Welcome to the African-American Community Session on Disparities in the Management of Spine Pain. I'm Angela Wonko, MD, and I'll be moderating this session for you. I'm joined by Dr. Carlo Adams, Dr. Deborah Lee Bernal, Dr. Ashley Eves, and Dr. Teresa Oney. So as far as disclosures, we do not have any financial disclosures to display, no relevant relationships to disclose, and no conflicts of interest. Our objectives, so we're going to be working on determining differences in the workup and treatment of spine pain conditions that are affected by racial and ethnic backgrounds. In addition to identifying methods for improvement of spine pain, patient care interactions who are from underrepresented and marginalized groups. We will also be developing home programs using cognitive behavioral intervention to enhance physical function while considering the effects of race and ethnicity for patients with spine pain. And lastly, we'll be learning how to mitigate bias attitudes in providers in chronic spine pain, care conditions, and the effects of patient race, socioeconomic status, and ethnicity. So we're going to do some introductions. So like I said, I'm Angela Wonko. I'm currently a PGY-2 upcoming resident and the Baylor College of Medicine PM&R program. I'm currently doing my transitional year at Baylor Scott and White Health. I'm honored to be a part of this presentation and eager to be involved as I also have personal interest in interventional spine and pain management in addition to disparities and rehabilitation care. Next, I'll be introducing Dr. Debra Bernal. She's a board certified physiatrist trained at Sinai and Baltimore and Johns Hopkins. She has extensive involvement in her community for the past 22 years and also served as a site director at WellSpan Physiatry. She is actively involved in the NAACP, Delta Sigma Theta sorority, the American College of Lifestyle Medicine, and AAPM&R on health disparities, diversity issues, and mentoring. Next, we have Dr. Ashley Eves. She is a board certified physiatrist and pain management physician, serves as assistant professor of PM&R at Vanderbilt and also in the Department of Anesthesiology. She completed her fellowship recently, a comprehensive pain and spine medicine fellowship at Wake Forest and is currently in practice. She enjoys collaborating with patients on function and quality of life and is also passionate about diversity, equity, and inclusion in addition to medical education, training, and community engagement. Dr. Carlo Adams is our next speaker. He is a board certified physiatrist and pain management physician. He practices in Arkansas and also works in the Detroit metro area. He currently focuses on serving underserved patients and giving them access to pain management, which is very keen for our presentation for today, and he works on long-term pain control and function. Lastly, we have Dr. Theresa Oney. She is also a board certified physiatrist, does non-surgical management of pain and musculoskeletal disorders, has stayed in Michigan for a while, but trained in Mayo Clinic for PM&R. She currently owns a private practice in Grosse Pointe, Michigan, and serves as the chair of the African American community of the AAPM&R. So now we're on to Dr. Bernal, who will get our presentation started. It's my pleasure tonight to set the stage for this presentation and call the question of racial disparities in pain management. We're doing this through a study that was done on racial and ethnic disparities in the treatment of chronic pain, and this reviewed 59 articles in order to accumulate this data. Next. So, just to give the lay of the land, approximately one in three US adults experience chronic pain. That's why our schedules are so busy. The annual cost of pain is greater than the cost of heart disease, cancer, and diabetes. Non-white patients are less likely to receive opioids while in the ED or at discharge. The patient's sociodemographic profile influences the treatment of acute pain in the ED. Next. So, the studies that were included focused on chronic pain. At least one aim or analysis centered on race or ethnic differences related to treatment and pain outcomes. The studies were cross-sectional, longitudinal, and interventional designed. The study only consisted of adults. The studies were published between January of 2000 and June of 2020. All were conducted in the US and non-English language children, acute pain, and case reports, focus groups, commentaries, and editorials were excluded. So the review articles were, studies were organized into the following categories based on key findings. Racial and ethnic disparities in the treatment of chronic pain, racial differences in the long-term monitoring of opioid use, the impact of chronic pain and interventions. And 59 articles met that criteria and were reviewed and summarized. Next. So how does this affect the quality of life for our patients? Numerous studies found that minorities were less likely to receive opioids for their treatment of chronic pain and the evidence being the strongest for Black patients. Racial and ethnic differences also existed among nursing home residents with chronic pain. Research on long-term monitoring of opioid use among patients with chronic pain revealed that Blacks are subject to closer monitoring for possible opioid misuse and chronic pain has a negative impact on the quality of life and mood while leading to more disability, especially powerful among these vulnerable populations. So we're here to find out what impact we can have. There are many factors that could contribute to these racial and ethnic differences. Possible mechanisms for disparities exist at the level of the patient, the provider, and the system. It is still unknown which of these factors, if intervened upon, would have the greatest impact on reducing disparities in the treatment of pain, but we don't have to choose one factor. We can work on all factors. So we will be addressing these contributors to the disparities. Mistrust of the health care system is something that leads to disparities and historical atrocities such as Sims, Laps, and Tuskegee does explain the Black community's distrust in the health care system. And these