# Implicit racial bias in EMS?



## simongretton (Jun 7, 2020)

In the wake of the death of George Floyd, and hearing so much about racial disparities in society, I think it behooves all people of good will to look to our own lives and ask ourselves to what extent we are part of the problem, and to what extent we are part of the solution. With that in mind, this piece in EMS world highlights some uncomfortable truths for those of us working in emergency medical services. Most of us would be appalled to think we treated patients differently based on race, but sadly, it's not hard to find reports of implicit bias at work in EMS. I know this is uncomfortable stuff to have civil conversations about, but I think we owe it to the world, our profession, the communities we serve, and ourselves to look at this.








						Ore. Study Reveals Racial Bias Among EMS Personnel
					






					www.emsworld.com


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## jdemt (Jun 7, 2020)

I don’t know how to respond to this. I think I can speak for many EMS professionals when I say that we’re tired. In the midst of a global pandemic we are already being put to the test. And now to top it all off we are having to add additional shifts and do additional work so the triggered citizens in our area can have a public temper tantrum. I am only speaking for myself but I come to this forum to forget about the world and learn about emergency medicine-not to be further inundated with politics and guilt. There are many problems in the world but I can say with complete confidence that every patient is treated the same on my ambulance. Society is making public service more and more difficult every day. I shouldn’t have to question every move I make based upon the color of my patients skin, but the more I see posts like this I find myself questioning my every move and thinking “is this a politically correct IV placement?” And in my personal opinion this is absolutely ridiculous. Of course the United Socialist State of Oregon thinks that EMS is racist. There are so many variables with analgesic administration that it would be almost impossible to do a quality study that correlates with skin tone. You would have to include local protocol, complete vital signs, nature of illness, and transport circumstances to name just a few. These are the things that I think about when it comes to analgesics not skin color. Long story short can there be any escape from the constant tiptoeing? I’m so tired. I already have patients questioning when I sniffle (allergies not COVID). I don’t know if I can take attacks of, “you don’t care about my pain because you’re white.”

Personal opinion only. Not trying to trigger anyone.


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## simongretton (Jun 7, 2020)

I appreciate the sentiment. Far be it from me to judge anyone else, or to accuse anyone of providing different care based on race. I hear enough about this, that I feel the need to ask myself these questions, but I shouldn't be pointing fingers at anyone other than myself. Thanks again for responding.


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## VFlutter (Jun 7, 2020)

"unconscious racial bias" seems to be the scapegoat that can always be assumed but never disproven. Not implying it is not a real phenomenon than may in some cases translate to treatment decisions however there never seems to be reasonable burden of proof other than it fits a narrative and is an easy explanation as opposed to the multitude of factors that probably are responsible.


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## E tank (Jun 7, 2020)

This isn't the forum for this. And what will result in this kind of baiting is a lot of uncomfortable questions surrounding socio-cultural problems that are not very flattering. The simplistic "institutional racism" script is on shaky ground when more honestly scrutinized.

This isn't even published peer reviewed research and it's being reported by Oregon Public Broadcasting. Might as well be an opinion piece from Fox News on Hillary Clinton.


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## mgr22 (Jun 7, 2020)

jdemt, I may be risking the "triggered" label merely by responding to you, but here goes: 

I think I understand the frustration you feel about dealing with politics. I feel that, too. I also accept that politics can't always be separated from substantive discussions about society. That's what we're having here.

We don't necessarily know what feels like racism to others. Perhaps there are changes we can make to increase the peace without compromising our own rights.

Sometimes we act in ways that are interpreted as bias. Sometimes those biases are real, even if we don't realize they're there. For example, when you said, "Of course, the United Socialist State of Oregon thinks that EMS is racist," I assumed you're biased against Oregon and are prone to generalizing. I could be wrong about both those points, but that's my impression.

I wouldn't want anyone to think I'm racist (or biased against Oregon ). If there's something I say or do that makes people feel that way about me, I'd like to know. Maybe I can learn something important about the way I come across. That doesn't have to make me so preoccupied with my behavior, I have trouble functioning.

Regarding the Oregon study, I don't know how valid it is, but I agree with the OP that it doesn't hurt to reflect on the ways we practice and to consider the possibility that we can do better.


