Skip to main content
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 Dec 1.
Published in final edited form as: Med Care. 2019 Dec;57(12):921–923. doi: 10.1097/MLR.0000000000001250

A Thousand Cuts: Racial and Ethnic Disparities in Emergency Medicine

William E Soares III 1, Kenneth J Knowles II 2, Peter D Friedmann 3
PMCID: PMC7069500  NIHMSID: NIHMS1068630  PMID: 31688566

Despite the many advances in emergency and prehospital medicine, racial and ethnic inequities in care persist.(1) In the emergency department, ethnic and racial minorities experience many different types of inequality, including increased wait times,(2,3) less frequent pain medication administration, (46), and decreased rates of CT and MRI imaging.(7) Although these disparities are well established in the hospital, their extent in the prehospital setting is less certain. Emergency medical services (EMS) treats over 16 million patients annually, yet relatively little is known with regards to treatment differences based on race and ethnicity. The article by Kennel, et al, explores differences in EMS pain management practices for racial and ethnic minority patients with blunt trauma injuries (cite article in Medical Care).

Using electronically captured self-reported medical records from the Oregon Emergency Medical Services Information Systems, which represents approximately 70% of EMS agencies in Oregon, Kennel et al conducted a retrospective evaluation of the frequency of EMS management of pain. Authors found that Hispanic and Asian patients were less likely than White patients to have a pain assessment recorded. Additionally, despite a similar frequency of completed pain assessment scores among Black (45.1%) and White (44.5%) patients, Black patients received pain medications less frequently (13.9% compared to White patients, 20.1%). When controlling for gender, age, location, insurance, and presence of a pain assessment score, compared to White patients, Black, Hispanic and Asian patients were less likely to receive pain medication from EMS for blunt traumatic injuries (32%,21% and 24% respectively).

The study contains limitations that must be considered when interpreting results. Of the over 25,000 patients included in the study, less than 15% were identified as a racial or ethnic minority by EMS providers. The low frequency of diversity in the sample population limits generalizability to other EMS agencies that treat different populations. Further, though the authors control for preidentified confounders, there are several other possible measured and unmeasured variables that may account for differences in pain assessment and treatment. For example, there is no adjustment for the population area of the EMS provider; it is likely that EMS providers who serve urban, rural and frontier areas and may have different patient practice patterns. Additionally, there is no discussion of distance from encounter to hospital; it may be that urban minority patient encounters are physically closer to hospitals, thus leaving less time for pain assessment and treatment.

Despite the above limitations, the findings support and add to previous literature which has demonstrated that, even in the prehospital setting, racial and ethnic minority patients receive a lower standard of care, including in pain management, (8,9) utilization of EMS during emergencies, (10) and likelihood of being transported to a safety net hospital.(11) Placed in the context of the overall literature, racial and ethnic minority patents experience disparities in all aspects of healthcare, from the initial EMS activation, throughout treatment in the hospital, and persisting post hospitalization, as the likelihood of being referred to rehabilitation after trauma also appears to be influenced by race and ethnicity.(12)

Racial and ethnic disparities in medicine may result, in part, from implicit bias at the level of the healthcare provider. Unlike explicit, conscious acts of discrimination, implicit bias is subconscious, silently informing healthcare decisions through the influence of underlying biased attitudes and beliefs. Implicit bias is prevalent throughout society, and well-documented in medicine, especially in healthcare settings with relatively limited contact with racial and ethnic minorities.(13) That said, the measurable effects of implicit bias on healthcare decisions are not always recognizable, and evidence suggests that implicit bias rarely overwhelms standard of care clinical decision-making and treatment algorithms.(14) For example, little evidence supports that discrimination or bias influence initial critical decisions involving acute trauma and surgical patients.(15,16)

Rather, implicit bias is more insidious and additive, subtly influencing a series of smaller, more subjective decisions. In some ways, implicit bias can be compared to Lingchi, the Chinese term that describes the concept of the death by 1000 cuts. Rather than striking a single mortal blow, Lingchi was a cruel method of torture meant to bring a slow death through a series of small, individually inconsequential injuries that together, created a fatal wound. In medical terms, implicit bias may not be the proximal deciding factor to perform a critical action, such as an emergency surgery or procedure. However, small additive acts of disparity, such as the delay in arrival of the ambulance in low income areas, the lack of a full assessment, the decision to transport to a safety net hospital, the increased wait time, the discrepancy in performing imaging, all contribute to an overall disparity in care. And, while each of these factors alone might not have a measurable impact, continued and persistent acts that promote racial and ethnic disparities in the pre-hospital and hospital setting are additive and likely result in the inequities we continue to find in clinically important outcomes.

