Study shows racial bias in pain management

ST. LOUIS - In a new study published in the medical journal Pain, researchers at Saint Louis University School of Medicine found that even though Caucasians and African-Americans had similar work-related back injuries and reported comparable pain, they were treated less than equally by the Workers' Compensation system.

The study of 184 claimants in St. Louis showed that Caucasians with low back pain received temporary disability payments 10 times higher than those of African-Americans -- $5,040 for Caucasians versus $352 for African-Americans.

The study also showed that Caucasians received impairment ratings that were four times higher than those assigned to African-Americans reporting the same level of pain. Impairment ratings are significant because they can play a role in determining permanent partial disability compensation.

The ethnicity-based disparities vanished, however, if African-Americans obtained legal representation. Claimants with legal representation also tended to receive more diagnostic testing as part of their treatment, but this finding was not moderated by ethnicity.

"The findings imply that doctors who know a patient has legal representation are more cautious, possibly because they know the courts are looking over their shoulders," said Raymond C. Tait, Ph.D., professor of psychiatry at Saint Louis University School of Medicine. "If the patient doesn't have legal representation, however, inherent biases have a way of working their way into the situation.

So, while having an attorney involved in a disability case can lengthen the time from injury to settlement, it may be an effective strategy for coping with inequities in the Workers' Compensation system, especially for African-Americans."

In the Missouri Workers' Compensation system, employees injured on the job are required to see physicians retained by their employers. Some workers receive temporary disability payments while they undergo treatment. When a physician determines a worker has reached maximum medical improvement, the worker is assigned an impairment rating. This rating is taken into consideration by an administrative law judge who mediates the determination of permanent partial disability compensation. Usually, the higher the rating, the higher the compensation.

The study also found that ethnicity differences disappeared at the level of the administrative law judge, probably because nearly all claimants had legal representation by this stage of the process.

Dr. Tait and co-author John T. Chibnall, Ph.D., associate professor of psychiatry at Saint Louis University, chose to study work-related low back pain because it costs the country close to $40 billion annually in lost wages and treatment. They also chose it because low back pain is subjective and difficult to evaluate diagnostically.

"I've been treating chronic pain for a quarter of a century, and I've never seen the same pain condition twice," Dr. Tait said. "Frankly, chronic low back pain puts doctors into a quandary. We expected that when thrown into a quandary, inherent biases would have a higher chance of operating. The fact that these biases clustered around ethnicity shouldn't surprise us, given that racial bias has been documented in other areas of health care."

Drs. Tait and Chibnall said a much larger study of claimants with work-related low back pain must be conducted to validate the present findings.

"In addition, it's important that the findings of our study not be over interpreted," Chibnall said. "They do not imply intent by health care professionals. It's more likely that physicians are influenced by some of the same biases and prejudices that influence our society at large. We need to dig more deeply into how the injuries are managed to see whether the disparities have to do with individual physicians or with the system in which they operate."

Saint Louis University is a Catholic, Jesuit university and leading research institution. Founded in 1818, the University strives to foster the intellectual and spiritual growth of its 11,000 students through a broad array of undergraduate, graduate and professional degree programs on campuses in St. Louis, Missouri, and Madrid, Spain.

Editor's Note: To arrange an interview with Drs. Tait or Chibnall, please contact Joe Muehlenkamp in Saint Louis University media relations at 314-977-8015.