Pain is one of the most common reasons patients seek medical care, yet it remains one of the most difficult symptoms to evaluate objectively. Unlike blood pressure or glucose levels, there is no laboratory test or imaging study that directly measures pain. Instead, clinicians rely on patient self-reporting, clinical judgment, and functional pain assessments to guess the severity of pain and to offer appropriate treatment.
For Black patients, this guessing game has not ended well. A growing body of research has found that Black Americans are less likely than white patients to receive adequate pain medication in emergency departments, after surgery, during childbirth, and for cancer-related pain. A 2026 study even found implicit bias affected sickle cell patients. While some of this disparity may be attributed to underreporting by patients who fear repercussions for complaining that a particular treatment remains inadequate, it is often due to provider bias in assessing pain thresholds and assuming drug-seeking behaviors for Black patients.
This isn’t just a problem in the U.S. In fact, a 2025 Dublin-based study also found that “Disparities in pain management, with respect to race and ethnicity, are still common.” And a BBC News article reported that pain management in childbirth is cross-cutting: “We have heard about stereotypes being used in maternity and neonatal services…,” it said. Black women described experiences of being deemed as having “tough skin” and “able to tolerate pain”
Improving pain management is about understanding how clinicians can adopt more consistent, patient-centered approaches that mitigate bias, lead to objective findings, and appropriate pain treatment for all patients.
Pain is inherently subjective because the patient is the only person who can describe what they are feeling. Numeric rating scales, visual analog scales, and questionnaires such as the Brief Pain Inventory or McGill Pain Questionnaire provide valuable information, but they measure a patient’s experience, not the pain itself.
“Pain is absolutely subjective because it is experienced differently by every individual, but that doesn’t mean it can’t be assessed systematically with a scale score,” said Francesco Bajani, MD, an internal and emergency medicine physician. He finds that the best approach is to combine the patient’s report with functional limitations, physical findings, and the evolution of symptoms over time. One of the first things he learned in clinical practice is that pain doesn’t always match what you see on examination. “I’ve had patients with a kidney stone and rated their pain as a 10/10 while still carrying on a conversation. I’ve also seen patients with severe injuries who barely complained at all,” he says, explaining why he uses pain scores in tandem with a patient’s function to determine treatment options. He draws on this combination approach even more in telemedicine, where there’s no physical examination at all.
Many pain specialists advocate moving beyond pain intensity alone. Quality-of-life measures, physical performance tests, and validated mental health questionnaires can help physicians develop a more comprehensive understanding of how pain affects an individual’s life — and determine what kind of treatment can restore quality of life.
Older studies looked into pain sensitivity by sex, race, and ethnicity, including the 2016 Demographic Predictors of Pain Sensitivity and a 2001 Johns Hopkins University study of noxious stimuli, to understand if self-reporting is really a useful tool. But identifying the difference on a macro level doesn’t really help physicians diagnose individual cases.
Racial pseudoscience has long tried to find differences between humans by ethnicity and race to justify medical racism. Thus, using the same premise to debunk misconceptions about biological differences in disease and pain tolerance can be equally as problematic.
A well-known study published in the Proceedings of the National Academy of Sciences found that a substantial proportion of medical trainees and clinicians held false beliefs about biological differences between Black and white patients, including the misconception that Black people have thicker skin or experience less pain. Those beliefs were associated with lower pain ratings and less appropriate treatment recommendations.
Jennifer DelVentura, PhD, ABPP, a board-certified Clinical Health Psychologist specializing in pain management in Atlanta, notes that the historical abuses by the medical system loom large for many Black and African American patients, perhaps particularly in the south where anti-Black bias in medical studies is top of mind, i.e. the Johns Hopkins lead paint study, Tuskegee syphilis study, use of Henrietta Lacks’ DNA without consent.
“These topics came up frequently in some of my therapy groups and sessions while at the Atlanta VA [Veterans’ Affairs office],” she said. “Providers need to realize that that history is in the room when they are meeting with a patient, and they need to take special care to build a relationship of trust and communication. Simply acting as an ‘authority’ as a provider when meeting with a patient is misguided and potentially harmful.”
Recognizing these disparities begins with acknowledging that every clinician, regardless of experience or intention, is susceptible to unconscious assumptions. Dr. DelVentura adds that these past transgressions may lead patients to believe that they will get more culturally competent care from Black doctors. While that may be true, it should not be the case. Patients of all backgrounds should be able to see competent providers of all backgrounds and receive high-quality, consistent care. Closing the pain management gap requires more physician education and clinical standardization, as well as improved patient-provider trust across health care provision.
“We will never be able to measure pain objectively because it is a complex experience that is processed in the brain,” admitted Georgios Matis, MD, MSc, PhD, a Neurosurgeon and the Director of Interventional Pain Management, Spasticity and Neuromodulation Unit at Hygeia Hospital. But he said physicians can standardize how they ask about pain, how it is written down in patient records, and how these assessments are tracked over time. “This is something we should be doing in all settings,” he said, but noted that in emergency cases it may be harder than during routine visits.
He said that providing too little pain medicine or overprescribing neuromodulatory therapies can be counterproductive. Patients may leave with unresolved pain and an even greater distrust in healthcare providers. “Black patients need to know that their pain will be taken seriously,” he reiterated.
“I ask patients what activities they can no longer do because of the pain, how the pain has changed over time, and whether it is interfering with sleep or normal daily life,” Dr. Bajani said. “If a patient tells me they can’t climb stairs, can’t lift an object they normally carry, or haven’t slept for three nights because of pain, that information is extremely valuable.”
In addition to patient self-reporting on scales, he said physicians should use the same structured questions for every patient to help reduce bias and ensure physicians don’t overlook important details. Also, it is imperative that each physician take a fresh look at the patient in their care, and not simply rely on previous notes. A 2022 study found that even medical records about Black patients often include stigmatizing and negative language, which can lead physicians to act on the prejudiced patient descriptors of their predecessors or colleagues in a multi-physician practice. Black patients may be recurring health care clients because their original symptoms and disease were never properly treated in the first place.
The American Academy of Family Physicians’ Chronic Pain Toolkit is a great place to start, offering considerations for safe opioid use that apply across diverse patient demographics.
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