Addressing the Impacts of Bias on the Quality of EMS Care

Disparities in care continue to impact the quality of care. Some EMS providers may get defensive when they're told that there are disparities in how patients of different races, genders, or other characteristics are treated. They often respond by saying that they're not racist, these studies can't be accurate, and that that type of care disparity certainly doesn't exist in their agency or ambulance. But as several speakers at EMS World Expo pointed out, it does.

To some extent, we are all biased and we all have stereotypes–it’s just how our brains work. And the evidence is clear that there are disparities in care. 

The question is no longer whether we have biases or how they impact patient care. The question is, what are we, as a profession, going to do about it?

A Session on Bias and EMS Education

That was the message from Jamie Kennel and Douglas Randell in their session, titled “A Conspiracy! How Hidden Curriculum and Bias May Be Affecting Our EMS Learners." Although Kennel, program director, and associate professor at the Oregon Health and Science University and Oregon Institute of Technology Paramedic Education Program, covered much of the evidence showing that there are racial, gender, and other disparities in EMS care, the session focused more on why they happen and how EMS educators, leaders, and clinicians can address them. 

Kennel began the session by presenting the research that demonstrates these disparities are happening. Black patients treated by EMS are less likely to receive pain medication than white patients. Black and white patients get transported to different hospitals. Women with obesity are less likely to have their pain assessed or treated. Patients with language barriers receive worse treatment–and EMS clinicians rarely use translation services, even when they’re available and needed.

He presented several theories to explain why these disparities exist. There’s the possibility that some EMS clinicians believe in the existence of biological differences caused by race, even though these have largely been disproven. This may be due to a lack of diversity in the workforce and educational materials, the speakers said, pointing to the low percentage of EMTs and paramedics in the country who are not white and textbooks that overwhelmingly portray clinicians as white.

“How can managers who are all the same make informed decisions about people who are different?” says Randell, who also shared his own experiences as a paramedic and training officer in St Louis and later as the fire department’s EMS division chief in Plainfield, Indiana.

There’s also the influence of pop culture and other sources of stereotypes.

“We’re working under heavy cognitive loads; when we do that we have to make shortcuts, we have to use heuristics,” Kennel said. But when we do that, they come with baggage. They come with bias.”

Actions to Combat Disparities in Care

While there is still limited research on how to mitigate some of these biases and the disparities they cause, Kennel and Randell proposed eleven actions EMS agencies, clinicians and educators can implement. 

1. Educate yourself. Read books such as Medical Apartheid by Harriet Washington to learn more about health disparities and the past and present impacts of structural racism.
2. Bolster policies and make translation more accessible to address caring for patients with limited English proficiency. 
3. Diversify the workforce, including leadership, so it better represents the community it serves. “A [good] idea would be to create a community advisory board. Now you're pulling from the community that you serve, as an educator or as a boss,” Randell said. “And you create this diverse group and you be honest with them. ‘Hey, we're looking for these groups of people. And we're just having a hard time.’”  
4. Use checklists. “Checklists are awesome. Checklists offer cognitive offloading for us,” Kennel said. “Because of that cognitive offloading, they also mitigate disparities in treatment.” 
5. Teach clinicians that race is a social, not a biological, construct 
6. Segment all your QA/QI reports by race to see how your agency is performing 
7. Educate frontline clinicians to properly collect data on race–and why it matters 
8. Track and report on whether race information is collected in patient care reports 
9. Understand and address stereotypes that influence your clinicians’ beliefs. One way to address these, the presenters suggested, is to have people come into the classroom and talk to EMS clinicians about their experiences in the health care system or being treated by EMS. Inviting someone who has previously or is currently experiencing homelessness, for example, to come to share their story can help eliminate negative stereotypes. “And so now your students become more and more comfortable with approaching those different groups,” Randell said. 
10. Diversify your training curriculum and instructor 
11. Confirm that your field training officers are equity champions in both attitude and clinical practice