TED Talks Daily - Sunday Pick: The bias behind your undiagnosed chronic pain

Episode Date: April 7, 2024

Each Sunday, TED shares an episode of another podcast we think you'll love, handpicked for you… by us. Today: an episode from TED Health, a podcast that shares ideas about your well-being -- from smart daily habits to new medical breakthroughs.While doctors take an oath to do no harm, there's a good chance their unconscious biases can seep into how seriously they treat pain. Physician Sheetal DeCaria explains how perception impacts medical care and treatment -- and calls for health care professionals to check in with themselves before checking in with their patients. Stay tuned after the talk as Shoshana, our TED Health Host, digs deeper into how implicit bias impacts the quality of health care Black women receive.

TED Audio Collective. Hey, TED Talks Daily listeners. I'm your host, Elise Hu. Today, an episode of another podcast from the TED Audio Collective, handpicked for you by us. In honor of World Health Day, we're sharing an episode from TED Health.

If you like TED Talks Daily and want to hear more TED content from a health perspective, look no further than TED Health. If you like TED Talks Daily and want to hear more TED content from a health perspective, look no further than TED Health. Each week, host Dr. Shoshana Ungerleider brings you a fascinating talk touching on some of today's most pressing health questions and tomorrow's most promising medical breakthroughs. Coming up, hear about the way unconscious biases affect how doctors treat chronic pain. You can check out TED Health wherever you get your podcasts and learn more about the TED Audio Collective at audiocollective.ted.com.

We'll get to the episode right after a quick break. Support for this show comes from Airbnb. If you know me, you know I love staying in Airbnbs when I travel. They make my family feel most at home when we're away from home. As we settled down at our Airbnb during a recent vacation to Palm Springs, I pictured my own home sitting empty. Wouldn't it be smart and better put to use welcoming a family like mine by hosting it on Airbnb? It feels like the practical thing to do, and with the extra income, I could save up for renovations to make the space even more inviting for ourselves and for future guests. Your home might be worth more than you think. Find out how much at airbnb.ca slash host.

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Don't get left behind. Listen to Disruptors, the innovation era, and stay ahead of the game in this fast-changing world. Follow Disruptors on Apple Podcasts, Spotify, or your favorite podcast platform. This is TED Health. I'm Dr. Shoshana Ungerleiter. On today's show, physician Sheetal Dakaria discusses unconscious bias in medicine. Far too often, it deprives women and people of color from receiving the life-saving care that they need. And after, I'll delve deeper into how unconscious bias keeps Black women in particular sicker than they should be.

The more we talk about it, the more conscious we are of it. So stay tuned. As a doctor in the field of pain management, I work in a world where you bring us your pain and we treat it. We ask questions. We take the symptoms you present. We decide what tests to run. We listen with compassion and wisdom and choose the best course of action based on our knowledge and experience combined with science, and sometimes in a very small window of time. As physicians, we took a sacred oath to do no harm,

and the system has gone to great lengths to teach us and set up guidelines to make sure that we treat every patient equally and without judgment. As we stand there in your moment of pain, we run your situation through every filter we have to give you the best care. And for most of us, this is more than just a job. It's a calling. But as we stand there in your moment, looking at your story from all the different angles and all the different rational voices in our head run through the decision-making process, there's another voice in the mix. And this voice, while it isn't rational or informed, yet it often dictates our decisions. And we don't give it a second thought because, you see,

this voice existed long before we began studying medicine. And so we accept it as truth. And this voice sometimes calls the shots. It's what I refer to as the undiagnosed bias, and it's causing suffering and death for many with chronic pain. I have spent the last 15 years studying pain, its cause, its treatment, and its management. But it wasn't until I found myself sitting on the other side of the exam room that I noticed the crack in the foundation of pain management. When I discovered that hidden voice that exists in all of us. That hidden voice, which I termed the undiagnosed bias,

