Good afternoon, everybody. Thank you for joining us. We are just a couple of minutes late because we're making some updates to our presentation. So in the meantime, I just wanted to welcome everybody. I'm the outgoing chair of the Latinx Emphysiatry Community. And with an idea from the African-American community, we really wanted to kind of like collaborate between communities, between physicians that either have a diverse population in terms of practice, but also kind of like personal experiences to bring you a topic that is about the pain management in diverse populations. So we have a couple of people here. I'm actually not a pain physician. I'm a pediatric rehab physician, but I've partnered with people that have extensive experience in not just in pain, but also in the management of diverse populations. So thank you so much for joining us today. In the meantime, I just, you know, probably there's going to be some questions or comments or interactions. We would love to have that toward the end of the presentation. Also a reminder that we also have people participating from home through the virtual. So that's why there are microphones. So if there's going to be a question later on, we please, we encourage people to come in into the microphone. And hopefully, you know, the people that are online, they're going to be sending us their questions through the platform. So we'll repeat them. So everybody is part of the discussion today. Thank you. I think we could just start like this. So first, we're going to have Dr. Camille Phillip, and she's an MD, PhD. She's currently in the University of Houston McGovern Medical School. All right. Thank you, Dr. Vasquez, for that introduction. Like she said, I'm Dr. Phillip. I'm one of the interventional pain faculty at McGovern Medical School at UT Health down in Houston. And I really want to thank Dr. Vasquez, my session co-director, for bringing this great group, just like she said, of pain management physicians from around the country to talk about a topic that I think is very relevant to a lot of us. Sorry, I shouldn't touch things. Okay, it went away. And that is pain medicine and the management of that in diverse populations, cultural and practical considerations. So the objectives of our session include describing the relationship between patient-related factors on the amplification of healthcare disparities among diverse populations and their impact on pain-related outcomes. We'll then move on to discuss and understand how trauma can have long-lasting physical, emotional, or even molecular effects and identify the importance of integrating trauma-informed care into our clinical practice. And lastly, we'll talk about how to integrate some of these strategies in a diverse set of clinical backgrounds and discuss how to optimize access for our patients to pertinent pain medication, sorry, pain management interventions. And so I wanted to start off kind of in this first section talking about, of course, what is pain and why does pain or diversity matter in pain management? Now the revised definition as by the International Association for the Study of Pain refers to or defines pain as an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage. And I'm going to put up this figure here, which I think is not new to any of us as physiatrists in the room, and that is the biopsychosocial model of pain. We realize that there are multiple factors into how this experience of pain may look like for our patients, whether that's biologic, the actual structural changes or inflammatory changes in our patient, what kind of social support system they have. Or we'll talk a little later today at the end of our presentation about cultural traditions and how that might impact their pain experience. And lastly, also, of course, the psychological experience of pain and as it refers to perceptions or pain beliefs. So I'm actually going to turn it over to one of our chief residents at UT Health. That's Dr. Vishal Bansal, who's going to go over why diversity matters as we're thinking about pain management in our patients. Thank you, Dr. Phillip, for explaining that. Hi, everyone. My name is Vishal Bansal. I'm a current PGY-4 resident at UT Health. Thank you for bearing with us while we figure out these complications. I'm going to try to see if we can upload the other PowerPoint, just so it's more clear for everyone. All right, so why does diversity matter? I think diversity can be broken down into many different domains, but for the purpose of this talk, what we're going to focus on is age, culture, and gender. So why does age matter? I think age matters, or for everyone it matters, because pain can be interpreted in a different perspective from both the patient and the provider across the aging continuum. So when we look at the geriatric population, studies actually show that up to 40% of patients living independently do experience pain. And then it varies a little bit further in terms of 20% to 80% of those individuals, they have enough pain that it actually impacts their activities of daily living. And studies have shown that even the geriatric population, in comparison to their younger generation, they are more likely to under-report their pain. And what does that translate into? Well, that translates into physical and social limitations amongst that population, right? Where the provider bias sometimes starts to come in is that we start to attribute that to the normal aging process, that you're getting older, that this is why you are experiencing that, you know, this type of pain, these aches that you're experiencing. Furthermore, we can go into culture. So multiple studies try to go into, you know, delineating why certain members of a certain group experience pain more or less compared to their counterparts. So if we look at another study that looked at Latino women in comparison to Caucasian women and males as well, they found out that Latinos and females were likely to experience more pain perception from the same painful stimulus. So this just kind of shows to us as pain management physicians or as physiatrists, we should be cognizant of this. Another study also looked at the African-American population, both males and females, and what they noticed was that in the African-American population in comparison to the Caucasian population, they were more likely to perceive higher prevalence of hopelessness as well as mismanagement of their pain complaints because of that hopelessness. Then furthermore, we can get into gender as well. So I think it's very well established that females do have a higher pain perception compared to the male counterparts, and multiple studies show that. The exact etiology as to why that is, that's still to be figured out, but it can be hypothesized due to either psychological factors, societal factors, and just a simple DNA makeup. So furthermore, alternative pain management. The reason why diversity plays a role into alternative pain management is when we are addressing that pain, we've got to be aware that we might be familiar with the standard of treatment, the opioids, muscle relaxants, but what about the other alternative pain management options, traditional Chinese medicine that some of these other individuals might focus heavily on? So that can include acupuncture, herbal medications, cupping, coining, or moxibustions. What we've got to do as physicians is work with either the pharmacist just to see if there's any impact to the medication that they're on, either for cancer pain or non-cancer pain, and as well as see if there's any impact to them in terms of their actual specific disease state as well. When we get into some of the palliative care, it's important to realize that pain is subjective. Whenever someone comes in with that pain complaint, that pain is experienced by that individual, and then they are telling us their subjective experience. It's a subjective phenomenon, and it's actually hypothesized that up to 50% of those patients in their final stages of life experience moderate to severe life. So we can allude to how impactful that is to their quality of life and ultimately survival as well. And one of the biggest notions and