D

uring a rotation in the emergency department, I watch a nurse do an initial assessment of an older woman lying on a gurney. An interpreter is called in, since the woman speaks only Spanish. After a few questions, I notice that the nurse is growing increasingly exasperated. She finishes with the evaluation and walks towards me. “I don’t know what’s wrong with her,” she says. “She has polymyalgia hispanica and I’m already done with her.”

Polymyalgia hispanica — a play on polymyalgia rheumatica, a condition in which the body’s immune system attacks the muscles causing widespread pain and stiffness. While I’ve never heard this particular phrase, I’ve often heard another version, total body dolor. It means pain all over. These phrases are a common way physicians and other health care providers express their frustration about the Latina women who come into our clinics in pain.

We seem most likely to use these phrases when we are overwhelmed, behind schedule, or can’t find a unifying diagnosis. We use them as a way to cope with the task of treating complex patients with limited time and often limited resources. But they also reflect our tendency to use language that separates us from them.

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Many doctors enter medicine to prevent and treat suffering. Yet it seems that as we advance in our training, the more bothersome and frustrating evaluations of pain become. We want to make people feel better, but we don’t always know why or how much someone is hurting. And there are consequences of both prescribing too much or too little pain relief. So we turn to this language to minimize the pain we don’t understand or can’t fix. Unfortunately, this tends to occur more often with patients of color.

Yet aren’t our patients of color, many of whom are subjected daily to racism and fear, most justified to be hurting? Racism hurts.

These patients may be confronting brutality and violence in their neighborhoods, often by forces that are supposed to protect them. They see members of their communities imprisoned into a system where racism is palpable. And those who are also immigrants may face daily reminders that their presence is being threatened, their freedoms limited, and their citizenship conditional. Not only is the medical profession failing to broadly acknowledge these realities, but with such disparaging language it further isolates the patients of color we are supposed to be healing.

Among nonwhite patients, pain is often undertreated. This has been demonstrated in women in labor, children with appendicitis, and palliative care for women with breast cancer.

One problem with diagnosing and treating pain is that pain is subjective, which open the floodgates to the impact of bias. Unlike the five objective vital signs we use as markers of physiologic stability — heart rate, breathing rate, oxygen saturation, body temperature, and blood pressure — pain is an experience influenced by an individual’s mental health, coping skills, and sense of control over his or her life and body. That makes it easy for clinicians’ interpretations of pain to be muddled by stereotypes.

A recent study prompted national attention when it found that half of medical students and resident physicians who took part in a survey held false beliefs about biological differences between black and white patients. This included the belief that black people have higher tolerance to pain, a message that is rooted in a 19th-century myth initially perpetrated by slave owners.

Doctors may be particularly susceptible to bias. In our need to synthesize vast amounts of information at an increasingly fast pace, we tell ourselves stories that best fit the data in front of us. Anchoring is one type of bias. It means maintaining an initial diagnosis despite evidence arguing against it. In one study of resident physicians’ reflections on their own diagnostic errors, anchoring was mentioned in 88 percent of clinical scenarios. When meeting a new patient, race is one of the first things a physician sees. Studies of simulated physician decision-making have shown that when all other clinical variables are controlled, race predicts management. For example, black patients receive fewer recommendations for lifesaving therapies, such as thrombolysis in acute stroke and cardiac catheterization for chest pain.

As a young white female physician in training, I’m increasingly uncomfortable hearing my colleagues vent their frustration with terms like polymyalgia hispanica and total body dolor. They highlight our limited fluidity with our patients’ languages and cultures, violate our patients’ trust, and excuse our unwillingness to further investigate their complaints.

I fear that these attitudes limit our patients’ workups and lead to misdiagnosis more often than we realize. Sometimes we may even overlook serious causes of their pain. In the case of my emergency room patient, while it took several hours of observation and conversation in her native language, we finally ordered the right test and discovered she had strep throat.

At a minimum, we must stop using racially charged language if we hope to develop therapeutic relationships. But I believe we can and should go much further. Even when we can’t find a clear cause of our patients’ pain, we should stop questioning whether our patients really are hurting. Instead, we should acknowledge the close ties between the pain we see in our patients and the discrimination, disparities, and violence they may be facing in their communities.

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Race is an undeniable risk factor for premature death. We must strive to investigate the subtle and not so subtle ways our biases may be contributing to poor health outcomes. We need new communication methods to investigate pain and new models to understand the structural forces that work to keep our patients unhealthy.

I am learning that when I don’t speak my patients’ languages, don’t understand their ways of describing their symptoms, or don’t feel culturally connected to where they come from, I should recognize the moment as dangerous. I must resist the urge to minimize their complaints or doubt their symptoms, and instead take responsibility for the limits of my own knowledge and delve purposefully into their stories.

Katherine Brooks, MD, is a resident physician in internal medicine at Harvard-affiliated Brigham and Women’s Hospital in Boston.

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  • Thank you, much needed article.

    A co-worker was denied any pain medication when he fell off a ladder and injured his leg/knee badly (so badly he still limped and had pain years later). In his case, he was an Anglo male, but felt the reason he was denied pain meds in the ED was he “looked like a hippie” (although in reality he was a very conservative Republican just had a country-style beard). Same sort of stereotyping at work. It’s tremendously harmful, and very common.

  • I suffer from pain. Raynards, back & shoulder. Being a carer l can not stop moving. I feel judged and humiliated when speaking with Drs about my conditions. Automatically their walls go up. Because no one can see pain they do not understand pain. The moments in the day when you lock yourself in the bathroom crying on agony so loved ones do not see how the last chore you did to help them made the pain even worse.
    One specialist told my GP ‘she’s in pain.seems distressed. Send to psychiatrist ‘. I would rather be in severe pain than be humiliated.

  • The problem is not that pain is subjective. The problem is the doctor cannot feel the pain so s/he by definition is not qualified to judge.

    Once doctors admit this truth, then they must assume what the patient says is fact. The doctor should giving them pain relief that WORKS for them, and begin scientifically eliminating possible causes.

  • This is excellent! and important.
    We see a lot of refugee patients in our clinic and diagnosing etiologies of pain or other symptoms can be difficult. Last week a woman complained of shortness of breath and when I asked her to describe she said (translated) “it feels like a hot snake is in my stomach and my whole body is slow. ” Sometimes its hard to distinguish physical and psychological pain (or often some combination) especially because not every culture experiences that divide the way we do; and 15 minute appointment slots dont leave much time to spend teasing it out. Even eliminating cultural differences, 10/10 pain will mean something completely different between two patients. Perhaps our streamlined “pain scale” and limited descriptors serve only the EMR and administration.

  • Great article! It is crucial to bring this discussion to public spaces like this one. The patients should never pay the consequences of our frustration. The words that we choose to use with our colleagues are just the tip of very deep prejudices that need to be identified.

  • My husband, an Emergency Medicine physician treated patients with fractured tibias or femurs for pain right away in the ED. The pharmacists went nuts and accused him of too much narcotic use. My husband told them he would be sure to restrict the amount of narcotics for pain relief they would receive if they came to the ED with similar injuries. 😊

  • Good for you. Black or white, if a patient has something unusual they can’t immediately identify, many docs are going to blow the patient off without really looking. I’m a physician with rare diseases–this attitude causes permanent damage to people’s lives.

  • Good luck with that. Who admits their prejudices? Everybody has a “minority friend” or “I voted for Obama” “I like Tupac and Beyoncé”

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