is more commonly known as implicit bias, which is a bias that exists based on our unconscious beliefs and associations. Implicit bias in health care was brought to light in 2003 when the Institute of Medicine published a report titled Unequal Treatment. They found that regardless of insurance and income status, racial and ethnic minorities received worse care. And when it comes to pain, research shows that bias extends beyond minorities to also include women and even children. Dr. Susan Moore was a Black female physician whose story was heard around the world in 2020. The story of a doctor who struggled to receive the care she knew she needed. Her pain was due to a health issue that she fully understood and described in

medical lingo to her doctors, yet her pain was dismissed. When she posted her experience, there was an uproar of support. I mean, no one could accept that a doctor would treat a patient, let alone a fellow colleague like this, simply based on how they look. But that's the problem with implicit bias. Most of the time, you are unaware you even have it. I remember the year I went from doctor to patient. It started off as a small pain in my foot that just wouldn't go away. Well, it grew worse to the point that it overshadowed my life. It was this

constant companion affecting my work and my family life. I finally went to go see a foot surgeon and was told, source not clear, probably tendons were inflamed, he said. And he prescribed a boot and some physical therapy. But the pain worsened and it spread to my hip and my back. I sought out more medical specialists, even holistic practitioners, all with different theories, but no clear diagnosis or source of pain. I began to feel like I was going to have to live with this forever. And as the pain kept progressing with no clear diagnosis, I even thought to myself, wait, am I making this up?

Is my pain even real? In an online survey of 2,400 American women with a variety of chronic pain conditions, 91% felt that the healthcare system discriminated against them. And nearly half were told that the pain was all in their heads. So let's go ahead and dispel that pain myth right away. If you're worried that your pain is in your head, you're right. Because pain is in everyone's heads. You see, pain can't take place without our brains. When you step on a nail, for example,

you stimulate nociceptors or specialized nerve cells that send a message through your spinal cord to your brain. Well, your brain then decides what it's going to do with that signal. If it senses something dangerous, it will process that experience as painful to prevent you from further injury. And the decision by the brain to process it as painful is based on environmental and social cues, as well as by culture and one's past experiences. Now, contrary to popular belief, not all pain is related to tissue damage. Pain is actually defined as an unpleasant sensory and emotional experience that can be associated with actual

or potential tissue damage. You can have real pain with no physical injury or source. Pain is the one thing that can't be measured by a monitor or lab test. It's hard to quantify or qualify. It's measured on a scale of zero to 10 that is based on one's own perception of what they're experiencing. Pain, then, is subjective. And as doctors, our process of treating pain begins with identifying its source, which presents a problem when there is no source. For when there's no source, it becomes open to interpretation. And interpretation becomes open to that undiagnosed bias. Did you know that the different sexes experience pain differently? Now, for the sake of this talk, when I say female versus male, I'm referencing sex assigned at birth. And when I say

woman versus man or non-binary, then gender identity is at the core of the point. Females have more nerve fibers than men, and there's a hormonal influence to a variety of chronic pain conditions. At puberty, rates of chronic pain rise faster in girls than boys. And as females approach menopause, sex differences in chronic pain begin to disappear. Females experience more recurrent pain, longer-lasting pain, and higher overall levels of chronic pain than men, yet the majority of studies on the treatment of chronic pain have only been conducted in men. Did you know that women are more likely than men to be given anti-anxiety medications instead of painkillers when they present to the emergency department complaining of severe abdominal pain? Even for extremely urgent conditions such as chest pain from a heart attack, women experience delays in life-saving interventions that can prevent death. Research shows that clinicians more often suggest psychosocial causes,

such as stress or family problems, to women patients in pain when they would more often order lab tests for a male patient with the exact same symptoms. For Black women, such as Dr. Moore, they suffer two blows. The insulting notion that they are overdramatic due to their gender, along with the erroneous view that because their skin is Black, they are impervious to pain. A 2016 study of a group of medical students found that nearly half believed Black people have thicker skin than white people, less sensitive nerve endings, or that their blood clots more quickly. The origin

