Pain
The concept of pain is something that we all learn about over our lives. For someone suffering from chronic pain, it can feel as though the world isn’t understanding.
Sometimes, the world just doesn’t get it.
Chronic pain can be hard to understand, even for medical professionals whose main role is to give care. Chronic pain is subjectively measured and poorly understood. This led to physicians interpreting chronic pain as a character flaw rather than a true disease. Although we have made great strides in understanding chronic pain from a pathophysiologic perspective, there is still much to learn. This historical bias may be due to a person’s socioeconomic status, gender, race, ethnicity, and gender. It could make their pain more “psychosomatic” than they are legitimate. This can lead to them not receiving the appropriate care.
For example, we know that people of color are less likely than whites to get adequate treatment for acute and chronic pain. This is despite controlling for factors such as gender, age and intensity. We also find that healthcare is less likely to consider women’s pain, even if it is documented in the literature. This is because women have a higher pain tolerance or are more likely than men to describe the pain.
People don’t receive the necessary treatment if the pain isn’t treated seriously. This is more apparent in interventional pain management, where therapies such as dorsal root stimulation, spinal cord stimulation and radiofrequency ablation are underutilized. It’s a matter of how long these therapies have been around and how many patients could benefit. However, increasing access or the number of interventional procedures won’t solve the problem. We need to be able to identify the obstacles and then address them.
The Physician Factor
The healthcare system is a key area to focus on. We see that women and minorities are underrepresented in medicine in general and in the interventional pain medicine specialties. This is despite recent advances. Just think that only 5% were African American doctors in 2018 despite making up over 13% of the U.S. populace. The numbers for interventional pain medicine specialties were even lower. Only 4.7% and 3.8% of neurosurgeons and anesthesiologists were made up of African Americans. The number rises slightly in the pain medicine specialty, where African American or black doctors make up 5.9% overall. Only by further segmenting the specialties and looking at gender and racial demographics can we find a double-digit representation–10.3% of all female pain medicine specialists are African American or black.
Athenahealth’s 2017 survey found that 60% of doctors under 35 were female, indicating a shift in gender roles in healthcare. However, 63% of all physicians are still male. Women are underrepresented in pain specialty, with only 26% of anesthesiologists and 19% of pain medicine specialists, respectively, and 9.3% among neurosurgeons. Although the situation is improving, women now make up 48% of medical students, 35% of anesthesiology residents and 22% of pain medicine fellow trainers.
The economic gap between medical school students and the general population is large. Although the financial history of physicians choosing to specialize in pain medicine is not easily available, it was found that 24% of first-year medical students came from families with the highest incomes, 51% from the top quintile, and 24% from families with the lowest. Only 5% of the lowest quintile came from this group.
This is important because, for example, it can be easier for women to understand the issues related to childbirth and chronic pelvic pain. Also, bias has been associated with socioeconomic, demographic, patient assessment, treatment, and outcomes.
The Root Cause of the Pain Problem
The patient perspective is the second thing to consider. It is well-known that the U.S. has significant barriers to healthcare. If a patient cannot access basic healthcare, specialty pain care will be impossible. Many factors can lead to this problem, including poverty, medical deserts, and the educational divide.
Of all these, poverty is the most prevalent. Wealth inequality can have a huge impact on one’s health. According to a December 2017 study, middle-aged Americans with the lowest income had a 17% more chance of dying than those with the highest income. This compares to just 5% for those who have the highest income. The chance of becoming disabled in the next ten years was 48% for those with low incomes, while it was only 15% for those with the highest incomes. Patients with chronic pain are more likely to be of lower socioeconomic status and feel pain when facing economic hardships.
People with lower incomes are more likely not to have health insurance. This can make it difficult to access care. For example, we know that almost 30 million Americans, who are not elderly, were without insurance coverage even after the Affordable Care Act was implemented in 2019. Of these, 1 in 5 earned less than the federal poverty level.
People without insurance are more likely than others to forego necessary care, even for chronic pain. One study showed that patients who had private insurance for white men were more likely than those without it to be able to access spinal cord stimulators to relieve their pain.
Education has also been associated with health and chronic pain. No matter their race or gender, adults with lower education levels, were more likely than others to report poorer health. National Health Interview Surveys showed that white women and men had a 57% chance of reporting poor or fair health if they didn’t have a high school diploma. This was compared to a mere 9% chance for college graduates. Non-specific low back pain was more common in those with lower education than those with higher education. People with lower education are more likely to report and experience pain with each generation. This is different from people with bachelor’s degrees.
All these factors assume that people have access to the healthcare they need. However, for many Americans, this is not true. They live in medical deserts. Medical deserts are areas that have poor access to basic medical services. They can often be found in rural areas, where many hospitals have closed or have had their providers move away. People are forced to travel long distances to get care, making it harder to access primary and specialist care for chronic pain. The greatest effect on seniors, who are most likely to be suffering from chronic pain, and low-income people because they often have transportation difficulties is the need to travel long distances to get care. These patients will be more inclined to delay or forego the necessary care if they don’t have an alternative.
Digital Health: An Option
Many people have limited options due to socioeconomic factors. Telehealth and digital health are possible solutions. Digital health can improve outcomes, compliance, and quality of life. It can also reduce healthcare spending. Digital health has resulted in cost savings of up $121 per visit. This is significant for patients who are struggling to pay. It can also help patients connect with their specialist physicians and primary care. Virtual clinic technology has made it possible for interventional pain specialists in the United States to adjust neurostimulation devices for patients suffering from chronic pain. This is a significant breakthrough in the U.S.
Despite all the advancements made, it is important to continue filling the gaps in healthcare. Digital health, such as, is only as good or as reliable as the internet access a patient has. People can’t benefit from digital health options if they have poor internet access, limited or no cell service, slow internet speeds, or lack of sufficient computer technology, especially if they live in rural areas.
All of us, from the healthcare provider to manufacturers to the policymaker, to remove these barriers to providing care for all Americans are responsible. To do this, we must first understand what it takes for them to achieve their best health. Only then can they be helped to restore their health.
