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Emergency Medical Responders Confront Racial Bias

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Emergency Medical Responders Confront Racial Bias

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A recent study out of Oregon suggests emergency medical responders - EMTs and paramedics - may be treating minority patients differently from the way they treat white patients.

Specifically, the scientists found that black patients in their study were 40 percent less likely to get pain medication than their white peers.

Jamie Kennel, head of emergency medical services programs at Oregon Health and Science University and the Oregon Institute of Technology, led the research, which was presented in December at the Institute for Healthcare Improvement Scientific Symposium in Orlando, Fla.

The researchers received a grant to produce the internal report for the Oregon Emergency Medical Services department and the Oregon Office of Rural Health.

Outright discrimination by paramedics is rare, the researchers say, and illegal; in this case unconscious bias may be at work.

A few years ago, Leslie Gregory was one of a very few black female emergency medical technicians working in Lenawee County, Mich. She says the study's findings ring true to what she has seen.

She remembers one particular call - the patient was down and in pain. As the EMTs arrived at the scene, Gregory could see the patient was black. And that's when one of her colleagues groaned.

"I think it was something like: 'Oh, my God. Here we go again,' " Gregory says. She worried - then, as now - that because the patient was black, her colleague assumed he was acting out to get pain medication.

"I am absolutely sure this was unconscious," adds Gregory, who now lives and works in Portland, Ore. "At the time, I remember, it increased my stress as we rode up on this person. Because I thought, 'Now am I going to have to fight my colleague for more pain medication, should that arise?' "

Unconscious bias can be subtle - but, as this new report shows, it may be one of factors behind race-linked health disparities seen across the U.S.

The study looked at 104,000 medical charts of ambulance patients between 2015 and 2017. It found minority patients were less likely to receive morphine and other pain medication compared with white patients - regardless of socioeconomic factors, such as health insurance status.

Gregory is now a physician assistant, and one of her current patients, a black veteran, has cyclic vomiting syndrome. That means he periodically experiences bouts of vomiting he can't stop without hydromorphone, a potent opioid.

If the man doesn't get the medicine when he needs it, he could rupture his esophagus and die, Gregory says.

So he doesn't call the ambulance anymore. Instead, he goes straight to a hospital emergency department for help. But, Gregory says, the same thing keeps happening - the health professionals in the ER won't prescribe him the medicine he needs.

"I took his entire medical record and faxed it over to the emergency department director of a local hospital system, in anticipation of this very problem," Gregory says. "And still, when he presented, it was the same exact thing."

During a shift change at American Medical Response headquarters in Portland, I discuss the problem with EMTs and paramedics who are getting their rigs ready for the next shift.

Jennifer Sanders, who has been a paramedic for 30 years, tells me she has heard about the new study. She is adamant that her work is not affected by race.

"I've never treated anybody different - regardless," says Sanders.

Most of the emergency responders I speak with, including Jason Dahlke, say race doesn't affect the treatment they give. But Dahlke also says he and some of his co-workers are thinking deeply about unconscious bias.

"Historically it's the way this country has been," Dahlke says. "In the beginning we had slavery and Jim Crow and redlining - and all of that stuff you can get lost in on a large, macro scale. Yeah. It's there."

Ask Dahlke where he thinks unconscious bias could slip in, and he talks about a patient he just treated.

The man was black and around 60 years old. Dahlke is white and in his 30s. The patient has diabetes and called 911 from home, complaining of extreme pain in his hands and feet.

When Dahlke arrived at the patient's house, he followed standard procedure and gave the patient a blood glucose test. The results showed that the man's blood sugar level was low.

"So it's my decision to treat this blood sugar first. Make sure that number comes up," Dahlke says.

He gave the patient glucose - but no pain medicine.

Dahlke says he did not address the man's pain in this case because by the time he had stabilized the patient they had arrived at the hospital - where it was the responsibility of the emergency department staff to take over.

"When people are acutely sick or injured, pain medication is important," Dahlke says. "But it's not the first thing we're going to worry about. We're going to worry about life threats. You're not necessarily going to die from pain, and we're going to do what satisfies the need in the moment to get you into the ambulance and to the hospital and to a higher level of care."

