The emergency department represents a critical point of entry into the health care system for vulnerable patient groups, and as emergency physicians, we must strive to make our departments free of racism and bias. In the fast-paced environment of the emergency department, where stressful and complex decisions must be made quickly with limited information while balancing a large patient load and constant stream of interruptions, emergency physicians may be particularly susceptible to bias-based decision making.^1,2 As such, it is more important than ever that emergency physicians remain cognizant of these potential biases and how they contribute to disparate care and, ultimately, structural racism. 

Defining Terms

Establishing common definitions for core concepts surrounding health care disparities is a critical first step in working toward health equity, defined by the Robert Wood Johnson Foundation as “everyone has a fair and just opportunity to be as healthy as possible.” Discussions surrounding equity can be challenging in nature, and conversations can become tenuous when participants use terms that are defined in different ways by different users.

Racism is a system consisting of structures, policies, practice, and norms that assigns value and determines opportunity based on the color of one’s skin and results in conditions that unfairly advantage some and disadvantage others.³ Racism can occur at various levels—internalized (acceptance of stigma within oneself), interpersonal (between persons), and structural (racism manifested in macro-level conditions such as policies, norms, laws, cultures, and institutions).³

Implicit bias refers to attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious way, making them difficult to control.⁴ This is in contrast to explicit bias, which refers to attitudes and stereotypes that we are aware of on a conscious level.

Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. Health disparities are inequitable and are directly related to the historical and currently unequal distribution of social, political, economic, and environmental resources.⁵

Racial and ethnic disparities in health care exist even when accounting for insurance status, income, age, and severity of conditions.⁶ Unfortunately, bias on the part of the health care practitioners may contribute to differences in direct care and medical education.^7,8 For instance, Black and Hispanic patients were more likely to be taken to a hospital for uninsured, low-income patients even if they were picked up in the same ZIP code as their white couinterparts.⁹ In general, nonwhite Americans are more likely to have longer wait times and be triaged at a lower acuity; to receive a less comprehensive workup or interventions for complaints such as chest pain, acute coronary syndrome, and stroke; to be discharged rather than admitted; and to be physically restrained.^1,10 A study of pediatric emergency department visits found that Black and Hispanic patients had lower odds of undergoing radiography, ultrasonography, CT, or MRI compared to non-Hispanic white patients.¹¹ Black women with heart failure were less likely to receive referrals for specialized treatment than white women with the same symptoms.¹² Similarly, Black men may suffer unequal treatment as a direct result of implicit biases regarding their anticipated level of cooperativeness, compliance, or danger as compared to non-Black counterparts.^1,10

What We Can Do

The evidence demonstrates that racial bias exists in health care, but actively addressing one’s own biases or witnessed racist behavior can be uncomfortable due to the lack of experience with constructive approaches to confront racist behavior.

Here are some concrete steps emergency physicians can take to address implicit bias:¹³

1. Identify stereotyped statements, reflect on why the response occurred, and consider how to replace the stereotype with unbiased responses.
2. Use counter-stereotypic imaging, a strategy that challenges a stereotype’s validity by pointing out positive examples that are salient to the audience.
3. Gather specific, personal information about members of the stereotyped group to permit individuation and cognitively replace group-based attributes.
4. Increase psychological closeness of the stigmatized group by taking the perspective from the first person of someone from the stereotyped group.
5. Increase contact opportunities to provide potentially positive interactions with the stigmatized group and alter the cognitive representations of the group.

Here are some concrete steps emergency physicians and health care organizations can use to address structural racism:^14,15

1. Articulate specific goals related to action and change, and link these goals to metrics.
2. Review hiring and employment practices for hidden biases.
3. Conduct anonymous surveys with current and former employees to assess areas of hidden bias or unfairness.
4. Offer training on implicit and explicit bias.
5. Provide anonymous third-party complaint channels such as an ombudsman.
6. Support projects that encourage positive images of persons of color and scrub the organization’s environment, processes, and practices of inequities.
7. Identify, support, and collaborate with effective programs that increase diversity across the organization.
8. Ensure leadership is diverse.
9. Invest financially in the dismantling of racism within the organization.

Both emergency physicians and health care organizations must address bias and racism to close health disparity gaps. Emergency departments should be leaders of this change, given the vulnerable populations they serve; they can begin by using the well-documented strategies described here.

Dr. Gilbert is a medical officer at the Centers for Disease Control and Prevention in Atlanta.

Dr. Hsu is a physician in the department of emergency medicine at St. Joseph Mercy Hospital in Ann Arbor, Michigan.

Dr. Diaz is a PGY3 emergency medicine resident at the University of Michigan in Ann Arbor.

Dr. Mishra is an instructor in clinical emergency medicine at Weill Cornell Medical College and assistant attending physician at NewYork-Presbyterian Hospital in New York City.

References

1. Dehon E, Weiss N, Jones J, et al. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895-904.
2. Johnson TJ, Hickey RW, Switzer GE, et al. The impact of cognitive stressors in the emergency department on physician implicit racial bias. Acad Emerg Med. 2016;23(3):297-305.
3. Jones CP. Confronting institutionalized racism. Phylon. 2002;50(1):7-22.
4. Greenwald AG, Banaji MR. Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychol Rev. 1995;102(1):4-27.
5. CDC. Community Health and Program Services (CHAPS): Health Disparities Among Racial/Ethnic Populations. Atlanta: US Department of Health and Human Services; 2008.
6. Nelson AR. Unequal treatment: report of the Institute of Medicine on racial and ethnic disparities in healthcare. Ann Thorac Surg. 2003;76(4):S1377-1381.
7. Smedley BD, Stith AY, Nelson AR, eds. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.
8. Fontanarosa PB, Flanagin A, Ayanian JZ, et al. Equity and the JAMA Network. JAMA. 2021;326(7):618-620.
9. Hanchate AD, Paasche-Orlow MK, Baker WE, et al. Association of race/ethnicity with emergency department destination of emergency medical services transport. JAMA Netw Open. 2019;2(9):e1910816.
10. Schnitzer K, Merideth F, Macias-Konstantopoulos W, et. Disparities in care: the role of race on the utilization of physical restraints in the emergency setting. Acad Emerg Med. 2020;27(10):943-950.
11. Marin JR, Rodean J, Hall M, et al. Racial and ethnic differences in emergency department diagnostic imaging at US children’s hospitals, 2016-2019. JAMA Netw Open. 2021;4(1):e2033710.
12. Nayak A, Hicks AJ, Morris AA. Understanding the complexity of heart failure risk and treatment in black patients. Circ Heart Fail. 2020;13(8):e007264.
13. Devine PG, Forscher PS, Austin AJ, et al. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol. 2012;48(6):1267-1278.
14. Ross H. Proven strategies for addressing unconscious bias in the workplace. Cook Ross website. Accessed Nov. 9, 2021.
15. Choo E. Seven things organizations should be doing to combat racism. Lancet. 2020;396(10245):157.