Pediatric EPs carry implicit biases, unconscious negative attitudes toward specific groups (Black, Hispanic, and obese patients), according to the authors of a recent study.1 “Our goal is to understand what biases — implicit and explicit — may exist in medical staff in the ED,” says Eric Fleegler, MD, MPH, FAAP, one of the study’s authors and assistant professor of pediatrics and emergency medicine at Harvard Medical School.

Fleegler and colleagues assessed both implicit and explicit biases of 101 pediatric EPs based on race, weight, and ethnicity. The explicit measures showed a weak preference for Black over white patients, no preferences between Hispanic and white patients, and a moderate preference for thin over obese patients. The implicit measures demonstrated a strong implicit bias against Hispanic, Black, and obese patients. The EPs surveyed did not report explicit bias against Black or Hispanic patients, but did show explicit bias against obese patients.

The researchers would like to use these data to determine if biases affect actual care. For example, in a busy ED, when a patient presents in pain, quick decisions are made about which medications are used to treat the pain, including acetaminophen, ibuprofen, and opioids. “Implicit biases against certain groups may lead to decreased utilization of opioids or other medications that may do a better job of relieving pain,” Fleegler says.

Fleegler and colleagues recommended EDs consider self-screening for implicit bias so EPs can improve their own awareness (e.g., The Implicit Association Test; learn more here). “I have spent nearly 30 years working to improve the care of everyone, with a particular focus on marginalized and unserved groups. To see my own implicit biases was humbling,” Fleegler reports.

The survey’s findings suggest ED providers probably do not treat everyone equally. This is true of pain management, antibiotic use, imaging, and child abuse evaluations. Another recent study revealed a lower rate of opioid use in Black and Hispanic children vs. white children with long bone fractures and suspected appendicitis.2 “We need to be aware of this,” says Fleegler, who worked on that study, too. “We need to understand the role of implicit biases in these decisions and work toward equitable care for all regardless of their race, ethnicity, or weight.”

Elsewhere, other investigators have found Black patients are more likely to be physically restrained in EDs vs. white patients.3,4 Black patients also are less likely to be given narcotic analgesics vs. white patients.5 “Implicit assumptions, based on the stereotypes that Black individuals are aggressive and have higher pain tolerance, may contribute to the disparities seen in use of physical restraints and pain treatments,” says Erin Dehon, PhD, associate professor in the department of emergency medicine and vice chair of diversity, equity, and inclusion at the University of Mississippi Medical Center in Jackson.

Individuals are more likely to unintentionally rely on stereotypes when they are multitasking, working under time pressure, working with a limited amount of information, or experiencing fatigue, according to Dehon. “Given these factors, ED physicians in particular may be at high risk,” she suggests.

There are many factors, including unconscious bias, that may influence EPs’ clinical interactions and decision-making. “While we think that our decisions are based purely on science, that is not always the case,” says Bernard L. Lopez, MD, MS, CPE, senior associate dean for diversity and community engagement and professor and executive vice chair in the department of emergency medicine at Thomas Jefferson University Sidney Kimmel Medical College.

One example of whether unconscious bias may play a role is women with chest pain. Studies have demonstrated disparities in outcomes in acute coronary syndrome based on gender. “While treatment decisions are complex, unconscious bias may have a significant role in these differences,” Lopez says. “Unconscious bias at play may result in less accurate diagnoses and less aggressive treatment — and may result in poorer outcomes.”

ED providers probably do not hold any overt bias toward women with acute coronary symptoms. “However, unconscious biases — the biases that are at play outside of our awareness — can cause a difference in treatment and outcomes based on gender. That’s how unconscious bias works,” Lopez says.

Education (e.g., lectures, seminars, and workshops) can mitigate unconscious bias. “While a one-time lecture can be informative, more in-depth education, especially ones that include an experiential component, can better educate one for the long term,” Lopez offers. Shorter, more frequent sessions are recommended to keep bias top of mind. “It takes a growth mindset — awareness, coupled with a desire to learn and improve — to best tackle unconscious bias,” Lopez explains.

ED providers can point out cases to each other where bias might be playing a role. “If you have a blind spot, having somebody who does not share that same blind spot can help you recognize it,” Lopez says.

EDs also can incorporate identifying disparities into their quality improvement process, according to Dehon. EDs could start by asking, “What disparities are unique to the ED setting?”

“Start by extracting potential health disparity data, such as restraint use, pain medication, lab test ordering, [and] assigned acuity levels at triage, from the EHR, stratified by race/ethnicity, gender, socioeconomic status, and any other relevant variables, to create a health disparities dashboard,” Dehon says.

Based on those findings, the next step is for EDs to develop interventions to alleviate subjectivity (and, therefore, reduce the potential for bias to affect decision-making). Standardized protocols or specific algorithms are examples of this.

For instance, the data may reveal white patients are far more likely to be assigned higher acuity levels at triage compared to Black patients. If so, Dehon says EDs should ask these questions: Why is this occurring? How is triage level assigned? Is it purely subjective? How can the process be altered so that it’s more objective? Is there an algorithm that could be applied? “Use the dashboard to monitor improvements over time,” Dehon adds.


  1. Guedj R, Marini M, Kossowsky J, et al. Explicit and implicit bias based on race, ethnicity, and weight among pediatric emergency physicians. Acad Emerg Med 2021; May 25. doi: 10.1111/acem.14301. [Online ahead of print].
  2. Guidj R, Marini M, Kossowsky J, et al. Racial and ethnic disparities in pain management of children with limb fractures or suspected appendicitis: A retrospective cross-sectional study. Front Pediatr 2021: In press. doi: 10.3389/fped.2021.652854.
  3. Wong AH, Whitfill T, Ohuabunwa EC, et al. Association of race/ethnicity and other demographic characteristics with use of physical restraints in the emergency department. JAMA Netw Open 2021;4:e2035241.
  4. Schnitzer K, Merideth F, Macias-Konstantopoulos W, et al. Disparities in care: The role of race on the utilization of physical restraints in the emergency setting. Acad Emerg Med 2020;27:943-950.
  5. Shah AA, Zogg CK, Zafar SN, et al. Analgesic access for acute abdominal pain in the emergency department among racial/ethnic minority patients: A nationwide examination. Med Care 2015;53:1000-1009.