Dahlke says he is not sure whether, if the patient had been white, he would have administered pain medicine, though he doesn't think so.

"Is it something that I think about when I come across a patient that does not look like me? I don't know that it changes my treatment," he says.

Asked whether treatment disparities might sometimes be a result of white people being more likely to ask for more medications, Dahlke smiles.

"I wonder that - if, in this study, if we're talking about people of color being denied or not given narcotic medicines as much as white people, then maybe we're overtreating white people with narcotic medicines."

Research has also found African-Americans more likely to be deeply distrustful of the medical community, and that might play a role in diminished care, too. Such distrust is understandable and goes back generations, says Gregory.

"How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?" she asks.

Gregory wrote an open letter to the Centers for Disease Control and Prevention in 2015, asking it to declare racism a threat to public health.

Past declarations of crisis - such as those focusing attention on problems such as smoking or HIV - have had significant results, Gregory notes.

But the CDC told Gregory, in its emailed response, that while it supports government policies to combat racial discrimination and acknowledges the role of racism in health disparities, "racism and racial discrimination in health is a societal issue as well as a public health one, and one that requires a broad-based societal strategy to effectively dismantle racism and its negative impacts in the U.S."

Kennel says false stereotypes about race-based differences in physiology that date to slavery also play a role in health care disparities. For example, despite a lack of any supporting science, some medical professionals still think the blood of African-Americans coagulates faster, Kennel says, citing a recent study of medical students at the University of Virginia.

Another question in the survey asked the students whether they thought African-Americans have fewer pain receptors than whites. "An uncomfortably large percentage of medical students said, 'Yes, that's true,' " says Kennel.

On top of that, he says, EMTs and paramedics often work in time-pressured situations, where they are limited to ambiguous clinical information and scarce resources. "In these situations, providers are much more likely to default to making decisions [based] on stereotypes," he says.

Disparities in health care are well-documented. Whites tend to get better care and experience better outcomes, whether they're in a doctor's office or the ER. But before Kennel's study, nobody knew whether the same was true in the back of an ambulance.

And they nearly didn't get to know, because the research required ambulance companies to release highly sensitive data.

"We were prepared to maybe not look that great," explains Robert McDonald, the operations manager at American Medical Response in Portland. AMR is one of the nation's largest ambulance organizations, and it shared its data from more than 100,000 charts with Kennel.

Some people chalk up the disparities he found to differences in demography and health insurance status, but Kennel says he controlled for those variables.

So now that AMR knows about disparities in its care, what can the company do?

"My feeling is we're probably going to put some education and training out to our folks in the field," McDonald says.

In addition, he says, AMR is going to hire more people of color.

"We want to see more ethnicities represented in EMS - which has historically been a white, male-dominated workforce," McDonald says.

AMR's policies must change, too, he adds. The company has purchased software that will enable patients to read medical permission forms in any of 17 different languages. And the firm is planning an outreach effort to communities of color to explain the role of EMS workers.

This story is part of NPR's reporting partnership with Oregon Public Broadcasting and Kaiser Health News, a nonprofit news service of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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Emergency Medical Responders Confront Racial Bias

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In a recent study of patients treated by emergency medical responders in Oregon, black patients were 40 percent less likely to get pain medicine than their white peers. Why?

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Racial/Ethnic Disparities in Pain Treatment: Evidence from Oregon Emergency Medical Services Agencies

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Racial/Ethnic Disparities in Pain Treatment: Evidence from Oregon Emergency Medical Services Agencies

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What EMS leaders need to know about unconscious bias

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What EMS leaders need to know about unconscious bias

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By Mike Taigman and Cheri C. Wilson

An Asian man dressed in a tattered football team T-shirt, worn blue jeans and old tennis shoes collapsed in a liquor store. 911 was called and the first responders started CPR. Paramedics worked through their protocols without result. As they arrived at the closest hospital they said, "Asian male, unknown age, found in cardiac arrest in a liquor store, fine ventricular fibrillation unresponsive to defibrillation or ALS medications."

After working the arrest for 15 or 20 minutes the hospital staff decided to call it and pronounced the patient dead. The ward clerk found his wallet and opened it to see about notifying the next of kin when she yelled, "Oh my god it's Dr. XXX."

