So, today we're going to be talking about pain scales and clinical responses as it relates to racial disparities. Of course, I had to put a picture of San Diego up there. Right now, they're underwater right now, so we're all suffering right now. I have no disclosures, and then my objectives are to give a historical basis as well, just like my colleagues have done, to discuss recent literature as it relates to pain and clinical responses, and how those responses impact clinical and patient outcomes, and how do we have approaches to overcome learned subconscious behavior, and then you will also be able to locate the SCCM Diversity, Equity, and Inclusion webpage, as I'm sure many of you guys are unaware that that actually exists, and it's a new undertaking that just kind of happened. So understanding our past leads to our path to our future, a history of intentional and unintentional implicit bias. So just like my colleagues that stood up here before, there's a lot of deep-rooted historical facts as it relates to 19th century beliefs, and even before that, the father of OBGYN in this particular book that I have listed here, Medical Apartheid, and I will just say that any literature source that I state is just simply something that I have read in my own practice, in which there are decades of instances given as it relates to black people and the experimentation that they have endured. And then, as my colleague so eloquently stated earlier, 2015, 2016, 50 percent of medical students believed that black patients had thicker skin than their white counterparts, and of that, 40 percent of the first and second year medical students endorsed the belief that black people's skin is thicker than white people. So when you think about that, you have to believe that if the medical students are thinking that, as that translates into nursing as well, the thoughts of our society implements and integrates into medicine as well. So this is a problem across the healthcare continuum. This is not just something that's just affecting whether it's physicians, nursing, physical therapy. It's across our entire healthcare continuum. So it's more than just black and white at this point. It not only affects just our black patients, but across the board. And so what ends up happening is that our patients are unseen, they're unheard, and they're still in pain as it relates to our inability to effectively treat them, identify, and believe them when it comes to their self-reported pain. And so this is actually a table that shows that in other minorities and marginalized populations that when they discuss and report pain, that significantly it's not that much different than their white counterparts. However, we know through research that their pain is inadequately treated. And I think that this is an important slide, and that's one of the reasons why, you know, most of the time, and I would say that most of the research is based on black people. However, there are multiple marginalized populations that require more research to know exactly what the issues are for them, but I would almost believe that they are undergoing the same issues as their black counterparts. So I decided to put, if you were in the opening session, we had one of our indigenous brothers come, Palmer, and he did a prayer for us, and he had an abalone shell. And so I put that there because a lot of times when we're looking at people, we only see them on the outside. However, if you open it up, we are not monoliths. No one in here is a monolith as it relates to who they are. So there's gender expression, sexual orientation, disability culture, economics stances. No one person is exactly the same. And so that does impact how they deal with pain, how they react to pain. And so I think that these are all the things that we have to look at instead of just looking at the outside and making these preformed judgments as it relates to treating pain in our patients. Same research, same results. Now that sounds a little pessimistic, and I will tell you why I decided to name the slide that. Research regarding pain, clinical responses, and racial disparity. This was an article that I found that was published, and it was specifically in the pain and nursing section. So this is the scale of most of the tools that we utilize to assess pain within our patients. And this is specifically based, and I'm talking to the nurses out there, people who have been nurses, you know, but even for my physician colleagues, most of the time we walk in and we ask our patient, what's your pain scale, or we utilize behavioral tools to readily identify what we believe our patient's pain scale is. And so I wanted to put these up here just to kind of give you guys an overview as to some of them are self-reported, and some of them are utilized from us from a standpoint for our intubated patients that can't talk, that can't tell us exactly where they are as it relates to pain. This was a retrospective study that was done from 2013 to 2021. It was done at UCSF. At the time, they discussed the time of completed pain assessment, they looked at the specified type of pain assessment tool used, and they documented the value of what the patient reported as far as their pain. What was self-reported was their gender, and their age, of course, was also self-reported. The important thing to remember about this, particularly for us, these were not ICU patients that we were dealing with, but pain is pain, no matter where the patient is identified. So any of this information I feel like is translational as it relates to either in an outpatient setting or an inpatient setting. 