historical traumas certainly provide critical content for interpreting present-day occurrences. Thank you. So next we're going to do a literature review. By no means is this comprehensive. This is only going to be 10 minutes, but we're just going to focus on some different things contributing to disparities in spine pain, including opioids, pain severity, imaging disparities, surgical management, perceived discrimination, depression, and social status. Next slide, please. So the first study that we'll look at is from the National Ambulatory Medical Care Survey. It's an annual national probability sample for office-based visits, and they looked at abdominal and low back pain visits between 2006 and 2015 for patients. There was over 5,000 patients in the study, and they looked at white, Black, and Hispanic patients. Next slide, please. They found that for abdominal pain, Black and Hispanic patients were 6% less likely to receive opioids than white patients. For low back pain, Black patients were 7% less likely, and Hispanic patients were 15% less likely to receive opioids than white patients. And Hispanic patients had shorter visits for back pain than white patients. There was no difference for Black patients. So overall, they found that Black and Hispanic patients were less likely to get opioids, and Hispanic patients had shorter visit times. Next slide, please. The next study we'll look at, they looked at disparities in pain severity through pain catastrophizing. So catastrophizing is something that a lot of our pain patients do have. It's a tendency to magnify the threat of value of pain stimulus and to feel helpless in the context of the pain. And so this study looked at 320 adults with low back pain. Next slide, please. And so they found that Black individuals had higher pain sensitivities from multiple measures of deep muscle hyperalgesia and mechanical punctate pain. So they did different tests with needles and other things to determine these types of pain, and that's what they found for Black patients. They also found that Black patients had a larger degree of pain-related catastrophizing that they think partially accounted for this increased sensitivity. And increased sensitivity means you have experienced more pain. It's not that you have a higher threshold. So their hypothesis is that Black individuals may have had increased catastrophizing frequency from enhanced pain sensitization through attentional and emotional responses. So if a Black person has a bad day for various reasons, they could then have more catastrophizing and more sensitization, which is why they experience pain. Next slide, please. The next study we'll look at was a prospective observational trial, and it looked at 600 patients. They were at 595. They were at three different sites, so 200 each one, that were coming into the emergency department with a complaint of low back pain. And so they found that patients who were White, 50 or older, or had red flag symptoms were more likely to receive an MRI or a CT scan. And patients who were African-American, less than 50, or had severe pain, or had no insurance, were less likely to receive this advanced imaging. Next slide. And so they found that race and insurance status both affected a patient's chances of receiving advanced imaging. And so their thought was that a non-operative spine specialist, like anesthesia or pre-MNR, like ourselves, would be helpful for both diagnostic and therapeutic management of back pain in the ED settings. I also think probably having a specialist who reflects the community that they're treating would also be helpful for that. Next slide, please. Next study is Disparities in Surgical Management. So this was a National Spine Network Outcomes database. They looked at over 5,000 patients from multiple centers. 85% were White, and then they looked at males and females. Next slide. They found for women, imaging was ordered more often for women. Non-White females were less likely to be offered surgery after their initial visit, and White females were more likely to receive non-surgical treatment, like an epidural steroid injection, for example, at the initial visit than White males. For men, they found surgery was offered or ordered more often, and they found that males were more likely to receive workers' compensation. And from a race standpoint, White and Asian patients were more likely to receive surgery than Black and Hispanic patients. So this study, that Black and Hispanic patients, specifically women, were less likely to receive surgery out of all the patients. Next slide, please. The next one we'll look at is about Perceived Discrimination. So this was called the MIDUS survey, and it focused on perceived discrimination for back pain in groups at risk for discrimination. This was 3,000 patients, and this was in the 90s over a telephone survey. So they asked people how they perceived, how much discrimination they were having. The people who experienced the most, surprising or unsurprising, depending on how you find, Black men had the most perceived discrimination than Black women, than White women, than White men. Next slide, please. And they found that the types of discrimination, so White women reported more gender discrimination, Black men reported more ethnic discrimination, and Black women reported more appearance-based discrimination. And overall, the reported frequency of low back pain was lower among African Americans, despite the fact that they had higher levels of perceived discrimination. So discrimination was not really related to back pain for White patients. For Black patients, however, perceived lifetime discrimination was a predictor of low back pain for Black men, and perceived daily discrimination was a predictor of back pain for Black women. So even though Black patients had less back pain, having perceived discrimination was a risk factor for that. Next slide, please. And the next study we'll look at is about Race, Social Status, and Depression. So this is called the ERASED study. It was pretty small. It was 105 participants. And they found that, or they cited that White people have a higher lifetime prevalence of major depressive disorder, but Black patients are less