Journal of General Internal Medicine

, Volume 34, Issue 3, pp 435–442 | Cite as

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. EpsteinEmail author
Original Research



Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer.


To examine the effect of race on physicians’ pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation.


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.


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 (, 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).


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



communication lung cancer doctor-patient relations pain management racial disparities 


Grant Support

The National Cancer Institute (NCI) supported this project: 1R01CA155376. Results from our study have not been published or presented before this submission. The study was conducted through the investigators’ institutions: Purdue University, the University of Rochester, and the University of Michigan.

Author Contributions

All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Cleveland G. Shields
    • 1
    • 2
    • 3
  • Jennifer J. Griggs
    • 4
    • 5
  • Kevin Fiscella
    • 6
    • 7
    • 8
  • Cezanne M. Elias
    • 3
  • Sharon L. Christ
    • 3
    • 9
  • Joseph Colbert
    • 10
  • Stephen G. Henry
    • 11
  • Beth G. Hoh
    • 12
  • Haslyn E. R. Hunte
    • 13
  • Mary Marshall
    • 3
  • Supriya Gupta Mohile
    • 14
  • Sandy Plumb
    • 6
    • 7
    • 14
  • Mohamedtaki A. Tejani
    • 14
  • Alison Venuti
    • 6
  • Ronald M. Epstein
    • 6
    • 7
    • 12
    • 14
    • 15
    • 16
    Email author
  1. 1.Center for Cancer ResearchPurdue UniversityWest LafayetteUSA
  2. 2.Regenstrief Center for Healthcare EngineeringPurdue UniversityWest LafayetteUSA
  3. 3.Human Development & Family StudiesPurdue UniversityWest LafayetteUSA
  4. 4.Department of Internal Medicine, Hematology/ Oncology Division, and Health Management and PolicyUniversity of Michigan School of MedicineAnn ArborUSA
  5. 5.Department of Health Management & PolicyUniversity of Michigan School of MedicineAnn ArborUSA
  6. 6.Center for Communication and Disparities ResearchUniversity of Rochester School of MedicineRochesterUSA
  7. 7.Department of Family MedicineUniversity of Rochester School of MedicineRochesterUSA
  8. 8.Department of Public Health SciencesUniversity of Rochester School of MedicineRochesterUSA
  9. 9.Department of StatisticsPurdue UniversityWest LafayetteUSA
  10. 10.Department of BiostatisticsUniversity of Michigan School of MedicineAnn ArborUSA
  11. 11.Department of Internal MedicineUniversity of California Davis School of MedicineSacramentoUSA
  12. 12.Department of PsychiatryUniversity of Rochester School of MedicineRochesterUSA
  13. 13.School of Public Health, Department of Social and Behavioral SciencesWest Virginia UniversityMorgantownUSA
  14. 14.James P Wilmot Cancer CenterUniversity of Rochester School of MedicineRochesterUSA
  15. 15.Department of MedicineUniversity of Rochester School of MedicineRochesterUSA
  16. 16.Family Medicine Research Programs University of RochesterRochesterUSA

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