The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment

Cleveland G. Shields, Jennifer J. Griggs, Kevin Fiscella, Cezanne M. Elias, Sharon L. Christ, Joseph Colbert, Stephen G Henry, Beth G. Hoh, Haslyn E.R. Hunte, Mary Marshall, Supriya Gupta Mohile, Sandy Plumb, Mohamedtaki A. Tejani, Alison Venuti, Ronald M. Epstein

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Background: Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer. Objective: To examine the effect of race on physicians’ pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation. Design: Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles—a 62-year-old man with advanced lung cancer and uncontrolled pain—differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions. Participants: Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians’ mean age was 52 years (SD = 27.17), 59% male, and 64% white. Main Measures: Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment. Key Results: SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81). Conclusions: Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain. Trial Registration: NCT01501006.

Original languageEnglish (US)
JournalJournal of General Internal Medicine
StateAccepted/In press - Jan 1 2019



  • communication
  • doctor-patient relations
  • lung cancer
  • pain management
  • racial disparities

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Shields, C. G., Griggs, J. J., Fiscella, K., Elias, C. M., Christ, S. L., Colbert, J., Henry, S. G., Hoh, B. G., Hunte, H. E. R., Marshall, M., Mohile, S. G., Plumb, S., Tejani, M. A., Venuti, A., & Epstein, R. M. (Accepted/In press). The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment. Journal of General Internal Medicine.