I went to the emergency dentist at NYU’s school of dentistry. I had a root canal several months earlier and my insurance declined to cover a crown. I didn’t have money for a crown and eventually the temporary filling fell out. I got an absess at the root of the root canal and had to have the remainder of my tooth pulled. It was painful.
As I was sitting in the waiting area, a professor of dentistry was reviewing the chart of a patient of one of his students. The student had prescribed a pain reliever of some variety to his patient. The professor showed the student how to tell which patients were Medicaid patients. “If you prescribe that to a Medicaid patient, he’ll take two pills and sell the rest on the street. Tell him that Tylenol is as effective as a prescription pain reliever.”
After my tooth was extracted, the student who treated me came back from his visit with the attending dentist to tell me that Tylenol is as effective as a prescription pain reliever. A week later I returned because I got dry socket and a localized infection that made the whole side of my face feel like it was collapsing, and I got the same story–Tylenol=Vicodan. In any event, the dentists seemed to feel the same about uninsured patients as those who received Medicaid (even though you have to pay before your procedure, so there’s no chance you won’t pay the bill).
When I’ve been to the NYU Dental School for treatment, it seems to me that the overwhelming majority of patients are uninsured or receive Medicaid. It would be interesting to look at a uniform group, like Medicaid patients who undergo painful dental procedures at high volume clinics like NYU’s and see whether there is racial bias when you remove the variables and uncertainties that exist in the ER (i.e. patients with different incomes, ethnicities, ailments, and insurance visit the ER; doctors may not know whether their patients are insured (whereas at the dental clinics, doctors have that information), doctors guesstimate pain, etc., and etc.)
I agree there is a racial bias, but I wonder if it results because of class assumptions. I am, by the way, a college educated, middle class woman with a white American parent and a Moroccan parent. Since I was in high school, I have had to answer the off-putting question “What are you?” meaning, “What is your ethnicity?” Most frequently, people think I am hispanic or Arab. So, it’s quite possible that racial bias affected my experience at the dentist, too.
It runs down the whole left side, but it is worst just under the shoulder blade. I’m not a hypochondriac (I actually err much more toward the “oh it’s nothing really” side), but I’ll admit a tiny part of me is a little freaked out by this not being attributable to any injury, like maybe this is the start of some terrible degenerative muscle disorder or something… nah, gonna shove that thought right out of my head. We’ll see what my doctor says friday.
One reason I like my GP is that he has listened to me in the past when I report what I know about my drug needs and reactions. I’ve often had my own self-knowledge dismissed by medical professionals in the past (b/c I’m not a doctor myself, so what could I know?) But my doctor now did listen about the anti-depressants I was already taking with good results and just need continuing scrips for, and paid attention when I told him about how antibiotic-resistant my sinus infections are and I really do need augmentin. My only previous pain issue with him was tennis elbows (in both elbows at once), which we did cortisone shots for along with various exercises — he did comment on my stoicness through several rounds of those shots so hopefully he knows I’m not generally a whiner and have decent pain tolerance.
Pam- have you tried keeping your arms above your head? It worked for me to relieve some of the pain when I had an ovarian cyst out. I know it sounds weird, but it helped me between the doses of painkiller.
Digger, I’ve been doing restorative yoga poses, some of which involve arms above the head positions, and it brings some relief. It does help for a while so I can stretch out my doses and rest. Today I was a bit restless since I slept a lot yesterday. Didn’t eat much; veg soup I tolerated.
Papadam, I was thinking about making a similar comment. Not so much about the anecdote, but about separating various underlying causes out as “race”, “class”, etc. I think the bottom line is that when you are a nice polite member of mainstream middle class white-dominated society (regardless of how you identify, racially), you are much more likely to use the medical system in a way that results in a minimum of questions or challenges or biased assumptions.
A lot of the time this is really because you have stable health insurance, a good relationship with your doctor, and little or no need to use the ER for non-urgent complaints. If you are a member of said society, you can actually call up your doctor and say “so the tylenol isn’t really working, and my back pain is unbearable. Is there a way I could get something stronger?” The doctor can advise you and arrange for you to get what you need, even if it means calling in a prescription to a 24 hour pharmacy (though I’m not sure how common this is for opioids).