the barriers to palliative care is some of the notions behind medication management. When we look at some certain population groups, they look at opioids as a form of euthanasia almost, and they are reluctant to start medications because of that negative connotation behind it. Studies have shown that when you start them on medications earlier on and they're evaluated by the palliative care team, that they have better improved quality of life and in turn improve survival as well. Other barriers to palliative care can be the misunderstanding of the scope and value of palliative care. This also translates into the community that you are in as well. If there's not enough resources, then they might not be privy to get that consult. Some other negative connotations behind medication management can be is certain ethnic groups look at opioids as a last resort. So they feel like if they start medication management now to improve their quality of life, that they might be limited in their options later on in life, which is not necessarily the case. Some also fear addiction. There's a lot of literature out there that pinpoints opioids equals addiction, which is not always the case. In the right setting, sometimes it can be used appropriately and improve the quality of life and also improve the survival as well. So all in all, humans are cultural beings. Culture refers to the group that one may identify with. That could be ethnic, religious, geographic, or socioeconomic status, and many other different domains that we didn't touch upon today. It directly influences the way we think, what we expect, and what we believe to be right. So for the next portion, we're going to talk about impact of trauma. This will be a little bit brief. And so the impact of trauma and how to move forward. We all know that adverse childhood experiences and race-based traumatic stress can both contribute to the body-self neuromatrix, which in turn contributes to that perception of pain. So every ethnic group has different perceptions of pain, different upbringings of pain, and also socioeconomic status as well, depending on the geographical location of that patient. So trauma-informed care is a key part of pain management in diverse populations because it takes into account the physical, emotional, and mental effects of pain. And we'll get into the longitudinal management considerations now. Hi, everyone. I'm Dr. Candice Burnett. I am an interventional pain management physician outside of Houston. And I'm going to be talking about addressing cultural and practical considerations in pain management as it pertains to three different settings or groups of patients in the acute pain population, chronic pain population, and then end-of-life or palliative care, and how we can optimize our treatment for these groups of people. So the first question is, why does this even matter? And I think it's very straightforward to understand why it's important to manage acute pain in a way that is useful. So one is costs, decreasing the cost of hospitalizations that were unplanned or unanticipated. Also decreasing costs related to length of stay, ICU admissions, and other hospital-related costs. But also, as we know, ineffective treatment of acute pain can lead to chronic pain. It can lead to increased morbidity and mortality, delayed recovery time, and overall poor quality of life and functionality deficits. So some cultural considerations. So studies have shown, as we've heard, that racial minorities, specifically blacks and Hispanic patients, are less likely to even be assessed, have their pain assessed on validated measures. They're also less likely to receive analgesia pre-hospitalization, and they're less likely to receive pain medications than their white counterparts. So I kind of like to bring it back to my own experience and my own practice. I have a friend who's a black doctor, and about a month ago, she went to the ER with excruciating abdominal pain, and she was told she had gas and constipation and was sent home with medications to treat that. The pain got worse, so she went back to the same ER, and she felt very uncomfortable. She felt like she wasn't being taken seriously, eye rolls, et cetera. And they told her, it's just gas. So she ended up calling our friend, who's an emergency medicine doctor herself, and I don't know why she didn't start there. I mean, that's what I would have done, but that's her. And under her care, it was identified that she actually had acute appendicitis and ended up undergoing an acute appendectomy. So this is just, was race a factor in this? Who knows? But these are the things to think about when treating these groups of patients. So as far as chronic pain, so why is it important? Because over 25% of United States citizens suffer from chronic pain. Failure to manage chronic pain adequately, again, can lead to morbidity and mortality. And then dollars, costs. Over $100 billion a year is spent on managing pain and opioid dependence. So some Hispanic women in their culture, they are less likely to choose epidurals for analgesia during childbirth than non-Hispanic women. And part of this is some of them have the belief that enduring pain is a sign of strength. It's like a natural rite of passage. So why am I mentioning that with chronic pain? Because it begs the question, could this translate into the lack of interest in epidural steroid injections for lumbar-mediated pain? And my answer, anecdotally in my practice, is absolutely. I've seen it all the time. But with this knowledge, I'm able to have a conversation with the patients, explain to them the difference and why an epidural steroid injection is different than an epidural that you would have for labor. Instead of just writing off epidurals for their back pain is not an option. And then as far as women, over half of female patients prefer to have female physicians. And in the Muslim population, a lot of them prefer to have all female providers, not just physicians, but everybody involved in their care. And so it's very important to understand this, manage the patient's expectations, and make accommodations when possible. So I'll give you an example. I have a patient, a Muslim female, who is actually going to be having an epidural steroid injection. And she requested all females for her treatment. And I told her, you know, we don't have a female C-arm tech. However, how would you feel if myself and the other female staff escorted you to the procedure room, prepped you, draped you, made sure you were comfortable, then had the male C-arm tech come in, do the procedure. And the same when it's done. He would leave and then all the females would take care of you afterwards. And just acknowledging her concerns, making what are minor adjustments on our end, you know, no sweat off our back to make those small changes. She was so appreciative. And I think her care, she felt like she was really getting good care. Okay. So as far as palliative care and end of life, it's so important because, as Vishal stated so nicely, it's often misdiagnosed, undertreated, and inadequately treated. There's a leadership alliance for the care of dying people. It's actually, it was formed in England, but it's an alliance tasked at improving care for these people who are dying. And they have five factors involved for adequate treatment of this population of patients that are used widely. So one is recognizing that someone is dying. Another is communicating sensitively with them and their families, involving them in their decision making, and then supporting them and their family in creating an individualized treatment plan instead of just a cookie cutter treatment plan. So in order to do this, to be effective and compassionate, it means being knowledgeable about ethnic and cultural beliefs, values, experiences of not only the patient, but also their families. And I'll go through some of those considerations. Some religions believe that pain is part of God's plan, a test of faith. Some Buddhists believe that drugs may cloud the mind near death and aren't interested in certain medications. Other groups, again, as you stated, Vishal, believe that euthanasia and the use of drugs may