By Mike Taigman and Cheri C. Wilson
An Asian man dressed in a tattered football team T-shirt, worn blue jeans and old tennis shoes collapsed in a liquor store. 911 was called and the first responders started CPR. Paramedics worked through their protocols without result. As they arrived at the closest hospital they said, “Asian male, unknown age, found in cardiac arrest in a liquor store, fine ventricular fibrillation unresponsive to defibrillation or ALS medications.”
After working the arrest for 15 or 20 minutes the hospital staff decided to call it and pronounced the patient dead. The ward clerk found his wallet and opened it to see about notifying the next of kin when she yelled, “Oh my god it’s Dr. XXX.”
The medical director of the emergency department, who had just pronounced the patient dead restarted CPR. They worked him for more than two hours before finally admitting it was futile.
One of the nurses wandered out of the room with tears in her eyes and said, “I’m so ashamed, I thought he was just a drunk in a liquor store.”
Understanding our own unconscious bias
We form ideas in our minds about people based on the color of their skin, hair style, tattoos, piercings, accent, credit score, occupation, perceived disability, gender expression, sexual orientation, political party, the location where we meet them and more. These ideas form instantly, automatically and in unconscious minds where we are not aware that it is happening.
Our distant ancestors relied on these split-second decisions (friend or threat) to keep them alive. While this instinctive mental process still helps protect us from real threats like someone posturing to hit us, it has not evolved to consider differences in people that are not threatening.
Many snap judgments go by unnoticed. Some are irritating. Some have a tangible negative impact on people’s careers. Some cause people to receive substandard medical care. And some result in preventable suffering or death.
“People who engage in this unthinking discrimination are not aware of the fact that they do it,” David Williams Ph.D., Harvard School of Public Health, said.
This dynamic is known as “Unconscious Bias” or “Unintended Bias.” It is a major component of the Institute for Healthcare Improvement’s focus on Equitable Healthcare. Unconscious bias is made up of attitudes, stereotypes and beliefs that affect our understanding, actions and decisions. These biases are activated involuntarily without our awareness or voluntary control.
Unconscious bias in EMS patient care
People with sickle cell disease who are in crisis are one of the best EMS examples of the impact this can have on health care. While there have been cases of sickle cell disease in many races it is much more common in African Americans (1 out of 365) or Hispanic Americans (1 out of every 16,300). People with sickle cell disease are at risk for anemia, infections, acute chest syndrome (like pneumonia), splenic sequestration (sickled cells getting trapped in the spleen), vision loss, leg ulcers, stroke and pulmonary embolism.
Of the many complications associated with sickle cell disease, the most common manifestation of a crisis is pain. This is caused by the sickled cells getting stuck in small blood vessels causing tissue hypoxia and pain, which is sometimes severe. The EMS management of people in sickle cell crisis includes assessing and treating their oxygenation, hydration and pain.
Many of the people in sickle cell crisis have had prior episodes and are knowledgeable about the appropriate treatment. This is where unconscious bias often flares up. A young black man or Latino calls 911 and tells their medic, “I’m having a sickle cell crisis and I need morphine because I hurt real bad all over.”
The image of a drug seeker may pop into the mind of the medic even if they are committed to providing good care for everyone. They look at the patient and don’t see anything that looks serious and of course they can’t see the pain or how severe it is. The care that this patient receives or does not receive largely depends on if the medic is aware of how unconscious bias can inappropriately inform their thinking. With awareness, the medic notices the thought, acknowledges it, and then re-focuses on the reality and the needs of the person they are caring for right now.
We have templates in our minds that help us organize what and who we see into broad categories. We automatically categorize people based on their skin color, hair, accent, girth, perceived gender, age and clothes. The people we meet are automatically mapped into these categories. The meanings associated with that category are immediately activated and influence our interaction with that person. Without awareness, these ingrained habits of thought can lead to errors in how we perceive, reason, remember and make decisions.
Assessing your own unconscious bias
It’s difficult to see into our own hidden bias. Both authors believe deeply in our hearts that we are open-minded, embracing of all kinds of people and are free of bias. It’s likely that those of you reading are wondering what if any unconscious bias may be going on for you.
One way to assess your own situation is to take the Implicit Association Test created in 1998 by three scientists from the University of Washington, Harvard University, and the University of Virginia.
I’m not sure what your results show, but both of us were disturbed to learn that our inclusive belief system did not know about our own unconscious biases. The results have helped us be more vigilant about pushing snap judgments aside to really connect with the person we are with, rather than the story our unconscious mind would have us believe. Although this test is not an exact science and there are critics of it, it can be a useful tool to improve awareness and relationships.
Another way to explore how your mind works is to notice what flashes into your mind when you think about a:
- New York lawyer
- Grateful Dead fan
- Volunteer EMT
- Transgender male paramedic
- Stay at home mom
- Vegan Republican
- Drug seeker
- EMS frequent flier
- Guy with a Confederate flag T-shirt
The key learning from this exploration is not to feel bad about yourself, but to become aware of your own biases so you can work to transform them so that they do not negatively impact the people you care for or work with. The most important thing you can do is pause for a moment or two before you act on your judgment. That will likely make your hiring decisions, disciplinary choices, relationships in general and your clinical care more equitable.
“In minor ways we differ, in major we’re the same.” – Maya Angelou
For more information:
Here are three resources to learn more about health equity and unconscious bias:
1. Achieving Health Equity White Paper
2. IOM unequal treatment report
3. Training to erase unconscious bias
This article, originally published April 13, 2017, has been updated.
About the author
Cheri C. Wilson, M.A., M.H.S., C.P.H.Q. is a nationally-recognized subject matter expert on diversity and inclusion, cultural and 
linguistic competence and health equity. Most recently, she served as the Director, Corporate Office of Diversity and Inclusion, at RWJ Barnabas Health in New Jersey. She previously was an Assistant Scientist in the Department of Health Policy and Management in the Johns Hopkins Bloomberg School of Public Health, Hopkins Center for Health Disparities Solutions. She received a B.A. in Russian from Howard University, an M.A. in Russian Area Studies from the University of Minnesota, an M.H.S. in Health Finance and Management from the Johns Hopkins Bloomberg School of Public Health, and was a Ph.D. candidate (ABD) in Russian history at the University of Minnesota. She is a Certified Professional in Healthcare Quality and Past President of the Maryland Association for Healthcare Quality.