If you are not a member in good standing of the Middle Class Whitfolks And Friends club, you won’t have those connections and thus are likely to be red flagged immediately as someone who can’t be trusted with Teh Hard Stuff, or someone whose pain isn’t worthy of special effort.
aimai’s comment was worth posting 3 times.
Blame much of this on the phony war on drugs. We doctors are being subtly (and not so subtly) threatened for prescribing opioids chronically. And when we do, are told (unethically in my mind) to have patients sign contracts, do drug testing, etc. We are not asked to do this with any other dangerous medicine that a patient misuses. In other words, the government wants us to put the patient second, after societal concerns. Unethical.
And shame on the doctors who would let a patient live in pain due to mistrust. Give the ER patients a couple days of opioids and send them back to their primary MD (if they have one–a topic for another day) and let us deal with them.
We are doing a terrible job with pain in this country, and we know better.
Pam, you sound like you are doing great. This was MAJOR surgery. Maybe try a sleeping pill at night instead of, or a supplement to a low dose of, your pain meds. Temazepam 30 mg. would likely get you more sleep than oxycodone, which wears off in about 3-4 hours, as you know. Either that, or try 20 mg. of Oxycontin at bed. If you are taking 5 mg. oxycodone at a time you should easily tolerate this. Keep breathing deep and coughing–clutch a pillow to your wound area when you do. Don’t let the pain interfere with deep breathing, or you could get pneumonia.
Really, no doctor ever makes that determination just by looking? Ever?
The question isn’t if no doctor ever makes that determination just by looking, ever. (Most likely, there’s a doc somewhere who does it.) The question is do most doctors do this and is that practice trend the most likely explanation for the study findings? I don’t think it is.
As to the case you mentioned, if, as you wrote, the nurse in charge called the police when Ms. Rodriguez started vomiting blood, that’s not racism, that’s utter incompetence.
I guess it speaks to the continued esteem in which doctors are held that people find it so hard to accept that doctors may have subtle biases that result in real differences in care. This isn’t an issue of “I hate black people, let them suffer.” It’s a collection of little prejudices about who black people are and what they’re like and who white people are and what they’re like that adds up to people getting treated differently. I suspect there are strong class elements to this and issues of insurance and War on Drugs issues, but why are people so resistent to the idea that race can be a factor?
The question is do most doctors do this and is that practice trend the most likely explanation for the study findings? I don’t think it is.
If this were the only study showing that minorities get substandard care, you might have a point. But it’s not. It’s one of twenty or thirty studies all showing the same thing.
Is every one of those studies wrong?
Is every one of those studies wrong?
Moreover, is every person who’s an expert, from long experience, in knowing what it feels like to experience racial discrimination wrong when they detect it coming from medical professionals?
Are we just supposed to be skeptical of their experiences because ema says she has a hunch that all these medical professionals, even if they happen to be products of a racist society, can’t possibly be influenced by racial biases?
I think it is because of not so slight racism, in a way.
From a friend that works in that profession: ‘They’ will demand that ‘we’ write scripts for Tylenol because medicaid will pay for them. ‘They’ will whine and cajole and stomp their feet to get narcotics. ‘They’ will stand in the department and yell and swear at near the top of their lungs if they don’t get the drugs they seek. ‘They’ often don’t take the drugs that are prescribed to them and sell them on the street. ‘They’ are often caught ’shopping’ for drugs at more than one hospital. ‘They’ often DEMAND narcotics for ‘headaches’ and ’stomach aches’ when no cause can be found. and it goes on…
Hell, one time a man got a script for 5 Vicodin and the supermarket pharmacy called to confirm that the script was for 35 because the freak added a 3.
Granted, ‘white folk’ do this too but the large numbers of non-white that pull that shit on the ER docs and even regular doctors is massive.
They also evidently demand antibiotics for nearly anything and everything. Colds, hang nails (yes), diarrhea (?) and a whole host of other maladies that don’t require antibiotics or where they are totally worthless. I’ve heard from more than one doc that will write a script ‘just to shut them up and get them out of the department’.
Granted, it’s a grungy city hospital and only a small number of docs but they all have stories. Oh, and there is a doc that WILL write scripts for narcotics more than the other docs. They come in and ask for him. If they call the department, people say that he isn’t working that day before he ‘got religion’ and stopped writing so many scripts.
