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Wednesday, July 29, 2020

No Matter What, EDs Care for Everyone

BY EDWIN LEAP, MD

I have always loved history, but a lifetime in medicine makes me consider it in more personal ways. When I drive through the Appalachians and see a chimney standing alone by a creek, I wonder how long ago the house fell in or burned, who the last person was to call that place home, if he is still alive, and if there is anyone who knows that his great-grandparents raised a family there by the creek.

I think the same about medicine. I contemplate on lonely mountain roads what happened 70 or 80 years ago when a person was injured, whether in a car, by a horse, or under a falling log. Where was he taken? Down the mountain to a basic hospital? To the house of a doctor? Did he have a chance? Was he remembered if he succumbed to injuries far from home?


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For all the ways that we're imperfect, the modern world of medicine is breathtaking in scope and compassion. Yes, it's expensive, and sometimes we do the wrong things. But on the balance, whatever happens to a person short of death (at least in the United States), he won't be taken to someone's house or left to suffer, and he won't be buried alone in the woods. Odds are he'll end up in some large or small emergency department staffed by our excellent colleagues.

No matter where he is, who he is, how dirty he is, how difficult he is, someone will put him in a room and talk with him. Thanks to compassionate professionalism (and federal law), that care will not be predicated on money or insurance.

However he smells, his clothes will be taken off, and however bloody his wounds, they will be cleaned, closed, and dressed. If he is wildly schizophrenic or his brain is basted in methamphetamine or alcohol, someone will try to calm him, temporarily restrain him for safety, and medicate him.

However depressed or suicidal he is, however many times it has been said before, someone will try to see just how much of a danger he is and decide (yet again, with a bit of cynicism and weariness) if he needs to be committed to a facility. The staff may just decide to keep him in the ED for another day, another assessment, and a few more sandwiches. Sometimes just because he is homeless and has no options.

Hope for All
If that patient is in handcuffs, if he has been arrested for what seems like a terrible crime, he will still have his illness and injury evaluated. Whether it's the pre-incarceration physical due to chest pain, pepper spray in the eyes, or a gunshot wound to the chest, he will be treated appropriately. The same is true for the officer, stabbed, shot, or beaten, who comes to the hospital in the midst of chaos and danger. Every effort will be made to return him to the family he loves.

However our colleagues feel about the T-shirt or tattoo on a patient, however vile the words he utters may be, the physicians, nurses, medics, clerks, and others who populate our world will do the right thing. They are remarkably adept at seeing the person behind the symbology, whatever viewpoint it represents, right or left, red or blue, up or down or sideways.

There were doubtless times in history when a physician would simply look at that difficult, dirty, angry, confused, insulting patient and have him dragged to the curb, cursing and threatening, even if he was bleeding, crying, hurting, or dying. Civilizations in the past seldom had anything like the safety net of our hospitals and our professionals. The weak, poor, and dying simply lied down, looked up at a fading sky, whispered to their deities, closed their tear-filled eyes, ceased their wheezing, gasping breaths, and bled out in the dirt. Then they were dragged away unceremoniously.

That is no longer the way, of course, not since we embraced an idea, a belief that has guided us with increasing clarity for millennia—the fundamental, intrinsic worth of the people who come to us and of every human being. Do we always do this perfectly? Hardly. But as I have worked around the country and watched as men and women working in emergency departments have lavished their time and energy on everyone, have exposed themselves to assault and infection, have worn themselves down for years, given themselves to every kind of person who came through the door, I have come to stand in awe.

The men and women of emergency departments are often as broken and difficult as the most broken and difficult patients. But through it all, no matter what, they put all of that aside and care for the sick, the wounded, the psychotic, the addicted, the violent, and the dying.

This is an expensive ethos in monetary terms, but it is priceless in terms of the humanity it conveys to society's bottom rungs, and it elevates and gives hope to us all.

