The Bias behind Your Undiagnosed Chronic Pain | Sheetal DeCaria | TED

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,

well, 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 to a group of thousands of fellow physicians,

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 percent felt that the health care 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,

health care 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 health care system has been teaching bias training,

and studies show little to no explicit bias in health care, which is great,

but we continue to see implicit bias

in a percentage of health care 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.

(Laughter)

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.

(Applause)