likely to seek or complete treatment for their depression. So they found that White patients' pain interference, so how pain interfered with their day-to-day life, was reduced by 0.47 units for every one unit increase in perceived social status. So the higher these patients felt they were in social status, the less pain interference they had. For Black patients, they found that their pain interference increased by 0.12 units for a one-unit increase in perceived social status. So while this was not statistically significant, again, this was a small study, they found that when Black patients had higher perceived social status, they had more pain interference. And then it's interesting to note that higher perceived social status reduced pain severity. So severity is different from pain interference, severity being like 0 to 10. But that was reduced for both Black and White patients. So typically, greater perceived social status is associated with less severe depression, which in turn is usually associated with less severe pain and interference. However, the Black patients in this study, again, while it wasn't significant, had increased depression when they had increased social status associated with increased pain interference. Next slide, please. So why is that? They suggest that as Black individuals climb the social ladder, systemic discrimination and organization structures may limit Black potential by placing less value on experience and economic reward. And then when Black patients are more aware of these limitations, then they become depressed and have fewer health benefits. So how this implicates our treatment of patients, these findings would suggest that Black patients with chronic low back pain may require more aggressive screening for depression when we see them. And it's important to note, again, that while race moderated the relationship between social status and pain interference, it did not moderate pain severity. So it's important to ask patients about both of these things when you're talking to them, severity and interference. Next slide, please. So we just went through a lot of information. So just to sum everything up, for opioids, Black and Hispanic patients are less likely than White patients to receive opioids in their clinic visits. Pain severity, Black patients have more pain-related catastrophizing. From an imaging perspective, African-American and uninsured patients are less likely to receive advanced imaging in the ED. For surgical management, Black women are the least likely group to be offered surgery. And then perceived discrimination, again, even though Black patients have less incidence of Black back pain, predictors of this included perceived lifetime discrimination for males and daily discrimination for Black females. And then depression and social status, like we just mentioned, as Black patients achieve elevated social status, they have heightened awareness, they think, of systemic discrimination and limitations that results in depression and more pain. And so presenting all of these things, while this is, again, by no means a comprehensive review of all of the literature out there, I think this goes to show how there's multiple different ways medications, diagnostics, treatments, social status can all affect our patients and how they experience pain, as well as opportunities that we can use to improve our care for disparities of pain. Next slide, please. Good evening, everyone. I'm going to present a case today, which I thought was somewhat representative of a typical patient that I see. Next slide, please. This is a 48-year-old diabetic African-American construction worker who presented with a five-year history of chronic progressive axial or back pain with some intermittent leg pains. He was referred by a new primary care physician. On a numeric rating scale, he reported his maximum pain level as 8 out of 10 over the last week, and it would reduce to 5 out of 10 with a seated rest. He denied any overt red flag symptoms. Previously, he had seen a pain practitioner and received Percocet opioid, which he stated did help with his back and leg pain. He also stated that he frequently has daytime pain exacerbations, particularly while at work. He tries to limit his heavy lifting at work, although he's a construction worker and will often lift objects up to 50 pounds, oftentimes even more than that. He also stated that he was often embarrassed to ask for help at work. Additionally, he felt as if his prior primary care physician did not believe his pain. This, in fact, did cause him to seek a new provider. He also stated that he felt as if his local pharmacist was limiting his access to some of his pain medication. He stated that the pharmacist would often question his need for opioid medications and had refused to fill higher doses of prescriptions for him. He stated he thinks he's a doctor or something. Next slide. On physical exam, this is a large, well-oriented Black male. He had some weakness with his left hip flexor abductors as well as his bilateral ankle plantar flexors. He had a negative straight leg raise. He did have some lumbar facet loading, also some positive SI provocative test. On further diagnostic testing, he had had multiple lower extremity Doppler studies, which were negative. He also had a lumbar x-ray, which showed moderate spondylotic changes, and had recently had a cervical CT in the ER, which showed moderate degenerative changes. Additionally, on the patient health questionnaire, which screens for depression and anhedonia, he scored two. On his SOPAR, which is risk assessment for aberrant medication use, he scored a 10, which is a moderate risk. On his urine drug screen, it was consistent with his reported history that there were no illicit medications found. On his maps, which here in Michigan is our prescription drug monitoring, it was consistent with his history. Next slide. For this case, I thought of some questions here along with the group. The first here is what treatment challenges might exist? These are somewhat open-ended questions, but I think this is something relevant to all of us. Of course, this is one of them is he had previously seen another pain practitioner and had