Dr. Leap practices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available at www.nursingcenter.com, and Working Knights, Cats Don't Hike, and The Practice Test, all available at www.booklocker.com, and of a blog, http://edwinleap.com/. Follow him on Twitter @edwinleap, and read his past columns at http://bit.ly/EMN-Emergistan.

Wednesday, July 22, 2020

Confronting the Racism Epidemic in Medicine

BY RICHARD PESCATORE, DO

The country is grappling with an unprecedented public health crisis in COVID-19 while it also struggles with another long-standing health care emergency. The systemic racial injustices that plague our country are visible within the COVID-19 landscape, which has disproportionately affected communities of color—black and Latino patients in particular. Data from major cities have shown the brutal effects of the coronavirus on minority populations.

But even as COVID-19 shines a glaring light on health inequities and disparities, the effects of racism on American health care and public health remain pervasive throughout our culture and require a reckoning by physicians and scientific leaders.

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The eruption of protests and civil rights movements following the death of George Floyd has incited a long-overdue nationwide introspection and necessitated a reconciliation of our values with our actions. As a physician, public health official, and communicator, I considered retreating from the conversation, using science and apolitical objectivity as a bulwark and excuse for silence.

But the respect afforded our profession bears with it an obligation to add to the chorus of voices speaking out against the glaring disparities and injustices laid bare, and to remain silent is to condone. We are inherently political actors, our silence often as loud as our words.

All Strata of Care
Inequities in health care among racial minorities take many forms. Minority communities have higher rates of chronic disease, maternal and child morbidity and mortality, and overall costs of care, all in part a result of diminished access to health resources. Structural racism compounds the health effects of poverty by concentrating its harm in racially segregated neighborhoods with limited health care options.

The direct and indirect effects of racism saturate all strata of medical care, and are linked to disparities in treating disease and the documented disenfranchisement among patients and physicians.

Black and Latino patients are taken to different emergency departments compared with their white neighbors. (JAMA Netw Open. 2019;2[9]:e1910816; https://bit.ly/37lvMj8.) Black patients in the emergency department are markedly less likely to get an ECG for chest pain than non-black patients, and they have a 66 percent greater chance of not receiving pain medicine for a long bone fracture than white patients. (Acad Emerg Med. 2007;14[2]:149; Ann Emerg Med. 2000;35[1]:11.)

Black infants in the United States are more than twice as likely to die as white infants, a tragedy intertwined with rising rates of preventable deaths among their mothers, whose pregnancy-related mortality has climbed to nearly four times that of white women. Black patients are more likely to die whether disease strikes when it is early and treatable or late and serious. (N Engl J Med. 1999; 341[16]:1198; https://bit.ly/30z8LIq.)

A Social Contract
The task of confronting structural shortcomings and biases within medicine seems overwhelming at times, but we must begin by recognizing the existence and impact of racism within our own institutions. The medical community must seek more opportunities to ensure the voices of people of color are heard.

Recruiting and hiring physicians and administrators of color, funding and amplifying research on the health issues in underrepresented communities (particularly research by those who are from such communities), training medical professionals to recognize implicit biases that prevent some patients and their families from being truly listened to, and engaging in the national discourse to raise awareness of these issues. These reforms must be part of a broader overhaul of the system that makes health care more accessible and equitable for all.

We cannot practice good medicine without taking into account those social factors and contexts that are inextricably linked to our patients' outcomes and our own profession. Our obligation to our patients and the progression of medicine extend beyond the walls of the emergency department, a social contract inherent in our medical school diplomas that compels us to advocate for the conditions that lead to the best health outcomes for all.

We must recognize that what we say as doctors is still held as intrinsically meaningful by the public, amplified by the eroded but still present trust in which our profession is held. We cannot simply choose to ignore injustices that exist because the failure to recognize the structural violence, racism, and discrimination in our society is to sacrifice what dwindling moral footing the profession of medicine holds in the public's eye.

