Pain management for Black patients and painful realities

This piece is inspired by my recent patient encounter. Within the past week, I received a call from the ER to admit a 29-year-old African-American female whom, for the sake of this essay, I will call Keisha. Keisha presented with severe lower abdominal pain and was found to be in hypertensive crisis. Her systolic blood pressure consistently was in the upper 200s. It turned out that the young lady suffered from a terrible case of polycystic kidney disease, and since she didn’t respond to oral medications, she was started on a Cardene drip, requiring ICU admission.

As I approached her bedside and introduced myself as an ICU doctor, the Keisher’s countenance swiftly shifted to one of distress, her eyes brimming with tears. Upon inquiry, she relayed a harrowing ordeal from her prior hospitalization wherein she was denied a more potent analgesic for her pain under the presumption of her exhibiting drug-seeking behavior. Despite her evident need for stronger medication, she was administered a less efficacious agent than what she was accustomed to at home. Fearing reprisal from her medical insurer, she reluctantly remained hospitalized against her own inclinations. Throughout her stay, she endured persistent and agonizing abdominal discomfort, her distress palpable as she contemplated the prospect of encountering the same health care provider who had previously disregarded her plight.

Offering some background, it’s noteworthy that this patient boasts a college-level education and maintains two stable jobs. Nevertheless, despite her credentials and the clear medical indicators of her condition, she encountered considerable difficulty in persuading health care providers that her intentions were not centered around obtaining narcotics. This skepticism persisted despite the well-documented association between her symptoms—abdominal pain and severely elevated blood pressure—and her diagnosed medical ailment. Connecting these dots is imperative, as effective pain management plays a pivotal role in addressing her hypertensive crisis.

Should one regard Keisha’s experience as an isolated anomaly, it suggests a lack of attentiveness to prevailing issues and perhaps even complicity in perpetuating systemic challenges. It is widely recognized that minority patients, particularly those of Black ethnicity, often receive inadequate pain management compared to their white counterparts. Despite the robust statistical evidence supporting this assertion, many health care providers remain oblivious to these glaring disparities.

As outlined in a study featured in the Proceedings of the National Academies of Science, a concerning 40 percent of first- and second-year medical students surveyed subscribed to the erroneous belief that “Black people’s skin is thicker than white people’s.” Furthermore, those who held such misconceptions were less inclined to administer appropriate pain management to Black individuals. Moreover, a comprehensive meta-analysis spanning two decades revealed a disturbing trend: Black/African American patients were 22 percent less likely than their white counterparts to receive any form of pain medication.

These disparities in pain treatment are not always deliberate acts of bias; rather, they often stem from intricate influences, including implicit biases that health care providers may not even recognize within themselves. Providers, like all individuals, are susceptible to the pervasive stereotypes perpetuated by media portrayals, particularly those associating African Americans with substance abuse.

When confronted with pain lacking an obvious physical origin, such as traumatic injury, health care professionals may lean towards subjective judgment, which is susceptible to the influence of personal biases and preconceptions. Shockingly, the meta-analysis highlighted that the most pronounced racial disparities in pain management occurred in cases of backache, migraine, and abdominal pain. Consequently, neglecting to adequately address a patient’s pain, as seen in Keisha’s case, cannot be brushed off as mere medical oversight; it represents a morally reprehensible action akin to evil.

When we contemplate evil, our minds often conjure up images of heinous acts like mass murder or ritualistic violence. However, there exist everyday manifestations of evil that are subtle and commonplace, yet deeply impactful. These evils can manifest through acts of omission or commission.

If, as a physician, you withhold pain medication from a suffering patient simply because you believe certain demographics are inclined to drug-seeking behavior without conducting a thorough assessment, that constitutes evil. Similarly, if you, as a patient care associate, allow a patient to endure suffering in their own waste and only attend to them when the family is present, that is an act of evil.

Treating patients differently based on their socioeconomic status is also a form of evil. Evil permeates our daily lives, and by remaining passive, we become complicit. Ultimately, those who rely on us for their well-being are left to endure needless suffering, and that is undeniably evil.

In the renowned work Eichmann in Jerusalem, author Hannah Arendt delves into the concept of the banality of evil. Through the lens of Adolf Eichmann’s trial for his role in the horror of the Holocaust, she illuminates how individuals can become complicit in perpetuating evil acts without fully comprehending their moral implications. As Eichmann orchestrated plans for the extermination of Jews, he justified his actions by claiming to merely follow orders as part of his duty.

Arendt emphasizes that the term “banality” in this context does not imply that Eichmann’s actions were ordinary or mundane but rather that they were driven by a disturbing sense of complacency and an absence of moral reflection. Eichmann’s compliance with orders highlights how individuals can become agents of evil through passive acquiescence to the actions or directions of others without critically questioning the ethical implications of their actions.

In confronting the insidious nature of systemic biases and the resulting injustices in health care, it’s imperative that we recognize the profound impact of our actions, both overt and subtle. As guardians of health and advocates for humanity, we must challenge the status quo, confront our biases, and strive for equitable care for all. For in the silence of indifference lies the perpetuation of suffering and evil. It’s only by actively acknowledging and addressing these injustices that we can truly fulfill our duty to heal and uphold the dignity of every individual under our care, irrespective of skin color or socio-economic status.

Osmund Agbo is a pulmonary physician.


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