Templates in our mind help us organize what and who we see into broad categories. (Photo/Pixabay)

The medical director of the emergency department, who had just pronounced the patient dead restarted CPR. They worked him for more than two hours before finally admitting it was futile.

One of the nurses wandered out of the room with tears in her eyes and said, "I'm so ashamed, I thought he was just a drunk in a liquor store."

Understanding our own unconscious bias

We form ideas in our minds about people based on the color of their skin, hair style, tattoos, piercings, accent, credit score, occupation, perceived disability, gender expression, sexual orientation, political party, the location where we meet them and more. These ideas form instantly, automatically and in unconscious minds where we are not aware that it is happening.

Our distant ancestors relied on these split-second decisions (friend or threat) to keep them alive. While this instinctive mental process still helps protect us from real threats like someone posturing to hit us, it has not evolved to consider differences in people that are not threatening.

Many snap judgments go by unnoticed. Some are irritating. Some have a tangible negative impact on people's careers. Some cause people to receive substandard medical care. And some result in preventable suffering or death.

"People who engage in this unthinking discrimination are not aware of the fact that they do it," David Williams Ph.D., Harvard School of Public Health, said.

This dynamic is known as "Unconscious Bias" or "Unintended Bias." It is a major component of the Institute for Healthcare Improvement's focus on Equitable Healthcare. Unconscious bias is made up of attitudes, stereotypes and beliefs that affect our understanding, actions and decisions. These biases are activated involuntarily without our awareness or voluntary control.

Unconscious bias in EMS patient care

People with sickle cell disease who are in crisis are one of the best EMS examples of the impact this can have on health care. While there have been cases of sickle cell disease in many races it is much more common in African Americans (1 out of 365) or Hispanic Americans (1 out of every 16,300). People with sickle cell disease are at risk for anemia, infections, acute chest syndrome (like pneumonia), splenic sequestration (sickled cells getting trapped in the spleen), vision loss, leg ulcers, stroke and pulmonary embolism.

Of the many complications associated with sickle cell disease, the most common manifestation of a crisis is pain. This is caused by the sickled cells getting stuck in small blood vessels causing tissue hypoxia and pain, which is sometimes severe. The EMS management of people in sickle cell crisis includes assessing and treating their oxygenation, hydration and pain.

Many of the people in sickle cell crisis have had prior episodes and are knowledgeable about the appropriate treatment. This is where unconscious bias often flares up. A young black man or Latino calls 911 and tells their medic, "I'm having a sickle cell crisis and I need morphine because I hurt real bad all over."

The image of a drug seeker may pop into the mind of the medic even if they are committed to providing good care for everyone. They look at the patient and don't see anything that looks serious and of course they can't see the pain or how severe it is. The care that this patient receives or does not receive largely depends on if the medic is aware of how unconscious bias can inappropriately inform their thinking. With awareness, the medic notices the thought, acknowledges it, and then re-focuses on the reality and the needs of the person they are caring for right now.

We have templates in our minds that help us organize what and who we see into broad categories. We automatically categorize people based on their skin color, hair, accent, girth, perceived gender, age and clothes. The people we meet are automatically mapped into these categories. The meanings associated with that category are immediately activated and influence our interaction with that person. Without awareness, these ingrained habits of thought can lead to errors in how we perceive, reason, remember and make decisions.

Assessing your own unconscious bias

It's difficult to see into our own hidden bias. Both authors believe deeply in our hearts that we are open-minded, embracing of all kinds of people and are free of bias. It's likely that those of you reading are wondering what if any unconscious bias may be going on for you.

One way to assess your own situation is to take the Implicit Association Test created in 1998 by three scientists from the University of Washington, Harvard University, and the University of Virginia.

I'm not sure what your results show, but both of us were disturbed to learn that our inclusive belief system did not know about our own unconscious biases. The results have helped us be more vigilant about pushing snap judgments aside to really connect with the person we are with, rather than the story our unconscious mind would have us believe. Although this test is not an exact science and there are critics of it, it can be a useful tool to improve awareness and relationships.