hasten death. They're not interested in those options. And then also interesting is that hospice is underutilized by Hispanics and African Americans. And some of this could be due to reluctance, due to fear of hastening death, also due to maybe lack of knowledge of what it is. So I think at the end of the day, in any pain situation or pain patient, it's important to have awareness, to have a good communication with our patients, to be knowledgeable, and to tailor their needs based on their individual preferences when we can. And here we have some references for you. Hi, everyone. My name is Paolo Mimbella, and I am an interventional pain physician based out of Seattle. And today I'm going to be talking to you about some of the applied concepts of these topics we were just talking about. The objectives of my subsection are we're going to work on learning the meaning of culture. We're going to work on increasing our own awareness of our biases. We're going to discuss a few cases, and then at the end, we're going to leave time for an open discussion with the audience. Disclosures, we have nothing to disclose except for our commitment to education. And I apologize in advance for the memes. It's part of my culture. But what is culture? So is this culture? How about our political beliefs, which can sometimes get contentious? If you need some coffee, please, now is the time. Is this culture, those that we call family, our nucleus? How about the music that we listen to? Can't talk about music without talking about Taylor Swift, who caused a magnitude 2.3 earthquake in Seattle in July. It was a trivia fact. It was actually during the Shake It Off song. So how about this? Our art. Is art culture? And the stories we tell future generations, is that culture? So a little test question here, which one was culture? Religion, political views, music, art, history, and everybody in here is probably a savvy test taker by now, but it's all of the above and then some. So we'll define culture. I don't think that's the definition we were looking for. So the Merriam-Webster dictionary definition of culture is the integrated pattern of human knowledge, belief, and behavior that depends upon man's capacity for learning and transmitting that knowledge to succeeding generations. I particularly like the image that we have at the bottom. And we're not going to go into explaining everything about culture. I mean, there's PhD level expertise on culture itself, but it's really just an overview. Manners of interacting, expected behaviors, patterns of thinking, courtesies, language, communication, and some of the more obvious ones like which flag you wave. These things are all a part of culture. So that was the Merriam-Webster dictionary definition. The Oxford dictionary definition of culture is the arts and other manifestations of human intellectual achievement regarded collectively. There's a reason that I underlined those three words, and that is whenever a topic is difficult to understand, for me personally, I try to simplify it as much as I can. And so those three words, manifestations of collective humans, I think pretty much emphasizes what it is that we're trying to understand here. Another way of looking at it is, you know, culture is what you'd need to explain to first contact were ever made to, you know, an alien race. Meme culture. So what is bias? Now that we've talked about defining culture, what is bias? So the Oxford definition of bias, prejudice in favor of or against one thing, person, or a group compared with another, usually in a way that is considered to be unfair. We have the statistics definition of bias, which you're all very well familiar with. And then it can be used as a noun or a verb as well. The next thing to define is implicit bias. And really, the only important thing to take away from this slide is what's underlined there. So it is the bias that you're not aware of. So the synonym is unconscious bias. And that's something that we're trying to always work on within ourselves, especially as practicing physicians. So some considerations for potential biases, ethnicity, race, age, biological sex, sexual orientation, socioeconomic status, gender identity, and many, many other ways of subcategorizing a group of humans. While we're on that topic, gender identity itself, these are discussions that are oftentimes difficult to have because they can be loaded with potential intrusions on human dignity and autonomy. But really what I wanted to, and those topics are really ethics topics, and they're beyond the scope of this talk. However, identity, how you see yourself, will absolutely dictate a large portion of your own culture. So we believe that a deeper understanding of identity itself, recognizing both our own and our patients' identities, and how that affects our relationship, the physician-patient relationship, will increase our own potential awareness of biases and augment our communication. And without communication, I mean, communication is critical for effective patient education, counseling, and of course, treatment. So here's an example of identity as a motivator. So it doesn't necessarily always have to have negative connotations to it. This is a case presented of a 19-year-old male motocross athlete involved in a motorcycle crash that resulted in a C6 Asia B spinal cord injury, and the subsequent motor and sensory deficits. He had no past medical history, no past surgical history, his BMI is listed there as 19.6. Psychologically, he's a highly motivated individual. He had a low level of premorbid disease, and his only co-injury, not to minimize it, I mean, a fractured femur is pretty severe, but considering his spinal cord injury, the fractured femur, his status posts, open reduction, internal fixation. And the important thing to note here is the small bullet afterward. It says, before the patient was discharged from acute rehab, he was able to self-transfer, self-propel for mobility, feed, and straight cath. And these patients within the realm of physiatry are sometimes talked about as patients that are super quadriplegic individuals with an SCI, or that's a bit of a mouthful, super C6 individuals, or super C6. The term super quad has been used, but we sometimes have to be careful not to label patients as a disease state. But here is this patient's, the factors that likely, multifactorial, led to his ability to reach a higher than expected level of function. We talked about hopelessness a little bit earlier, but there's a study that was done in the 1950s, and many of you are probably familiar with Dr. Kurt Richter's study out of Johns Hopkins, studying hope or hopelessness. If you flip it, I think it's a little bit better to look at it the other way, as hope. It's an obviously cruel study by today's scientific standards, and I will oversimplify what it is that occurred for those that are unfamiliar with the study. But Dr. Richter essentially put rats into a tub of water, and then allowed them to swim to exhaustion until they drowned. And so when the rats were initially placed in, they lasted on average, and again I'm oversimplifying here, about 15 minutes, exhausted, drowned, passed away. Then he tried a different arm of the study, where at anywhere from the 12 to 14 minute mark he'd remove them from the water, dry them off very briefly, and then put them back in the water. And he would continue these cycles to see when it is that the rats actually physically exhausted. And amazingly, they went from swimming 15 minutes to somewhere around 60 hours. And so the only way to really explain that, it's not physiologically a ATP replenishment mechanism. It's more of a hope versus hopelessness issue. There's many historical cases, and just for the sake of time, we're not going to go into each and every one of them. But there are historical examples of subgroups or cultural groups being exploited for medical research, and these are important to be aware of. And so I do suggest that when you have some time, maybe read up on these. Many of these are taught in medical school and you've probably been made aware of them. But the Tuskegee syphilis study, the Guatemala syphilis study, I don't know what was