Introduction
Emergency rooms (ERs) offer an assorted range of services to a diverse patient population, providing medical care at all hours, catering to immediate health concerns, and supplying primary health care to the urban poor. Private hospitals often redirect uninsured and impoverished patients who cannot afford care to public ERs, which treat patients who are unable to pay typical hospital fees (Lara-Millán 2014). For the urban poor, there are currently few to no viable alternatives available for receiving health care, and when denied the ‘safety net’ ERs provide, this patient population is often left untreated. Therefore, studying the role of demographic features in determining admission and treatment can give insight into the macro- scale sociological conversation surrounding health disparities and provide a mechanism for the cyclical nature of poverty.
While several theories have been proposed to explain health disparities, this review focuses on the processes which contribute to differential access to quality medical treatment, closely aligning with the newly proposed theory of health power resources. Under this theory, those with power and authority consolidate resources to propagate discrimination, consistent with emergency healthcare providers commodifying and take advantaging of their power by both intentionally and unintentionally discriminating against minorities and blocking them from quality health care (Reynolds 2021). This theory ties the study of emergency medical care access to long-term health disparities between races and socioeconomic classes by explaining how power imbalances in ERs create a cycle of disadvantage: minorities have less social power, and thus receive inferior health care, which decreases their quality of life, further eroding their power. This review has two main goals. First, it aims to analyze methods and rates of admission into ERs, as well as obtention of effective treatment, to discover how healthcare providers’ judgment of patient race and socioeconomic status (SES) acts as a barrier to obtaining quality medical care in American emergency rooms among racial minorities (especially African Americans) and the urban poor. Second, discrimination is not an isolated phenomenon; rather, systematic inequality persists due to inequality in serially linked stages of fundamental processes (Korver-Glenn 2018). Thus, this review also aims to determine the combinatory effect of barriers to emergency medicine present along three steps of the admission process: the ambulance ride, the ER waiting room, and treatment (or the lack thereof) inside the ER.
Research Rationale
The United States healthcare system ranks twelfth out of twelfth out of the thirteen most economically developed nations when taking sixteen different health indicators into account – a circumstance which can be attributed to inaccessible treatment (Gutierrez 2018). More than 40 million Americans do not have health insurance, while other Americans are scantily covered under providers such as Medicare, which do not allocate sufficient funds to serious medical conditions (Kronenfield 2007). A disproportionate number of uninsured Americans are racial minorities, as 84 percent of white adults have coverage, compared to 73 percent of black adults and 57 percent of Latino adults (Gutierrez 2018). Unlike private hospitals, ERs must supply care regardless of insurance status, resulting in racial minorities and the urban poor increasingly relying on ERs. Inevitably, provider bias is especially pervasive and potent amongst these populations, and subpar treatment may be the best-case scenario for patients who cannot afford alternative avenues of treatment. As 32% of African Americans have reported instances of physician discrimination, further research into the basis behind provider decisions is necessary (Yearby 2018).
As ER visits increased 27% from 1992 to 2003, studying the quality of care in ERs is of the utmost importance today (Kronenfield 2009). However, past research into health disparities has been unsuccessful in explaining the durability of health inequalities and encompassing the complexities of ER admissions, including the different pathways to entrance and the multitude of checkpoints patients must pass to receive treatment (Shim 2010). Such gaps exist as the unpredictability of emergency medicine poses a unique challenge, rendering tracking individual patients impractical. Thus, medical sociology inherently lends itself to micro-level studies which analyze provider and patient interactions in a single location; however, these studies do not encapsulate the full combinatory effect of discrimination, minimizing perception of barriers to quality healthcare (Hillman 2014; Korver-Glenn 2018). Hence, this review focuses on how discrimination sequentially prevents access to quality medical care in the institution which racial minorities and low-income households rely most on to obtain medical treatment in order to explicate the flaws in the American healthcare system which lead to persistent differential health outcomes of minorities.