Dr. Pescatore is the chief physician for the Delaware Division of Public Health and an emergency physician in New Jersey and the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine: http://bit.ly/EMNLive. Follow him on Twitter @Rick_Pescatore, and read his past columns at http://bit.ly/EMN-Pescatore.

Wednesday, July 15, 2020

The Racial Biases Lurking in Our Subconscious

BY SANDRA SCOTT SIMONS, MD

American society is deeply fractionated, and racial inequality is more pervasive than many of us believe or admit. We physicians can no longer turn a blind eye to racial disparities in our health care system. Acting like everyone is treated equally disrespects the struggles of our minority patients and allows us to continue in blissful ignorance instead of trying to do better. We must start trying to change any discriminatory care within our control.

Of the many opportunities to diminish the struggles of minority patients, the one most within our control may be addressing the detrimental effects of unconscious racial bias, to which none of us is immune. I wrote last month about how unconscious bias infiltrates clinical encounters, resulting in discriminatory care. (EMN. 2020;42[7]:1; http://bit.ly/EMN-ERGoddess.)

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  Photo by
Sandra Scott Simons.

EPs are vulnerable to implicit bias because what we do requires rapid pattern identification and categorization of people we have never met to diagnose medical problems swiftly. Under the time constraints and high cognitive demands of a busy ED, we are more likely to make snap judgments based on subconscious stereotypes we've internalized. This puts us at risk for statistical discrimination—applying population statistics to conclude that something true about some members of an ethnic group is also true for the patient in front of us, even when that is not supported by anything the patient says or that is in his chart. Such discrimination is not intentional. It's natural for our minds to generalize and simplify input to reduce our cognitive load when we are bombarded with complex stimuli.

Fortunately, unconscious prejudices are malleable. Once we're aware of the automatic cognitive processes that lead to inadvertent discrimination, it's possible to change if we're willing to work at it. When physicians recognize their own unintentional bias, they are able to neutralize its impact on treatment decisions. (Matthew, D.B. 2015. Just Medicine: A Cure for Racial Inequality in American Health Care. New York University Press.)

Physicians in one study who knew the research was evaluating the influence of implicit bias on clinical decisions were more willing to prescribe thrombolytics to black patients than physicians who were unaware. (J Gen Intern Med. 2007;22[9]:1231; https://bit.ly/37fXEoU.) Encouraging personal awareness of the racial biases that lurk in our subconscious is the first step toward overcoming their effect on our clinical judgment and conduct.

Neutralizing Bias
We owe it to our patients to combat systemic racism by taking the next step too: incorporating and teaching active strategies for neutralizing bias. Just as we learn negative stereotypes through repeated exposure, we can learn to reduce the activation of ingrained stereotypes through repeated exposure to new and positive counter-stereotypes. One study found it possible to reduce negative attitudes by more than 50 percent by repeatedly showing participants photographs of famous and admired black people such as Martin Luther King or Denzel Washington and photographs of infamous and disliked white people such as Charles Manson. (J Pers Soc Psych. 2001;81[5]:800; https://bit.ly/3f5VdYL.) Video images of black people engaged in positive activities such as going to church or enjoying a family barbecue also reduced implicit bias. (J Pers Soc Psych. 2001;81[5]:815; https://bit.ly/3dOSO4q.)

Understanding the benefit of counter-stereotypical images, the Virginia Museum of Fine Arts in my hometown of Richmond recently commissioned a statue of a young black man to counter the city's statues of white Confederate generals, helping to reset pervasive stereotypes.

Counter-stereotypes do not need to be externally introduced; they may also be internally generated by one's own deliberate imaging. This is priming, a phenomenon in which exposure to a stimulus, such as a word or an image, influences behavior by triggering conscious or unconscious awareness of a specific attribute. Intentional priming with stereotypes has been proven to affect social behavior.

We can combat unconscious racial bias by thinking about positive counter-stereotypes of minorities. The next time you head to a minority patient's bedside, prime yourself with thoughts of admired members of that minority. We still have a long way to go to dismantle systemic racism, but strategies like these are at least baby steps in the right direction.

