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OBJECTIVE: To determine if patient gender and race affect decisions about pain management.
DESIGN, SETTING, AND PARTICIPANTS: Experimental design using medical vignettes to evaluate treatment decisions. A convenience sample of 111 primary care physicians (61 men, 50 women) in the Northeast was asked to treat 3 hypothetical patients with pain (kidney stone, back pain) or a control condition (sinusitis). Symptom presentation and severity were held constant, but patient gender and race were varied.
MEASUREMENTS AND MAIN RESULTS: The maximum permitted doses of narcotic analgesics (hydrocodone) prescribed at initial and return visits were calculated by multiplying mg per pill × number of pills per day × number of days × number of refills. No overall differences with respect to patient gender or race were found in decisions to treat or in the maximum permitted doses. However, for renal colic, male physicians prescribed higher doses of hydrocodone to white patients versus black patients (426 mg vs 238 mg), while female physicians prescribed higher doses to blacks (335 mg vs 161 mg, F1,85 = 9.65 , P = .003). This pattern was repeated for persistent kidney stone pain. For persistent back pain, male physicians prescribed higher doses of hydrocodone to males than to females (406 mg vs 201 mg), but female physicians prescribed higher doses to females (327 mg v. 163 mg, F1,28 = 5.50 , P = .03).
CONCLUSION: When treating pain, gender and racial differences were evident only when the role of physician gender was examined, suggesting that male and female physicians may react differently to gender and/or racial cues.
Patient gender and race predict the amount of analgesic given to patients in a variety of clinical settings. In general, women1–3 and minorities3–6 receive less analgesic than men and nonminority patients undergoing similar medical procedures. These findings suggest that, for pain as well as for other medical conditions,7–11 women and minority patients are treated less aggressively. Such findings raise concerns that decisions about pain management may be influenced by patient characteristics unrelated to clinical condition and point to possible treatment biases. Because these studies involved retrospective reviews of medical records, however, it is unclear whether treatment differences reflected patient behavior, the behavior of the medical staff, or both.6 Gender or ethnic differences in style of communication,3,5,12 language spoken, insurance coverage, disease manifestations, or body weight may have resulted in the treatment differences found in these studies.
The aim of this study was to determine whether patient gender and race would influence decisions about pain management. An experimental design using medical vignettes was employed to hold disease characteristics and body weight constant and to vary patient gender and race systematically. Decisions about pain management were assessed by asking physicians to select a course of treatment (i.e., a dose of analgesic) and report on follow-up care in cases where the patient's pain persisted. It was predicted that patients presented as female and as black would receive lower doses of narcotic analgesics than patients described as male and as white.
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We expected on the basis of previous studies1–6 that physicians presented with medical vignettes would treat the pain of women and minority patients less aggressively, but we found no overall differences in decisions to prescribe analgesic or in doses of analgesic selected. In fact, physicians' initial decisions to treat patients' medical complaints were unaffected by patient gender or race across all 3 medical conditions. The lack of overall treatment bias revealed in this study is an important finding, especially given recent concerns about the media's overstatement of research findings implying that discrimination pervades medical decision making.15
We did find, however, a more complicated set of treatment patterns that suggest possible differences in the treatment approaches of male and female physicians. When treating hypothetical kidney stone pain, male physicians prescribed twice as much hydrocodone to white patients than to black patients, whereas female physicians did the reverse. In addition, male physicians treating hypothetical patients presenting with unresponsive lower back pain prescribed twice as much hydrocodone to male patients than to female patients; female physicians did the reverse and prescribed more hydrocodone to female patients than to male patients. Therefore, gender and racial differences were evident only when the role of physician gender was examined, suggesting that male and female physicians may react differently to gender and/or racial cues.
The decision to treat sinusitis, like the decision to prescribe narcotics at all for pain, was not related to patient gender or race. Only the types of antibiotics selected and their duration reflected differences by gender or race. While these results are in accordance with other studies reporting gender and racial differences in the treatment of medical conditions where pain is not the primary complaint,7,9,10 they illustrate that treatment differences observed in one clinical condition do not always mirror the type or direction of differences in another. The finding that treatment bias did not occur in all scenarios and that the differences observed occurred only with regard to the aggressiveness of the regimen selected and not decisions to treat is reassuring.
It is unclear why treatment approaches varied according to the gender of the physician in this study. The reasons for these differences can only be speculative. Physicians may sympathize or identify with patients of the same gender7 or race (in the case of male physicians), or with patients of disadvantaged groups (in the case of female physicians). It is also unclear why physician gender interacted with patient race when treating acute kidney stone pain but with patient gender when treating persistent lower back pain. The differences noted between the prescribing patterns of male and female physicians were unexpected and may be spurious. They warrant further investigation; if confirmed, they could help explain previous reports of less aggressive pain management in women and minorities, at least in studies where male physicians did4 or may have predominated.
In testing whether patient gender and race would influence decisions about pain management, we tried to overcome some of the problems found in previous studies. All physicians in the study read identical vignettes that held symptom presentation, body weight, and disease severity constant in a systematic fashion to minimize the influence of factors that may have accounted for differences in treatment reported in previous studies of gender and race.1–6 Therefore, the findings raise the possibility that treatment disparities may not necessarily be a function of the way patients present their illnesses or interact with physicians.4,12
The limitations of the study are that the sample was one of convenience, moderate in size, and restricted to physicians primarily in the Northeast. In addition, only half of the physicians solicited chose to participate. Therefore, these findings may not be representative of all primary care providers. In addition, we were unable to control for physicians' overall prescribing habits. However, given the manner with which physicians were assigned patient vignettes, and the balance of male and female physicians across the 4 experimental conditions that varied patient gender and race, it is unlikely that patients of a particular gender or race were consistently assigned to physicians with particular prescribing habits.
Future projects would be to study a larger sample of physicians and to include physicians of different ethnic backgrounds. The majority of physicians in the sample were white, so that the impact of physician race could not be ascertained. Future studies could involve an expanded set of different pain scenarios, and they could allow systematic variation of other patient factors such as socioeconomic status or age. The extent to which gender and race influence physician-patient communication also calls for further study, especially given evidence that health care messages are more effective when the educator's race matches that of the audience.16
Although male and female physicians exhibited different treatment patterns in this study, the meaning of these different treatment approaches is difficult to ascertain. More treatment, whether with narcotics for back pain or kidney stone pain or with antibiotics for presumed sinusitis, does not necessarily indicate better care and may, indeed, reflect worse care. Therefore, the clinical significance of the findings is unclear. In addition, whether the results accurately reflect treatment patterns occurring in clinical practice is unknown because this study used vignettes and did not assess physician responses to actual patients. Still, the results of this study raise the possibility that physicians' decisions about pain management are impacted differently by gender and racial cues, a finding that warrants further research, particularly in light of the fact that physician gender has been largely ignored in studies of treatment bias.