Methods in Medical Sociology
The wider field of health disparities uses a combination of database analyses, ethnographic studies, and hands-on experiments to obtain a comprehensive view of the medical field. As healthcare relies on extensive documentation, meta-databases of health information and research grants have been useful tools for sociological analysis, especially when cross-referenced with demographic information obtained from sources such as the U.S. Census Bureau, the Bureau of Labor Statistics, the Bureau of Justice Statistics, the Center for American Women and Politics, and Guttmacher Institute. Demographic information allows researchers to produce maps which depict structural inequality on the state level, while medical meta-databases such as the Behavioral Risk Factor Surveillance System (BRFSS) and NIH RePORTER link these structural inequalities to the health field (Homan et al. 2021). Modern database analyses not only map health inequalities but examine how they are portrayed, focusing whether literature attributes differential health outcomes to poor life choices on the part of disadvantaged groups or to discrimination from advantaged groups (Link and Garcia 2021). These studies can simultaneously provide an exhaustive view of where health disparities are concentrated and be applied to future research on ER-specific health disparities to determine what population the blame is directed towards. Experiments have traditionally determined causal relationships between provider biases and medical decisions. A common experimental technique is subliminal priming, in which providers are exposed to words related to a particular race prior to evaluating fictional case studies, such as medical vignettes expressing ambiguous symptoms, allowing for analysis of implicit biases (Stepanikova 2012). Other studies have evaluated more explicit manifestations of discrimination. In Kugelmass’s 2016 experiment, actors with racially distinctive voices and names recorded messages asking for medical appointments, mentioning the same symptoms and insurance and asking for appointments during weekday evenings. As the recordings only varied in SES and race, the proportion of callers which were offered appointments was indicative of the effect of demographics on access to medicine. While such studies are useful in controlling extraneous factors and pinpointing causes of discrimination which can be applied to this study, experiments (as of now) are not feasible in true emergency settings. The fast-paced nature of emergency medicine makes ethnography combined with interviews a particularly useful method of research, with sociologists first observing medical professionals in ambulance and hospital settings and later asking paramedics, nurses, and physicians to justify their medical decisions (Manzer and Bell 2021). In his 2014 ethnographic study of ER waiting rooms, Lara-Millán conducted observations during all shifts over the normal course of operation, focusing on initial patient assessment and assignment, emergency treatment administered prior to comprehensive examination, selection for bed slots, and reassessments by police and nurses in waiting rooms. Other interviews establish patient perspectives by asking whether respondents or their families needed to see a healthcare provider but could not afford to, the amount of debt, loans, and assets they have, experiences with ambulance and ER staff, and self-characterization of health (Kalousova and Burgard 2013; Schoonhooven et al. 2022).
Ethical Considerations
Patients are considered vulnerable populations and are protected by HIPAA laws; additionally, those in emergency situations are particularly unable to provide consent, as many are either unconscious or in mentally distressing situations. Thus, to maintain confidentiality, only limited patient information should be included in studies (i.e., demographic information, the vague nature of their complaints, and admission/treatment outcomes), and no identifiable information should be disclosed. Furthermore, there are too many actors on medical emergency scenes and in a hospital to receive consent from everyone (e.g., cops on crime scenes where people require medical attention). Thus, to address ethical concerns, ethnographic studies require waiver of consent forms from the IRB and a full board level of review, with possible interviews from board members (Office for the Protection of Research Subjects 2022; Seim 2020). Furthermore, there must be constant coordination with program directors and the administration to ensure compliance with company policies for privacy (e.g., no voice recordings) (Corman 2018). Researchers in all ethnographic settings must maintain a social responsibility to assist the communities which they serve (American Sociological Association 2018). Much of medical sociology is aimed at exposing health disparities affecting a vulnerable population, figuring out how discrimination accumulates through the different levels of emergency care, and discovering
how safety net medical facilities are susceptible to biases, making it possible to eliminate (or at the very least decrease) barriers to receiving quality medicine. However, there are significant ethical concerns associated with observing patients suffer and receive unequal or subpar treatment without intervening in any way. Thus, ethnographers must find the balance between minimal intervention and ethical considerations (Jusionyte 2018).
