Policy Playbook: Emergency Medicine & Health Inequalities
- Jul 29th, 2020
- Summer Chavez
Author: Summer Chavez, DO, MPH, MPM (Health Policy Fellow, Georgetown University/Medstar) // Reviewed by: Alex Koyfman, MD (@EMHighAK); and Brit Long, MD (@long_brit)
What’s the issue?
With each shift in the emergency department, we see a small slice of American life. We see anyone, regardless of ability to pay, for any condition, at any time. Many of our patients come to the emergency department because they have nowhere else to turn to. While 2020 has highlighted the importance of emergency preparedness and public health, the recent public demonstrations and protests for racial equality and police brutality reflect something that as medical professionals we have known, sometimes turned a blind eye to and even participated in–medicine is not immune from socioeconomic disparities or the effects of social determinants.
What does emergency medicine have to do with health disparities?
Although 1932 marked the beginning of the infamous Tuskegee study, originally composed of 600 black men, it was not until the late 1960’s that serious questions were raised about its ethics.1 Sadly, portions of the medical community including the Centers for Disease Control & Prevention, National Medical Association and American Medical Association continued to support the study which did not officially conclude until 1972.1 Health disparities and inequalities continue to this day.
Patients presenting with a sickle cell pain crisis, typically seen in the African-American population, experience longer delays to initial dose of analgesia compared to patients with kidney stones in the emergency department.2,3 Compared to non-Hispanic whites, black and Hispanic patients are less likely to receive pain medication in the emergency department and are more likely to be transported to safety net hospitals instead of the nearest hospital.4,5 Black patients have significantly longer lengths-of-stay in the ED, especially those admitted to the ICU.6 Health disparities are associated with an additional $93 billion in medical costs per year.7,8 The literature describes a multitude of other disparities and worse outcomes, but ultimately just recognizance by the medical profession is not enough.6,8
Why is this important?
Throughout our shifts, we advocate for our patients—those who cannot speak for themselves, the marginalized and disadvantaged. Some of these patients are homeless, victims of human trafficking, from jail or in police custody, or face scrutiny due to their immigration status. While the structural characteristics and framework that surrounds health inequities and racism is complex, we would be remiss to say taking an active effort in improving disparities is outside the scope of our duty as physicians. Because health disparities exist and they are associated with poorer outcomes, we should be tackling this issue.9 Instead of continuing to embrace the idea of the emergency department acting as a safety net, we need to be filling in the gaps to create a quilt that reflects our communities and effectively serve our patients.
Where do we go from here? What can I do during my next shift?
- Listen first. Seek to learn from others and understand their experiences. Reflect on past encounters and your behavior.
- Take some time to learn about health disparities. In addition to the Recommended Reading at the end of this post, consider watching Health and Wealth Inequality in America: How COVID-19 Makes Clear the Need for Changefrom the House Committee on the Budget and Prioritizing Equity: The Root Cause from the American Medical Association.
- Be intentional about efforts to reduce health disparities. While this will look different for everyone, some potential ideas include:
- Organize a townhall meeting
- Support your coworkers
- Restructure recruitment
- Join a taskforce
- Implicit bias training
- Cross-cultural education
- Dedicated journal club
- Disparities in Health and Health Care: Five Key Questions and Answers
- Health Care Disparities in Emergency Medicine
- Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
- Centers for Disease Control and Prevention. Tuskegee Study – Timeline – CDC – NCHHSTP. U.S. Public Health Service Syphilis Study. Published March 2, 2020. Accessed June 29, 2020. https://www.cdc.gov/tuskegee/timeline.htm
- Lazio MP, Costello HH, Courtney DM, et al. A Comparison of Analgesic Management for Emergency Department Patients with Sickle Cell Disease and Renal Colic. Clin J Pain. 2010;26(3):199-205. doi:10.1097/AJP.0b013e3181bed10c
- Benderly BL. Fighting Painful Misconceptions About Sickle Cell Disease In The ER. Kaiser Health News. Published January 24, 2013. Accessed June 29, 2020. https://khn.org/news/sickle-cell-misconceptions-and-the-er/
- 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(9):1770-1777. doi:10.1016/j.ajem.2019.06.014
- Hanchate AD, Paasche-Orlow MK, Baker WE, Lin M-Y, Banerjee S, Feldman J. Association of Race/Ethnicity With Emergency Department Destination of Emergency Medical Services Transport. JAMA Netw Open. 2019;2(9):e1910816. doi:10.1001/jamanetworkopen.2019.10816
- Pines JM, Localio AR, Hollander JE. Racial Disparities in Emergency Department Length of Stay for Admitted Patients in the United States. Acad Emerg Med. 2009;16(5):403-410. doi:10.1111/j.1553-2712.2009.00381.x
- Turner A. The Business Case for Racial Equity. Natl Civ Rev. 2016;105(1):21-29. doi:10.1002/ncr.21263
- Orgera K, Artiga S. Disparities in Health and Health Care: Five Key Questions and Answers. Kaiser Family Foundation. Published August 8, 2018. Accessed February 7, 2020. https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/
- Cone D, Richardson L, Todd K, Betancourt J, Lowe R. Health Care Disparities in Emergency Medicine. Acad Emerg Med. 2003;10(11):1176-1183.