I am a black male who lives in two worlds. I am a physician in a busy inner-city emergency department who works closely and respectfully with the law enforcement professionals who bring in patients. I am also someone who has been pulled over for driving while black, has been followed in stores for shopping while black, and is aware that we live in a country where black people can be killed for minor offenses like selling cigarettes, having broken tail lights, and holding sandwiches.

The busyness of the emergency department can act as a barrier to conversations and actions that would ideally lead to systemic change. Worse yet, the racism in the academic medical environment is covert as it is often systemic. Therefore, as a person of color and often the only black physician present in the room, I am compelled to share my perspective in order to create awareness and encourage change.

Here are four ways to help avoid racism in your emergency department.

1 Understand the difference between “systemic racism” and “personal racism.”

As with any issue, the first step is acceptance that there is a problem.  Systemic racism is as real as sepsis, myocardial infarction, and ringworm. It is often conflated with the more overt racism that we experience on a personal level. Systemic racism is defined by a set of policies that are put into place in order to maintain the disenfranchisement of a group based on race.¹ The personal racism we traditionally think of belongs to an individual who wields their own position of power to disenfranchise a people.

Emergency physicians should be very familiar with systemic racism to provide insight into their own practice. Knox Todd, MD, MPH, who has published extensively in the pain and disparity space, noted these disparities in several studies. We know that black people with long-bone fractures get fewer pain medications, but we also know that there are not sufficient data to support provider/patient concordance in these disparities.² A true understanding of why this occurs (and keeps occurring) cannot be obtained without accepting that all races and ethnicities of providers are complicit in the creation of this systemic racism.

2 Continue to educate about health care disparities.

In addition to oligoanalgesia, we know that blacks are less likely to get invasive cardiology procedures.³ We know that blacks are less likely to survive cardiac arrest even when it happens in the hospital.⁴ We know that blacks are less likely to receive thrombolytics for stroke.⁵ We know that blacks do worse in many aspects of the care we deliver to patients. We may never be able to adequately control for all variables and confounders, and perhaps, black patients are somehow predisposed to worse outcomes.

Very few of us would readily be able to name an overtly racist colleague. However, we must consider racism (personal or systemic) or subconscious bias as a contributing factor. We can educate residents and medical students on these concepts and further teach them that even when we try to do “everything right,” we can still be part of harmful outcomes for our patients. That said, we cannot let ourselves become defensive because of confusion about systemic racism. To combat this, we must continue to review the evidence that says that these differences in care are not entirely explained by other factors. Every department can approach these evidence-based realities behind the data from the vantage point that every member of the department is complicit in the creation of these disparities.

Unfortunately, there are also some who think that this systemic racism is imagined, that the evidence is a fluke, and that black patients should inherently trust the American health care system. Those folks need a reminder that the last survivor of the Tuskegee experiments (the one where we just watched black people with syphilis suffer while there was a cure available), Ernest Hendon, died in 2004.

3 Participate in hospital policies.

As we continue to answer the demands of The Joint Commission and other regulatory bodies, we can be wary of unintended consequences of new policies and initiatives. Today, everyone from rappers to President Barack Obama point at medical professionals as both the cause and the solution to our country’s opioid problem. In 2012, Mehgani and others performed a meta-analysis of the oligoanalgesia in health care and found considerable racial disparities in pain control.⁶ Ironically, some researchers suggest that there is a “silver lining” to this oligoanalgesia that has protected non-Hispanic blacks from the rise in heroin overdose deaths. Although this epidemic is sad for all races, participating in the guidance of hospital policies that protect ED patients from being collateral damage could be an actionable item. In many guidelines and among expert panels, opioid pain medications remain the mainstay of therapy for severe pain in a sickle cell pain crisis.⁷ Combating policies that make it harder or more demeaning for sickle cell patients, who are essentially all black, to get pain medications is an example of how an individual department can address systemic racism. In our individual shops, we can advocate for this often at-risk group. You don’t have to be a diversity expert to be a part of the change.

To combat this, we must continue to review the evidence that says that these differences in care are not entirely explained by other factors. Every department can approach these evidence-based realities behind the data from the vantage point that every member of the department is complicit in the creation of these disparities.

4 Grasp opportunities to discuss.

We cannot be afraid to have an open dialogue about messaging during times of crisis (perceived or actual). The conversations about systemic racism can occur simultaneously with any other. In drafting guidelines for management of pain or the treatment of acute coronary syndrome, we should overtly discuss how to avoid disparities in care. Let’s take it one step further: We should talk about disaster preparedness in the setting of a nearby demonstration, regardless of its cause, and we can talk about how most emergency physicians neither report nor know how to report brutality toward persons in custody.⁸ Failing to address such issues insults our position in society.

Even though another task can be cumbersome, making sure that providers and staff understand the issues at hand should be imperative. Emergency physicians are inherent leaders in health care who interact with all segments of society. Therefore, turning a blind eye to disparities in care is counterproductive. Surely, we’d all define ourselves as scientists. So adherence to the evidence should elevate us above our own experiences, which unfortunately seem to convince some that racism is an overreaction of blacks. Culture change is hard. Avoiding difficult issues is not the approach that led to a decrease in heart disease mortality, extended the life expectancy of persons with HIV, or helped avoid the spread of Ebola in the United States.

We can all do something to combat the racism of our workplace. Obviously, many of us are already taking steps to overcome the systemic racism that we know exists. Further, some disparities may be improving, as evidenced by some of the newer studies on analgesia administration. We can suggest journal clubs on health disparities, join hospital committees that inform institutional policies, or encourage discussion at faculty meetings. Again, you don’t have to be a diversity expert to act.

Dr. Osborne is assistant professor of emergency medicine and internal medicine at Emory University School of Medicine and medical director of the chest pain center and the observation unit at Emory University Hospital Midtown, both in Atlanta.

References

1. The Stephen Lawrence Inquiry. GOV.UK website. Accessed Aug. 1, 2016.
2. Todd KH, Deaton C, D’Adamo AP, et al. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16.
3. Ford E, Newman J, Deosaransingh K. Racial and ethnic differences in the use of cardiovascular procedures: findings from the California Cooperative Cardiovascular Project. Am J Public Health. 2000;90(7):1128-1134.
4. Chan PS, Nichol G, Krumholz HM, et al. Racial differences in survival after in-hospital cardiac arrest. JAMA. 2009;302(11):1195-1201.
5. Hsia AW, Edwards DF, Morgenstern LB, et al. Racial disparities in tissue plasminogen activator treatment rate for stroke: a population-based study. Stroke. 2011;42(8):2217-2221.
6. Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150-174. Yawn BP, Buchanan GR, Afenyi-Annan AN, et al.
7. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA. 2014;312(10):1033-1048.
8. Hutson HR, Anglin D, Rice P, et al. Excessive use of force by police: a survey of academic emergency physicians. Emerg Med J. 2009;26(1):20-22.