Unconscious bias, the subject Uché Blackstock, MD, wrote a November 2019 column on in ACEP Now, can be defined as “a person’s tendency to associate a group or category attribute, such as being black, with a negative evaluation (unconscious prejudice) or another category attribute, such as being violent (unconscious stereotype).”¹ People in all walks of life throughout society, including physicians, possess these unconscious (or implicit) biases.

These subtle subconscious feelings that we and other health care workers might harbor toward our patients have likely been present since the beginnings of the profession. However, it is only relatively recently that we have recognized these implicit biases, sought to better understand them, and devised strategies to ameliorate them.² Racial and ethnic disparities in the emergency department delivery of analgesia for something as universally painful as a long-bone fracture have been known for several decades; a recent study extends the concern about a potential unconscious bias prevalent in prehospital care.³

Controlling for socioeconomic status and geography, researchers investigated if patients were transported to safety-net facilities based on their race. For black patients, transport to a safety-net facility by EMS occurred approximately 5 percent more often than for white patients; for Hispanic patients, transport to a safety-net facility occurred about 2.5 percent more often.⁴

These data reflect a snapshot in time, suggesting—but not proving—implicit biases may be at play in the prehospital setting. We should ask whether these are the results of individual decisions made by prehospital health care workers. Or are these results the effect of systemic issues involving medical direction protocols? Or perhaps they can be explained by less nefarious means, such as patient preference.

Regardless of the cause(s), the National Association of EMS Educators recommends the following as one possible solution: “A diverse EMS workforce, representative of the patients it serves, is crucial to promote understanding among EMTs and paramedics, patients and other providers in the health care system, and to eliminate disparities in care experienced by minority patients.”

As in business and in medicine, the time for greater workforce diversity in prehospital care is at hand.  

Dr. Dark is assistant professor of emergency medicine at Baylor College of Medicine in Houston and executive editor of PolicyRx.org.

References

1. Blackstock U. Overcoming unconscious bias takes strategy and collective effort. ACEP Now. 2019;38(11):19.
2. Brownstein M. Implicit bias. Stanford Encyclopedia of Philosophy website. Accessed May 11, 2020.
3. Todd KH, Deaton C, D’Adamo AP, et al. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16.
4. 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.