already been prescribed opioids. I thought oftentimes when I see this in clinic, and I'm sure you guys do too, is that the expectation for the patient in this interaction? Also to his previous experience, I'm not going to call it bad, but his previous experience with his primary care physician that he felt did not fully believe his symptoms. Also, I felt his workup was somewhat limited. He had not had advanced imaging. He was a poorly controlled diabetic. He did not have an EMG. These were, I thought, somewhat limited treatment thus far. Another question here, were there overt barriers to pain care access? Once again, this somewhat of an open-ended question. I think some of this we will find out the more you see the patient, but some of them that I saw was the patient's preconceived notions that he brought. He already brought somewhat of a guarded or negative view of a practitioner. As previously stated, particularly amongst African-Americans, there's a historical history there. Oftentimes, it's not always thought that it's also current to the NAACP had studied early on COVID, where there was a large amount of COVID vaccine hesitancy amongst the Black community. On a survey they found, and this was, I believe it was November 2020, only 18 percent of African-Americans stated they would get the COVID vaccine. I state this to say that there's still, we talk about historical context, but remember, it is still ongoing. It's not a thing of the past. It's still ongoing. Then, another key question that we thought of, were there some preconceived judgments influencing your treatment or with your patients? Of course, the patients come with theirs, but we also have ours. We play a role in this interaction, a critical role. Most of us are trained to do no harm, but there has been some research that clearly shows that we also, practitioners, physicians, come with preconceived judgments. Many of them are false, somewhat false beliefs. There's a study out of the University of Virginia, Dr. Hoffman, where she did questionnaires for medical students and residents, asking some questions regarding various patients of racial background and ethnicity. What that study found was, many of the medical students and the residents found, still, that there was still thought that Black patients had higher pain tolerances, that also they were non-compliant with many of their treatments, and unfortunately, also, that some even felt that they had thicker skin. This was a study from 2016. It's unfortunate that we're still talking about this in modern day. These are old, old, some of these beliefs, and they're still happening. I state that to say that we still need some rethinking of this. Next slide. Then, key points, key takeaways I thought that we could use. Always think of the environment and the context that you interact with your patients. Is it a clinic? Is it private? Is it hospital-based? I know, with my patients, they often talk about how far the clinic is from the parking lot. All that comes into play in that interaction. Also, too, your own personal preconceived thoughts, as well as the patient's. Also, there's an increasing field of research of this concept of pain versus suffering. I think Dr. Eves talks about it. The perception, sometimes people's perception can severely affect their pain. That's a growing field of research. Lastly, we want to present to you today that, overwhelmingly, that disparities continue to exist. It's not a question of if they exist. That's clear. There should be no denial. The focus should be, at what stage can we start to change this? Thank you. Dr. Oni, I think you're on mute. Sorry, thank you. Okay, can we actually go forward one more here? Can we go forward one slide, please? Okay, so what is it that we can do to help our patients, our black and brown patients? So first of all, at a systemic level, it is imperative that physicians and other medical health providers are properly educated on disparities and potential barriers to care. One study found that continuing medical education certified activities focus on disparities and pain management led to increased physician confidence in their ability to identify potential barriers when treating minorities and patients of lower socioeconomic status, as well as increased confidence in their ability to implement strategies to minimize biases. And we always want to continue to strive towards ensuring equal access to care. Next study, or sorry, next slide, sorry. Also, as far as improving outcomes, other things that have been shown to improve outcomes include addressing language barriers. One recent study found that addressing language barriers improves patient's adherence to attending an initial visit at a chronic pain clinic. You can address language barriers with appointment reminders in a patient's preferred language, having front desk staff who are native speakers. There are also translator services, and now there are even apps that can assist in this regard. Another study explored the effects of an electronic health toolkit for chronic pain on pain-related outcomes. The toolkit helps to eliminate barriers to care and does increase access. It can convey information to patients, including important resources and activities that can be a benefit to patients. Massachusetts General Hospital is actually a facility that does use an electronic health toolkit for their chronic pain patients. Next slide. Underserved African-American and Latino older adults suffering from chronic pain are more likely to use emergency room, or use emergency department services. And therefore, one study found that incorporating pain management positions in ED care may be helpful to better manage these patients suffering from chronic pain. Primary care physicians are also often the first to identify minority older patients and chronic low back pain patients, and they can have a significant impact on their care. And so educating our primary care physicians can be very helpful in terms of management of our minority patients. Also, one study, the HELP survey, one study evaluated the HELP survey. The HELP survey stands for Health Disparity Influence on Level of Chronic Pain, Comprehensive, sorry, Chronic Pain. This is a