going on with researchers at the time in STDs. Pesticide testing in poor communities where specific selected neighborhoods were picked to investigate the effects of pesticides on human health. Radiation experiments that spanned from the 1940s to the 70s where specific subgroups of patients were exposed to radiation just to see what the effects were. And now we have some specific case studies. So we have a questionable case of pain-seeking behavior. So here's the case of an 18-year-old male with a past medical history of sickle cell disease, frequent acute chest syndrome, and vaso-occlusive crises, especially of the right knee, leading to frequent hospitalizations. He's well known to the PEDS teams, so hematology, PEDS hospitalist, PEDS PM&R, and PEDS pain. Then he turns 18 and he transitions out of the PD hospital into an adult hospital. He's new to the adult system. He's evaluated as a new patient. And when he's requesting his PCA pump and medications that he's been accustomed to for previous crises, some of these medications are withheld, including his PCA pump. Concerns are expressed by the hospitalist team for what they labeled as, quote-unquote, potential pain-seeking behavior. And so the thing to highlight from this case, there's no right or wrong answer to these cases, by the way. It's really just for us to think about. But were there some internal biases by the hospitalist team? Was there a lack of continuity of care when there was that break from the PD system to the adult system? Here we have another case. This is of a 48-year-old female with a past medical history of breast cancer. She presents after a fall, resulting in T12 and L1 vertebral compression fractures. The surgeon insists he can speak Spanish. He says he's at level two of Duolingo. And he refuses a translator. The patient is very polite, very reserved, and is trusting and relying on the fact that the surgeon read all of her medical history, which, by the way, she labeled in Venezuelan Spanish. For any Spanish speaker, it's probably well-known to you that, you know, different Spanishes, if that's a word, are very, yeah, very regional and not always perfectly understood from one country to the next. Anyway, he misunderstood. He refuses kyphoplasty, given that Medicare does not reimburse traumatic fractures. They only reimburse for malignant fractures. And the patient's treatment is a brace and medications. So did the patient receive optimal or suboptimal care? Again, food for thought. Here's another case, this time of a 35-year-old Haitian-American non-English-speaking construction worker who suffers a large intracerebral hemorrhage after cocaine use. He has no health insurance or living family in the country. He speaks only Haitian Creole, as well as French. And he presents to the office aphasic. At the time, they didn't know he was broke as aphasic. But able to ambulate independently. Because of this, there are some perceived lack of deficits, coupled with the observed lack of insurance coverage. He does not receive home health services. This case continues. So secondary to his language and cognitive barriers, he really doesn't explain well what's going on with his pain. And he's given repeat hip injections by his primary care doc, by an ortho doc, and by a sports med doc, who are all working independently of one another, aren't even aware of what the other doctors are doing. The patient starts to feel very confused, is urinating frequently, severe fatigue. He feels like things are off. He goes to the ER. And routine labs show that he's got a glucose level of over 500, and he's hospitalized. In the hospital, translating services combined with a more in-depth history and cognitive assessment result in us figuring out what it is that was going on with his neuro findings, with his broke as aphasia. And he has an L1 disc herniation, as well. And I apologize for running through these kind of quickly, but I've been limited on time because I've been known to talk too much. So the next case is a very pleasant 51-year-old Ghanese female. She's a custodian at the local university medical center, and she suffers a slip and fall downstairs while she's carrying a load of bedding. She reports twisting her right knee, landing on her buttock, and feeling sharp pain in her lower back that the next day started to radiate down that left leg. She's seen at the university ER, and an x-ray is done of her back. The x-ray is read as negative. She's sent home with muscle relaxers and three tablets of oxycodone and told to see her PCP. She calls her PCP, does not have availability for the next seven weeks. Her daughter is a nurse and makes a few phone calls, gets her in to see an occupational med specialist at a different system, so not at the university system. God sees her and refers her back to sports med over at the university system. Sports med sees her, uses translating service, doesn't use translating services, and orders a hip MRI. There's no acute or subacute findings on hip MRI. She then searches the web, finds a private practice, physiatry office, comes in. Now, being that this happened at work, this was a workers' comp slash L&I. In the state of Washington, L&I is labor and industries, but it's equivalent to the state's workers' compensation plan. Workers' compensation initially refuses further imaging studies. After peer-to-peer and some paperwork, MRI L-spine reveals that she has an L5-S1 discopathy with neuroforaminal encroachment on the left side greater than the right. A bedside sono shows that her right knee has a large effusion. She's drained. The knee feels better, but there's some locking symptoms. Another peer-to-peer, she has an MRI done of the right knee, and it reveals a longitudinal tear of her medial meniscus. So what I really wanted to highlight there is oftentimes, and I think one of the other cases showed this, fractured siloed care, so with all of us hyper-subspecializing, sometimes can also contribute to these less than optimal outcomes. Language barriers, cultural barriers, all of these contributed in this case, in my opinion, to delayed optimal care. These cultural implications don't necessarily have to be on a one-to-one basis. Sometimes they're on a macroscopic scale. In the state of Washington, that's why I put the little flag at the bottom, in the state of Washington, the HTCC makes decisions as to whether states spinal cord stimulation. Currently, Washington state is the only state that does not cover SCS for any indication, but this is up for review, as I mentioned, tomorrow. The H-Analogy Assessment, which reviews the literature and presents that to the HTCC and they make their determinations. This is a cover of the report. This is all available on the government website. There's this grassroots group of physicians. They're mostly interventional physiatrists from different systems, some from the VA, large corporate health systems, University of Washington and private practice. They've reviewed the literature and prepared a report to counter the findings of the HTA that in specific diagnoses, SCS should be covered. Why did I want to bring this up? I wanted to bring this up because the question that I looked at with this particular case, if you want to look at it as one big case, is, is a particular subgroup affected more so than others by these HTCC decisions? If we scroll back to the HTCC, I know the arrows are a little small, but the three plans that the HTCC specifically makes decisions on whether they're going to cover or not is state-sponsored Medicaid, the UMP, Uniform Medical Plan, and the Department of Labor and Industries, which as we discussed a second ago, is Workman's Comp in the state of Washington. Who's covered by Medicaid? Is it a particular subgroup or subculture that is covered? By definition, Medicaid covers low-income groups, so yes, it is one particular subgroup of the population that is affected by these decisions. The same thing with the UMP. The UMP provides healthcare coverage to state employees, so school district employees, education employees, local government employees. They're all covered by this plan. And then Workman's Comp, or LNI, as it's known in Washington state, covers