Examining the effects of contextually-imposed cognitive load on providers' chronic pain treatment decisions for racially and socioeconomically diverse patients

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Project Summary/Abstract Compared to individuals who are White and have high socioeconomic status (SES), those who are Black and have low SES experience greater pain and disability and are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making. There is compelling evidence that providers are influenced by patient race and SES when making treatment decisions. Pain is subjective, and providers often make pain care decisions with insufficient information. Consequently, providers may fill these information gaps with stereotypes about race and SES groups, leading to systematic differences in pain care. According to the dual process model (DPM) and previous studies, people are more likely to use such stereotypes when they are under high cognitive load (i.e., mental workload). Health care settings place high cognitive demands on providers via time pressures, noises levels, and interruptions. Another factor that may contribute to biased provider decision-making is implicit beliefs (subconscious, automatic stereotyping), which have been found to be associated with health care disparities. One stereotype belief relevant to pain care is that Black and low SES individuals are more pain tolerant. Previous studies suggest that many providers hold these beliefs about pain tolerance. Consistent with the DPM, providers who are under high cognitive load and who have strong beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments for Black and low SES patients. To test these hypotheses, the proposed study will recruit physician residents and fellows to view videos and make pain treatment decisions for 12 computer-simulated patients with low back pain that vary by race (Black/White) and SES (low/high); treatment options will include analgesic medications, complementary and alternative approaches, lifestyle changes, and referrals to specialty care. Half of the providers will be randomized to the high cognitive load group in which they will be interrupted during the treatment decision task to make Morphine Equivalent Dose conversions. Providers in the control group will not be interrupted during the treatment decision task. Providers’ implicit beliefs about race and SES differences in pain tolerance will be measured with Implicit Association Tests. The primary analyses will examine the main and interaction effects of patient race and SES on providers’ treatment decisions for chronic pain (aim 1), examine the main and interaction effects of patient race [SES] and cognitive load on providers’ treatment decisions (aim 2), and examine the main and interaction effects of patient race [SES], cognitive load, and providers’ implicit beliefs about race [SES] differences in pain tolerance on providers’ treatment decisions (aim 3). Multilevel modeling will allow for the examination of these effects at the individual provider and group levels. The proposed study is highly innovative and represents a crucial step in combating disparities in pain care. Ultimately, the project findings may lead to evidence-based interventions that target cognitive load and biased provider beliefs and thereby reduce disparities.