Strategies that stress ignoring differences rather than eliminating and replacing stereotypes simply don't work. Merely instructing people not to think about race backfires and actually causes an increase in implicit bias. (J Pers Soc Psych. 2001;81[5]:8; https://bit.ly/3f7UwhD.) Saying things like, "I don't even notice race" is not positive; thinking and talking about race is required to overcome bias.

Cultural Sensitivity
Medical schools have taken positive steps by funneling time and money into cultural competency training to counteract bias. What medical students learn in the classroom does not counteract transferring bias to them at the bedside, however. Senior physicians modeling racist behavior on the wards—even if it was an unintentional manifestation of implicit bias—can rapidly undo cultural sensitivity training in the classroom.

A concerning study showed that the decision-making of physicians who were farther along in their training was significantly more tainted by implicit bias than the decision-making of incoming first-year medical students. (JAMA. 2011;306[9]:942; https://bit.ly/2YoCK38.) This raises a legitimate concern that the egalitarian objectives in medical school are at war with the clinical education our future doctors receive.Groupthink affects us all. When it comes to unconscious racism, our colleagues' views matter more than we realize. Studies show that negative implicit attitudes and behaviors were greatest for students who believed their views were widely shared. Just as bias can spread from senior to junior physicians, willingness to denounce ingrained negative stereotypes can also spread. People are more likely to inhibit racial prejudice when feedback indicates that the majority of others disagree with racially prejudiced opinions. (Pers Soc Psych Bull. 2001;27[4]:486; https://bit.ly/3f81svf.) Because social consensus can reinforce or diminish stereotypes, we can start breaking the cycle of bias by setting a better example. If a colleague makes a racist joke, call him out. If a minority voice is being ignored, highlight it so others will listen. Together we can propagate another narrative.

Ask yourself why most physicians are white and most patients are black in so many urban hospitals in our country. The old narrative was that white physicians worked hard or were smart. Perhaps the narrative should be that racism creates disadvantages for people of color and advantages for white people that make success easier to achieve. Perhaps many of the benefits we've enjoyed in life are the direct result of someone else not having the same benefits. Yes, becoming a physician was a result of my drive, but that doesn't mean that minorities without the same achievements don't have the same drive. The reality is that racism puts the starting line much farther back for some, making it much harder for them to cross the finish line.

It's painfully clear from everything that's happened so far this year—from COVID-19 disproportionately affecting people of color and the protests prompted by George Floyd's death and the deaths and mistreatment of many other black people—that it is time for all of us to start making intentional efforts to correct our own unconscious racial biases. We can only neutralize them when we acknowledge the ubiquitous effects of these implicit biases. Don't turn the page and ignore the issue. Inaction is action too. The fact that this article likely made a few people uncomfortable or even indignant is precisely why we need to continue this discussion.

Dr. Simons is a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns at http://bit.ly/EMN-ERGoddess.

Wednesday, July 8, 2020

Restraints and Restraint

BY GRAHAM WALKER, MD

I have been grabbed.

I have been spat on.

I have been punched.

I have been kicked.

I have been bitten.

I have had feces kicked at me.

I have had urinals—full ones, mind you—thrown at me.

I have been called every rotten name you can think of. (My patients can be creative.)

My life has been threatened by patients carrying weapons.

I do not carry a weapon on me.

Lucky for me, I have not been hurt in any of these instances. Others in our field have not been so lucky.

Lucky for me, I had co-workers (nurses, doctors, security) in all of these instances to help protect me and to restrain:

The patient who was drunk.

The patient who was high.

The patient who was psychotic.

The patient who was angry.

The patient who was in pain.

The patient who was under arrest.

The patient who was lying.

The patient who was hungry.

In all these instances, we were able to restrain the patient, usually through a combination of chemical sedatives and physical restraints.

