New study finds racial disparities in ER care
Poor, Black men are more likely to be restrained by staff
Using their own hospital’s data, Connecticut emergency room doctors have published a series of studies showing that patients in the emergency room are more likely to be chemically or physically restrained if they are poor, Black or male.
“There is statistical significance to show that Black individuals and specifically Black men have higher odds,” said Ambrose Wong, an assistant professor of emergency medicine at the Yale School of Medicine, an emergency physician at Yale New Haven Hospital and an author on all three studies.
Wong explained that he and his fellow researchers attempted to filter out the statistical noise. They did not compare psychiatric patients to those with broken arms, for example: “If you take an individual and you control for them coming for the same reason, under the same circumstances, or at least very similar circumstances, if you are Black, then, unfortunately, you’re more likely to have a physical restraint during your stay.”
The numbers aren’t huge, though they are statistically significant. For example, if you’re Black, you are 1.13 times more likely to be physically restrained and 1.43 times more likely to be chemically restrained. People on Medicare are 1.67 times more likely to be physically restrained than patients with private insurance, and people without a permanent residence are 1.35 more likely than people with homes.
But Wong said very often, people aren’t one thing or another. There’s the question of “intersectionality.”
“You come in, and you’re not just a Black person and nothing else, but you’re Black, homeless, and uninsured, for example,” he said. “These things add up for
each other.”
The trend is true for children, too. A Black child under 16 is 1.8 times more likely to be physically restrained. Black boys are 1.95 times as likely, and children between the ages of 10 and 16 are 4.43 times as likely.
“I applaud the clinicians and researchers who looked into the data within their own organization to uncover these issues,” said Tiffany Donelson, president and CEO of the Connecticut Health Foundation. “I’m sure these were not the results they were hoping to find, but the only way to assure we can improve care for everyone is to look at the data, take a hard look at the problems, and work to make changes to assure that everyone receives the best care possible.”
“The authors are correct that documenting inequities is important but not enough; it’s critically important to find interventions to eliminate these inequities,” she said.
‘I am that person on the stretcher’
One of the doctors responsible for those studies was Isaac K. Agboola, who, before they were published, released a paper titled “‘The coats that we can take off and the ones we can’t’: The role of trauma-informed care on race and bias during agitation in the emergency department.”
“I feel deeply conflicted when I have to restrain a patient who looks like me,” Agboola wrote in that paper. “I am a 5-foot 10-inch, 195-pound, athletically built Black man. If you take away my white coat and stethoscope, I am that person on the stretcher. It scares me to know that I am a wardrobe change away from being someone who can have his civil liberties stripped from him in an instant.”
Agboola was, at the time, a Yale New Haven Health resident. He’s since moved on to the NorthShore University HealthSystem in Chicago. He said he was aware of the disparities in restraints before they had analyzed the data, and confronting that reality was the reason for the paper.
“As a Black man, as a Black doctor, it’s a horrible position to be in the situation where you’re feeling like you are a part of that system,” he said. “I could be this person that’s on the stretcher. I could be the person that’s being restrained, who you’ve caught on a bad day who maybe was upset and because of your own personal threat perception because of your own biases. You saw me more as a threat rather than seeing me as who I am in this moment.”
Agboola now works in a more suburban, less diverse environment than New Haven, and he said the experience is far different. Wealthier people do have substance abuse and mental health problems, but they tend to face those problems in the ER less often. There is better access to care.
“That’s not to say that if you’re rich, you don’t have psych issues or drug issues. I just think that you have the means to step in a lot sooner,” he said. “I don’t restrain patients anywhere near as much as I did in training and when I was at Yale.”
Nonetheless, after the research, Agboola said he still feels conflicted when restraining someone who looks like him. The research, he said, “gives you a cause to pause.”
“Being aware that there’s a bias that exists not necessarily with me but with my community that I’m a part of, it just makes you think twice,” he said. “That goes back to some of the importance of research, so that you have that awareness, and you can be like, ‘OK, am I part of the problem here? Am I part of the solution?’”
Structural or specific bias
Wong stressed that the results of his study do not suggest that emergency room doctors are consciously biased.
