Racism in the ER: Black Kids Get Shortchanged

A new study shows huge differences in how people are treated.

Photo by Shutterstock

By Sheryl Estrada

Photo by Shutterstock

Photo by Shutterstock

Black youth suffering from acute appendicitis who visit an emergency room in the U.S. will most likely remain in intense pain.

According to the study “Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments,” published on Monday in the Journal of the American Medical Association’s JAMA Pediatrics, racial differences do exist in the administration of analgesia or painkillers.

“There has been literature documenting racial disparities in the pain management of adults,” lead author Dr. Monika K. Goyal of the Children’s National Health System in Washington, D.C., told DiversityInc. “Our goal was to determine whether these racial disparities also existed in the care of children.”

Goyal said she and her team specifically chose appendicitis because “it is well regarded as a painful surgical condition, and management of pain, specifically with opioids, is one of the mainstays of treatment.”

Using data from the National Hospital Ambulatory Medical Care Survey from 2003 to 2010, the researchers analyzed data of almost one million patients age 21 or younger, including the variables of race, ethnicity, age, gender, insurance status, triage level and pain score.

Goyal and coauthors note that in the past there were persistent perceptions among clinicians that administering painkillers may mask symptoms, leading to diagnostic delays. However, several randomized trials have shown those concerns to be unfounded. And there are protocols to ensure children do not overdose or become dependent on the medication.

Yet only 56.8 percent of youth evaluated in emergency departments diagnosed with appendicitis received pain medication, and about 41.3 percent received at least one dose of an opioid, such as morphine and fentanyl.

Black patients in severe pain were 80 percent less likely than white patients to receive opioids for their pain. Approximately 21 percent of Black patients, compared to more than 40 percent of white patients, received opioids. Black patients with moderate pain were also less likely to receive any pain medication compared to white patients.

Moderate pain

(Credit: From “Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments”)

Goyal’s team wrote that while clinicians may recognize pain equally across racial groups, they may be reacting to the pain differently by treating Black patients with painkillers, such as ibuprofen and acetaminophen, while treating white patients with opioids for similar pain.

Severe pain

(Credit: From “Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments”)

“This analysis by pain strata suggests that there may be a higher threshold of pain score for administering analgesia to Black patients with appendicitis,” the authors wrote.

Goyal said she was surprised the results of their research demonstrated such dramatic differences in opioid administration by race.

“We assess pain scores in the emergency department, meaning, we ask patients to rate the pain they are experiencing,” Goyal told DiversityInc. “We should be responding to the pain scores the patients provide us.”

The current study was not designed to understand why these disparities exist, so Goyal and her team are planning studies to further delve into the topic in order to “help inform the development of interventions to achieve health equity.”

“I believe that the causes of such racial disparities are multifactorial,” she explained, “which include both conscious and unconscious bias, institutional practices, parental preferences, and societal expectations.”

Dr. Imani Jackson Rosario is a clinical instructor at Rutgers New Jersey Medical School in Newark, N.J., who served as director of the Urology Residency Program. She agreed with Goyal’s perspective and said socioeconomic inequality and racial bias contribute to the disparity.

“Hospitals serving minority communities are often underfunded and understaffed,” Rosario told DiversityInc. “They serve a low-income population of patients who are uninsured or underinsured, which affects the hospital’s bottom line. These hospitals often operate under a deficit, which affects equipment purchasing and staffing, which ultimately affects quality of care.”

In regards to racial bias, she said, “There is data that shows medical professionals, including and often specifically doctors, carry personal biases related to culture and race that influence the way they care for patients. This phenomenon is well documented and this most recent study is further evidence of the problem. There has been a concerted effort, though more effort is needed in my opinion, to address this problem at the level of medical student education.”

The Institute of Medicine of the National Academy of Sciences has called for more studies looking at the role that the unconscious behavior of doctors plays in health care.

Goyal explained racial disparities in health care are also a societal issue.

“We are all accountable for these disparities,” she said. “I hope that our work makes us acknowledge that these disparities exist and motivates us to all work towards creating a more equitable health care system.”

She noted organizations participating in a movement in health care to eliminate disparities.

“The American Association of Medical Colleges has developed an initiative for health equity,” Goyal said. “The National Institutes of Health have an Institute on Minority Health and Health Disparities, the Institute of Medicine also has an initiative to reduce health disparities and the Center for Disease Control and Prevention’s Healthy People 2020 [agenda for improving the nation’s health] includes achievement of health equity as one of its goals.”