Another way to explore how your mind works is to notice what flashes into your mind when you think about a:

New York lawyer

Grateful Dead fan

Volunteer EMT

Transgender male paramedic

Stay at home mom

Vegan Republican

Drug seeker

EMS frequent flier

Guy with a Confederate flag T-shirt

The key learning from this exploration is not to feel bad about yourself, but to become aware of your own biases so you can work to transform them so that they do not negatively impact the people you care for or work with. The most important thing you can do is pause for a moment or two before you act on your judgment. That will likely make your hiring decisions, disciplinary choices, relationships in general and your clinical care more equitable.

"In minor ways we differ, in major we're the same." - Maya Angelou

For more information:

Here are three resources to learn more about health equity and unconscious bias:

1. Achieving Health Equity White Paper
2. IOM unequal treatment report
3. Training to erase unconscious bias
This article, originally published April 13, 2017, has been updated.
About the author
Cheri C. Wilson, M.A., M.H.S., C.P.H.Q. is a nationally-recognized subject matter expert on diversity and inclusion, cultural and linguistic competence and health equity. Most recently, she served as the Director, Corporate Office of Diversity and Inclusion, at RWJ Barnabas Health in New Jersey. She previously was an Assistant Scientist in the Department of Health Policy and Management in the Johns Hopkins Bloomberg School of Public Health, Hopkins Center for Health Disparities Solutions. She received a B.A. in Russian from Howard University, an M.A. in Russian Area Studies from the University of Minnesota, an M.H.S. in Health Finance and Management from the Johns Hopkins Bloomberg School of Public Health, and was a Ph.D. candidate (ABD) in Russian history at the University of Minnesota. She is a Certified Professional in Healthcare Quality and Past President of the Maryland Association for Healthcare Quality.

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What EMS leaders need to know about unconscious bias

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Understanding your unconscious biases will make hiring decisions, disciplinary choices, relationships and clinical care more equitable

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Diversity in EMS: Recognizing Implicit Bias in the Prehospital Environment

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Diversity in EMS: Recognizing Implicit Bias in the Prehospital Environment

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Diversity in EMS is a new bimonthly column in which rotating authors will confront difficult questions of bias and discrimination in the emergency medical services and how agencies can lead change in their communities.
It's only been in the last decade or so that professionals in various spheres have awakened to a more accurate understanding of how bias and prejudice manifest in people and can produce differential treatment of groups.

For many years we thought all prejudice and bias took the form of what we now label explicit bias. This form of bias is consciously held. The person with explicit bias links various groups to negative stereotypes based on animus and hostility toward those groups. These attitudes and stereotypes can produce discriminatory behavior, and the person with explicit bias is unconcerned about this outcome. 1,2 Racism is an example of an explicit bias.

We all know about this form of bias, and many of us legitimately claim, "That's not me." Then we go about our lives and work thinking we are bias-free and don't treat groups differently.

However, social psychologists have discovered a second form of prejudice, implicit bias. None of us can say, "That's not me" because all of us have implicit biases, regardless of our good intentions. Our minds automatically link groups of people (e.g., based on race, religion, sexual orientation, economic status) to positive or negative generalizations, or "stereotypes," about those groups. These implicit associations can occur outside our conscious awareness and differ from our conscious attitudes and beliefs, yet still impact how we perceive and treat people. Implicit associations can produce differential treatment of groups-that is, discriminatory behavior. ³

People in many professions-such as education, medicine, law enforcement, and retail sales-are thinking about how implicit associations might affect their service provision, and EMS providers should do the same. Below we explore how implicit associations might affect an EMT during the course of his or her work.

The General and the Individual

As possible examples, an EMT might have stereotypes about the demographics of alcoholics (based on economic status, gender, or race) and assume a particular person is drunk, rather than experiencing hypoglycemia. He or she might assume a homeless person is asking for painkillers not because she is in pain but because she is a drug addict. An EMT might assume law enforcement called for service not because they had a patient in need of care but rather because they didn't want to deal with the drunk or high subject. Or, relatedly, the EMT might assume an arrestee is not really having chest pains as claimed but suffering from a "handcuff allergy." A paramedic may not believe the health complaints of the person with mental illness.