comprehensive survey that combines the social determinants of health with mental health. And so incorporating a more comprehensive survey can better serve our patients and identify problems that may be barriers for their care. Next slide. And so the social determinants of health is extremely important in terms of identifying potential problems and barriers to care. This is an extremely important toolkit and it provides important information. Honestly, this slide can be a whole conference or a whole presentation in and of itself, but briefly kind of reviewing some of the social determinants of health. This incorporates economic stability. Obviously, most people receive their healthcare through their employment. If they don't have employment, they often lack access to healthcare. Oftentimes people will have medical bills that will limit their ability to pursue and continue healthcare services. There's also neighborhood and physiological environment issues such as housing and transportation. There are many individuals who are unable to physically get to their appointments due to transportation issues. Education can be a barrier. There are issues with literacy, as I said earlier, language barriers, and just sometimes just not understanding what is being told or conveyed to them from their healthcare providers can be a barrier for access to care. Food, we all know that there is definitely a lot of food insecurity in this country at this time. And if you don't have access to your basic needs, it's difficult to be healthy and it's difficult to pursue adequate healthcare for yourself. Community safety and social context. So having just support systems. Oftentimes the healthcare system also relies on the support of family members and friends to provide support and care for our patients because the healthcare system can only do so much. But if an individual doesn't have the support of family members, friends, or their community, they often don't receive the best healthcare and it can lead to bad healthcare outcomes. So all of these things can be barriers to access to care and underlying all of these can be racism and discrimination, which can even further cause health inequities. And next slide. There are current efforts that are being made that we can see. Many departments, including hospitals, residency programs, medical schools, are incorporating DEI departments. DEI stands for diversity, equity, and inclusion. So there's much more emphasis on this as being very important for care for our patients. This focus on diversity, equity, and inclusion. There are many classes in medical training for cultural competency and unconscious bias courses. We can see this across the nation in medical schools, also residency training. There are a handful of states in the United States, including four states, including California, Maryland, Washington, and Michigan. I know here in Michigan, in order to receive your medical license or renew your medical license, you have to complete an implicit bias course. There are organizations such as Black Men in White Coats, which is an organization that is focused on increasing the numbers of Black men in the field of medicine. And organizations such as the National Medical Association, or NMA, which has been in existence since 1895 and has been a strong advocate for African-American physicians and also the care of African-American patients. And underlying all of this is the importance of being able to build trust with our patients. If a patient doesn't trust you, it's very hard to provide adequate care and they're not going to follow through on your recommendations. One NAACP study showed that Black Americans were twice as likely to trust a messenger of their own racial ethnic group than one from outside of it. And when trust is in short supply everywhere, we need all hands on deck to begin rebuilding trust in our healthcare system. We believe the best way to learn from the atrocities of the past is to change our present. So, I think this would go back to Dr. Nwankwo. So, we have some resources here that we wanted to provide you guys for extra learning in regards to our topic. The first part we have are some articles. One that's very important is this one from the Harvard Business Review, which has kind of been a topic highlighted through all of our presenters' slides, is that research has shown that having a doctor of the same race, in this case, a black doctor, led to black men receiving more effective care. So, when we talk about having increased diversity, equity, inclusion, and implicit bias training for our white counterparts or other counterparts, they may treat patients of a different race. It also is important to keep in mind that it has been clinically shown that having a doctor of the similar race does improve your health outcomes. Going back to a point that Dr. Bernal and Dr. Oni kind of touched on regarding distrust, a majority of us have heard of the Tuskegee studies. So, beyond that, this article from the New England Journal of Medicine is talking about vaccine distrust and everyday racism. That was something that was highlighted a lot during the COVID-19 pandemic, as we had populations, particularly African American, Hispanic, Native Americans, that were more affected by COVID, but when the vaccine came out, we did have a lot of trouble getting these populations vaccinated because they already had a natural distrust of our health care system. So, that's something to think about as we go through these health care events every day, that that keeps cycling on and on. And then, the last article here we have is the FDA initiative to assure racial and ethnic diversity in clinical trials, because a lot of the medications we use, and even over the past couple of years, some of them are shown to be more or less effective, particularly in African American populations. So, I think it's important, you know, even though we have a limited use of medications, particularly in PM&R, even in primary care, you know, looking at the studies of some of the medications we use for our patients and noting those differences in race that could be particularly noted in the studies that they occur in. So, next slide, please. We have