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J Natl Med Assoc. May 2007; 99(5): 532–538.
PMCID: PMC2576060

When race matters: disagreement in pain perception between patients and their physicians in primary care.


Patients and physicians often disagree in their assessment of pain intensity. This study explores the impact of patient factors on underestimation of pain intensity in chronic noncancer pain. We surveyed patients and their physicians in 12 primary care centers. To measure pain intensity, patients completed an 11-point numeric rating scale for which pain scores range from 0 (no pain) to 10 (unbearable pain). Physicians rated patients' pain on the same scale. We defined disagreement of pain intensity as underestimation or overestimation by 22 points. Of 601 patients approached, 463 (77%) completed the survey. The majority of participants were black (39%) or white (47%), 67% were female, and the mean age was 53 years. Physicians underestimated pain intensity relative to their patients 39% of the time. Forty-six percent agreed with their patients' pain perception, and 15% of physicians overestimated their patients' pain levels by > or =2 points. In both the bivariate and multivariable models, black race was a significant variable associated with underestimation of pain by physicians (p < 0.05; OR = 1.92; 95% CI: 1.31-2.81). This study finds that physicians are twice as likely to underestimate pain in blacks patients compared to all other ethnicities combined. A qualitative study exploring why physicians rate blacks patients' pain low is warranted.