I think it is because of not so slight racism, in a way.
From a friend that works in that profession: ‘They’ will demand that ‘we’ write scripts for Tylenol because medicaid will pay for them. ‘They’ will whine and cajole and stomp their feet to get narcotics. ‘They’ will stand in the department and yell and swear at near the top of their lungs if they don’t get the drugs they seek. ‘They’ often don’t take the drugs that are prescribed to them and sell them on the street. ‘They’ are often caught ’shopping’ for drugs at more than one hospital. ‘They’ often DEMAND narcotics for ‘headaches’ and ’stomach aches’ when no cause can be found. and it goes on…
Hell, one time a man got a script for 5 Vicodin and the supermarket pharmacy called to confirm that the script was for 35 because the freak added a 3.
Granted, ‘white folk’ do this too but the large numbers of non-white that pull that shit on the ER docs and even regular doctors is massive.
They also evidently demand antibiotics for nearly anything and everything. Colds, hang nails (yes), diarrhea (?) and a whole host of other maladies that don’t require antibiotics or where they are totally worthless. I’ve heard from more than one doc that will write a script ‘just to shut them up and get them out of the department’.
Granted, it’s a grungy city hospital and only a small number of docs but they all have stories. Oh, and there is a doc that WILL write scripts for narcotics more than the other docs. They come in and ask for him. If they call the department, people say that he isn’t working that day before he ‘got religion’ and stopped writing so many scripts.
Ah, but TR, the plural of anecdote is not data, so we must show ema the data.
Of course, our doctor friend seems to be ignoring the data in favor of his/her gut feeling about what should be going on instead of what multiple studies have shown is going on. Not good practice, even on “House.”
I’ve got a few friends in the ER doctor profession who say that many minority groups demand narcotics and abuse, both verbally and occasionally physically those docs that don’t give them what they want.
Vicodin for headaches, oxycontin for ingrown toe nails, you name it and they’ve seen it.
Some of these drug seekers actually visit the other hospital ER to try to get drugs, or ask for certain docs who have written for them in the past.
Some, a few each year but growing, forge scripts for increased amounts of whatever the script was for. Now they use computer generated scripts so fraud is harder but it has happened.
Many minorities also demand scripts for Tylenol and even diapers because of some loophole in public assistance.
It’s a madhouse in the ER many nights. I’m amazed at what they have to put up with. I’m glad I’m not 1) a cop and 2) an ER doc. But ER’s have to treat everyone that walks or is wheeled in the door. Whether the hospital gets paid for it or not.
I can’t seem to post anything (but this?) to this thread…
That worked but nothing else does… *sigh*
If this were the only study showing that minorities get substandard care….But it’s not. It’s one of twenty or thirty studies all showing the same thing.
Is every one of those studies wrong?
Wrong about what? The study’s finding–there’s a difference in prescribing pain meds between whites and non-whites [”minorities get substandard care”]–is not under discussion. The reason/s for the difference is/are.
As the post mentions, [t]he study doesn’t go into motivation for withholding adequate pain management. So maybe it’s the doctors’ racist beliefs, or the pt’s insurance status, or the War on Drugs (an important contributor, in my opinion), etc.
My point was that we shouldn’t just assume the motivation for the difference in Rx trends is racism, and be done with it.
Moreover, is every person who’s an expert, from long experience, in knowing what it feels like to experience racial discrimination wrong when they detect it coming from medical professionals?
No more wrong than every physician who’s an expert, from long experience, in knowing what it feels like to treat patients adequately, regardless of their race.
Are we just supposed to be skeptical of their experiences because ema says she has a hunch that all these medical professionals, even if they happen to be products of a racist society, can’t possibly be influenced by racial biases?
You’re not supposed to discount anyone’s experience because of what I say, but you are supposed to not distort what I write. Which was that, even if doctors are influenced by racial biases, in order to diagnose drug seeking behavior, they still have to take a history/examine the patient.
Not *all* doctors do that. Some practice substandard care and only look at their pt’s race to determine if pain meds are needed. However, *most* doctors examine their patients before reaching a diagnosis. Hence, my statement that I think the assumption that a doctor’s personal beliefs…play an important role in who does or does not get a Rx for pain meds is incorrect.