Theory
For many years, the sociological study of health disparities has been dominated by Link and Phelan’s fundamental cause theory (1995). This theory postulates SES (which is racially and ethnically stratified) directly influences the likelihood of experiencing diseases as it regulates both social factors such as smoking, diet, and exercise and access to resources such as healthy food and information about techniques to ensure well-being. However, this theory has recently been subject to criticism as it places undue emphasis on risk factors prior to contracting a disease while ignoring differential access to treatment, somewhat displacing blame from medical providers. Furthermore, this model has been deemed unsuitable to explain disparities – especially racial ones – in conditions for which preventative resources are universally accessible (Daw 2015). Unlike fundamental-cause theory, which views race and ethnicity as merely modulating factors for one’s SES, modern theories pose race and physically distinctive demographic features (e.g., skin color) as direct contributors to health disparities (Monk 2021). The theory of efficiency-equity trade-offs proposes a meta-mechanism for health disparities in which the scarcity of medical resources requires providers to make decisions which result in the maximization of human life (Daw 2015). Providers consider higher-status individuals as more deserving of treatment as they provide more meaningful contributions to humanity due to the nature of their work and have inherently longer lifespans due to situational factors. Thus, providers prioritize treating and developing effective medications for higher-status individuals when taking into account different population-level responses to treatments. This theory is especially relevant in the case of emergency medicine as overcrowding of ERs due to mass incarceration and treatment of the growing urban poor necessitates extensive resource allocation
(Lara-Millán 2014). Fundamental cause theory is unable to explain the durability of differential health outcomes despite new policies aimed at increasing access to resources (Korver-Glenn 2018). Consequently, two other modern theories aim to explain the persistence of health disparities in the absence of the underlying mechanisms and risk factors which Link and Phelan emphasize: cultural health capital theory (CHC) and health power resources theory (HPR). CHC focuses on more than merely the causes of diseases, emphasizing the contribution of various treatments to overall health and the interplay between patient choice and ingrained ideologies (Shim 2010). For instance, debt prompts patients to forego medical care, indicating both a degree of choice and ingrained cultural ideas of prioritizing financial stability over health (Kalousova and Burgard 2013). This theory concentrates on interactions between patients and providers, accounting for the set of cultural skills (e.g., communication, decision-making, and interpersonal skills) and health literacy patients need to properly acquire quality treatment. CHC also emphasizes the
cyclical nature of health disparities as race – whether consciously or unconsciously – affects providers’ interpretations of various health situations, and consequently influences the amount of information that is conveyed to patients (i.e., their health literacy). Admission of walk-in patients into ERs is highly dependent on provider-patient interactions, as patients must negotiate with providers for admission, and can therefore be viewed in context of this theory (Hillman 2014). HPR theory most extensively encompasses the range of factors which influence health by considering the gradient of power differentials between groups as race, SES, patient-provider
interactions, health literacy, and exposure to risk factors have a combinatory effect on level of power; thus, HPR theory incorporates aspects of fundamental cause theory, efficiency-equity trade-off theory, and CHC while accounting for their shortcomings. Under this theory, power imbalances in the form of stratification, commodification, discrimination, and devitalization influence access and value of health resources (Reynolds 2021). Power imbalances affect exposure to risk factors of disease as well as dominate interactions between patients and providers; therefore, this theory explains both the factors which lead patients to need emergency treatment as well as the elements which influence provider decisions on ER admission and treatment (Tang et al. 2015). Consistent with the idea of power gradients is the intersectionality of forms of discrimination in contributing to health disparities. The more types of inequality faced (e.g., race, gender, low SES, etc.), the more a patient’s power is eroded, and the worse their health outcomes (Homan et al. 2021). This theory further emphasizes advantaged groups’ abuse of power differentials to control the direction of research; therefore, viewing health disparities through this framework uniquely incorporates the role of advantaged groups in perpetuating health disparities (Link and Garcia 2021).
