Are EMS treatment disparities related to race or class?
Ensuring equitable treatment for all communities begins with understanding how unintentional racism can produce racist outcomes in EMS
By Remle Crowe, PhD; and Jamie Kennel, MS, NRP
Words like "bias," "disparity" or "inequity" often evoke discomfort and strong emotional reactions. We may instinctively respond with statements like, "I treat all my patients the same," or "I don't see color," or "I'm not racist!" However, research consistently demonstrates racial and ethnic inequities are present in prehospital care and healthcare more broadly.
To address these gaps, we must acknowledge that while EMS clinicians are explicitly non-racists, we need to have uncomfortable conversations and comprehend the structural root causes influencing disparate treatment administered to patients of color.
1. The erroneous concept that people of different races are biologically different. First, we’ll look at an incorrect understanding of what race is and isn’t. Race and ethnicity are a social construct, not a biological one.
One of the potential justifications for treating patients of different races differently is if we believe that they are biologically different. This belief is a proven erroneous concept, yet so deeply held in the founding of U.S. medicine that its belief systems impact medical students today.
For example, according to the Proceedings of the National Academy of Sciences (PNAS), in 2016, large portions of first- and second-year medical students believed in true biological differences between Black and White people that have since been proven false, such as:
- "Black people's nerve endings are less sensitive than white people’s."
- "Black people's skin is thicker than white people’s."
- "Black people's blood coagulates more quickly than white people’s."
2. Cognitive shortcuts. Second, using cognitive shortcuts in EMS practice, while necessary, often involves bias and inaccurate generalizations about different groups of people. EMS clinicians working under time pressure and incomplete clinical information may experience exacerbated biases due to stereotype activation. This automatic and unintentional process persists despite attempts to ignore it.
For instance, the misconception that opioid use disorders are more associated with Black individuals, despite higher prevalence among White individuals from 2000 to 2020, can impact EMS clinicians’ perceptions of opioid misuse. Unquestioned stereotypes can lead to more biased treatment decisions.
3. Aversive racism. Third, growing up, living, working and playing in undiversified racial and ethnic circles can lead to discomfort when encountering people different from oneself. This uneasiness is known as Aversive racism, and it may influence EMS treatment, especially during crises.
4. Language barrier. Finally, patients who don't speak English often receive substandard medical treatment in and out of the hospital, which have a disproportionate effect on racial and ethnic minorities.
These four example drivers of racial and ethnic treatment disparities are structural and systematic, often operating outside the awareness of EMS clinicians. These four points exemplify how unintentional racism can produce racist outcomes in medicine, including EMS.
What EMS leaders need to know about unconscious bias
Understanding your unconscious biases will make hiring decisions, disciplinary choices, relationships and clinical care more equitable
Continued racial disparities in prehospital pain management
Now let’s look at the recent evidence in more detail and review why it matters. First and foremost, inadequate pain management can lead to increased suffering, delayed recovery, psychological impacts, lack of trust in healthcare, inadequate diagnosis, and legal/ethical concerns.
More recently, research from the ESO Data Collaborative, one of the nation's largest healthcare research databases, shows that among EMS-transported patients with ED-diagnosed long bone fractures, 72% of White patients with severe pain received prehospital analgesic medication, compared to only 59% of Black patients. The study analyzed the EMS medical charts from over 35,000 patients transported by 400 EMS agencies between Jan. 1, 2019, and Dec. 31, 2022.
What sets this study apart?
This study uses EMS records linked to hospital outcomes to identify patients with objectively painful long bone fractures. It explored the relationship between race, ethnicity and socioeconomic status by using the CDC's Social Vulnerability Index to assess the community's socioeconomic conditions.
Results showed that patients in areas of lower socioeconomic resources received less pain medication. Even Black patients in communities of high-socioeconomic resources received less prehospital pain medication than White patients. The study adjusted for pain severity, transport time, fracture location, age, sex and insurance status. Additionally, researchers examined EMS narratives for potential explanations, but found no differences in pain medication refusal rates by race and ethnicity.
The study emphasizes two significant findings:
- First, wealth doesn’t remove racial treatment disparities. Black patients received less pain medication regardless of receiving EMS treatment in a poor or wealthy area of town.
- Second, all individuals in poor areas received lower-quality care, irrespective of race when compared to wealthy areas of town for the same long bone fracture.
Addressing these disparities requires a conscious and multi-faceted approach by every EMS agency involved, understanding the underlying structural reasons, and swiftly testing interventions to ensure equitable EMS treatment for all communities.
To request the full ESO study, you can visit this link.
About the authors
Remle Crowe, PhD, is director of clinical and operational research, ESO.
Jamie Kennel, PhD, HMS, NRP, is a professor and program director of the Paramedic Program, a joint program between Oregon Health and Science University, and Oregon Institute of Technology.