Ah, but TR, the plural of anecdote is not data, so we must show ema the data.
Not quite, since we’re talking about assumptions and opinions about assumptions here. Hard data is great, but nothing says we can’t engage in a bit of speculation every now and then.
Of course, our doctor friend seems to be ignoring the data in favor of his/her gut feeling about what should be going on instead of what multiple studies have shown is going on.
Heh, my bad, ignoring nonexistent data and all that. [The study offers no data on the topic of our discussion–possible motivation/s for withholding adequate pain management for minority pts.]
I’ve got a few friends in the ER doctor profession who say that many minority groups demand narcotics and abuse, both verbally and occasionally physically those docs that don’t give them what they want.
I think that’s part of that selection bias I was talking about above: poor, minority drug seekers will end up in the ER while middle-class white drug seekers end up in a series of private doctors’ offices*. It doesn’t mean there are more minority drug seekers on an absolute basis.
I can’t even imagine being an ER doc, especially in a large city. The burnout rate must be horrific.
* Or they send their maids out to meet dealers in parking lots when the doctors in the area finally catch on. Same difference.
Pinky, did you not read the post?
so if your friends in the ER are buckling to the outrageous demands of those minorities (yelling, screaming, abusing the hard-working medical professions) they must be anomalies.
or they don’t exist.
ema:
The abstract says that controlling for other factors, race remains the determinant in the difference in the prescription of opiods for pain relief between groups despite an overall increase in the prescription of opiod pain killers. I’m assuming that the controlling for other factois would take care of inequalities in the types of hospitals and whether or not the patients had access to insurance.
If it is the effect of the “War on Drugs” I don’t see how you would separate that from racism.
Pinky, I wonder how many internists deal with the same stuff from white and middle class patients?
In fact, I’d even venture to wonder how many ER doctors deem minority patients’ behavior abusive and demanding who happily write wildly inappropriate opioid scips for white middle class folks who come in.
In fact, while I know data is not the plural form of anecdote, I saw that very thing happen to my teenage brother when he broke his arm. The ER doc, a coworker of my mother’s (very same ER where black people are routinely denied painkillers) wrote him a prescription for vicodin for the pain. Which he did not take at the time, but shared with friends the following weekend at a party. My brother will never find his record red-flagged as a potential prescription drug abuser.
Not to mention of course that most of what you wrote causes me to wonder if the reason the poor blacks who ask for oxy for an ingrown toenail do so because they’re ignorant about how the medical system works, what drugs are appropriate for what kinds of pain, what’s OTC and what’s only available by prescription, and the like. They ask for vicodin because they know it’s the name of a strong painkiller, and they know it hurts too bad to be fixed with an aspirin. Most patients in the ER have not been to medical school. Which is something else I feel is at the root of a lot of ER doctors’ and nurses’ prejudices about patients — they forget that not every member of the human race knows as much about medicine as they do.
And regarding patients who ask for tylenol, diapers, etc. Shit, if I was on medicaid, I’d want all the help I could get, too. I’m not even that poor, and still there’ve been days I had a cold and just had to deal with it and feel like shit because I couldn’t afford Sudafed.
I think everyone in nursing or medical school should have to spend a month living the lifestyle of a medicaid patient. That would solve about half this crap.
we shouldn’t just assume the motivation for the difference in Rx trends is racism, and be done with it
Hmm. I thought that when people got medical care based on their skin color rather than their health condition, that was an example of racism in action, not an outcome that needed further investigation.
By definition, race is not a factor in how patients feel pain or contract injury or disease requiring ER treatment; otherwise, the headline would be ‘Asians feel less pain than whites’ or ‘Blacks more likely to fall off ladders and break their clavicles’.
So since the story is ‘whites getting medicated for pain more than everyone else with same ER contact’ I’m assuming that’s what happening, and that is definitely racism.
What to do about it? is a far more interesting and complex question than What is going on here?
Sorry, my point was that they DON’T prescribe narcotics and have a
great deal of either dislike or disbelief when minorities come in and ask for drugs. I can assume that it also extends to those that ‘need’ the drugs. I don’t know. There is a large traffic network for prescription drugs in this town.