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  • Greg Thrasher

    The pervasive nature of racism in our nation towards Black Americans has been a centuries old reality.

    We still are impacted by the racial holocaust White America inflicted on us.

    Our very existence remains a daily challenge.

    Greg Thrasher
    Plane Ideas
    Alternative Think Tank

  • I have personally experienced this as a Black person with sickle-cell anemia. It’d be bad enough to be in intense pain, but I also had to sometimes deal with the attitudes of the medical staff thinking that I was drug-seeking. It was horrible. I was both physically and emotionally in pain. I think the reason that they relented and gave me medication was because they found that I hadn’t been to the ER in months. It’s a terrible experience that no one should have to go through. Medical students definitely need to be trained in how to be more empathetic no matter who their patient is. One would think though, that this would already be a part of the curriculum.

    • Vangy I imagine you experience this often. My sister suffered from Sickle-Cell anemia and although there was a protocol on file to administer certain medications once she arrived in the ER, these would only be done hours later once a family member raised the alarm. I could arrive with her, complain about not applying the protocol, threaten to call the local TV stations THEN she’d receive some of the medication never nearly enough. I also mention, she would attend a hospital with a Sickle-Cell Clinic and still receive the same lack of treatment; no one should ever have to experience that type of neglect.

      It’s not a lack of training, it is the bias.

      • Yes, Jai, I totally agree with you that it is bias. I didn’t get help until my mom raised a fuss – and this was well into adulthood! One HAS to have someone there to advocate for them. It should not have to happen this way but it does. I only say that cross-cultural training is important because I found that some medical staff have a lack of awareness of what a patient might be going through. They have to learn to deal with each patient as an individual as opposed to assuming that they know what’s going on because of who the patient is. However, I have to say that while I was away at school in Indiana, where they had very limited experience with SSD, I was treated with the utmost care and concern. You would think that these “Bible-Belters” wouldn’t understand, but what they lacked in experience with the disease they more than made up for in empathy and kindness. I think how the hospital staff treats patients reflects their own experiences in that town/city. If there are a lot of people who are drug-seeking, they are told to watch and withhold medicine, and unfortunately, everyone suffers because of the badly-behaving few.

  • I am not surprised at the study findings. I have seen it many times. While a white child will be attended to, with patience and sympathy: a Black child is often treated as an annoyance. I have watched the way Black as well as Latino people are treated in an emergency room, and it is obvious they are not treated with as much respect as white people are given. Don’t dare come in if you can’t speak English well, you will be treated even worse!
    A nurse told me once, “That Black woman there, she came in with a toothache, we aren’t going to give her anything; she needs to have it pulled. Lot’s of people like her come in and expect us to give them pain medication; we have to look at them, but we aren’t going to give them anything”.

  • I can’t say this has been my personal experience. In one hospitalization for a condition that is considered painful, I was constantly assessed (I didn’t want any). As an aside, while I was waiting to be taken upstairs, I overheard a husband (white) arguing for more pain meds for his wife, which the staff was refusing on the basis that she had been administered the maximum strength dosage. I’m guessing, but I bet she could have tolerated three times that amount. (The husband seemed used his wife demanding more pain meds.)

    In another instance I was given a morphine pump after surgery. In this case my feeling of pain was unusual, as I felt it as increased anxiety and agitation rather than pain as we are used to it, probably because nerves were generating and sending out wild signals. I recall one nurse wanting to take away the meds because I was barely using it. NO, I want it when I need it. It stayed. One nurse remarked she wasn’t concerned about me being sent home with meds considering my usage in the hospital. So patients do get watched, although I didn’t feel it would have been removed.

    The one thing I do wish I was offered was a decent sleeping pill (that was held back for some bizarre reason when I asked and I decided on some Benadryl to push me over the edge) so I could get some sleep. Hospitals: noisy, noisy, noisy.

    I wonder if my experience is different because a. I have excellent insurance coverage and b. I live in predominately white areas so the medical personnel have not formed policies conscious or unconscious about dealing with large populations of black people. I have an older black male friend (70) who’s doctor did insult him by acting as though he was drug seeking when he asked for something while suffering what later turn out to pressure on a nerve in his hip that was severely disrupting his active lifestyle.

    Despite my personal experience, I’m not surprised by the results.

    • It is the culture of the hospital that determines care. I spent five weeks inpatient uat JFK hospital in Edison New Jersey and the past 16 months and outpatient rehab. They treat everyone with the same care and empathy. I’ve never seen anything quite like it. They are beautiful people.

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