injured workers. And as anybody who's taking care of an injured worker, we're usually talking about blue-collar workers here, not exclusively, but usually. One last slide that I wanted to add in here, and this we actually added. Some of the delays earlier were my fault. It's because I added this slide in maybe three hours ago. This study was just published last week in JAMA, and the study was talking about hepatitis C rates in black individuals in the United States. The study is a literature review. They included 65 studies, so quite a bit of numerical power to it. And they discovered that from 2015 to 2021, in general, hepatitis C infection rates had increased overall, but most notably in people who are black. Now, this is clearly multifactorial, and their discussion does highlight some of the factors that we previously discussed, but really it's just about increasing awareness, because their own conclusions, which I put in quotations at the bottom, are that if more point of care testing is available, patient education, unrestricted access to the treatment of HCV in community-based settings, all of this has the potential to improve outcomes in people who are black. So we'll bring it back to a question that was asked a little bit earlier by my colleagues, and why does any of this matter? At the end of the day, what is a doctor, and what is the job or the objective of a doctor? As we seated here, we fundamentally believe that if these concepts are better understood, we can reach more patients, increase the quality of care, and more importantly, the quality of lives of our patients as practicing physiatrists. And honestly, this extends beyond just the subspecialty of pain medicine or physiatry itself. We have some suggested reading, if you'd like. All of this is included in the slides on cultural competence in the healthcare setting. And that's just sharing a little bit of my culture with you all. So now what we're going to do is we are going to open up the panel to an open discussion. If you have any questions about what we just discussed, any comments, any observations, or any of your own cases that you've seen, or patients you've taken care of, please feel free, and please feel free to use the microphones. Thank you for the very interesting and important presentation. I'm wondering, based on your experience, what do you think are some of the most pressing gaps in the literature for racial and gender disparities in pain, you know, treatment, outcomes, perceptions, that might benefit from more research? I would say all of it. I know that's kind of a cop-out answer, but I think there needs to be just more research in general just to try to fine-tune why this is happening and what we can do to change the disparities, in my opinion. Hello. I wouldn't say there's any one disease process or pain process, but I think in my, you know, experiences in attending and newer attending, I'd say healthcare access is probably the one thing that I definitely see or hear from my patients that are coming in, some of them driving like literally five to six hours from the border towards Houston, where I'm at, just to see someone like me, an interventional, like, physiatrist. So I, you know, I definitely say healthcare access is probably what, amongst everything, just like Dr. Burnett said. Thank you. We actually have an online question from Rebecca McConnell. They say, thank you for this important talk. I work for a chronic pain population that is 25 to 50% Medicaid in a more rural, low socioeconomical area. I'm wondering how or if the panelists changed their personal behaviors, caring for these have-nots as someone who, by many social standards, is a have. For example, I might be hesitant to get a nice attending car when seeing my patient who can rarely afford a bus ticket. For a similar reason, I only wear scrubs to not appear too fancy. And any thoughts about, you know, personal behaviors in treating patient populations? So a couple of things that I would want to address there. I think at the end of the day, it ties into understanding the culture of the patient that's coming to you. So certain, like I come from a Hispanic background, and the vast majority of my patients have actually, they wear, let me put it this way, they wear their Sunday's best. It's actually quite flattering when they show up, especially the older Hispanic generation, and they're literally wearing, you know, 80-year-old, you know, grandpa, and he's wearing his nicest suit. You know, grandma's there with him. She's accompanying him. She's, you know, you can smell the perfume. They specifically dressed up for this reason, to see you, because to them, seeing the physician is a big thing. There's a lot of authority there, and they expect that from you. So I think it's important, really, just to understand there is no one-size-fits-all to approaching this. It's really just understanding your patients on a cultural level, and then, hopefully, on an individual level, as you build more and more of a relationship with them. I think that will help your communication. I think that will help your education and treatment for those patients. And to piggyback on what was said in regards to your question, I think one great place to start with further research is maybe working not even just within the subspecialty of pain, but with, like, emergency medicine physicians, anybody who sees somebody as an entry point for healthcare, because that's usually where you see the underrepresented, you know, minorities showing up. These are not patients, you know, a patient on Medicaid is, in my experience, and forgive me, it's just my experience, is not usually going to their primary care doctor every six months, getting their lab work done, getting their blood pressure checked, getting their meds refilled. These are patients that haven't, they might be 55, and they haven't seen a physician in 30 years. And so, they end up using things like the ER or urgent care as their, hey, you know what, something's now broke, let's go fix it. And so, I would say maybe partnering, you know, with other specialties and working on research in that way, that might help bridge the gap when it comes to cultural competency in healthcare. Just another thing, one of the other questions was, what have we learned while we were drafting up this presentation? I think one of the most important things is that it's never too early to become cognizant of some of these biases and exactly understand what culture is. I mean, as Dr. Mbella said, I think it's an evolving definition always. There's new different domains that can define culture, but kind of understanding what it is and then changing your mindset is probably the first step that, you know, is going to make you a successful clinician. Hi. So, I was actually going to ask about, you know, involving other people, so that answered one of my questions. But so, I also see a lot of some transgenders and non-binary patients, and so I am purely musculoskeletal. I don't do pain procedures per se. But so, do any of you have experience or recommendations? Because obviously, you know, especially if people have transitioned later in life once their past puberty, they have lived the first however many years in their, you know, with say a female body and their pelvis outlet has formed a certain way, their Q angle is a certain angle, and that's not something that can necessarily be, you know, easily altered with our therapies or other medications or physical therapies. I mean, so how do you kind of involve those patients in, you know, in understanding kind of where they've come from, where they can go with their, with the body that they have, but also that identity they feel comfortable in? How do you, how do we approach that culturally, I guess? So, I want to start by saying I am absolutely not an expert on transgender issues at all. I have seen a couple of patients, and the best thing that I could think of doing was actually reaching out to their primary physician and their endocrinologist. They usually have those specialties involved. It's something that, and I apologize for, you know, standing on a soapbox here, but I literally am kind of seated, but