How then, do we move forward to address the racial and ethnic bias experienced by our patients? Because implicit bias may influence insidiously, we must be cautious interpreting negative studies as evidence that disparity does not exist. Rather, we recommend focusing future research efforts on identifying factors that modify implicit bias and measured disparities in outcomes to help refine understanding and promote solutions. For example, a recent study found no significant racial or ethnic difference in the treatment of patients with migraine and fractures, both of which have objective pain management algorithms. In contrast, Black patients were less likely to receive opioid medications for the treatment of low back pain, a complaint that relies heavily on the subjective interpretation of pain by the healthcare providers.(5) Further, development of a standardized emergency department chest pain algorithm led to reductions in measured differences in management of racial and ethnically diverse patients. (17) The implementation of algorithms and protocols that recognize race as a risk factor for disparate care may help decrease inequities, such as the subjective perception of pain in the EMS patient population.

From a policy standpoint, promoting racial and ethnic diversity in the prehospital workforce may also help. Patients who receive care from healthcare providers who share their racial and ethnic backgrounds are more participatory during the exam and more likely to engage in self-advocacy.(18) However, this solution is challenging in the current EMS environment, where less than 10% of the workforce identifies as a racial or ethnic minority.(19,20) Policies that remove barriers and promote diversity in emergency medicine professionals may raise the quality of care we provide to all patients.

In summary, prehospital and emergency medicine providers share the goal of providing exceptional care for all patients. However, as Kennel et al found, racial and ethnic differences continue to influence quality of care. Moving forward as a healthcare community, we must focus on effectively acknowledging and counteracting the impact of race and ethnicity on the assessment and treatment of emergency patients. Provider education and recognition of inequalities, addressing the lack of diversity in the prehospital and emergency workforce, and incorporation of treatment algorithms and protocols that acknowledge race and ethnicity as a risk factor may help to lessen the impact of race and ethnicity on treatment decisions. Ultimately preventing a death by 1000 cuts is not about avoiding a single blow, just as improving racial and ethnic disparities is not about implementing a single measure. Rather, it will take a coordinated, purposeful, and comprehensive series of steps to reduce the injustice inflicted on our racial and ethnic minority patients.

Footnotes

Conflicts of interest: Authors WS, PF, KK report no conflicts of interests in the following editorial. This editorial did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Works Cited