some books here. Anybody who's into reading, the most popular one, we have White Fragility, Talking to Strangers that helps know what you should know about people you don't know in medicine. We talk to people all the day who are from different backgrounds from us, so these resources could help us in furthering our knowledge of people from different backgrounds and how that affects how we treat and care for them in these crucial populations, particularly those who face difficulties in pain management, because as we all know in clinical practice, you know, you can't really understand someone's pain, it's not something we're always actively going through, but just developing that empathy and being able to understand where they're coming from makes the more difference for clinical practice. Some other books listed here, My Grandmother's Hands, Blindspot, The Racial Contract, and Weathering the Extraordinary Stress in Ordinary Life in Unjust Society. Any of these books would be a good read to get some more knowledge for your background. And lastly, we have some podcasts. We wanted to include a variety of resources for all different populations, different generations. I know podcasts are pretty popular with some people nowadays, so some of the ones we've included are the Praxis, Connecting Theory and Practice for Health Justice. This one is hosted by Edwin Lindo, JD. We have Fresh Air, a particular episode we wanted to highlight came out a couple months ago talking about how discrimination and poverty make you sick, so this kind of goes back to health disparities and social determinants of health, that it's really more of your environment that plays into your health more than people realize. Another good lesson is a New England Journal of Medicine podcast, not otherwise specified. The April 12th episode talks about examining inequity, something that we hear again and again in medicine, but I think you can never learn too much about it because there's always so many differences between the people who you even think you have the most in common with that could affect how you practice medicine. And our last one is off the charts, examining the health equity emergency, so just going back to that topic about how inequities are so important and how they really do play a difference into the pain management. We want to give some thanks to our project team, although we have our main presenters here talking today, we did have a lot of help and background from our medical students and residents who could not have made this possible. Our medical students are interested in PMNR and our residents are interested in pain management. First, I'd like to highlight Queen Denise Okeke, she's an MS3 at Philadelphia College of Osteopathic Medicine, Dr. Chiamako Okoha, she is a PGY2 at UT Southwestern PMNR, Sidney Woods, an MS3 at Meharry Medical College, Dr. Onye Chidomere, she's a PGY3 at Virginia Commonwealth University Health System, Ms. Norris-Akban, an LSU medical student in her third year, and Dr. Kamaria Coleman, or soon to be Dr. Kamaria Coleman, MS4 at Southern University, Illinois School of Medicine. Okay, so now we are going to take some questions, I see one question in the chat that will address, but feel free to type your questions in or raise your hand, and we'll get those addressed. But our first one is from Dr. Lisa, she says, what do you find is an ideal approach to obtain a good history of African American patients? I'm going to hand this one to Dr. Adams, just because you touched on the case presentation there, and then anyone else can also chime in. Great, great question. I would recommend from my experience also with reading, I think really trying to educate your patients and time. The one thing that I hear consistently with my new patients are, I feel so rushed, right? The experience is so rushed, and I remember even from medical school that I remember patients saying, the doctor never looks at me, the doctor's on the computer, and I really didn't get a sense of that until I got in practice, and I realized that we got to be going quick. So it's a fine dance of trying to be efficient, but also given that time. But I do notice with some of my patients that are the most distrustful, it's the time that they want, it's the education on their condition, that's another big thing that they may have come and been treated other ways, but oftentimes they don't know the details of their condition. I always like to show, if I can, I like to show people the imaging, particularly of the spine, or if they have hardware, and I love to watch their face, because they always say, that's my back, that's my neck, right? And I say, yeah, yeah, you've never seen it, no, no one's ever showed me. And I always say to myself, you had this 10 years ago, and nobody ever showed you that, right? So I know this is a long-winded response here, but time, right, and education. And I think that all our patients want that, right? I don't think that's not just Black patients, all our patients want that. But I understand that our challenge with medicine today is that time, how can you do that efficiently? And lastly, I would say that I'm always thinking about this, I think trying to find, particularly with technology now, how are other ways that we can help with their education? So if I'm running late, or I can't, you know, I don't have a lot of time for this particular visit, trying to give them some good resources, hey, this is a good app, hey, this is a good website. Now, unfortunately, with that, there comes the information divide, right, the technological divide, right? That's a whole nother talk. And I've heard that that should be a new, another social determinant of health. But I have some patients that I say, oh, I know this great app. And then, you know, they say, well, I don't know what an app is. I'm like, what? Right, so that's another, you know, that's another barrier. But I'm always trying to say, well, how with my little time, how can I get that information across? I had also a comment. In treating patients over the years, what I have found is a question that I ask, I always look into their history before I see them. I look at their images. I have some background, so I'm not