anyway. I think that's missing in medicine today, is intercollegiality between different specialties. Because it actually sounds like you know the answer to your question. It's how do I explain to the patient that their Q angle is different in a sensitive way? How do I explain to them that traditional therapies are not going to solve the issues in a traditional way, and that we're basically in uncharted territory, right? But that we're here together. And I think that's what most patients want, is just to know, like, we're in this together, right? That, in and of itself, will probably, you know, I can't guarantee anything, but augment your physician-patient relationship. But working with the other specialists that are treating that patient, I think will also show that patient. I mean, we're all human too. Every once in a while, something's broke on us, and we have to go to the doctor as well. And so, when your specialists are talking to your other specialists or primary care provider, I mean, how does that make you feel? So that might be one easy place to start. Does that help? Thank you. The other online question that we have comes from David Richman. They state, the emotional slash perceptual component of managing both acute and, more importantly, chronic pain is under-addressed. Please address how we can better equip PMR doctors to address this important aspect of pain management. I think for me, personally, as I'm meeting these patients for the first time who either have maybe acute or subacute or now in their chronic phase of spine or musculoskeletal pain, what I try to do, and I maybe harp on some of my residents about, is get a good social history. And so, at some point, everyone's L4-5, 5S1 discs all look the same, or their radiculopathy sounds the same, or their shoulder pain sounds the same. But what I remember and what I want everyone to learn and to start to ask to say is, where do they live? Who lives at home with them? I think we all learn to ask these questions like a functional history. And I ask all my patients that. It's in my clinic template. I want to know what they do for a living. Are they working right now? What kinds of jobs have they had before? And we can be creative in how we ask that to our patients while still getting the history that we need or the parts of the physical exam that are relevant. And then I'll always ask a likes-to, likes-to, dot, dot, dot, if you're familiar with Epic. And so that helps me remember what is meaningful to the patient, what do they like to do in their fun time? What activity are they looking to get back into? And so for me, for each one of my patients, that's what I usually remember about them. Okay, this is my avid pickleball player. We need to get his hip taken care of so that he can go and win his next national pickleball tournament. And so I think when you're approaching patients with acute or chronic pain, just being mindful of how their pain is limiting or restricting their activities, those things that bring meaning to them is important and showing them that, hey, we can, this is just one little step in the road and get them back to being as functional as they want to do and ultimately improving their quality of life. And one of our speakers is actually absent, and one of the things that we actually wanted to incorporate into this talk is that we need to be very aware that some of our patients actually come with significant trauma into our practices, okay? Trauma in their family life, trauma in their social life, and that may also be contributing not just to the physical pain but also to this kind of like emotional and perceptual pain in addition to potentially mistrust in the healthcare system. So there's a lot of to unpack. So trauma informed care can be a specific resource that I highly encourage you all to arm yourselves with to be able to manage this by patient population and be a better resource in terms of access and also understanding your patients. I agree and to kind of piggyback on what you were saying Dr. Philip, I think it's also important not to get into the routine of having like a cookie cutter or conveyor belt practice. You know really it's important to individualize a patient's care based on their specific needs which is why you get all that information because the same treatment is not going to be the right treatment for every patient who walks in the door and unfortunately with pain management, at least in the Houston area, we're seeing a lot more of that. Just you know a patient comes in and they get boom boom boom boom down the line and that's just not right and it's not a way to optimize care for those patients. Hi my name is Robert Emme. I'm a fourth year medical student and I'm applying to payment artist cycle and I'm with the no need of people dealing with chronic pain. I'm really interested in pain medicine but when I've talked to some mentors or colleagues about my interest in pain medicine sometimes I hear oh don't do it. Dealing with that population can be very frustrating so I'm curious to know what the time that y'all spent in this field are there some frustrations that y'all deal with on a daily basis and if so how do you shape your mental and emotional framework to make sure that you don't stay frustrated so that you enjoy what you do and that you can provide the best care possible. As a as a trainee I don't have much experience with this population but what some of my mentors have taught me is that try not to be so reactive. You know when that patient is coming in and they might seem difficult to you they're not really being difficult but they're expressing their frustrations to you so try to take like that one deep big deep breath and understand that you know they might have had a bad day a lot of times they have other comorbidities anxiety bipolar disorder a lot of times that accompanies their higher perception of pain as well so kind of understanding their situation and taking a step back might make you not be so reactive and then be able to move forward with that and work with them essentially and you can let them know that too. One of the other pieces of advice that I got was set your boundaries right you know who you are as an individual you are still human but make sure you set your boundaries out to make sure that you can still take care of that patient and not tolerate other things that otherwise is usually not acceptable. Vishal are you sure you're not in attending already? Quite a bit of experience no that's excellent advice first of all congratulations you know PM&R is the right choice. Not that we have any biases. I think Vishal was touching upon a couple of things there it's you need to have your own boundaries and you need to have your own emotional resolve so it is tough and it's not for everybody but neither is psychiatry neither is emergency medicine neither is medicine itself you know I mean we're dealing with human suffering so I think if you're mentally prepared for that that will help making sure that you know you are maintaining your own health I think there's some old hip you know Hippocrates quote I don't know how true this is and we're talking about BC but you know you can't help anybody if you yourself are not healthy right so those things are important. Yeah I would say work on work on you know your own balance in life and then keep in mind the physiatry approach you know the social approach the functional approach and know that being a pain physician is not just being you know to piggyback on what dr. Burnett was saying you don't want to feel like you're just in an assembly line just doing epidural steroid all day you'll drive yourself crazy take take each patient as their own story and each patient has probably seen several physicians multiple urgent care visits ER visits I mean one of the cases we talked about that patient saw the ER doc a here's the muscle relaxers go home you know saw an occupational med doc hey you should see sports medicine sports medicine you know didn't translate right so these things happen and they happen fairly frequently but if you're aware that they're happening then you know hey this patient's probably gonna be frustrated by the time