  • 1.Nelson A Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002;94(8):3. [PMC free article] [PubMed] [Google Scholar]
  • 2.Sonnenfeld N, Pitts SR, Schappert SM, Decker SL. Emergency Department Volume and Racial and Ethnic Differences in Waiting Times in the United States: Medical Care. 2012. April;50(4):335–41. [DOI] [PubMed] [Google Scholar]
  • 3.Mahmoudi E, Swiatek PR, Chung KC. Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter? Plastic and Reconstructive Surgery. 2017. February;139(2):444e–54e. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Shah AA, Zogg CK, Zafar SN, Schneider EB, Cooper LA, Chapital AB, et al. Analgesic Access for Acute Abdominal Pain in the Emergency Department Among Racial/Ethnic Minority Patients: A Nationwide Examination. Medical Care. 2015. December;53(12):1000–9. [DOI] [PubMed] [Google Scholar]
  • 5.Dickason R, Chauhan V, Mor A, Ibler E, Kuehnle S, Mahoney D, et al. Racial Differences in Opiate Administration for Pain Relief at an Academic Emergency Department. Western Journal of Emergency Medicine. 2015. May 1;16(3):372–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments. JAMA [Internet]. 2008. January 2 [cited 2019 Sep 13];299(1). Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2007.64 [DOI] [PubMed] [Google Scholar]
  • 7.Schrager JD, Patzer RE, Kim JJ, Pitts SR, Chokshi FH, Phillips JS, et al. Racial and Ethnic Differences in Diagnostic Imaging Utilization During Adult Emergency Department Visits in the United States, 2005 to 2014. Journal of the American College of Radiology. 2019. August;16(8):1036–45. [DOI] [PubMed] [Google Scholar]
  • 8.Hewes HA, Dai M, Mann NC, Baca T, Taillac P. Prehospital Pain Management: Disparity By Age and Race. Prehospital Emergency Care. 2018. March 4;22(2):189–97. [DOI] [PubMed] [Google Scholar]
  • 9.Young MF, Hern HG, Alter HJ, Barger J, Vahidnia F. Racial Differences in Receiving Morphine among Prehospital Patients with Blunt Trauma. The Journal of Emergency Medicine. 2013. July;45(1):46–52. [DOI] [PubMed] [Google Scholar]
  • 10.Mochari‐Greenberger H, Xian Y, Hellkamp AS, Schulte PJ, Bhatt DL, Fonarow GC, et al. Racial/Ethnic and Sex Differences in Emergency Medical Services Transport Among Hospitalized US Stroke Patients: Analysis of the National Get With The Guidelines–Stroke Registry. Journal of the American Heart Association [Internet]. 2015. August 25 [cited 2019 Sep 13];4(8). Available from: https://www.ahajournals.org/doi/10.1161/JAHA.115.002099 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Hanchate AD, Paasche-Orlow MK, Baker WE, Lin M-Y, Banerjee S, Feldman J. Association of Race/Ethnicity With Emergency Department Destination of Emergency Medical Services Transport. JAMA Network Open. 2019. September 6;2(9):e1910816. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Shafi S, de la Plata CM, Diaz-Arrastia R, Bransky A, Frankel H, Elliott AC, et al. Ethnic Disparities Exist in Trauma Care: The Journal of Trauma: Injury, Infection, and Critical Care. 2007. November;63(5):1138–42. [DOI] [PubMed] [Google Scholar]
  • 13.Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science & Medicine. 2018. February;199:219–29. [DOI] [PubMed] [Google Scholar]
  • 14.Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Choo EK, editor. Academic Emergency Medicine. 2017. August;24(8):895–904. [DOI] [PubMed] [Google Scholar]
  • 15.Shafi S Ethnic Disparities in Initial Management of Trauma Patients in a Nationwide Sample of Emergency Department Visits. Archives of Surgery. 2008. November 17;143(11):1057. [DOI] [PubMed] [Google Scholar]
  • 16.Haider AH, Schneider EB, Sriram N, Dossick DS, Scott VK, Swoboda SM, et al. Unconscious Race and Social Class Bias Among Acute Care Surgical Clinicians and Clinical Treatment Decisions. JAMA Surgery. 2015. May 1;150(5):457. [DOI] [PubMed] [Google Scholar]
  • 17.Miller CD, Stopyra JP, Mahler SA, Case LD, Vasu S, Bell RA, et al. ACES (Accelerated Chest Pain Evaluation With Stress Imaging) Protocols Eliminate Testing Disparities in Patients With Chest Pain: Critical Pathways in Cardiology. 2019. March;18(1):5–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Race Cooper-Patrick L., Gender, and Partnership in the Patient-Physician Relationship. JAMA. 1999. August 11;282(6):583. [DOI] [PubMed] [Google Scholar]
  • 19.Crowe RP, Krebs W, Cash RE, Rivard MK, Lincoln EW, Panchal AR. Females and Minority Racial/Ethnic Groups Remain Underrepresented in Emergency Medical Services: A Ten-Year Assessment, 2008–2017. Prehospital Emergency Care. 2019. July 24;1–8. [DOI] [PubMed] [Google Scholar]
  • 20.Crowe RP, Levine R, Eggerichs JJ, Bentley MA. A Longitudinal Description of Emergency Medical Services Professionals by Race/Ethnicity. Prehospital and Disaster Medicine. 2016. December;31(S1):S30–69. [DOI] [PubMed] [Google Scholar]

RESOURCES