I don’t know if it’s outright racism as in ‘you’re black so you don’t get it’ as much as it could be that they’ve gotten burnt out dealing with people that really don’t need a Tylenol that come in gaming for 20 Vicodin because they banged their ankle…
What also surprises me is that most of the docs I know are rather more liberal than I’d have expected so looking at the idea that ER’s are racist and denying medication to minority patients is surprising. I’ll have to ask some of them next time I see some of them.
I can imagine that dealing with some patients gets very trying for them. I can’t mention exact cases that I’ve heard about over the years but to have someone race their child into the ER at x o’clock in the morning because they stubbed their toe trying to get to the bathroom and then the parents demand to be seen ‘right now god dammit’ and then demand antibiotics AND a big time narcotic and that’ll probably affect you too.
Also, I’m very sorry that there were 2 posts of that comment and that I commented (as a test) to see if they will post. It’s strange that things take so long to post at times…
Oh, I went into an ER when I was having what was decided to be cluster headaches. I was prescribed Vicodin and some other drug that I can’t remember and I asked for a Vicodin to cut the pain. They actually refused to give me one. They called my doc and finally got the clue. It turned out to be some complication from back problems and after that was treated the headaches disappeared. So, white folks are denied narcotics too.
One topic BTW that got heated once was talk about the ‘morning after pill’. It was interesting that a few people said that they would never prescribe it. It was termed an ‘accountability’ moment. Amazing. Even if birth control failed?
Hey, OK, not all patients are medical school graduates BUT evidently some get it in their head that they ‘deserve’ Vicodin or Valium and that nothing else is going to do. One doc did have a black person yell at them that they were racist for not writing for Vicodins for them and the doc yelled back that he wouldn’t write that for a white person with the same condition. It got very heated…
I don’t know. Maybe it is racism. Maybe it’s part of being in an economically challenging situation and needing the drugs to supplement their income. Maybe it’s something else. I’d like to think that human doctors aren’t denying needed medical treatment to patients.
BTW: the real villains in emergency care are often the specialties that refuse to treat, or under treat, people suffering from ‘under insured syndrome’.
Nearly every doc also said that drugs being advertised on teevee is a bad idea…
Do please remember that Pandagon is a both/and blog, not an either/or one.
No more wrong than every physician who’s an expert, from long experience, in knowing what it feels like to treat patients adequately, regardless of their race.
It’s astonishing that you think people can judge for themselves whether they’re treating someone unfairly based on race. The large majority of people do not, in fact, want to perpetuate racism, and yet almost everyone ends up doing it at least some of the time in some ways–including doctors.
The rejection of culturally-ingrained biases is hard, especially when a lot of the culture is insisting there *isn’t* a problem of racism, just of people worrying about being “PC” and non-white people not doing enough to help themselves. We’re all products of a racist culture, and refusing to participate in racist cultural assumptions takes active awareness of the problem and constant vigilance against it, as well as the humility to admit when one’s being part of the problem.
Even when doctors decide to examine a patient instead of make a snap judgment (and, believe me, there are plenty of doctors who simply make snap judgments and refuse to listen to patients), they begin forming impressions of the patient immediately, and those impressions unconsciously influence how they will diagnose and treat the patient.
Unless the doctors have the humility to realize that they’re vulnerable to racial bias, just like everyone in this culture is, and unless they’re working hard to resist it, racial bias is going to play an unconscious part in how they treat the patient. And the doctors are not going to be aware they’re doing it because that’s what unconscious means.
The 19th century view from Nietzsche:
“Now, when suffering always has to march out as the first among the arguments against existence, as its most serious question mark, it’s good for us to remember the times when people judged things the other way around, because they couldn’t do without making people suffer and saw a first-class magic in it, a really tempting enticement for living. Perhaps, and let me say this as a consolation for the delicate, at that time pain didn’t hurt as much as it does nowadays. At least that could be the conclusion of a doctor who had treated a Negro (taking the latter as a representative of pre-historical man) for a bad case of inner inflammation, which drives the European, even one with the best constitution, almost to despair but which doesn’t have the same effect on the Negro. (The graph of the human sensitivity to pain seems in fact to sink down remarkably and almost immediately after the first ten thousand or ten million of the top members of the higher culture. And I personally have no doubt that, in comparison with one painful night of a single hysterical well-educated female, the total suffering of all animals which up to now have been interrogated by the knife for scientific purposes is simply not worth considering).”
