An Essay on Diversity in the Field of Pain Medicine

Benjamin Johnson, MD

I would like to thank our president, Ann Quinlan-Colwell, PhD, APN, for the invitation to write an article regarding diversity in our field of pain medicine.  As the first president of the Southern Pain Society possessing African-American heritage, I was overwhelmed with the sage advice and enthusiastic support that I received from the “parents” of the Southern Pain Society, Hugh and Renee Rosomoff, as well as the board of directors and past presidents during my term of office.   In this brief article, I will address the issue of diversity in pain medicine in two parts: first, my own personal experience; and then offer some strategies to consider for the purpose of increasing diversity in the field of pain medicine.

My own introduction to medicine began with my family physician; and accelerated when I began to work as an electronmicroscopist with a Polish nephrologist in Chicago, Dr. Robert Muercke, who pioneered the percutaneous renal biopsy in the US.  While teaching me to interpret renal histopathology from his percutaneous renal biopsies, he encouraged me to pursue a career in medicine; and his letters of recommendation were instrumental in helping me to gain admission into the University of Illinois College of Medicine.

My first experience with blatant racism occurred during the process of applying for admission into medical school.   My undergraduate college (0.5% black enrollment) declined to write a letter of recommendation (the dean’s letter) for me to the medical schools, stating that they were afraid that I would adversely affect their percentage of successful admissions to medical school if I did not gain admission. 

My next major experience with overt racism came during my general surgery residency.  As a medical student, I had received high ratings in my advanced surgical rotations, and was strongly encouraged to pursue a career in general surgery.   I enrolled into a University of Illinois affiliated program that had a pyramidal structure. There were eight residents during the first two years of the program, and then only four residents were chosen to complete the last two years of the residency.  In my class, the eight residents consisted of four white males, one white female, and three black males.  At the end of two years, the four white males were chosen to complete the final years.  At this point, I interviewed with the Navy and applied for an anesthesiology residency at the Navy Hospital – San Diego.  While considering this move with my family, I was contacted by the general surgery residency director, who wanted to know if I was interested in re-joining the surgery program.  I suspected that the parent program had notified them that their resident selection results were somewhat suspect.  I decided to accept the anesthesiology residency program position with the Navy, which turned out to be one of the best decisions of my professional life. 

Regarding my experience in the noble field of pain medicine, I have been blessed to come in contact with several mentors of color, who have been instrumental in shaping my career. Dr. Winston Parris and the late Dr. Richard Payne are two mentors whose influence on me has been especially noteworthy.  Their involvement in the field of pain medicine since the Bonica era gave them a unique perspective, which they were eager to share with me. They gave freely of their knowledge, expertise and wisdom in both academic and private practice environments.  Due to their example, inspiration and encouragement, I have had the privilege to influence and mentor other physicians of diverse cultures and nationalities, including my African-American colleagues, in the wonderful field of pain medicine.  Additional mentors of diverse backgrounds, such as Gabor Racz, Prithi Raj, Claudio Feler and others have welcomed me into their practices to share their priceless wisdom and experience. This level of mentorship is crucial for the purpose of attracting diversity into our noble profession. 

Our president, Dr. Ann Quinlan-Colwell, asked me to address the question of what we as providers can do to increase diversity of our specialized field of pain medicine.   This is a complex issue, but I will offer some possible practical strategies for us to consider.  I will approach this subject from a broad perspective, and then offer some more specific concepts.

Before addressing possible strategies to increase diversity in our field of pain medicine, I would like to try to define a term that is often used when discussing the issues of diversity and disparity, that is the term “systemic racism”.  One sociological definition, by Eduardo Bonilla-Silva is the reference to systems in place that perpetuate racial injustice.  As defined, systemic racism has three primary components:

  1. Historic specificity: the systems adapt to changing conditions to maintain the disenfranchisement of a group of people
  2. A distinct structural phenomenon: the practices and behaviors are “baked” into the system itself; therefore the people in the system are consciously or unconsciously an essential part of the system. Regardless of intention, most people participate in some way, usually by being either passive or neutral.
  3. The system provides advantages for some, and disadvantages for others.

