Systematic review of clinical decision-makers’ attitudes, beliefs, and biases that contribute to a marginalized process of care in persistent musculoskeletal pain. Part II: case vignettes

Abstract

Background

Healthcare clinical decision makers’ (CDMs) attitudes, beliefs, and biases can negatively contribute to both clinical conversations and subsequent inequitable management decisions in persistent musculoskeletal pain (PMP). Understanding the factors that may contribute to CDMs’ decisions is particularly important for vulnerable patient populations.

Objectives

The aim of this systematic review was to synthesize the current research investigating the impact of CDM’s attitudes, beliefs, and biases on the process of care in PMP management in adults.

Methods

A systematic search following PRISMA guidelines was run in five databases: CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science. Included studies: vulnerable adult populations with chronic pain. Methodological quality was assessed with the Downs and Black tool.

Results

Nine studies were included. Studies examined CDMs’ perceptions of case vignettes used in medical schools, allied health professional programs, and in healthcare settings. Implicit biases related to pain severity and favoring medical evidence influenced CDMs’ perceptions of case legitimacy. Pharmaceutical management decisions were influenced by race/ethnicity, gender, pain severity, medical evidence, and non-verbal patient behavior. Pain severity influenced non-pharmaceutical management decisions.

Conclusion

Implicit biases related to race/ethnicity, gender, supporting medical evidence, and pain severity were demonstrated in educational settings and persisted in clinical settings. Health professional curricula should include training with a focus on outcomes that demonstrate increased awareness of the factors that could lead to inequitable management decisions. Addressing biases during the training of CDMs will be necessary to improve congruency of clinical conversations and minimize marginalization of patient care in PMP.

Keywords:

• Systematic review
• implicit biases
• educational case vignettes
• chronic pain
• judgments

Acknowledgements

The authors would like to acknowledge Ramakrishnan Mani, PT, PhD, for his assistance in the project.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Additional information

Notes on contributors

Alicia J. Emerson

Dr. Alicia J. Emerson is an Assistant Professor in the Department of Physical Therapy at High Point University and Director of High Point University’s Pro Bono Physical Therapy Clinic. She is also a PhD student at the University of Otago. Her research interests include the functional implications of pain processing in the management of musculoskeletal conditions, clinical reasoning, health inequities, and pain education pedagogy.

Lauren E. Chandler

Lauren E. Chandler is a student in the Department of Physical Therapy at High Point University. She earned her Master’s Degree in Exercise Science from Adelphi University.

Riley H. Oxendine

Riley H. Oxendine is a student in the Department of Physical Therapy at High Point University. She earned her Bachelor’s Degree from Appalachian State University. Her research interest includes the management of musculoskeletal conditions.

Corey M. Huff

Corey M. Huff is a student in the Department of Physical Therapy at High Point University. He earned his Bachelor of Science Degree from the University of Florida.

Gabrielle M. Harris

Gabrielle M. Harris is a student in the Department of Physical Therapy at High Point University. She earned her Bachelor of Science Degree from High Point University.

G. David Baxter

Professor G. David Baxter is Dean of the School of Physiotherapy at the University of Otago. He is Co-Director of Ageing Well with National Science Challenge. David completed his physiotherapy and doctoral research training in the UK; his doctoral research focused on the use of therapeutic lasers in rehabilitation. Prior to taking up his current post at Otago, he held various posts at the University of Ulster, and completed an MBA in Higher Education Management at the Institute of Education, London.

Elizabeth C. Wonsetler Jones

Elizabeth C. Wonsetler Jones is an Assistant Professor and Assistant Director of Clinical Education in the Doctor of Physical Therapy Program at Tufts University School of Medicine. She has earned a PhD in Health and Rehabilitation Science from the Medical University of South Carolina, a Doctorate in Physical Therapy from Duke University, and a Bachelor of Science degree in Education and Human Sciences from the University of Nebraska – Lincoln.