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## simongretton (Jun 7, 2020)

Hey All. I was the one who originally posted this. Thanks for all the comments. I certainly don't want to be causing unnecessary controversy. I chose to post the thought/question here because it is something I have been thinking about, that I wanted to run by others in the field. If this isn't the forum for this I can certainly close the thread.


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## jdemt (Jun 7, 2020)

mgr22:

While I’m not triggered, I am confused. When did an EMS forum become a posting ground for “substantive” sociological discussion/debate? Instead of debating actual treatment modalities and clinical advances were here having a back and forth on whether or not EMS professionals have racial bias in their treatments (which to me is ridiculous). I’m willing to guess that none of this would be the case back in 2008-2012 because we were so “progressive” back then (the political motivation I’m speaking of). I would think that if this is a big enough problem to actually perform an anecdotal “scientific study” and spark a debate in 2020 of all years, that it would have been a problem back then too.

I think this saying applies to the actions and attitudes of a scary amount of people right now and it goes, “If it isn’t broken, fix it until it is”.

So riddle me this. What problem are we going to create in 2021?


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## E tank (Jun 7, 2020)

jdemt said:


> mgr22:
> While I’m not triggered, I am confused. When did an EMS forum become a posting ground for “substantive” sociological discussion/debate?



Just to be clear...when I said this isn't the forum for this, I meant that it should be in the EMS lounge section....Not that we shouldn't be talking about it.


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## simongretton (Jun 7, 2020)

E tank said:


> Just to be clear...when I said this isn't the forum for this, I meant that it should be in the EMS lounge section....Not that we shouldn't be talking about it.


Thanks for that. I am new to this and have not done much on these forums in the past, so forgive me for posting in the wrong place. I can certainly take this elsewhere if that is more appropriate. Thanks again.


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## jdemt (Jun 7, 2020)

Here I go regretting the expression of my opinions again...lol

Simon: you don’t need to apologize. Far be it from me to limit discussions in any way.

I’m done arguing haha


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## mgr22 (Jun 7, 2020)

simongretton said:


> Thanks for that. I am new to this and have not done much on these forums in the past, so forgive me for posting in the wrong place. I can certainly take this elsewhere if that is more appropriate. Thanks again.



Simongretton, we're just having a conversation. It's not a problem.


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## ffemt8978 (Jun 7, 2020)

Belive me.. If it was a problem I'd have already been involved.  I decided to go ahead and move it to the lounge.


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## DrParasite (Jun 8, 2020)

So I read the EMSword article on the study.... It looks like it took an issue (treating of pain management with narcotics), and took a very superficial analysis on why it wasn't given (because of the patient's race).  Based on the study, black people received pain meds less often than white people.  The study doesn't ask why morphine wasn't given (maybe it wasn't indicated, maybe other treatments were a higher priority, etc), only assuming that the reason was implied racism.  as @VFlutter said, it fits a narrative, and is an easy explanation as opposed to the multitude of factors that probably are responsible.

How do you prove you don't suffer from unconscious racism?   Many of our colleagues in law enforcement are going through that right now... and many of the claims that are being made about them are being supported by facts, however those facts are being portrayed with a district lack of context.   Once you add that context, and you analyze why they are happening, you see that many of the facts actually made sense, and are not the result of racism, but of a particular set of circumstances.  depending on your political leanings, you might agree or disagree with that statements.

Do we all have biases?  absolutely.  Do I think the 20 year old college student in the dorms who reaks of  alcohol and is throwing up is just drunk?  yep.   am I going to treat the 20 year old black college student the same as the 20 year old white college student?   give them a bucket, and say "in the bucket, not on me."  That doesn't mean I'm being racist because I didn't start an 18G in the student's arm, administer 1 L of fluid, administrator zofran, do a 12 lead, and give narcs because the students abdomen is hurting after all that throwing up.  If you think i should have, than I'm just a poor clinical provider, not someone who is allowing unconscious bias to affect my treatment plan.

If someone complains of pain, we do NEED to give them IV narcotic pain meds?  if we don't, is that due to unconscious bias, or our clinical assessment that says it would be inappropriate?  More importantly, should we be giving everyone narcs to prevent the (potentially false and incorrect) assumption of unconscious bias?  Here is another one: if the black patient is in pain, and demands to be given pain meds, and you refuse, are you discriminating because of their race?

