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Welcome back to Nat’s Civic Issues blog! I hope you enjoyed my last blog analyzing the racial disparities in maternal medicine. Today, we are going to continue with our exploration of racial bias in medicine, but we will be learning about the inequities in emergency medicine. There are a lot of factors involved in this issue, starting from the demographic of EMS or paramedics, what hospitals different racial groups are brought to, and everything that happens from intake to discharge. Let’s get into it.

 

First, emergency medicine, especially EMS, is a largely white and largely male field, which can pose some notable public health concerns. For instance, by diversifying the emergency services workforce, it can limit many language or communication barriers that prevent adequate treatment, especially in areas with a large Hispanic population with lower levels of English fluency. A study done in 2017 found that while the proportion of underrepresented minorities certified as EMTs or paramedics is rising, the percentage is still embarrassingly low. Black EMTs make up about 5% of the workforce, and Black paramedics make up only 3% of the field, which is startlingly low considering that Black people make up about 13.4% of the US population. Unfortunately, there still aren’t enough diversity initiatives aimed at EMT and paramedic education programs, which will leave us with a very white-dominated emergency workforce. This kind of discrimination is associated closely with delays in seeking care and lower adherence to medical treatment, which widens the health gap between demographics.

 

After a patient calls 911, regardless of who their EMT or paramedic is, there is a notable difference in the ambulance destination depending on the patient’s race. There was also a cohort study published in 2019 that examined ambulance trips for over 850,000 patients on Medicare by race, and it found that 61.3% of white patients were transported to the nearest facility, compared with 58.8% of Hispanics and 56% of Black patients. Black and Hispanic patients were much more likely to be transported to a “safety-net” hospital than white patients. These safety-net hospitals may have less capabilities of trauma care, advanced life support, or treatment for strokes and cardiovascular accidents. This is a huge issue, since our EMTs and paramedics, since they are not diverse enough to represent the population, already deal with language barriers with patients that may need higher levels of care than safety-net hospitals can give.

 

Now, the patients in question are in the emergency room, but their run-ins with racial inequities don’t stop at the ambulance bay doors. Studies over the last few decades show clear differences in ED wait times as well as diagnosis, admissions, and prescriptions. For instance, Hispanic and Asian patients were less likely to receive a pain assessment procedure, and all minority demographic patients were less likely to receive pain medications compared with white patients. Black patients in particular were 32% less likely to receive a prescription for pain medication at their visit. This reflects a deeper bias in many emergency rooms across the country that has plagued our society since the war on drugs and the Nixon administration. The stereotypes and biases surrounding this has created a deep mistrust between the healthcare system and many minority groups. With less people willing to enter emergency departments and doctors less willing to accept their patient’s pain levels, we are leaving entire demographics vulnerable instead of correcting these implicit biases.

 

There is more evidence for this among children in emergency rooms across the country. For patients under 18 years old, these disparities are shockingly high. For instance, a study conducted using data from 2005 to 2016 among children in the US found several startling statistics surrounding emergency department admissions and evaluations. First, researchers noted a large difference in waiting room times for each demographic, with Black and Hispanic patients waiting an average of 8 to 10 minutes longer than white patients with the same medical concerns. Their visits were also an average of 15-25 minutes longer than their white counterparts for no obvious reason. They also found that Black and Hispanic patients were 8% and 14% less likely to have their care needs classified as immediate or emergent in comparison to white patients, and Black children were 28% less likely to be admitted to the hospital following triage. Finally, they found that Black patients were 24% less likely to receive a blood test and 28% less likely to receive a CT scan during their visit. Keep in mind that these statistics mean that emergency departments across the country are making children who belong to certain demographics wait longer in waiting rooms, sit in their triage bed longer, not identifying their conditions as emergent, and discharging them prematurely, simply due to their race.

 

Obviously, there needs to be drastic, systemic change in our healthcare system to address these disparities. It needs to start from the beginning with a new generation of doctors that better represent the populations that they will be treating. While diversity is improving among newly matriculated medical students, there must be better undergraduate preparation programs for pre-med students around the country who may not have access to MCAT study materials or academic support. These programs will allow a more diverse class of medical students across the country, hopefully one that represents US demographics better. Then, medical schools must include diversity and equity training in their curriculum, specifically focusing on the exaggerated disparities in emergency medicine. Finally, we need to expand training on the biological and genetic differences in different populations, such as the prevalence of genetic disorders like sickle cell anemia in the Black population compared to the white population. While sickle cell anemia is fairly common, there are many other biological risk factors that are not well understood, but play a large role in emergency medicine.

 

While these statistics are startling and horrifying, there is meaningful change to be had. We can train our doctors to treat patients thoughtfully and consider all appropriate factors in healthcare. We can fundamentally change stereotypes, especially surrounding pain treatment, and help to repair the lack of trust between the healthcare system and minority groups in the US. With racial disparities in healthcare spotlighted by the COVID-19 pandemic, there is perhaps no time more urgent than now to correct these inequities.

 

Resources:

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

https://www.usnews.com/news/healthiest-communities/articles/2019-09-06/study-finds-racial-disparities-in-emergency-medical-care#:~:text=Black%20and%20Hispanic%20patients%20were,than%20the%20nearest%20emergency%20room.

https://www.census.gov/quickfacts/fact/table/US/PST045218

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2749448?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=090619

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6951392/

https://onlinelibrary.wiley.com/doi/abs/10.1197/S1069-6563%2803%2900486-X?sid=nlm%3Apubmed