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  • Fishman P, Von Korff M, Lozano P, Hecht J. Chronic care costs in managed care. Health Aff (Millwood) 1997 May-Jun;16(3):239–247. [PubMed]
  • Davis Mellar P, Walsh Declan. Cancer pain: how to measure the fifth vital sign. Cleve Clin J Med. 2004 Aug;71(8):625–632. [PubMed]
  • Merboth MK, Barnason S. Managing pain: the fifth vital sign. Nurs Clin North Am. 2000 Jun;35(2):375–383. [PubMed]
  • Lynch M. Pain: the fifth vital sign. Comprehensive assessment leads to proper treatment. Adv Nurse Pract. 2001 Nov;9(11):28–36. [PubMed]
  • Pasero C, McCaffery M. The undertreatment of pain. Am J Nurs. 2001 Nov;101(11):62–65. [PubMed]
  • Rich Ben A. A legacy of silence: bioethics and the culture of pain. J Med Humanit. 1997 Winter;18(4):233–259. [PubMed]
  • Resnik DB, Rehm M, Minard RB. The undertreatment of pain: scientific, clinical, cultural, and philosophical factors. Med Health Care Philos. 2001;4(3):277–288. [PubMed]
  • Edwards RR, Fillingim RB, Yamauchi S, Sigurdsson A, Bunting S, Mohorn SG, Maixner W. Effects of gender and acute dental pain on thermal pain responses. Clin J Pain. 1999 Sep;15(3):233–237. [PubMed]
  • Suarez-Almazor Maria E, Souchek Julianne, Kelly P Adam, O'Malley Kimberly, Byrne Margaret, Richardson Marsha, Pak Chong. Ethnic variation in knee replacement: patient preferences or uninformed disparity? Arch Intern Med. 2005 May 23;165(10):1117–1124. [PubMed]
  • Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993 Mar 24;269(12):1537–1539. [PubMed]
  • Apkarian A Vania, Sosa Yamaya, Krauss Beth R, Thomas P Sebastian, Fredrickson Bruce E, Levy Robert E, Harden R Norman, Chialvo Dante R. Chronic pain patients are impaired on an emotional decision-making task. Pain. 2004 Mar;108(1-2):129–136. [PubMed]
  • Cleeland CS, Cleeland LM, Dar R, Rinehardt LC. Factors influencing physician management of cancer pain. Cancer. 1986 Aug 1;58(3):796–800. [PubMed]
  • Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya KJ. Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med. 1997 Nov 1;127(9):813–816. [PubMed]
  • Green Carmen R, Anderson Karen O, Baker Tamara A, Campbell Lisa C, Decker Sheila, Fillingim Roger B, Kalauokalani Donna A, Kaloukalani Donna A, Lasch Kathyrn E, Myers Cynthia, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med. 2003 Sep;4(3):277–294. [PubMed]
  • Mäntyselkä P, Kumpusalo E, Ahonen R, Takala J. Patients' versus general practitioners' assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract. 2001 Dec;51(473):995–997. [PMC free article] [PubMed]
  • Edwards RR, Fillingim RB. Ethnic differences in thermal pain responses. Psychosom Med. 1999 May-Jun;61(3):346–354. [PubMed]
  • Green Carmen Reneé, Baker Tamara A, Smith Edna M, Sato Yuka. The effect of race in older adults presenting for chronic pain management: a comparative study of black and white Americans. J Pain. 2003 Mar;4(2):82–90. [PubMed]
  • Green Carmen R, Ndao-Brumblay S Khady, Nagrant Andrew M, Baker Tamara A, Rothman Edward. Race, age, and gender influences among clusters of African American and white patients with chronic pain. J Pain. 2004 Apr;5(3):171–182. [PubMed]
  • Weingart Saul N, Tess Anjala, Driver Jeffrey, Aronson Mark D, Sands Kenneth. Creating a quality improvement elective for medical house officers. J Gen Intern Med. 2004 Aug;19(8):861–867. [PMC free article] [PubMed]
  • Edwards Robert R, Doleys Daniel M, Lowery Daniel, Fillingim Roger B. Pain tolerance as a predictor of outcome following multidisciplinary treatment for chronic pain: differential effects as a function of sex. Pain. 2003 Dec;106(3):419–426. [PubMed]
  • Chen Ian, Kurz James, Pasanen Mark, Faselis Charles, Panda Mukta, Staton Lisa J, O'Rorke Jane, Menon Madhusudan, Genao Inginia, Wood JoAnn, et al. Racial differences in opioid use for chronic nonmalignant pain. J Gen Intern Med. 2005 Jul;20(7):593–598. [PMC free article] [PubMed]
  • Farrar JT, Young JP, Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001 Nov;94(2):149–158. [PubMed]
  • Anderson KO, Mendoza TR, Valero V, Richman SP, Russell C, Hurley J, DeLeon C, Washington P, Palos G, Payne R, et al. Minority cancer patients and their providers: pain management attitudes and practice. Cancer. 2000 Apr 15;88(8):1929–1938. [PubMed]
  • Stewart Walter F, Ricci Judith A, Chee Elsbeth, Morganstein David, Lipton Richard. Lost productive time and cost due to common pain conditions in the US workforce. JAMA. 2003 Nov 12;290(18):2443–2454. [PubMed]
  • Edwards RR, Doleys DM, Fillingim RB, Lowery D. Ethnic differences in pain tolerance: clinical implications in a chronic pain population. Psychosom Med. 2001 Mar-Apr;63(2):316–323. [PubMed]
  • Edwards RR, Fillingim RB. Ethnic differences in thermal pain responses. Psychosom Med. 1999 May-Jun;61(3):346–354. [PubMed]
  • Edwards Robert R, Moric Mario, Husfeldt Brenda, Buvanendran Asokumar, Ivankovich Olga. Ethnic similarities and differences in the chronic pain experience: a comparison of african american, Hispanic, and white patients. Pain Med. 2005 Jan-Feb;6(1):88–98. [PubMed]
  • Asrani S, D'Anna S, Alkan-Onyuksel H, Wang W, Goodman D, Zeimer R. Systemic toxicology and laser safety of laser targeted angiography with heat sensitive liposomes. J Ocul Pharmacol Ther. 1995 Winter;11(4):575–584. [PubMed]
  • Smith BH, Elliott AM, Chambers WA, Smith WC, Hannaford PC, Penny K. The impact of chronic pain in the community. Fam Pract. 2001 Jun;18(3):292–299. [PubMed]
  • Baker Tamara A, Green Carmen Reneé Intrarace differences among black and white americans presenting for chronic pain management: the influence of age, physical health, and psychosocial factors. Pain Med. 2005 Jan-Feb;6(1):29–38. [PubMed]
  • Bates MS, Edwards WT, Anderson KO. Ethnocultural influences on variation in chronic pain perception. Pain. 1993 Jan;52(1):101–112. [PubMed]
  • Bates MS, Rankin-Hill L. Control, culture and chronic pain. Soc Sci Med. 1994 Sep;39(5):629–645. [PubMed]
  • Bates MS, Rankin-Hill L, Sanchez-Ayendez M. The effects of the cultural context of health care on treatment of and response to chronic pain and illness. Soc Sci Med. 1997 Nov;45(9):1433–1447. [PubMed]
  • Ndao-Brumblay S Khady, Green Carmen R. Racial differences in the physical and psychosocial health among black and white women with chronic pain. J Natl Med Assoc. 2005 Oct;97(10):1369–1377. [PMC free article] [PubMed]
  • Bussey-Jones Jada, Genao Inginia. Impact of culture on health care. J Natl Med Assoc. 2003 Aug;95(8):732–735. [PMC free article] [PubMed]
  • Green Carmen R, Wheeler John R C. Physician variability in the management of acute postoperative and cancer pain: a quantitative analysis of the Michigan experience. Pain Med. 2003 Mar;4(1):8–20. [PubMed]
  • Skarupski Kimberly A, de Leon Carlos F Mendes, Bienias Julia L, Scherr Paul A, Zack Matthew M, Moriarty David G, Evans Denis A. Black-white differences in health-related quality of life among older adults. Qual Life Res. 2007 Mar;16(2):287–296. [PubMed]
  • Ritter Philip L, González Virginia M, Laurent Diana D, Lorig Kate R. Measurement of pain using the visual numeric scale. J Rheumatol. 2006 Mar;33(3):574–580. [PubMed]
  • Berger Vance W. Can pain be quantified numerically? J Rheumatol. 2006 Nov;33(11):2364–2365. [PubMed]

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