We can even tie this back to George Floyd: if he had been a white guy, same situation, would the EMS crew have worked the arrest right there, potentially giving him a higher chance of survival?  was it institutional racism that made them chose to load and go and leave the scene, condemning him to die?  or did they recognize an unsafe scene, with an angry crowd, and decide it was better for the EMS crew's safety to load and go, and assess in a safer location, and then start their interventions?


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## RocketMedic (Jun 8, 2020)

So, a few thoughts:

Distance, local protocols, etc. drive what we do to a large extent. A lot of black patients live in concentrated areas with relatively short transport times, and are serviced by agencies that maintain fairly conservative cultural and clinical practices for pain management, combined with high volumes. This is amplified when you factor in organizational and regulatory factors.

With that being said, there are certainly racists and racial biases in EMS. I’ve seen Klan affiliation stickers, outright expressions of racism, and yes, a considerable amount of subconscious and open bias. And I do think that these biases have driven patient care decisions. But proving it, or even determining ‘why’ it happened, is next to impossible with any available data set.

I do also think that there is an interesting other question here- namely, the racial composition of EMS. Most of us are white folks, and although I’m not saying that’s a bad thing, I think it is certainly relevant to our practice in that many of our people are introduced to issues not through a relevant cultural lens, but by another culture’s perception of an issue based on extremely slim understandings of clinical concepts. Sickle-cell is the ultimate example of this: it’s a disease process that primarily affects the black community and is primarily understood in EMS from one-page protocol sheets and lectures in paramedic school. The socio-economic implications, challenges of access to care and deeper health consequences are often glossed over, and for a service with short transport times or conservative protocols or both, it’s pretty easy to fall into the VOMIT + fluid bolus solution and perpetuate that model of care. And it’s not ‘wrong’ entirely. If they start giving fentanyl (especially in clinically-relevant doses) to every sickle-cell patient, they’ll often find themselves being questioned for deviation from the mean, accused of diversion and facing increased scrutiny in their decision-making. I think a lot of providers look at patients with chronic pain, or acute pain from events like sickle cell, and are judging not necessarily their own biases, but their perceptions of the biases and beliefs of the people overseeing their practice and weighing how to negotiate that. And that sometimes results in inaction, which reinforces the perception that inaction is the answer, which perpetuates those biases. A more diverse provider and administrative base, people who understand complaints on a holistic level, are probably going to be more amicable to allowing effective treatment.


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## Seirende (Jun 9, 2020)

I think we could have a very interesting discussion on unconscious bias, which we all have to some degree or another. I'll try to dig up some literature on the topic.


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## DrParasite (Jun 9, 2020)

If anyone wants to read the actual study, it can be found here. 

Draw your own conclusions


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## DrParasite (Jun 9, 2020)

And some other reading









						What EMS leaders need to know about unconscious bias
					

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




					www.ems1.com
				






			https://www.tandfonline.com/doi/abs/10.1080/10903127.2019.1634167?journalCode=ipec20
		










						How EMS providers can manage bias in routine care
					

EMS providers can acknowledge their bias as they strive to deliver the best empathetic care to the patients they serve




					www.ems1.com
				






			https://www.usnews.com/news/healthiest-communities/articles/2019-08-19/diversity-emergency-women-minorities-underrepresented-in-ems


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## Tigger (Jun 9, 2020)

jdemt said:


> And now to top it all off we are having to add additional shifts and do additional work so the triggered citizens in our area can have a public temper tantrum.


Which is in fact their right to do. Perhaps you lack some perspective on why people would choose to protest, which is in fact the correct term? Maybe disparaging people who feel they have no other way to speak up is an example of your own biases?


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## E tank (Jun 9, 2020)

DrParasite said:


> If anyone wants to read the actual study, it can be found here.
> 
> Draw your own conclusions



This paper would never be published in a peer reviewed journal because just the group sampling is so skewed. The selection bias would be pretty hard to get around. Doesn't matter how large the sample groups are.