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Occasionally, someone sustained a minor injury while helping to protect me: a thigh contusion, a sprained wrist, a concussion. Luckily, nothing more. Others in our field have not been so lucky.

Restraining a patient has been identified as such a high-risk procedure in medical care (for the patient and provider) that it comes with the most powerful of physician and nurse requirements: paperwork. Here I am, a physician with nine years of schooling, four years of training in emergency medicine, and almost 10 years of attending experience, and I have to attest that the restraints I'm using are properly and safely placed. I must explain why exactly I've decided to order restraints.

If something went wrong—the patient had a seizure, aspirated, or said, "I can't breathe"—I can't really think of any person more qualified to respond than an emergency physician. If there were a bad outcome—or god forbid a deaththe case would be closely scrutinized by no less than 100 people, I'd imagine, including my peers and people who know nothing about me, nothing about the specifics of the case, nothing about emergency medicine at all.

So, please, someone, anyone, explain to me why my restraint requires paperwork, reassessment, documentation, and constant attention in my hospital, but seemingly none of that is required when an officer of the law kneels on a black man's neck for eight minutes and 46 seconds?

Why is it taking the death of George Floyd—and Manuel Ellis and Eric Garner before him, as well as countless others—for us to realize that restraint (particularly restraint of the neck) can kill people, and it is only now starting to be banned?

Eric Garner died in July 2014. The Eric Garner Anti-Chokehold Act was passed by the New York State Assembly in June. June 2020. Why is it that doctors and nurses can manage to restrain a patient with Velcro, not a knee on the neck or a chokehold to the throat, but police need to use lethal force?

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at http://bit.ly/EMN-Emergentology.

Read all of EMN's breaking COVID-19 coverage at http://bit.ly/COVID-19-EMN.

Stay updated on our new COVID-19 articles by following us on Twitter @EMNews.

Wednesday, July 1, 2020

Racism: The Elephant in the ED

BY ITALO M. BROWN, MD, MPH

Difficult conversations are an occupational hazard in emergency medicine. We accept that they are part and parcel of the specialty and invite the discomfort, for better or for worse.

When radiology calls characterizing a new lesion, we assume the responsibility of sharing those findings with our patients and factor in the gravity of the discussion. We show our compassion by standing with families who practice different religions from ours as they pray over a declining loved one. We deliver the heart-wrenching news of fetal demise to an expectant mother with complete cognizance of the emotions we may trigger. And we explain to the weary son or daughter that their ill parent unfortunately did not survive despite our best efforts, and we remain in their presence for the fallout.

We anticipate these circumstances and conjure our prior training to navigate them confidently. Our tone, posture, and gestures—the entire gamut of verbal and nonverbal cues—are rehearsed down to a science. We make a preemptive decision as emergency physicians to lean into discomfort even when it is to our own detriment. When it comes to racism, racial inequality, social injustice, and the various ways that each affects our specialty, however, we yield.

This has historically been perceived as a volatile dialogue, and it is often driven to the outskirts of emergency medicine to remain unaddressed. But for whose comfort, or more importantly, for whose benefit? This dialogue aligns with evidence-based practice. We know the downstream effects of explicit and implicit biases. We are familiar with the multitude of studies that demonstrates worse health outcomes for black men and women in comparison with their white counterparts. (The New York Times. Jan. 13, 2020; https://nyti.ms/3dMk8PY.)

We understand the literature on the mismanagement of pain symptoms (Pain Med. 2012;13[2]:150; https://bit.ly/31tMFaC), mistriaging of black patients (Medicine. 2016;95[14]:e3191; https://bit.ly/2CMINah), and preferential prehospital services. (JAMA Netw Open. 2019;2[9]:e1910816; http://bit.ly/36OZQCp.) The evidence of racial health disparities continues to mount as COVID-19 decimates communities of color across the United States. From a societal vantage point, and more finely within the practice of emergency medicine, the discussion of race, racism, and inequality has become unavoidable. Yet we continue to deprioritize it. These topics are difficult to broach for a few reasons.