of these outrageous claims dates back to slavery and the 19th century experiments by Dr. Thomas Hamilton, who tortured Black slaves to prove that Black skin was deeper than white skin. And Dr. James Sims, a gynecologist, conducted experimental surgeries on enslaved black women without anesthesia, contributing further to false beliefs that black women experience less pain. There were times that I found it ironic that as an anesthesiologist whose livelihood is centered around managing pain, that I would suffer from chronic pain myself. And so, like Dr. Moore, I became my own advocate and dove deep into the root causes of my own pain. After five years, thousands of dollars, and many hours spent in pain, I finally found the cause by diving into integrative and functional medicine. Now, my pain was due to physical imbalances triggered by childbirth, years of stress and sleep deprivation, and a dietary sensitivity that had been triggering inflammation.

Over time, I healed myself, and finally, the pain began to ease. But while my own pain did fade, my passion for other people with chronic pain grew stronger. Now, doctors aren't the enemy. If you ask physicians why they went into medicine, you would hear, to help people. So much so that during disasters and global pandemics, healthcare workers kiss their own families goodbye to go take care of yours. They work tirelessly during codes to resuscitate your loved ones and shed tears when they lose them. But with exhaustion, time pressures, and overcrowded emergency rooms, comes the ability for that hidden voice to take over our rational one. Now, the healthcare system has been teaching bias training,

and studies show little to no explicit bias in healthcare, which is great. But we continue to see implicit bias in a percentage of healthcare practitioners. Because it operates in an unintentional and unconscious manner, implicit bias begins outside the walls of the hospital and is brought in unknowingly. And it's not just doctors. Bias exists in all of us. We can all do better. How? Well, the first step is awareness. We need to begin by identifying our stereotypes and then rewrite the stories of the people we meet. When a woman sits down next to us, ask ourselves, what would we say if this were a man? Would our answer change? And for those whose pain has been dismissed, fight to be heard.

Finding the right doctor can feel a little bit like dating. You may need to swipe through a few to find the right one for you. But don't give up, and don't delay seeking treatment. The sooner you are properly diagnosed, the greater chance you have of breaking your pain cycle. As physicians, we took an oath at our white coat ceremonies to first do no harm. And most of us live by that sacred oath. But part of that vow needs to include

staying in check with that inner voice to make sure that we aren't writing a story that our patients haven't told us yet. Because it is our duty as physicians to replace the undiagnosed bias with empathy. And to all of you out there who are suffering with chronic pain, we hear you and we're ready to listen. Thank you. Can Indigenous ways of knowing help kids cope with online bullying?

At the University of British Columbia, we believe that they can. Dr. Johanna Sam and her team are researching how both Indigenous and non-Indigenous youth cope with cyber aggression, working to bridge the diversity gap in child psychology research. At UBC, our researchers are answering today's most pressing questions. To learn how we're moving the world forward, visit ubc.ca forward happens here. Support for this show comes from Airbnb. If you know me, you know I love staying in Airbnbs when I travel. They make my family feel most at home when we're away from home. As we settled down at our Airbnb during a recent vacation to Palm Springs, I

pictured my own home sitting empty. Wouldn't it be smart and better put to use welcoming a family like mine by hosting it on Airbnb? It feels like the practical thing to do, and with the extra income, I could save up for renovations to make the space even more inviting for ourselves and for future guests. Your home might be worth more than you think. Find out how much at Airbnb.ca slash host. Hey listeners, it's Shoshana again. As a doctor and a woman, I was dismayed to hear about Dr. D'Caria's experience of going for years without the medical attention she needed, simply because she was a woman of color. Hearing these stories makes me reflect hard on every conversation I've had in the exam room. But as I learn more about

implicit bias in the history of medical care for Black patients, I understand why it happens. Before we begin, I must warn you that these stories are graphic, involving torture and brutal mistreatment of the Black community. But understanding them might provide the necessary context to make sense of implicit bias today. Many studies have shown that Black people, especially Black women, aren't taken seriously when they need treatment for pain and other medical issues. That's partly because a biased understanding of Black patients has seeped into medical decision-making because of the history of racism in America and false stories told about the Black experience.

