Implicit racial bias in EMS?

[VFlutter]

"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

 

[GMCmedic]

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.

 

[simongretton]

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.

 

[DrParasite]

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.

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/

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.

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

 

[Seirende]

Take a Test

implicit.harvard.edu

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

 

[simongretton]

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

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

 

[simongretton]

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.

 

[Kevin L]

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.

 

[E tank]

"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.

 

[Emily Starton]

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.