walking into the room cold. And my question is, what happened to you? And that brings out the story that they want to tell about what led them into this predicament. And often, you get a lot of information on social determinants of health and other issues that you can help a person deal with, with their lifestyle in as well as dealing with their pain. And I have the benefit in my practice to see my new patients for an hour. And also, I have something called a DAX. So it records the visit while I'm in so I can just talk to the patient. And when I leave a couple hours later, I have a note in the chart that I can read over and sign. So technology can be helpful. And I fortunately have access to that. Dr. Eves, Dr. Oni, any comments? I just think, once again, kind of the building of trust. I actually had a patient recently that just when I walked in the room, she was immediately just, there was a barrier right there. She just, and she just right out, and I could sense that she wasn't really warming up to me, which is OK, but it was just odd because she was really, really, really cold. And she said to me, well, you just don't care about me. And you're going to treat me like I'm a number, an experiment. And I said, whoa, that's a lot of assumptions. And so I spent a lot of time just talking to her and made sure that she felt very comfortable with our treatment plan and kind of understanding her history and just trying to make a connection with her. Because I think, like I said, it's really about just listening to our patients, understanding what's going on. Because a lot of times when they present with pain, there's a whole backstory behind it. And so sometimes, and that may take the relationship to evolve over time, over multiple visits. But I think it is important to understand that there's a lot going on for a lot of our patients and to really try to support them as best that we can, obviously managing their pain as a provider, but also just trying to better provide them with other types of support that they may need, that they're struggling with, that may be contributing to their pain in ways that, you know, may not be directly contributing to their pain. And so I really think that building up that trust and just understanding their history, I do a depression anxiety screen on all of my patients when I evaluate them, because I think that, you know, high levels of depression, anxiety obviously are linked with chronic pain and you really can't separate the two. I think that if there's psychological depression or anxiety, that has to be treated in conjunction to their physical pain. And so I think just taking a more, a very comprehensive view of our patients, building up trust, I think is very important in terms of providing the best care that we can. Yeah, I would echo the building of the trust, more from a treatment perspective. I have patients come in and I'm very interventional and they say they don't want to do injections or interventions because they don't trust something or the other. So we do what they're comfortable with, medications, therapy, they come back after a few more visits, then they're willing to try interventions just because they know me and things like that. So definitely the trust thing is the biggest thing I would say. Awesome. Thank you guys so much. So it sounds like, you know, trust is the biggest part in establishing a relationship, particularly with African American patients. And we know given the history of the unjust nature of the health system, that's kind of why those feelings are there. So just patience and taking a little bit more effort to establish that relationship goes a long way with these patients. Dr. Grace has a question, which I think is particularly interesting. She says one of her Black patients prefers not to see Black doctors and declines to explain the reason. What could the reason be? So I'm not sure any of the doctors on the panel, if you guys have had this experience or care to highlight on what you guys think could be going on. It looks like Dr. Lisa pointed towards like white superiority, internalized racism, which I also agree could be a component, but let's talk about that. White man's ice is colder. That's basically it, you know. So if you have that mentality, then you don't want to see another Black physician. And that has been inbred in the society. So it's quite unfortunate that that happens, but I don't find it to be a large barrier. It has decreased over my 40 years of practice. Yes, I agree, because really the statistics show us the opposite. The statistics show us that when minorities have physicians that look like them or from a similar background, they actually tend to receive better care. So the fact that they would not want to see somebody of their own background or Black physician goes against the science. So there's really not, it's not logical. And so, you know, that's just rooted in their own preconceived notions or other things that they may have, but that's not really rooted in the science. And I would just also just add, maybe they just had a bad relationship, a bad experience with a Black doctor, and now we're making a larger assumption, right? Which many of us can do. You have a bad experience with someone, a group, and you make assumptions with that. So I see that a lot. Not this particular case, but when I have people that have strong feelings about something, oftentimes they had a bad experience, right? Yeah, I would echo all of those same things. Yeah, like we mentioned earlier. Dr. Lisa, you can go ahead. Yeah. Hi. So I think this, you know, there's different components as gender and age and regionality as well, that, you know, older patients have different kinds of expectations than younger patients or different experiences that they've been to, good, bad, and otherwise, you know, depending on what the situation is. I think also the, like if you're dealing with workers' comp, a personal injury where there's litigation involved, that's another dimension that you have to think about. But I think the most important thing is listening to the patient, and you can do it efficiently. Like Deb said, you know, we've been doing it a minute, and there's just ways of like