Aside from ER visits from DS (drug-seeking) patients, the real issue here is not with doctors, but with nurses. I am a nurse and I can tell you that doctors won’t second guess a request for pain meds if the nurse is astute enough to the patient’s needs.
In school, the one thing that was pounded into my head: A patient’s pain is a patient’s pain. I cannot do ANY interpreting when it comes to pain because it is such a subjective/personal thing. I hope and pray that I don’t have any implicit biases (race,gender, what have you). I try as hard as possible to be as nondiscriminatory as possible in my pain med administration. Yeeks. I tend to think that I am a little more sympathetic with traditionally “shunned” patients - dirty, loud, cussing, etc. because I oftentimes receive the bias because I caught Teh Gay.
For what it’s worth, a lot of foreign (read: imported, read: majority) nurses do not respond the same way to patients in pain. My experience has been that it’s not a major part of their education. The focus seems to be more science and medicine for the nurses. Which is sad, because nursing is so rich and deep…but that’s neither here nor there, except that it is another variable in this disparity found in the study.
Ugh. My edit didn’t catch. I meant to amend my first sentence:
*Even in the ER, nurses in their role as patient advocate can have a MAJOR impact on who does/does not receive pain medication.
Jennifer Cascadia Emphatically:
Fascinating Nietzsche quote. Where is it from?
bety- sorry about the delay getting back. I hope you have a good trip to the doctor and it does sound a bit like what I had- a frozen rib. This doesn’t show on most tests as it is where it should be, just not moving as it should. It really messes up the area around the shoulder and it takes a hands on approach to track it down. In the meantime- ice the area down and it should bring the inflammation down. Sleep on your back and wear a sling to relieve pressure on the shoulder. Best wishes and a speedy recovery.
As for bias in pain relieve, the first thing to do is get the government out of the medecine racket except to pay their bills and train the staff. People who are treated promptly and accurately are way more productive than those who aren’t and that should be the government’s only concern.
“A patient’s pain is a patient’s pain.”
I am very glad to hear this is coming out of medical school.
I can actually manage coherent speech until the point I am midway through fainting from pain. I wouldn’t consider my pain a 10 unless I passed out from it– but a prolonged period of what I would consider a 6 or 7 can be enough to drive me to thoughts of suicide. I have fibromyalgia, from early childhood, and it seems I react to pain a little differently from most people.
And I’ve usually done better getting nurses to understand my issues– asthma, for instance. I played saxophone for 9 years *and* practiced distance running. A peak flow meter will show you I have a greater ability to exhale at high speeds than the average woman my age, but it doesn’t matter, because I’m not an average woman my age, I’m a woman who breathes with every muscle in her torso and then nearly collapses with exhaustion because it shouldn’t take that much effort to get through sitting in a doctor’s office. And this is after taking my emergency meds before leaving the house.
Considering how hard it is for me, a white woman, to advocate against the idea that everybody is cookie-cutter textbook average people, I can’t help but feel that some of those patients demanding heavy medication for a hangnail may also have inexplicable back pains they couldn’t get treatment for, or an immune system that makes their lymph glands swell and throb when they have an infection, or some other fairly good reason for kicking up a fuss. Real patients often get desperate for help in a system that tends to shrug off the subjective.
Once subjective stuff is taken more seriously by more doctors, maybe there will be less questionable requests by patients because they can get what they need without having to rely on referring to a more objective symptom (that doesn’t usually need what they want) to try to persuade.
gaming for 20 Vicodin because they banged their ankle
Yeah, see, that’s the thing. In fact, that’s the way I see everyday racism happen in the US these days. Seeing and hearing things that were not in any way intended, because you see a black person and immediately your mind fills with stereotypes. Anything said person actually does in the situation is irrelevant.
I see this happen every time I go out with friends in my hometown of New Orleans. If you’re standing outside waiting for somebody and a black man walks by and looks at you twice, suddenly “omigod, that black guy was so trying to pick me up!” which can turn surprisingly quickly to “man, that black guy was probably going to rape me if you hadn’t shown up when you did!”
