The healing relationship in Indigenous patients' pain care: Influences of racial concordance and patient ethnic salience on healthcare providers' pain assessment

Abstract

Indigenous persons suffer from among the highest rates of chronic pain in the United States. Using a relationship-centered medical decision-making framework, this study sought to examine the influence of Indigenous racial concordance and patient ethnic salience on providers' assessment of pain. From May to October 2010, pre-identified healthcare providers working exclusively with Indigenous patients in the United States were randomly assigned an online clinical case vignette presenting an Indigenous patient reporting chronic lower back pain. A 2 × 2 analysis of variance, between-subjects design, was conducted with the predictor variables racial concordance and patient ethnic salience on the outcome measure of providers' ratings of patient's pain on a visual analogue scale. We found a significant interactional effect between racial concordance and patient ethnic salience on providers' pain assessment ratings. Indigenous providers tended to rate the patient with higher Indigenous ethnic salience more congruently with the self-reported pain ratings, perhaps due to perceived similarities and lowered unconscious bias. This is the first known study to examine racial concordance of the healthcare provider and ethnic salience of the patient in pain care. This study informs healthcare provider practice and consideration of patients' racial/cultural attributes and possible influence on assessment bias, which may be particularly relevant among Indigenous patients. More research is needed to identify specific interventions to improve cultural awareness and sensitivity for Indigenous persons who suffer from pain.

The use of experimental vignette studies to identify drivers of variations in the delivery of health care: a scoping review

“…Nurses generally rated female, African American, older patients’ pain higher and were more ready to prescribe opioids. Johnson-Jennings et al, 2018 [ 65 , 75 ] To test whether patient-provider racial concordance and patient ethnic salience is associated with 1) provider pain assessment 2) attitudes toward referral for traditional healing practices for indigenous patients USA Primary care Other clinical professional 1) Prescription 2) referral Ethnicity (Indigenous American - high/low ethnic salience) Racial concordance (patient & physician) Chronic lower back pain 1) Indigenous providers rated patient with higher Indigenous ethnic salience more congruently with the self-reported pain ratings 2) Provider–patient racial concordance increased likelihood of consulting with and referring patients to traditional healing practices. Lutfey et al, 2009 & 2010 [ 66 , 67 ] 1) Whether physician certainty is associated with decision making.…”

“…For example, Burt et al based vignettes on previously video-recorded patient-clinician encounters [ 42 ]. In a three studies, content was based on national guidelines [ 65 , 72 , 75 ].…”

And [They] Even Followed Her Into the Hospital: Primary Care Providers’ Attitudes Toward Referral for Traditional Healing Practices and Integrating Care for Indigenous Patients

“…The first author designed the case vignette and the ethnic salience of the simulated patient. Both were pilot tested and approved by an advisory panel of 10 experts consisting of IHS/tribal clinic physicians, nurse practitioners, and physician assistants reviewed the Provider Acceptance of Traditional Healing–Referral and Consult (PATH-RC) before distribution (see Johnson-Jennings et al, 2015, for more in-depth details on the method). Participants were presented the online case vignette with either a low or high ethnic salience condition.…”

“…The patient’s medical chart also presented a patient-reported visual analogue scale score of 9/10, which represents “severe” pain. Both the case vignette and ethnic salience were pilot tested (see Johnson-Jennings et al, 2015, for more in-depth details on the method).…”

“…If a patient seeks alternative traditional healing practices, the provider may not realize the patient is still seeking health care, and subsequently label patients as “noncompliant” (Street, Gordon, & Haidet, 2007). Over time, providers may unconsciously associate noncompliant behavior with Indigenous persons, as suggested in an Indigenous Relationship-Centered Medical Decision-Making Framework proposed by Johnson-Jennings, Tarraf, and González (2015). Drawing from previous literature, this framework posits that health care providers, overtime, may act on their implicit bias in a discriminatory manner, leading to poor treatment and health outcomes among Indigenous patients.…”