Dr. DiCaria pointed out some of these archaic beliefs and how they can distort medical care. Here's a couple more. There's the common belief that Black people are stronger athletes, more agile, and therefore more robust in the face of pain. Or, just as strange, the belief that Black people are stronger athletes, more agile, and therefore more robust in the face of pain. Or, just as strange, the belief that Black people have a more sensitive sense of smell than white people, which can cloud physician judgment. So how did we get here? The roots of contemporary false beliefs stem from the slavery era. To justify the brutal treatment of enslaved Black people, physicians, scientists, and enslavers wanted to show that Black people were biologically different from whites. So they conducted experiments and medical procedures like

electric shock, amputations, and even brain surgeries to quote-unquote prove a biological difference. Novel medical procedures like treatments for congenital anomalies, tumors, and other injuries were carried out without anesthesia or pain relief. And even after emancipation, examples of brutal mistreatment of people of color continued to happen over centuries. For example, during World War II, the military covertly tested mustard gas and other toxic chemicals on Black soldiers. Between 1932 to 1972, the U.S. Public Health Service, in collaboration with the Tuskegee Institute, conducted a long-term experiment known today as the Tuskegee Experiment. The study observed what would happen to the body when syphilis went untreated.

Although penicillin was becoming widely available as the treatment of choice for syphilis by the mid-1940s, participants were not offered treatment, and as a result, over a hundred of them died. These kinds of experiments aren't allowed anymore, but some of the ideas they instilled in the practice of medicine still linger. Perhaps it's no wonder that today people of color mistrust the medical system, often avoiding medical care, including life-saving vaccinations, for fear that they too will be harmed. And that mistrust itself contributes to pain. In 2008, the Journal of Women's Health published a study examining the causes of chronic pain in older Black women. Results from this study showed that factors like younger age, depression, and the belief that one has control over their own health were significant predictors of greater pain intensity.

So what can be done about this bias? As a healthcare system, we have a lot of work to do to address implicit racial bias in medicine. It's complicated and sometimes controversial work. But I'll tell you what I want to see. Some researchers recently suggested that removing race from the first line of a patient's illness history can improve treatment equity. I think that's just a first step. Medical schools are also trying to reform education to undo racist policies and practices. As they do this, I want to see them include the social and historical context of disease and why many illnesses disproportionately impact communities of color.

In 2018, only 4 in 10 medical schools had racial health disparities content included in their curricula. I also want to support increased efforts to increase minority representation in training programs for all health professions. And what can you, as a patient seeking medical care, do about this? As hard as it can be to speak up, it makes a difference. I encourage you to advocate for yourself by communicating openly with your doctor. Also, be sure that key information is included in your medical chart and revisited often with your doctor so they can make the right recommendations based on your personal medical history and your preferences. As a doctor, I am responsible for my beliefs and actions.

To combat bias, we must be aware of our own, and we have a responsibility to hold our colleagues in medicine accountable when we see bias. We must call it out. Only then can we break the cycle. Since I've learned about implicit bias and its effects, I always try to pause and reflect before jumping to any conclusions about a patient's experience. It's a start, and I'm continually learning and striving to do more. Thanks so much for listening today.

This episode was produced by Joanne DeLuna and fact-checked by Ted. And special thanks to Anna Phelan, Grace Rubenstein, Maria Ladgis, Michelle Quint, and Colin Helms. I'm Dr. Shoshana Ungerleider. Stay well, and I'll talk to you next week. Looking for a fun challenge to share with your friends and family? Today, Ted now has games designed to keep your mind sharp while having fun. Visit TED.com slash games to explore the joy and wonder of TED Games.