Black hospital patients are more likely to face a security emergency response call in hospitals than their White counterparts, according to a new study published in The Journal of General Internal Medicine.
The paper is the latest in a flurry of publications that have showcased Black patient inequity in hospital systems across the country. From bias in medical records to worse safety outcomes in hospitals, to being more likely to die from a COVID-19 infection, Black patients face more barriers and risks in hospitals than White patients.
Yannis Valtis, a senior resident of internal medicine and pediatrics at Brigham and Women’s Hospital and lead author of the paper, said that the study was prompted by the 2020 murder of George Floyd and subsequent peer discussions among a group of residents about police violence.
“The group felt that it was important to also turn our eyes inward and ask, what are ways in which we might interact inequitably or unjustly with our Black patients inside the hospital?” Valtis said.
The study, which analyzed data from 24,212 patients between September 2018 to December 2019 at Brigham and Women’s Hospital, found that Black patients are 1.37 times more likely to experience a security response than White patients.
The publication follows two 2021 studies which found that Black patients were more likely to face physical restraints in emergency departments than White patients. One, conducted in Massachusetts, found that Black and Hispanic patients under an involuntary emergency psychiatric hold were physically restrained at higher rates than White patients. The other, which gathered data from three hospitals in the Yale-New Haven Health system, also found that Black patients were more likely to be restrained than white patients in the emergency department.
Security emergency response calls are typically ordered when staff feels that a patient poses a threat to themselves or others, a definition that Valtis says is “broad” but necessary due to violent threats against nurses and doctors. Workplace violence in healthcare has been increasing over the past decade, a statistic recently cited in a BWH press release. Security officials are usually a mix between security guards, who are trained to de-escalate situations, and police officers, according to Valtis,
Although the study was not designed to “elucidate a mechanism” and did not involve interviews with patients or staff, the authors have several hypotheses about the results including implicit bias and racism.
“I think that there's a lot of studies out there that show that healthcare workers do carry implicit or unconscious biases … I don't think this is unique to the healthcare field in any way,” Valtis said. “Historically, there has been structural racism in the healthcare field that might lead to staff members perceiving a Black patient as threatening.”
Other hypotheses include Black patients harboring past negative healthcare experiences in hospitals, potentially heightening negative scenarios, he said, adding that racially charged language used in electronic medical records could have also contributed. A January study found that negative descriptors like “noncompliant” and “aggressive” are disproportionately used in Black and minority patient records.
Unlike the 2021 Massachusetts study, the recent paper found no statistically significant correlation between race, ethnicity and physical restraining. The results could show a lower threshold to call security on Black patients, with hospital personnel potentially de-escalating situations or eventually realizing that patients don’t pose an “actual threat,” Valtis said. Physical restraints are also more complex decisions that can involve agreements between doctors, nurses and security and are only used as a last resort, he added.
“So maybe taking more time to consider the decision [to restrain] and bringing more people to consider the decision makes it less likely that bias and racism will guide the decision,” Valtis said.
Black patients face a risk when entering hospital systems in which they are the minority, said Gail Christopher, executive director of the D.C.-based nonprofit the National Collaborative for Health Equity. Hospital systems are still “woefully lacking” in physicians of color and other high-level staff roles, she said.
“Whenever you're in a system like that, particularly a medical system where as soon as you show up you’re vulnerable and showing up in need, then you're at risk for individual biases being expressed,” Christopher said. “And because you're vulnerable, and others have authority, either the authority over your body as a physician or the authority over your behavior as a security person, then you're vulnerable to the manifestation of those biases.”
Risk and vulnerability in hospitals is so prevalent that Christopher advises patients of color not to go into medical systems alone.
“And that’s sad that we live in such a time,” Christopher said. “But it’s the truth.”
The Collaborative recognizes that healthcare disparities can’t be fixed only by hospitals, the public sector, or other single entities, the executive director said. Instead, the non-profit takes a multi-prong approach to eliminating racism including a curriculum called TRHT, a five-pillared strategy including narrative change, racial healing and relationship building, segregation and separation, law and economy.
Brigham is trying to address healthcare disparities by running anti-racism and trauma-informed de-escalation training in the emergency medicine department. The program, which was funded by a 2020-2021 internal department grant, developed pilot training for interdisciplinary groups to de-escalate patients in a more unbiased way. The program is currently ongoing and has trained about 120 staff members with the goal of training approximately 500 staff, said Dana Im, director of quality and safety at Brigham’s emergency medicine department.
The training provides safe spaces for staff to ask questions and analyze the data, Im said. Sensitivity is a factor as well, the director said, adding that the study results were “really hard” and “difficult” to hear for staff.
“It’s tough to be having these conversations, but they’re so important,” Valtis said. “At the end of the day it’s just important for us to keep in mind that we're doing this to take better care of our patients.”