they have their first conversation with me because although it's our first conversation it's not their first conversation with a medical expert about a particular medical problem. I'm not a pain physician but I always tell my trainees and there's like three of them in this panel that in order to be a good rehab physician you need to be a good physician and thing needs to make sense physiologically pathophysiologically so if something is not making sense think kind of like outside the box and I think as PMNR physicians we're even better you know skilled to take care of this patient population because we go beyond the technical aspects of procedure management for this patient population we can actually offer them so much more but let's hear from the other pain physicians in the panel. I completely agree with what everyone has said for me I will say about 10% of the patients cause 90% of the problems right so you're gonna know once you establish your practice it's not gonna be everyone and you got to take care of yourself whether that's yoga meditation deep breaths and then just remember they're in pain and that's a lot of the reason that they might be difficult also what I found very very helpful in my practice is just listening to a patient doing nothing else not looking at a computer not typing not writing and let them go on for a while and then kind of regurgitate what they said later in the visit and they are just I mean because you're listening you care right so it's the art of doing a 45-minute exam in five minutes. Dr. Philip. Yeah definitely echo all the things that Dr. Bosquez, Dr. Bonsal, Vernette and Mimbella said already I think you may not remember but I felt like we had a difficult patient interaction maybe the last week that you were rotating with me and I think it came down to once again taking the time listening to the patient and realizing what he was lacking for example in terms of insight about what I was asking regarding some imaging and so then taking the time to pull up Google and show him what the difference was between an MRI and a CT myelogram and why I needed you know or wanted a CT myelogram compared to whatever other imaging he had done to date right he had he would have no reason to know any of those things and he was someone that you know Dr. Mimbella was saying had already gone through emergency medicine and then was sent to or like a ER was sent to orthopedics sports medicine multiple visits eventually sent to spine surgery spine surgery says no surgery and we don't have the imaging we need and then still coming you know go get an injection but I'm like well no one knows actually what's going on I can't do an injection I still need this imaging right and so obviously he was very frustrated and you know just like Dr. Bonsal was saying I shouldn't and we didn't look at him as a difficult patient it's just that he has understandable frustrations and taking the time to be patient and walk him through in that example you know what why we needed this and I do that with all my patients as far as imaging goes like I want them to take ownership of like what their actual spine structure looks like it shouldn't be some black box and like oh well a doc said I have like a facet joint problem like I want them to understand like what those joints are so I spent a lot of time with my patients just going over that so they feel like they have ownership of that knowledge to a tip look at their eyes and remember their color of their eyes when you are able to look in the eyes of your patients and remember their color you're making a instant connection with your patient and you're able to read them so much better and they're able to interact with you so much better thank you for the answers I appreciate it Esther hi thank you for covering this really important topic I wanted it this is more of a like a comment or something to add to this discussion you know when we talk about the doctor-patient relationship there's also a patient doctor relationship and that the cultural biases and a lot of the things that we're talking about go both ways for instance I used to work for a hospital-based spine practice and now I opened up my own spine practice and the way when patients patients often are finding me versus being just you know refer to me by somebody else like you have to go see her because she's part of this system they're finding me through Google and stuff and they're coming in with their own biases of like how I am as a private practice owner versus like a hospital-based owner and like what they perceive as the level of care that they're gonna get they kind of they transfer that back on to you as well also I have many times been you know I always ask a new patient like why you know why did you pick me out of Google like there's a ton of doctors around here that are doing what I do although I argue I do some different stuff they're like oh I was just looking for a Jewish name a Jewish doctor or something like that so like because there's this perceived notion that Jewish doctors provide a certain kind of a care or a female physician will be easier to get pain meds from or whatever so you have to like realize that the cultural bias is a it's a two-way street and you also have to kind of have this awareness of what they might be trying to get out of you as well in that situation and I've just been experiencing that a lot more in the last couple years going out on my own in regards to difficult patients I don't know if that med students still here every specialty that I know has difficult patients cardiology neurology whatever endocrine whatever it is don't put pain management as in like up on a pedestal is like we're gonna have the hardest patients because they're you know there they exist everywhere and it's just part of health care and yeah and the late and the labeling right so sometimes when like another specialty or someone else in your practice label someone as difficult it might be because they're trying to be assertive it might be because they're asking questions so so you know kind of like even question that label from someone else about the difficult patient because you might be the only one that understands why they're being difficult about absolutely and just just be aware of that two-way highway because it is it is thank you there yes it was interesting in those examples what looked like maybe conscious or unconscious bias and the team members that led those patients to our care and physiatry how do we go back and raise consciousness in our referring providers team because you know they're all part of the patient's team we have to start looking at it as these are the caregivers for that patient how do we when we find these things at the end make sure we go back so that this doesn't happen to the next sickle cell patient that's 18 and rolls into the ER I mean how do we backtrack and make sure that we're elevating the consciousness of humanity in our little sphere of medicine so I think that's a fantastic question and it's not an easy question to answer because if it was easy I think it would have been fixed by now right I think what you're asking and it's something I think we all want to do is maybe change a little the culture of medicine it's understanding specialties understanding your referral source I mean dr. Philip was talking about a second ago how the surgeon may have told the patient no surgery you need an injection go see this person they're gonna give you an injection what just happened they just created an expectation in that patient that I'm coming into this office to see this specialist who's gonna inject my back guess what now you're having an evaluation patients furious even if you did the best history best physical exam you just explained everything their expectation was I'm coming in for an injection I'm bringing this up because anybody who's practiced physiatry probably not even just interventional pain has experienced this and so it's what's the simple answer is a conversation with your referral basis it's educating your referral basis probably a little easier in an academic setting we'll start there since it's maybe a little easier there but hosting