“By no means am I saying that individual doctors or clinicians are racist or that Yale is racist. That’s a very simplified way of thinking about it,” he said. “I work there myself, and I know these people, I know the system, and I know everyone’s trying really hard to take care of every patient.”
When asked to explain some of the reasons this might be true, Wong said, “I think the answer is we don’t truly know,” calling it a question of “structural racism.”
“I think we can make some theories around why that might be based on a lot of things that are actually ongoing conversations we’re having in society right now in American life,” he said. “It goes everywhere from where you live, what neighborhood you live in, sort of what circumstances are around you when you’re growing up, and the way that, unfortunately, certain groups and certain minorities — Blacks, Hispanics — to a certain degree, potentially have less access to health care, to social services, to upward mobility in American society.”
The practice of medicine, Wong said, whether doctors themselves mean to or not, can “reinforce that bias.”
“All those things sort of feed into what happens when they ultimately come to the emergency department,” he said.
Donelson listed several similar studies from other hospitals showing similar bias.
“These findings are in line with previous research that has identified disparate treatment experienced by people of color,” she said.
“Among people who went to the emergency room with a broken bone, Hispanic patients were found to be half as likely as non-Hispanic white patients to receive pain medication,” Donelson said, citing a decades-old study published by researchers at UCLA Emergency Medicine Center, Los Angeles, Calif.
A 2015 study from researchers at Children’s National Health System in Washington, D.C., found that “among children and teenagers with appendicitis, Black patients were significantly less likely than white patients to receive opioid pain medication,” Donelson said.
“Among patients with heart issues, Black patients were significantly less likely than white patients to receive therapeutic interventions, including those that could prolong long-term survival,” she said, citing a 2014 study by researchers at Ohio State University College of Medicine.
Lou Hart, medical director of health equity for Yale New Haven Health, said often people are not surprised to learn of racial disparities in the hospital, calling it an example of “learned helplessness.”
“We’ve been so conditioned in this society, in this country, to expect certain outcomes,” he said.
Like Wong, Hart does not believe the data is the result of “explicit interpersonal racism” but “structural.”
“Who is more likely to be on Medicaid, who is more likely to be dressed in a certain outfit? Who is more likely to come to the emergency department as opposed to go see their primary care doctor? That has to do with the way we’ve ordered opportunity in our country,” he said. “That’s the institutional or structural issue, and we’re just plain agents. We’re just representatives of systems that have been driving this outcome or have been conditioned to believe that these outcomes are normal.”
Part of Hart’s job is to take data like Wong’s and attempt to alter practices within the hospital setting itself in response. He said there are three pathways to take if you want to effect change.
First is “global education about the disparity,” teaching doctors in a general way that this disparity exists. Then there’s education on the specific department and doctors and nurses who work there, what Hart called “the sectionalized idea that this is happening in your department, and you’re contributing to it.”
The third part of that education is even more personal and granular, speaking directly to doctors about their professional practices, saying, “This is how your clinical decisions are contributing to this,” Hart said.
That brings you back to structural bias because doctors don’t practice in a void. Many patients have been in emergency rooms or mental health facilities before, and many are brought in by police officers who are not trained as doctors or social workers. The emergency room doctor deciding to restrain a patient is rarely the first person to see that patient.
“Who was more likely to have the cops called on them? Who was more likely to have pre-trauma before they even get in your emergency department and thus might be more willing to escalate?” Hart said. “That’s probably not fully appreciated or understood by the doctor or the nurse taking care of them in that moment.”
Donelson said Wong’s studies suggest the importance of “having health care providers collect self-reported data on patients’ race, ethnicity, and language preferences — and then examining the data to see if there are gaps in care or outcomes, and addressing those that are identified.”
A Connecticut state law passed in 2021 “requires health care providers to collect this data from patients, and many health systems and care providers in the state are working together to implement standardized data collection processes within their organizations,” according to Donelson, though she said data collection is only the beginning.
“Having the data to identify when certain patients are experiencing disparate treatment is the first step toward addressing these gaps,” she said.