The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions

J Pain. 2015 Jun;16(6):558-68. doi: 10.1016/j.jpain.2015.03.003. Epub 2015 Mar 28.


Although racial disparities in pain care are widely reported, much remains to be known about the role of provider and contextual factors. We used computer-simulated patients to examine the influence of patient race, provider racial bias, and clinical ambiguity on pain decisions. One hundred twenty-nine medical residents/fellows made assessment (pain intensity) and treatment (opioid and nonopioid analgesics) decisions for 12 virtual patients with acute pain. Race (black/white) and clinical ambiguity (high/low) were manipulated across vignettes. Participants completed the Implicit Association Test and feeling thermometers, which assess implicit and explicit racial biases, respectively. Individual- and group-level analyses indicated that race and ambiguity had an interactive effect on providers' decisions, such that decisions varied as a function of ambiguity for white but not for black patients. Individual differences across providers were observed for the effect of race and ambiguity on decisions; however, providers' implicit and explicit biases did not account for this variability. These data highlight the complexity of racial disparities and suggest that differences in care between white and black patients are, in part, attributable to the nature (ie, ambiguity) of the clinical scenario. The current study suggests that interventions to reduce disparities should differentially target patient, provider, and contextual factors.

Perspective: This study examined the unique and collective influence of patient race, provider racial bias, and clinical ambiguity on providers' pain management decisions. These results could inform the development of interventions aimed at reducing disparities and improving pain care.

Keywords: Race; bias; decision making; disparities.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • African Americans
  • Aged
  • Aged, 80 and over
  • Analgesics, Opioid / therapeutic use
  • Attitude of Health Personnel
  • Decision Making / physiology*
  • European Continental Ancestry Group
  • Female
  • Healthcare Disparities / ethnology*
  • Humans
  • Male
  • Middle Aged
  • Pain Management*
  • Pain* / diagnosis
  • Pain* / drug therapy
  • Pain* / psychology
  • Racism*
  • Surveys and Questionnaires


  • Analgesics, Opioid