Grand Rounds you know multidisciplinary Grand Rounds and educating your colleagues your neurosurgical colleagues your ortho colleagues your sports med your primary care physicians who are sending you patients like hey maybe instead of wording it this way maybe you word it this way hey I think you might need an injection this specialist does all sorts of injections I think they should evaluate you to see what might help you best now the patient comes in with a completely different expectation the case you were talking about the sickle cell disease patient how do you bridge that gap I mean that case was a patient leaving a pediatric hospital and going to a completely different hospital so that's not as easy as just hosting a Grand Rounds right but I think it still boils down to communication and changing a little bit of the culture of medicine part of the reason I brought up the case of the female Ghanese patient was because it actually frustrated me when I realized this is a university healthcare employee and she is kind of being pushed you know for seven weeks eight weeks ten weeks without any real care and because her daughter was a nurse she actually got into my office a little bit faster than you know some other patients were taking six months eight months to get in just because they don't know where to go so again I think it's communication it's education it's making sure that our referring bases understand maybe maybe you don't want to tell them hey don't do it that way maybe you'd rather maybe you'd say hey how about this other approach or maybe you can say this to the patient and then we'll have better outcomes with our with our joint patients that's just a suggestion but it's not a perfect answer because I don't think there is a perfect solution it's a little bit of a shift in cult in our own culture as as providers and I think it's incumbent upon us when we see those gaps to reach out and make those communications on a one-on-one with basis and I love having epic access to a lot of providers because I can send them a chat or an in basket that will just trigger something we might have a little conversation back and forth and hopefully raise their awareness of their maybe conscious or unconscious bias and how that has played into a patient situation so it won't go on but I'm just really encouraging us to take that little bit of time to save somebody else that can end up in the same predicament as the person in front of you if you don't reach back and elevate and bring consciousness to our colleagues about biases that they have that come out that you pick up so I'm just encouraging all of us in this room to have that kind of mindset so that use the little technology we have to reach out and elevate these situations moving forward and one thing to think about if there is delay in care or near miss or potential harm evidence if it's minor if you're in a system write up that safety report okay because every time that you write up a safety report at least it should be reviewed so if you can become that squeaky wheel and if there's enough you know data for either a specific program or a specific service line or something that is showing some of these behaviors then it hopefully it also becomes a systematic kind of like question regarding the the policies of the hospital or something and I think it's completely unacceptable for physicians to not have this linguistic translation that is appropriate for the patient while they're caring oh yeah that's inappropriate care yeah and it shouldn't be allowed by any health system and so I think we should be elevating things like that because that leads to misdiagnosis that leads to could be catastrophes in the patient care so I don't know where you are in your practice I guess as you get more seasoned you don't care what happens to you you just become that squeaky wheel and you know whatever come what may my team has directives to write an EHR every time that they hear or see that a team member has not used the appropriate translator services right yes so I just think it's important that we we know how important that communication is and that we advocate for it in all team members Lisa you're the last one oh yeah well I just want to thank everybody for coming well it's the end of the session but you know what I'm just saying I mean at least and everyone here I think this was really more than what we had even hoped for envisioning this I think it's a powerful moment for the Academy I love the collaboration with the african-american and latinx communities and our populations that we represent in bringing this truth I will say that it is unfortunate that we still have to have these kind of conversations with so much data that we know and in my practice certainly and in my early work in California I was part of the whole state multicultural task force that led to the implementation of cultural and linguistics competency as a requirement for licensure and the whole establishment of the California Health Interpreters Association which set a precedent on a standard on you know you just don't bring the nephew in to translate it the great-grandmother's GYN appointment you know I mean we would see such egregious things so I think this whole cultural and cultural I love the pictures of culture and linguistics competence is so important and I think it is also very important to be aware the implicit association test is something people can do for themselves know yourself all of us in this country in particular with the type of imagery and all the social media influences it embeds misinformation it embeds associations often negative with certain groups and certain images and it's important to get in touch with your stuff what are you bringing in you may think that you're all good and maybe you really aren't and to be aware of body language I think that's super important and that's something I try to model when I'm on rounds when I'm working with residents is the way in which we approach patients and the I'd like the idea about the eyes that was great but your body language and how you come in on when whether it's an inpatient setting an outpatient setting and how you interact with patients says an awful lot on what you're going to find out from them and we know that 80 90 percent of the diagnosis is going to be in that history especially when it comes to pain so taking that time and understanding what many of these people are laboring under and I just wanted to point out a few quick other things and that's the whole idea of water therapy is super helpful but then again it's an access issue that some people may not necessarily have that and then the environmental issue which of course we'll talk about more on Saturday but there are so many environmental influences and toxicities and we just got a grant at UC Davis will be looking at adding in as part of the social determinants of health history to look at environmental influences you know a lot of the war veterans with Agent Orange exposure working in different chemical explain you know this whole belt Louisiana Texas Alabama etc refinery row a lot of toxic exposures so a lot of these weird unexplained pain syndromes actually can tie into strange neurological dysfunctions because of past environmental things but there's no necessary testness you can do some really highly sophisticated analysis in fact analysis in toxicology and all that so keep in mind that the patient generally wants to be helped there's a tendency when you're dealing with pain that this paranoid suspicion that they're just trying to get over but you know you have working people that have to take time off to come see you because they're trying to get help they generally need help and we should always try to have that mindset about it and I just want to thank you all to remember the humanity that's within all of us that we keep striving for that and to keep up the good work thank you thank you all

pain management

diverse populations

healthcare disparities

trauma-informed care

cultural considerations

bias and implicit bias

case studies

challenges in pain management

effective communication

cultural competence

individualized treatment plans