It is not hard to imagine patients suspecting racial bias if they experience a rushed exam, long delays, or poor communication in the emergency department (ED).
“There are good historical, and current, reasons for minorities to mistrust the healthcare system,” says Daniel Pallin, MD, MPH, former assistant professor of emergency medicine at Harvard Medical School.
Race is much more likely to become an issue if an ED provider behaves disrespectfully toward the patient. “A particular worry would be if a physician had posted racially insensitive comments on social media,” Pallin notes.
The best way for emergency physicians (EPs) to avoid this allegation in the first place is to “be sure to bond with their patients and demonstrate concern,” Pallin says.
That means respecting that ED patients may be from cultures that differ from that of the EP, present with different levels of health literacy, and understand disease and treatment differently. “Take the time to be sure you are explaining things in a way that accounts for this,” Pallin suggests.
Involving family members whenever there is a sense of disconnect also is helpful. “Document that you talked to a family member. Document the point of view of both the patient and family member,” Pallin says.
Concern for the patient’s welfare should be clear to anyone who later reviews the ED medical record. “All documentation should be free from sarcasm or other tone or content that could imply lack of concern,” Pallin cautions.
Sparse documentation can be used against the EP defendant easily. On its own, a statement like “patient attributes trouble to gas pain” can appear as though the EP did not take the patient’s abdominal pain complaint too seriously. Pallin gives this example of better documentation: “She thought the discomfort might be due to gastrointestinal upset, but I am mindful of the possibility that it could be something more serious.”
“Women and minorities are known to present with symptoms that aren’t typical,” Pallin notes.
Another example of documentation that appears dismissive: “He continues to complain of chest pain, and this is his fourth ED visit. Prior providers explained the chest pain was due to costochondritis.”
In contrast, Pallin says this charting demonstrates thoughtful concern: “I’m concerned this pain still is bothering him. However, the nature of the pain and its chronicity lead me to believe that the benefit of hospitalization would be outweighed by the risks and difficulties entailed. I spoke to his primary care physician, who will be sure follow-up occurs promptly.”
ED nurses can demonstrate concern by checking on patients at regular intervals, and carefully documenting this. “Not to do so is asking for trouble,” Pallin warns. “Nurses should demonstrate kindness, even by providing Tylenol or something to drink.”
The way patients are described should reflect compassion, such as “gentleman” or “pleasant lady.”
“Don’t allow anything conceivably derogatory to make its way into the chart,” Pallin says.
Even if there are patients who are rude, shouting, and intoxicated, there remains a way to convey compassionate care. Pallin offers these examples: “This is a 50-year-old man who, according to the medical record, suffers from alcoholism.” Or “This is a 50-year-old lady who, sadly, is homeless.”
Sometimes, the EP-patient relationship breaks down completely. It is still possible to convey the person was treated compassionately. Pallin offers these examples: “The patient seemed really upset, and I offered to provide a gentle medicine to alleviate the trauma of the emergency visit. She accepted. After receiving 1 mg lorazepam, she seems less upset.” Or “The nurse and I met to talk about the case. We discussed that the patient seemed upset, and we met with the patient together. It didn’t seem like we were very successful at winning the patient’s trust, but we will certainly keep trying.”
Poor pain management gives the impression no one cared about the patient. Black and Hispanic patients are less likely to receive analgesia for acute pain than white patients.1 “Document your awareness of the patient’s pain and your desire to mitigate it within the bounds of safety,” Pallin says.
This means documenting the reason for withholding medication “in a tone of concern, not condemnation,” Pallin adds.
A good example: “This gentleman really seems to be suffering, but I’m afraid that giving opioids would do more harm than good, considering the history of heroin use.”
Implicit biases that affect the way providers care for one person vs. another probably are more common in the ED, according to Nathan Irvin, MD, assistant professor in the department of emergency medicine at Johns Hopkins. “In the ED, where people have to think on their feet and make lots of decisions, subconscious bias probably tend to come out more so than other areas,” Irvin observes.
Bias hinders good communication. “It provides the kindling for malpractice lawsuits,” Irvin says.
Patients who perceive bias are less likely to tell EPs all the necessary details. EPs might not fully comprehend what the patients are trying to say. Additionally, patients from ethnic minorities may be less likely to follow through with recommended treatment plans. “All of those things lead to opportunities for disparities to develop, and for patients to be harmed. And lawsuits can evolve,” Irvin warns.
If patients believe they received poor care because of their race, it stands to reason they would be more likely to pursue litigation if a bad outcome happens. “There are times you make a mistake that exposes you to risk. In some of those situations, the patient’s perception of their interaction with you can tip the scale on what they do,” Irvin explains.
There is no easy way to eradicate bias. “It takes people being aware of their biases and pushing them to rise above it,” Irvin says. “When you create an awareness that disparities exist, it’s an opportunity.”
In the ED, patients, providers, and (sometimes) family members share decisions on admissions or discharge. If communication is frayed, it is difficult to engage in meaningful discussions. “The answer is not to admit everybody,” Irvin says. “You have to work to try to meet each patient where they are.”
Population-level data can show that for all ED patients with a certain condition, Black patients fared worse than white patients. This shows disparities exist in general. However, at the level of the ED visit, “it is much more personal,” Irvin notes. “Individual patient interactions, how you address a certain medical condition for an individual patient — each of those matters a lot.”
The antidote to bias, says Irvin, is “empathic, relationship-centered listening” on the part of the EP. “When people have our biases and are rushed, lots of that stuff goes out of the window. It creates opportunities for some patients to not do as well as others,” Irvin explains.
Asking questions such as “Do you have any barriers to getting your medication?” are helpful. If the EP is aware the patient cannot afford medication, there may be other options. The same is true if a patient is about to be discharged under the condition that follow-up within 24 hours with a cardiologist happens.
If the EP truly is concerned about the patient, and the patient is not really going to follow up as instructed, says Irvin, “that’s a patient that you probably should have kept in the hospital.”
Patients who previously experienced bias might be reluctant to visit the ED at all. “If they’ve been mistreated as an ‘other’ or ignored or not given the dignity they deserve, they’re very unlikely to come back even if they have to,” Irvin reports. “They are going to come back under duress.”
If patients in the ED waiting room suspect they are receiving subpar care because of their race, some will choose to leave. Of that group, some people will go home and experience a bad outcome. “We are the front door of the healthcare system,” Irvin says. “That initial perception really matters. We definitely have to make a good impression from the jump.” A relationship-centered approach to ED care can prevent bias, or the perception of it, from getting in the way of good medical care.
“It can overcome some of these troubles so patients feel safe and reassured that they are going to get excellent healthcare,” Irvin adds.
- Lee P, Le Saux M, Siegel R, et al. Racial and ethnic disparities in the management of acute pain in US emergency departments: Meta-analysis and systematic review. Am J Emerg Med 2019;37:1770-1777.