Looking Beneath the Surface: Racial Bias in the Treatment and Management of Pain.

Research has consistently documented inequities in the quality of care experienced by Black patients, with negative downstream effects on patient outcomes. Chronic pain is an area where substantial racial and ethnic differences in the management and treatment of Black individuals’ pain have been well-documented. While previous research posits that the patient-physician relationship is a primary mechanism for these disparities, little empirical research has examined this association. The study by Licciardone et al1 aims to fill this gap in the evidence-base by evaluating whether the quality of the patient-physician relationship serves as a mediator between patient race and pain and physical function outcomes among adults with chronic low back pain. This cross-sectional study included 1177 Black and White adults recruited from the University of North Texas Health Center’s Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation from 2016 to 2021. The quality of the patient-physician relationship was assessed using 3 self-report measures, which were completed by the study participants at registry enrollment: participant’s perception of physician communication was assessed with the Communication Behavior Questionnaire; perceived physician empathy was measured with the Consultation and Relational Empathy scale; and perceived satisfaction with medical care was assessed with the Patient Satisfaction Questionnaire. All were linearly transformed to create a score ranging from 0 to 100 to facilitate direct comparison of the measures. Intensity of chronic low back pain was measured as the average pain level over the 7 days prior to registry enrollment using a 0 (no pain) to 10 (worst pain) scale. The Roland-Morris Disability Questionnaire was also administered at registry enrollment to assess the perceived adverse impact of low back pain on physical function. Overall, the authors found comparable ratings in Black and White participants’ perceptions of the patient-physician relationship across all three measures, with only one significant difference in ratings of effective and open physician communication (mean for Black participants vs White participants, 72.1 vs 67.9; P = .03). However, this was not considered a clinically significant finding (Cohen d, 0.16; 95% CI, 0.01-0.30). Alternatively, the authors found significant racial differences in the pain-related outcomes, including higher pain intensity and greater back-related disability among Black participants compared with White participants (intensity mean: 7.1 vs 5.8; P < .001; disability mean: 15.8 vs 14.1; P < .001). The quality of the patient-physician relationship did not explain the association between participant race and the pain outcomes in the mediation analysis. This study has several strengths. First, more than 18.4% of participants self-identified as Black, which is important for diversity in clinical research. Second, the authors made use of a patient registry, which can be a valuable resource for research. Third, the mediation analysis helps to advance the scholarship of health disparities in pain, which is of public health significance. These strengths must be taken into context of notable limitations, which may explain why none of the association between participants’ race was attributable to measures of the patient-physician relationship, and the pain outcomes. Participation was limited to individuals who could access the digital registry and had a regular source of care, which offers a narrow view of how these findings relate to vulnerable patients who are most likely to experience disparities in pain. Important limitations in the measures of patientphysician relationship may also explain the null findings. First, the Communication Behavior Questionnaire was designed to assess the attributes of the relationship that are considered important to individuals when talking with his or her physician rather than the perceived quality of their physician’s communication. Thus, a positive interpretation of the study results are that Black + Related article