Emergency medicine is not as racially diverse as we think. Black men and women comprise about 13 percent of the U.S. population and are among the highest utilizers of emergency department services (of note, this is due to the greater likelihood of underinsurance or lack of primary care). (Int J Health Serv. 2018;48[2]:267.) Black people comprise roughly five percent of all U.S. physicians, however. (AAMC. Fig. 18. July 1, 2019; https://bit.ly/3cx5e08.) The nature of our work supports the illusion that our field is diverse (i.e., service to marginalized communities, interaction across all ethnicities and socioeconomic statuses). Yet the disparity among providers indicates otherwise. Without adequate representation, conversations about racism are chronically placed on the back burner.

This challenges the culture of medicine at a foundational level. We struggle as physicians to acknowledge that racism is woven into the fabric of medical education. Our understanding of BMI, for instance, is based on the body types of white men. The beliefs that black patients possess thicker skin and have higher thresholds for pain are a direct result of the eugenics movement of the 1920s, but medical students and residents expressed similar false beliefs as recently as 2016. (PNAS. 2016;113[16]:4296; https://bit.ly/2VqFRGL.) The principle of nonmaleficence in medical ethics was formed to combat inhumane research practices; historically, black people are overrepresented among subjects. (The New York Times. Jan. 13, 2020; https://nyti.ms/3dMk8PY.) These along with other prejudices subconsciously shape the lens through which we view our patients and our peers. Moreover, we would be forced to admit that our training is inherently biased.

Cognizance will warrant action. Emergency physicians identify life-threatening causes of illness and infirmity. If racism is identified as a root cause of mortality for black men and women, there will also be an obligation to address it. Emergency physicians are wired to think downstream and to advance care. In that vein, our awareness of racism is a one-way valve; we wouldn't just be encouraged to act, but rather, it would be a call to action. Our pragmatism would extend this action beyond an academic or thought exercise. In fact, it would drive us to change behaviors at all levels.

We are risk-averse when it comes to difficult conversations on racism, racial inequality, and social injustice. It is as though we fear disturbing the comfortable equilibrium established across the field, but these conversations are essential to the evolution of our specialty. Emergency medicine is unique because we do not get to hand-select our patients. By definition (and by mandate), we accept every creed, color, and character. Those who present to an emergency department are entitled to optimal care by the team that receives them. In eschewing dialogue on the racial prejudices and biases that frame our reality as physicians, however, we have failed to deliver the full dimension of optimal.

We chose to care for patients at the fringes of society and operate at the intersection of critical social issues. Not only is engaging in this conversation in our best interest, but there is a clear, data-supported value proposition—the vast improvement in health outcomes for black men and women. We should strive to be thought leaders in this space, from acknowledging our own racial biases and improving the systems that are subject to bias to supporting legislation and policies that seek to lessen the impact of these systemic inequities.

If we truly wish to advance the specialty, we need to figure out how to tackle racism internally and externally. Yes, it will likely be wrought with discomfort, awkward moments, debate, and an inevitable struggle for common ground. Fortunately, we have our 10,000 hours of practice and preparation to fall back on. If we treat the difficult conversation of racism with the same gravity as the unsettling news we deliver within the ED, then maybe it becomes a priority. Maybe we won't have to act like there's an elephant in the emergency department.

Dr. Brown is an emergency physician and an assistant professor in social emergency medicine at Stanford Hospital. He is also the chief impact officer of T.R.A.P. Medicine, a barbershop-based wellness initiative that leverages the cultural capital of barbershops to address the physical and emotional health of black men and boys. He also served with the ABC News Medical Unit, and has contributed health equity and wellness pieces to The New York Times, USA Today, GQ, and The Root. Follow him on Twitter @gr8vision. Read his articles at https://bit.ly/EMN-DiversityMatters.