In view of this definition, the answer to solving a systemic problem involves a systemic solution. 

The effects of systemic racism occur in some of our most fundamental structures:

  1. Where you live
  2. What kind of education you’re able to receive
  3. How or if your family acquires wealth
  4. The quality of healthcare you can easily access
  5. How likely it is to face violent and deadly policing
  6. Your access to voting
  7. Where you worship

As we can see from the above definition, the issue of increasing diversity in the field of medicine, specifically pain medicine is only a part of a very large and systemic challenge.  In the next section, I will attempt to suggest how we as individuals can be a part of the solution, as opposed to being an unconscious participant in the problem.

Although I realize that the field of pain medicine is perhaps the best example of a truly multi-disciplinary field of healthcare, I will use the field of medicine as an example, since I know it best.  A number of years ago, I attended a meeting hosted by the Association of American Medical Colleges (AAMC), which dealt with determining strategies of increasing diversity in medical schools.  One of the key points brought out at this summit meeting was that the pipeline for medical school begins in pre-school, if not in utero.  Factors such as maternal health and nutrition, the quality of elementary and undergraduate education, and other socioeconomic conditions all weigh heavily on an individual’s ability to gain entry into medical school.  Potential physicians fall out of this pipeline anywhere along the pathway, as the above-mentioned variables adversely affect them.  Factors such as poor nutrition, dysfunctional families, substandard housing, poorly funded education, and economic deprivation, many of which are the result of systemic racism, all reduce the viable pool of physician candidates.  Therefore, the field of pain medicine is adversely affected as well. Although I’m using medicine as an example, other components of our multidisciplinary specialty, such as psychology, nursing, pharmacology, and others all suffer in similar manner.

What can we as citizens in this country do about such a pervasive and multifactorial problem?

First, it is important to be politically knowledgeable and active. 

Even though we are all busy practitioners with demanding, high stress positions, we must remember that we are still functioning members of society.  In a democratic society, we must be active participants in order to be agents of change. As an example, I used to be a volunteer anesthesiologist in the Philippines for a medical group called Operation Smile.  On several trips, I had the pleasure of working with some politically active women on the island of Negros Occidental.  I found out that they were so influential in their local communities, that if they backed a political candidate, the other candidates might as well give up!  It is this kind of political influence that can make a difference in our communities and nation.  We can accomplish this through our local civic organizations, churches, and other areas of influence.  Although the results of political activity are not always instant or readily observable, the long-term effects can be substantial. One of the things that I admire about the American Society of Interventional Pain Physicians (ASIPP) is their emphasis on political activity.  On an annual basis, member pain physicians have travelled to our nation’s capital to speak personally with our senators and members of Congress and inform them of how their legislative activity affects us as providers, as well as the patients who put their well-being into our hands. 

More specifically, what we can do as individual providers is to be role models and mentors to young potential pain medicine providers of diverse backgrounds and cultures.  Such activities as local career fairs, school classroom activities, medical student mentoring, and hosting of medical students or pain fellows in our practices can inspire our youth to enter our chosen field.  I know from experience that such activities can interfere with a practice’s operational efficiency; but it is a meaningful contribution to our communities and career specialties.  An added value is that such activities help to ameliorate the stigma that a pain practice can have in the community.  I have personally participated in each of the above-listed activities, and I can say without hesitation that having an individual thank you for inspiring them into a fulfilling career can really brighten your day.  I am a direct beneficiary of scientists who allowed me to work in their laboratories during my summers in high school, which introduced me to the field of electronmicroscopy and subsequently into medicine.  An additional benefit is the positive affirmation of pain medicine as a legitimate specialty within our communities.  These activities can also bring in new patients without spending marketing dollars.

I trust that this brief article has introduced you to some of the challenges in regard to creating diversity in our wonderful and fulfilling field of pain medicine.  Hopefully, we will have some stimulating discussions on these topics in the future.  My hope is that we can all be agents of change in our spheres of influence.