In the south, EVERYTHING a black person does is reinterpreted via stereotypes. A spacey or surly service industry worker is “obviously on crack”. A teenage boy who is walking down the street, having the nerve to actually exist is actually “probably running drugs” or “totally scouting gang turf”.
Again, I have to wonder how many doctors and nurses see all black people who ask for painkillers as “gaming” for them.
Pinky:
You seem to be missing the point that these results are not necessarily caused by conscious decisions made by doctors. If you ask someone about their bias, it’s likely that they’re going to say, all in good faith, that they’re not biased, that they’re doing the best they can in difficult circumstances and to the best of their abilities, they treat every one the same.
But, and this is the big but, biases are usually invisible to the holder. That’s why that IAT site is so interesting. We don’t always have a great deal of control over our associations and assumptions and tend to get down right huffy (as shown on this thread) when anyone suggests we or people we know and like are anything but Simon pure in thought and deed.
Pinky:
Sorry, my point was that they DON’T prescribe narcotics and have a great deal of either dislike or disbelief when minorities come in and ask for drugs.
Yes, that was covered in the post you failed to read. What was ALSO covered is that there is a distinct racial biases, even when other things are controlled for, and there is significant evidence that the biases are not based on fact, but rather stereoptypes of non-whites as “drug seeking” and thus not worthy of drugs.
So, white folks are denied narcotics too.
I recommend you reread the post, since this is, in fact, covered in it. Last time I checked, 50% is not the same as 100%.
Also, you were initially denied a pill in an ER (where they usually inject pain medication through an IV) but not a prescription, and then they CALLED YOUR DOCTOR (how lucky of you to have one; I don’t). Interesting what your definition of “denied” is. It sounds an awful lot like “not denied and in fact catered to.”
Looking at your posts, one might almost think you have an implicit bias to define whites who received medication as “wrongfully denied” and non-whites not receiving medication as “drug seeking”. It’s like it’s somehow both systematic and below your conscious awareness.
There is another issue that isn’t clear from the results. The people in the study didn’t go to one single ER. The study was done at many different hospitals. Could some of the bias in the study be because the black patients are going to very busy big city hospitals?
Or what about general policies? Imagine two hospitals on opposite sides of a city. At Hospital A, the director believes that pain medications should be used less often and averages 40% of patients in pain getting medication. At Hospital B, the director believes in responding quickly with pain medication and averages 60%. Hospital A because of its location sees a majority of minority patients. Suppose out of 100 patients, 80 are black and 20 are white. Hospital B sees 80 whites and 20 blacks. Guess what. Even though blacks and whites were treated identically at each separate hospital, 44% of blacks got pain medication while 56% of whites got pain medication. And it had nothing to do with racial bias and had everything to do with hospital policy.
I have no idea if the study has these kind of potential built-in biases but it isn’t clear from the results that it doesn’t.
OK, I could have sworn I posted another response to this, around noon. STILL in moderation. Wow.
Maybe it really just disappeared into the ether of Teh Series Of Tubes?
Sheesh, knowing how hard it has been for me (an educated, insured, white woman) to get adequate pain meds when they were really warranted, I can’t imagine how much pain must go untreated for people of color or those without insurance.
Same here, Beth. And the doctor who accused me of being drug seeking had in fact been busted by the state medical board for writing himself Vicodin prescriptions (found that out later on — sigh).
This comment will just make you cry:
http://www.metafilter.com/67578/Pepsi-BlueCross-BlueShield#1951436
American woman marries English guy, moves there & suffers through enormous tooth pain until he makes her actually go to the doctor. I quote:
I marched her to the GP the next morning (called and got her an appointment and a rapid registration within an hour). She saw a nurse (also a US expat, funnily enough), and after starting into the litany of reasons why she needed antibiotics, was stopped dead in her tracks with
“Honey, you’ll get the medicine you need, you don’t have to pitch me for it.”
That’s the problem. We’ve been conditioned to believe the right care is not OUR right. I have migraines — bad ones — and other problems that have required serious pain meds in the past. Yet any time I go to a new doctor, I spend half my time detailing my unusual drug reaction quirks to a disbelieving audience. It’s not fair!