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## VFlutter (Jun 9, 2020)

"While the primary regression analysis (Tables4-6) controlled for the contribution that a patient’s insurance status had on that patient’s receipt of pain medication,the secondary analysis (Table 7)investigated adjusted racial treatment differences for patients who were matched on insurance status. Interestingly, for patients with private health insurance, an indication of the presence of a full-time job for the patient or their immediate family member, there is evidence to support that the treatment disparity for both Black and Asian patients compared to White patients is larger than when compared to all insurance types. Evidence of this increased treatment disparity was also present in Black and White patients that indicated that they do not have health insurance."

Never once in my career have I thought about, nor usually know, a patient's insurance status while providing patient care 🤷‍♂️


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## GMCmedic (Jun 9, 2020)

There was a black kid in his early twenties I think, he had over 90 visits each to our 3 local EDs in a10 month time frame. Every single time he came in by ambulance complaining of some type of pain,and never recieved pain medication. Thats not relevant to anything, It just crossed my mind about how terrible ems would look if his data was pulled for a study.


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## simongretton (Jun 10, 2020)

I appreciate all the comments. Yes who knows about the Oregan study, or any study for that matter. You can find studies done in a myriad of places that suggest that implicit bias is a significant problem, but for all the reasons stated by others, this stuff is hard to study and pin down, and there is always the risk of confirmation bias.

Putting studies aside, I do think I have seen elements of implicit bias at play in places where I have lived and practiced, and unfortunately probably in myself. I have been involved in homelessness, and other work with people on the margins over the years. I have certainly heard disparaging generalizations about homeless people, and people living in the "bad" neighborhoods from some I have worked with over the years. I have been a part of and involved with different services, all of which I considered well run, but I have seen/heard this attitude from some people in a number of these services. I have seen cases where my co-workers pick up a person who appears to be on the margins, and who is complaining of some kind of pain/distress, and in later conversation with my coworkers, I have heard the coworker assert that the person was "faking it" or "over acting". In one such case, the patient was later discovered to have a perforated ulcer, in another the patient had their appendix removed shortly thereafter, and still another the patient was found to have a humeral fracture. I only knew about these because these were patients with whom I was acquainted. In all of these cases, I was somewhat inclined to agree with my coworkers, until I heard the outcome. These and other instances have made me think of times where I may have unconsciously and unfairly profiled people.

I am not trying to beat any of us up here. We have a tough job, and we have to make speedy treatment decisions based on scant information, and any of us who has been doing this for a while will make some wrong calls. However, I know that many of us are more suspicious when people who appear to be on the margins are complaining of pain/distress, and the fact that people of color are more likely to live in poorer more marginalized neighborhoods, it doesn't surprise me that I might unconsciously start to connect being black or brown, with being more questionable. 

I should add, and it probably goes without saying, that I frequently see excellent care delivered to all people where race, economic status and other such factors apparently play no role. I would like to think that I operate this way the vast majority of the time. I started this whole thread, mostly to look at myself and how I operate in my work and in the world, so thanks to all of you who have given this any thought, and have engaged in the conversation.


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## DrParasite (Jun 10, 2020)

simongretton said:


> I have certainly heard disparaging generalizations about homeless people, and people living in the "bad" neighborhoods from some I have worked with over the years.


I've heard disparaging comments made about men, women, liberals, conservatives, Jews, Muslims, white people, black people, Hispanic people, firefighters, nurses, cops, etc, in both good and bad neighborhoods.  While I won't defend the comments, I will say simply making a statement doesn't translate into inappropriate care.  Generalizations, like stereotypes, are usually formed by a person's experiences and are rarely applicable to an entire group of people.


simongretton said:


> who is complaining of some kind of pain/distress, and in later conversation with my coworkers, I have heard the coworker assert that the person was "faking it" or "over acting".


EMS, as a whole, downplays pain management, and there really aren't great ways to manage all types of pain. Yes, we can give Narcs to anyone complaining of pain, maybe some IV Toradol, but it's often a subjective assessment based on the provider's experience, initial training, medical director/protocols, cultural and societal upbringing and yes, personal biases. For example, check out this 11 page thread that I started 11 years ago: https://emtlife.com/threads/is-a-broken-arm-an-als-or-bls-call.14922/


simongretton said:


> In all of these cases, I was somewhat inclined to agree with my coworkers, until I heard the outcome. These and other instances have made me think of times where I may have unconsciously and unfairly profiled people.