how you come in, your body language, eye contact, that you have read the chart before you got in the room. So you go in there, you're not wasting the time with the patient, trying to figure out what's going on with the patient, because you both know you don't have time. So, you know, just skimming, just having a, and just kind of run through. I just will. So hi, you know, like Deb, I'll ask like, you know, what are they doing, whatever, and then as we get in the conversation, I'll run down and let them know what's going on and make sure they understand what's going on, because that is true. A lot of times they don't even understand what's wrong, what was done, why was it done, what's to worry about, why do they have to take certain medicines. And you know, as we were taught, if you really have a good conversation, you pretty much have 80 to 90% of the diagnosis before you have to order any tests, do anything. I just want to really emphasize that that's a really important skill, and it's the art. And I also want to emphasize that trauma and whatever that is, whether it's early in life or whatever, is hugely associated with chronic pain. And we would be remiss not to talk about that aspect of how that can translate in coming in for a pain management consult, where you're not trying to get into so much psychological stuff, but that may be exactly what you need to do to really help that person before you jump right into that and find something you can fix and you stick a block. But you know, it's like, you can see that in other people, and it's not causing them that much pain. So why in this person is it? What else happened to them? What else is going on? What's associated with that structural problem? So I think that's really important to get into that aspect. And you know, somebody depressed, somebody just moved somebody, did they just witness a violent event, especially now, since we're just coming through the pandemic, there's been a lot of losses, a lot of sadness, a lot of uncertainty, people are really struggling on many levels. This is a great program, I'm so proud to watch this, this is really excellent. Thank you all. Thank you so much for your comments, Dr. Lisa, I think that's important to highlight as well. Just getting back to the basics, you know, the art of communication, studies showed, you know, just even sitting down in a patient's room, they perceive that so much more of you spending twice as much time with them than you really did. And getting to know your patients is the best way to know their story and will help establish so much trust, which is something we really need to work on in the African American population. So we have about a few more minutes here. We can probably get to one or a couple questions if anybody else in the audience has anything else to ask. I know it's mainly African American doctors in here, but we do have people from other backgrounds. If you have any questions you want to ask doctors who are African American and are guarding to African American patients and get their insight, I think this would be a great opportunity to do that as well. So just opening up the floor for anybody else. I had a quick comment as we waited. When I'm looking through the patient's chart, I have them fill out some forms that are very helpful to me, like the opioid risk tool, which asks about trauma, and some of the oswestry and neck disability index that talks about function. And so it gives them an idea that you're wanting to help them with things that are important to them. How they slept. Can they work? Can they take care of their home? So I think it's important that we use those kinds of tools, and it helps me because they're filling it out while I'm looking through their chart and looking at their x-rays and MRIs and meds and nutrition. So we need to make sure we're taking the time to get those important bits of information from our patients so that they have an idea. We're physiatrists, so we're all about function. Dr. Janice, did you have a question? Oh, I took off the right. No, I just wanted to, I don't know if you guys mentioned it, but just making sure. I think somebody touched upon it, cultural, because the African diaspora is quite wide. It's not just here in the U.S., but also from the Caribbean. I'm from the Caribbean. Then you also have people from Africa that are going to have different cultural norms and expectations. So that's something to also take into consideration. Thank you, Janice. I agree wholeheartedly, and the other thing that's important is those language barriers. Having someone to interpret if there is a language barrier and taking the time to still ask all the same questions, whether there's a language barrier or not. Patients feel when you're upset or anxious about language and communication. So it's better to take time and just relax and get the information you need from them so that you can do the quality of care that we all expect and should expect of each other. So our presenters, anyone else have any last comments or anything we just want to bring up again to the audience? Looks like everyone was able to get their concerns out and get everything addressed. So we'll go ahead and close up the program. Thank you guys so much for joining us in the African American PM&R community. We really appreciate having everyone's ears open and minds aware to this issue that we're trying to solve. We're going to have the PowerPoint slides on the APM&R side, I believe. So you guys can access the resources that we provide and also have this presentation for your review. Other than that, thank you guys so much for joining us. And Dr. Lisa, you have a plug here to come see us at the NMA in August from July 29th to August 3rd. You can get more information at nmanet.org. Can I close it out with the quote that was in one of our slides but wasn't shown? Yeah. You cannot go back and change the beginning, but you can start where you are and change the ending from C.S. Lewis. So thank you, everyone.

spine pain

African-American patients

disparities in management

patient care

underrepresented groups

marginalized groups

social determinants of health

barriers to care

trust with patients

cultural competency