51,000 patients who were hospitalized, and they actually documented up to 1.9 million patient-level pain assessment values. So over the course of all these patients, every time they were asked what their pain score was. That is the geographical breakdown of the people who were in the study. I'm not going to read those to you for the sake of time. And then the majority of them were English-speaking, and 13.2 of them had limited English proficiency. Now, in this study, I don't know how they determined what the proficiency was for English. So I will say that that is something that could be seen as an outlier for something that needed to be better identified. The primary outcome examined the frequency in which the pain tool was used, the relationship between pain assessment and the administered opioid. So they essentially looked at the relationship between the two. And patients with numeric ratings were more likely to be white, English-speaking, younger, and interestingly enough, they were on opioids prior to admission and had lower comorbidities. However, Asian patients and patients with limited English proficiency status were less likely than other groups to have a numeric pain assessment and receive fewer opioids. So one would have to maybe infer that since they had a lower amount of English proficiency, were they actually being asked what their pain score was? Because that might include needing translation, having to go get a MARTI, that extra step that it takes, that sometimes providers, we take shortcuts at times to try to limit our time to move on to the next thing, which can impact our patients. Racial ethnic differences in staff-assessed pain behaviors, this study looked at nonverbal pain behavior as a effective way of treating pain. There are very few studies that actually looked at the difference in racial and ethnic and nonverbal patients as it relates to pain management. And then this was primarily utilized also in nursing homes. Racial ethnic differences in self-reported pain and pain management have been documented. Mostly vocal complaints that were mostly recorded were those in the non-Hispanic black residents, 19.3 of Hispanic residents. And the reason why I picked this, even though you'd think that it would not be applicable here in a society of critical care medicine, is that documentation of pain behaviors was less frequent. That means they're not documenting the pain scales for non-Hispanic black and Hispanic residents versus their white counterparts. So in looking about pain, there is a saying in nursing, pain is the sixth vital sign. And the American Nurses Association believes that nurses have an ethical responsibility to relieve pain and suffering that it costs. And I would say that this involves all of health care. Nurses should provide individualized nursing interventions, whatever those interventions are, a multimodal and interprofessional approach. And that nurses must advocate for policies to change how we actually treat patients. And then nursing leadership is necessary for the society to properly impact change. Now I told you that in the beginning that I put same research, same result. All the research that all of us have stated up here on this stage goes back decades. Nothing has changed. The research remains the same. Our patients continue to be impacted, and the outcomes are no different. We keep doing research on things that we already have the information for and know what the outcomes are. And if you were in opening ceremony, I also took this slide from there, from our former Surgeon General, in which every system is designed to get the result that it gets. You have to understand as it relates to marginalized patients, the system was not set up for us. We had a different system when health care started. And so the system that we're using now for people who are marginalized was not set up for us. And so that is why we're getting the results that we get. So we have to change the system. A bad system will beat a good person every single time. So we are working with old, antiquated solutions. Our patients continue to suffer the consequences of health care mistrust, delayed pain management, development of chronic pain issues because we're not dealing with their pain when it's in an acute phase. They have feelings of isolation, despair, and depression. We're not talking about the financial loss that people have as a result of uncontrolled pain. We're not talking about the time away from family. We're not talking about the additional health care costs in marginalized populations that already have problems from an environmental standpoint as it relates to society. So what's the solution? As it relates to diversity, equity, inclusion, anti-racism, and access, we are all evidence-based providers and we should know that we should collect data. We should identify our own biases. Taking implicit bias tests helps us. There's one, the implicit association test. SCCM has an implicit bias test that I don't know if you guys were aware of. It's a test that we use to identify people who have implicit bias, and it's a test that we use to identify people who have implicit bias, and it's a test that we use to identify people who have implicit bias, and it's a test that we use to identify people who have implicit bias, and it's a test that we use to identify people who have implicit bias. We know that our patients like to see a diverse workforce, but we knew that already. Grassroots community engagement, engaging with the community where they live and worship, getting out into the community and understanding people's perspective as acute care providers is very important. And then having real, honest conversations with their colleagues, friends, and family. And then how diverse are the people around you? Taking self-accountability as it relates to this subject. And then people don't know how much, people don't care about how much you know until they know how much you care, and we have to care about these things. And so, these are the list of my references. Here are some additional books that I utilize. There are a litany of books. And then as promised, there is a QR code that you guys can use to go to the diversity, equity, and inclusion page there. There are tools listed there. There is a DEI lexicon for SCCM members to utilize. Take back to your individual institutions for correct vocabulary as it relates to marginalized populations, implicit bias training. And then please consider joining one of these underrepresented groups. The knowledge education groups are very important, so we have the underrepresented in critical care keg, the global outreach keg, and the women in critical care keg. And with that, I leave you. Thank you.

racial disparities

pain management

systemic bias

inclusive healthcare

implicit bias training