Or, you are experiencing what is called "20/20 hindsight" where, once you are given the outcome, you see many of the signs as being clear as day, despite the fact that in the other 999 calls with similar criteria, you would have a different outcome.


simongretton said:


> However, I know that many of us are more suspicious when people who appear to be on the margins are complaining of pain/distress, and the fact that people of color are more likely to live in poorer more marginalized neighborhoods, it doesn't surprise me that I might unconsciously start to connect being black or brown, with being more questionable.


we could also discuss the opioid epidemic, and how we might be exasperating The Opioid Crisis in Black Communities by treating any complaint of pain with opioid meds, further causing THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION


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## Seirende (Jun 10, 2020)

__





						Take a Test
					






					implicit.harvard.edu
				




I read about this project a while ago and found it fascinating


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## simongretton (Jun 11, 2020)

DrParasite said:


> I've heard disparaging comments made about men, women, liberals, conservatives, Jews, Muslims, white people, black people, Hispanic people, firefighters, nurses, cops, etc, in both good and bad neighborhoods.  While I won't defend the comments, I will say simply making a statement doesn't translate into inappropriate care.  Generalizations, like stereotypes, are usually formed by a person's experiences and are rarely applicable to an entire group of people.
> EMS, as a whole, downplays pain management, and there really aren't great ways to manage all types of pain. Yes, we can give Narcs to anyone complaining of pain, maybe some IV Toradol, but it's often a subjective assessment based on the provider's experience, initial training, medical director/protocols, cultural and societal upbringing and yes, personal biases. For example, check out this 11 page thread that I started 11 years ago: https://emtlife.com/threads/is-a-broken-arm-an-als-or-bls-call.14922/
> Or, you are experiencing what is called "20/20 hindsight" where, once you are given the outcome, you see many of the signs as being clear as day, despite the fact that in the other 999 calls with similar criteria, you would have a different outcome.
> we could also discuss the opioid epidemic, and how we might be exasperating The Opioid Crisis in Black Communities by treating any complaint of pain with opioid meds, further causing THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION





DrParasite said:


> I've heard disparaging comments made about men, women, liberals, conservatives, Jews, Muslims, white people, black people, Hispanic people, firefighters, nurses, cops, etc, in both good and bad neighborhoods.  While I won't defend the comments, I will say simply making a statement doesn't translate into inappropriate care.  Generalizations, like stereotypes, are usually formed by a person's experiences and are rarely applicable to an entire group of people.
> EMS, as a whole, downplays pain management, and there really aren't great ways to manage all types of pain. Yes, we can give Narcs to anyone complaining of pain, maybe some IV Toradol, but it's often a subjective assessment based on the provider's experience, initial training, medical director/protocols, cultural and societal upbringing and yes, personal biases. For example, check out this 11 page thread that I started 11 years ago: https://emtlife.com/threads/is-a-broken-arm-an-als-or-bls-call.14922/
> Or, you are experiencing what is called "20/20 hindsight" where, once you are given the outcome, you see many of the signs as being clear as day, despite the fact that in the other 999 calls with similar criteria, you would have a different outcome.
> we could also discuss the opioid epidemic, and how we might be exasperating The Opioid Crisis in Black Communities by treating any complaint of pain with opioid meds, further causing THE OPIOID CRISIS AND THE BLACK/AFRICAN AMERICAN POPULATION


D


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## simongretton (Jun 11, 2020)

simongretton said:


> All fair points. I think for me that much of this comes down to some honest self reflection. When I am honest with myself, I think that over the years I have had a sometimes viscerally different reaction when I respond to scenes in "the hood", than I do when responding to more wealthy neighborhoods, and I can imagine that in some cases this has the potential to translate to how I have treated patients. Likewise, I suspect there is a part of me that judges black people to generally be more dangerous, emotional, and unpredictable than white people. That's a terrible thing to say, I wish that non of these feelings existed, and of course I don't believe any of this on an intellectual level. I would like to think I treat all people the same and that I am totally colorblind. But I suspect that these feelings that I wish didn't exist, may have some effect on how I interact with patients, and possibly how seriously I take a patient's complaints. I think it is probably hard to grow up in the world, and not internalize some of these biases. My hope is that in owning up to some of this, I can better move beyond it.
> 
> As far the patients who turned out to have major physical problems that we kind of wrote off at the time as "faking it", certainly it was a 20/20 hindsight thing. However, I do think that part of the reason that my coworkers and to some extent I wrote these people off as likely fakers, was based on an unfair profiling issue. Had they been less marginal people in nicer neighborhoods, I suspect we may have looked at them a little differently. While it is sadly true that disparaging comments are made about people for any number of reasons, I often sense less respect for people who appear to live in poorer, more marginal circumstances.
> 
> I am not proud of any of this of course, and I can't put any of this on anyone other than myself. This is tough stuff to admit to, because of course I want to be totally free of all kinds of bias, especially racial bias.


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## Kevin L (Apr 5, 2021)

When I was in EMS years ago, there was tons of bias and profiling, as it was a time of transition between the "good old days" when EMS was a "white boys' club" to more modern values of inclusiveness.

I tend (because I have high-functioning autism, formerly called Asperger's Syndrome) to take policies and rules very seriously and literally, and this actually used to occasionally get me in trouble when it came to treating patients in an unbaised manner.

As an example, we had protocols to use morphine, nitroglycerine, oxygen, aspirin, and a few other things when patients were complaining of chest pain (I am oversimplifying here, but please stay with me).

I would often get in deep s---t with my boss because I gave morphine (in accordance with our protocols) to homeless patients who complained of chest pain, as I treated them like any other patient.

The reason why I had problems was because I was seen as an enabler who was giving "homeless drug addicts" morphine when they didn't have enough money to score actual heroin . . . and our medical director doesn't give us drugs for this purpose.

My point was that our protocols are our protocols, and if I pick and choose who is or isn't deserving of a certain standard of care, then it's like playing God.  Also, a homeless person usually has a bad diet and an unhealthy lifestyle that would--if anything--lead me to a higher index of suspicion for cardiac issues.  Also, if the person is a heroin addict, then the few milligrams of morphine that I'm authorized to use would probably do nothing because of a high tolerance for opiates.  Also, homeless people can and do file lawsuits.

My leadership would then tell me that I have no common sense, and that I'm applying my protocols out of context, and that I shouldn't enable drug addicts by giving homeless people narcotics and making their problems worse.

There were similar issues when it came to treating gay people and people of certain religions.

After poking around on this forum, it does seem like a lot of these problems have been ironed out.

As an example, gay people were not allowed the same courtesies that married couples were.  See below:





__





						The lonely death of Lisa Pond
					

When Janice  Langbehn’s partner of 18 years, Lisa Pond, was dying of a brain aneurysm, Langbehn and the couple’s three children were not allowed to visit her. Pond died in her hospital bed at Jackson Memorial Hospital in Miami, alone.



					www.workers.org
				




I'm glad things have changed.


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## E tank (Apr 5, 2021)

VFlutter said:


> "While the primary regression analysis (Tables4-6) controlled for the contribution that a patient’s insurance status had on that patient’s receipt of pain medication,the secondary analysis (Table 7)investigated adjusted racial treatment differences for patients who were matched on insurance status. Interestingly, for patients with private health insurance, an indication of the presence of a full-time job for the patient or their immediate family member, there is evidence to support that the treatment disparity for both Black and Asian patients compared to White patients is larger than when compared to all insurance types. Evidence of this increased treatment disparity was also present in Black and White patients that indicated that they do not have health insurance."
> 
> Never once in my career have I thought about, nor usually know, a patient's insurance status while providing patient care 🤷‍♂️


retrospective chart reviews labeled as "studies" have bias confirmation errors baked right into them. It's an after the fact observation that can be adjusted to fit any outcome, not a real time observational inventory, which has problems of it's own. 

 About as useful as random axe grinding on an anonymous forum.


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## Emily Starton (May 10, 2021)

E tank said:


> retrospective chart reviews labeled as "studies" have bias confirmation errors baked right into them. It's an after the fact observation that can be adjusted to fit any outcome, not a real time observational inventory, which has problems of it's own.
> 
> About as useful as random axe grinding on an anonymous forum.


You're right, I agree with you.


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