Associations between groups and characteristics such as those suggested above may be conscious or exist instead as implicit associations that manifest outside of conscious awareness despite the EMS provider's best intentions.

Stereotypes are not necessarily untrue-quite the opposite. An EMT might associate homeless people with drug use because that reflects her 15 years of experience on the job. She might associate arrestees with "handcuff allergy" because that has been the reality nine times out of 10. Indeed, we can acknowledge that many of our implicit associations are based at least in part on fact. The danger, however, is treating an individual-the patient in front of you-as if she fits that stereotype. In fact, she may be the one in 10 who needs your diligent care.

The consequences of treating the patient as if she fits the stereotype can be dire. Biases can impact EMS providers wherever we have discretion in our job. We decide whether to test for hypoglycemia, test for a stroke, or perform an EKG. Some of us might have discretion as to where we take a patient-to the private hospital or to the safety-net hospital. ⁴ We decide whether to provide pain medication and how much. In fact, a number of studies of doctors have documented differing provision of pain medication based on the race and/or gender of the doctor, patient, or both. 5,6 Similarly, a recent study examined both pain assessment procedures and pain medication provision on the part of EMS agencies and found racial/ethnic minorities were less likely to receive both, even when other important variables were controlled. 7,8

Implications for Practice

All these discretionary decisions could be impacted by our implicit associations and lead to complacency in our medicine, producing failure to act. The University of North Carolina's William J. Hall and colleagues reviewed research that examined the levels of implicit bias in healthcare professionals and the link between biases and patient outcomes. They found, "Implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes." ⁹

All of the above represents the bad news. All humans have implicit biases that can affect our perceptions and behavior. In our second column (to appear in the October issue of EMS World), we share the good news: It turns out we can address this. Professions that have recognized how bias might impact the services they provide have implemented training programs to educate their professionals on the ways biases manifest, how they are formed, and the consequences of acting on them. Importantly, these programs provide skills to help individuals reduce and manage their biases. In the next column we'll discuss these programs and share practical information on how to address your own biases to ensure they do not affect the important work you do.

Resources

1. Hardin CD, Banaji MR. The nature of implicit prejudice: Implications for personal and public policy. In: Shafir E (ed.), The Behavioral Foundations of Public Policy. Princeton, N.J.: Princeton University Press, 2013, pp. 13-31.

2. Devine PG. Stereotypes and prejudice: Their automatic and controlled components. J Personality Social Psych, 1989; 56(1): 5-18.

3. Op. cit., Hardin. For a summary of the research, see Fridell L, Producing Bias-Free Policing: A Science-Based Approach, Springer Publishers, 2017.

4. Hanchate AD, Paasche-Orlow MK, Baker WE, et al. Association of race/ethnicity with emergency department destination of emergency medical services transport. JAMA Open, 2019; 2(9): e1910816.

5. Weisse CS, Sorum PC, Sanders KN, Syat BL. Do gender and race affect decisions about pain management? J Gen Int Med, 2001; 16: 211-27.

6. Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: Pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health, 2012; 102: 988-95.

7. Kennel J, Withers E, Parsons N, Woo H. Racial/ethnic disparities in pain treatment: Evidence from Oregon Emergency Medical services agencies. Medical Care, 2019; 57(12): 924-9.

8. Young MF, Hern HG, Altern HJ, Barger J, Vahidnia F. Racial differences in receiving morphine among prehospital patients with blunt trauma. J Emerg Med, 2013; 45(1): 46-52.

9. Hall WJ, Chapman MV, Lee KM, et al. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. Am J Public Health, 2015; 105(12): e60-e76.
Brad Keating, MPH, NRP, is a fire-medic with Mountain View Fire Rescue, Longmont, Colo. Lorie Fridell, PhD, is a professor of criminology at the University of South Florida and founder of Fair and Impartial Policing, Tampa, Fla.

# data[].attributes.attachment_link.title
Diversity in EMS: Recognizing Implicit Bias in the Prehospital Environment

# data[].attributes.attachment_link.description
Diversity in EMS is a new bimonthly column in which rotating authors will confront difficult questions of bias and discrimination in the emergency medical services and how agencies can lead change in their communities.