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Diversity in EMS: Recognizing Implicit Bias in the Prehospital Environment
Diversity in EMS is a new bimonthly column in which rotating authors will confront difficult questions of bias and discrimination in the emergency medical services and how agencies can lead change in their communities.
It’s only been in the last decade or so that professionals in various spheres have awakened to a more accurate understanding of how bias and prejudice manifest in people and can produce differential treatment of groups.
For many years we thought all prejudice and bias took the form of what we now label explicit bias. This form of bias is consciously held. The person with explicit bias links various groups to negative stereotypes based on animus and hostility toward those groups. These attitudes and stereotypes can produce discriminatory behavior, and the person with explicit bias is unconcerned about this outcome.1,2 Racism is an example of an explicit bias.
We all know about this form of bias, and many of us legitimately claim, “That’s not me.” Then we go about our lives and work thinking we are bias-free and don’t treat groups differently.
However, social psychologists have discovered a second form of prejudice, implicit bias. None of us can say, “That’s not me” because all of us have implicit biases, regardless of our good intentions. Our minds automatically link groups of people (e.g., based on race, religion, sexual orientation, economic status) to positive or negative generalizations, or "stereotypes," about those groups. These implicit associations can occur outside our conscious awareness and differ from our conscious attitudes and beliefs, yet still impact how we perceive and treat people. Implicit associations can produce differential treatment of groups—that is, discriminatory behavior.3
People in many professions—such as education, medicine, law enforcement, and retail sales—are thinking about how implicit associations might affect their service provision, and EMS providers should do the same. Below we explore how implicit associations might affect an EMT during the course of his or her work.
The General and the Individual
As possible examples, an EMT might have stereotypes about the demographics of alcoholics (based on economic status, gender, or race) and assume a particular person is drunk, rather than experiencing hypoglycemia. He or she might assume a homeless person is asking for painkillers not because she is in pain but because she is a drug addict. An EMT might assume law enforcement called for service not because they had a patient in need of care but rather because they didn’t want to deal with the drunk or high subject. Or, relatedly, the EMT might assume an arrestee is not really having chest pains as claimed but suffering from a “handcuff allergy.” A paramedic may not believe the health complaints of the person with mental illness.
Associations between groups and characteristics such as those suggested above may be conscious or exist instead as implicit associations that manifest outside of conscious awareness despite the EMS provider’s best intentions.
Stereotypes are not necessarily untrue—quite the opposite. An EMT might associate homeless people with drug use because that reflects her 15 years of experience on the job. She might associate arrestees with “handcuff allergy” because that has been the reality nine times out of 10. Indeed, we can acknowledge that many of our implicit associations are based at least in part on fact. The danger, however, is treating an individual—the patient in front of you—as if she fits that stereotype. In fact, she may be the one in 10 who needs your diligent care.
The consequences of treating the patient as if she fits the stereotype can be dire. Biases can impact EMS providers wherever we have discretion in our job. We decide whether to test for hypoglycemia, test for a stroke, or perform an EKG. Some of us might have discretion as to where we take a patient—to the private hospital or to the safety-net hospital.4 We decide whether to provide pain medication and how much. In fact, a number of studies of doctors have documented differing provision of pain medication based on the race and/or gender of the doctor, patient, or both.5,6 Similarly, a recent study examined both pain assessment procedures and pain medication provision on the part of EMS agencies and found racial/ethnic minorities were less likely to receive both, even when other important variables were controlled.7,8
Implications for Practice
All these discretionary decisions could be impacted by our implicit associations and lead to complacency in our medicine, producing failure to act. The University of North Carolina’s William J. Hall and colleagues reviewed research that examined the levels of implicit bias in healthcare professionals and the link between biases and patient outcomes. They found, “Implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes.”9
All of the above represents the bad news. All humans have implicit biases that can affect our perceptions and behavior. In our second column (to appear in the October issue of EMS World), we share the good news: It turns out we can address this. Professions that have recognized how bias might impact the services they provide have implemented training programs to educate their professionals on the ways biases manifest, how they are formed, and the consequences of acting on them. Importantly, these programs provide skills to help individuals reduce and manage their biases. In the next column we’ll discuss these programs and share practical information on how to address your own biases to ensure they do not affect the important work you do.
Resources
1. Hardin CD, Banaji MR. The nature of implicit prejudice: Implications for personal and public policy. In: Shafir E (ed.), The Behavioral Foundations of Public Policy. Princeton, N.J.: Princeton University Press, 2013, pp. 13–31.
2. Devine PG. Stereotypes and prejudice: Their automatic and controlled components. J Personality Social Psych, 1989; 56(1): 5–18.
3. Op. cit., Hardin. For a summary of the research, see Fridell L, Producing Bias-Free Policing: A Science-Based Approach, Springer Publishers, 2017.
4. Hanchate AD, Paasche-Orlow MK, Baker WE, et al. Association of race/ethnicity with emergency department destination of emergency medical services transport. JAMA Open, 2019; 2(9): e1910816.
5. Weisse CS, Sorum PC, Sanders KN, Syat BL. Do gender and race affect decisions about pain management? J Gen Int Med, 2001; 16: 211–27.
6. Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: Pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health, 2012; 102: 988–95.
7. Kennel J, Withers E, Parsons N, Woo H. Racial/ethnic disparities in pain treatment: Evidence from Oregon Emergency Medical services agencies. Medical Care, 2019; 57(12): 924–9.
8. Young MF, Hern HG, Altern HJ, Barger J, Vahidnia F. Racial differences in receiving morphine among prehospital patients with blunt trauma. J Emerg Med, 2013; 45(1): 46–52.
9. Hall WJ, Chapman MV, Lee KM, et al. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. Am J Public Health, 2015; 105(12): e60–e76.
Brad Keating, MPH, NRP, is a fire-medic with Mountain View Fire Rescue, Longmont, Colo.
Lorie Fridell, PhD, is a professor of criminology at the University of South Florida and founder of Fair and Impartial Policing, Tampa, Fla.