That’s the problem. We’ve been conditioned to believe the right care is not OUR right. I have migraines — bad ones — and other problems that have required serious pain meds in the past. Yet any time I go to a new doctor, I spend half my time detailing my unusual drug reaction quirks to a disbelieving audience. It’s not fair!
I ended up switching away from Kaiser — where I do like the doctors — because they wouldn’t even cover my freakin’ rosacea medicine. They kept trying to make me use MetroGel when it doesn’t work for me and in fact makes my rosacea worse. So I was having to pay out of pocket for Noritate, which was just expensive enough to make a dent in my budget ($100 every four months) but not nearly expensive enough for them to deny (IMO, of course). And that’s something for my face, not something vital.
Sorry, that rant’s been building for a while.
“They kept trying to make me use MetroGel when it doesn’t work for me and in fact makes my rosacea worse. So I was having to pay out of pocket for Noritate, which was just expensive enough to make a dent in my budget ($100 every four months) but not nearly expensive enough for them to deny (IMO, of course).”
This one-size-fits-all thinking helps alienate patients and increases overall dissatisfaction with medical care in the US - which may actually be a feature.
Insurance companies make money by trying to avoid paying out. The same is true for medical care (mostly paid for by insurance companies).
Another big issue is that we are not actually customers in a medical care “transaction”. We are consumers, i.e. we get the benefit of the medical care we seek. But because we don’t actually pay for the services, we are not the actual customers - the insurance companies are. “He who pays the piper calls the tune…”
Single Payer: It’s the right thing to do…
Tom:
If you trackback to the original abstract, you’ll see that the authors say that race was the only significant factor. Since this is JAM, I’m assuming that they (and their reviewers) know enough elementary statics to control for factors among the hospitals and so on.
Also note that minorities (not just blacks) are being prescribed painkilliers, just not the more effective opioid compounds.
Really, why is this so hard for people to believe?
Epistemology — The Nietzsche quote is from the second essay of Genealogy of Morals. Copy and paste a section of it into google to find out exactly where.
Not always a good assumption. But until an analysis of the actual report and not just a newspaper article about it has been done, I think it needs to be taken with a grain of salt or two.
For the simple reason that statistics are VERY HARD to do right and JAMA isn’t as good at reviewing studies as some people seem to think. As long as the numbers are correct and reasonable controls are done, JAMA will accept the article. The numbers I made up above are accurate and unless more detailed analysis was done at each individual hospital they might not even be noticed as misleading because they are accurate.
Actually statistics are not all that hard to do right, though people are often sloppy about assumptions and inferences.
Your point was that a hospital that consistently under-prescribed for painkillers and treated a larger number of blacks would skew the data.
But the report is not saying that blacks get fewer prescriptions for painkillers, but for opioid painkillers, even in an environment when overall opioid prescription is higher. I don’t think your point holds.
Again, go and look at the abstract, not just the article.
I did read the abstract and my point still holds. If the director of Hospital A believed that opioids should only be used in extreme circumstances, his hospital would skew the data and it isn’t clear that the authors of the study have accounted for these and other possible variables.
It skews the data for a sample of two, but think about what’s being measured.
There are more than 150,000 visits recorded. This is when the power of large numbers kicks in. The statistical trends are very likely to have captured what the researchers say they do. The peculiarities of a single hospital administrator (or even a few) aren’t going to have an effect on the data.
If you’re arguing that the behavior of director B is somehow characteristic of many of the hospitals in the study, that conclusion is at odds with the overall increase in prescription of opioid painkillers. It doesn’t follow.
150,000 visits over 10 years represents a minuscule percentage of all ER visits. There are more than 100 million ER visits per year in the US. That means that out of 1 billion ER visits, the study looked at 150,000. How many different hospitals? In how many different states? Did they compare private to public facilities? Did they compare urban vs rural facilities? Did they give preference to large facilities or small facilities? I am sure that by carefully choosing my facilities I can give you whatever results you would like.
Number 1, whites are minority. I say this because I am white. Number 2, whites get seen last in the ER. Number 3, hardly anyone gets the right meds in the hospital because they think everyone is faking it, lying, or just not sick. Alot of doctors today suck! I think because of the stupid DEA AND THE MEDICAL BOARD!