Findings
As barriers to quality medical care accumulate along each stage of the ER admission process, this review analyzes literature spanning the initial acquisition of treatment in an ambulance, acceptance into ERs, and obtention of actual treatment following admission – all of which allow for provider discretion. During ambulance rides, EMTs and paramedics decide what cases necessitate medical attention and are considered urgent. The rise in capitalism and attempts to conserve hospital resources has placed a greater importance on ambulance services, allowing for greater autonomy in what cases require only “on-the-spot” treatment (Corman 2018). Rather than only looking at the extent to which a condition requires medical attention, emergency responders often apply labels to patients – some of which are offensive and focus on superficial aspects like obesity, cleanliness, attractiveness, and race – which effect whether these responders view the patients as deserving of suffering (Seim 2020). These labels gain legitimacy and mask the presence of bias when offensive terms are replaced by medical terms (e.g., “obesity” rather than “fat”) (Manzer and Bell 2021). Providers possess an ingrained desire not only to provide medical care, but to be recognized as having successfully provided medical care (sometimes termed a ‘hero-complex’ or ‘hero-syndrome’). Thus, consistent with the efficiency-equity trade off theory, the cases for which ambulances have the proper resources for, and thus can provide the most efficient treatment for, are prioritized over other cases, regardless of severity. Successfully providing treatment additionally increases the power of emergency responders by creating the impression of paramedics as lifesavers and heroes. Emergency responders thus exploit the power differential by choosing what cases they consider legitimate, which in turn leads to more accumulation of power, creating a cyclical effect. This is significant as emergency responders’ classification of cases as legitimate directly affects whether patients are admitted into an ER, with discourse between paramedics and ER providers dictating allotment of bedspaces.
While ambulances play a crucial role in transporting patients to ERs, there are multiple pathways for the actual admission process, including deposition by a police vehicle, referral from another clinic, hospital, or provider, and walk-ins. Provider discretion can most be exerted in the last case, as professional input from paramedics, police, or other providers is seen as more reliable than patient claims of injury or illness. Such discretion can result in providers responsible for ER admissions subjecting patients they view as less deserving or who violate social norms to longer wait times or denying them access to emergency rooms altogether under the assumption their visit is due to non-clinical reasons, such as for shelter or food (Tang et al. 2015). Triage nurses also supply non-opiate painkillers in the waiting room to patients who they interpret to have superficial complaints, altering vital signs and creating a false sense of normality, resulting in a decreased likelihood of subsequent admission (Kronenfield 2009). Speculation about the genuine motivations of patients allows for healthcare professionals to operationalize biases by providing a seemingly legitimate basis for denying treatment. In reality, these justifications are dependent on implicit biases, demonstrated by provider preference for white, middle-class patients (Kugelmass 2016). Furthermore, race and appearance influence whether a patient is perceived as associated with the criminal system, in which case patient
admission is more likely to be delayed (Lara-Millán 2014). Emergency medicine is unique from other forms of healthcare as providers are not always able to obtain a comprehensive medical history prior to treatment, and thus rely on superficial information to fill in gaps of knowledge.
Providers frequently apply race and SES biases to attribute criminal or delinquent status to patients, which fills in missing medical information by diminishing the severity of provider perception of symptoms. Even after admission, patients are not guaranteed quality treatment. A major concern for many ER patients – especially low-income patients – is pain management, which often manifests in the form of opioid treatment. Some patients falsify records of pain for the purpose of obtaining
drugs, and physicians develop strategies to recognize such patients (Kronenfield 2009). In deciding who is deserving of opioids as a treatment, providers consider irrelevant characteristics, favoring those with socially acceptable traits that poor patients typically lack (e.g., jobs that are considered respectable, new and clean clothes, etc.). This process is also highly racialized, as providers view racial minorities as most likely to abuse drugs and hence are unlikely to prescribe them opioids. Due to biases coupled with limited resources, ERs often provide no actual care, instead referring patients to a primary care provider (PCP). However, underclass patients without health insurance are unable to afford subsequent visits and never receive treatment for their pain (Buchbinder 2017). Moreover, time pressure is inherent in emergency situations, and overcrowding only worsens such pressure (Lara-Millán 2014). Experimentation by Stepanikova shows high time pressure heightens implicit physician biases and results in providers underestimating the severity of symptoms of racial minorities, providing a less serious diagnosis (and not referring patients for higher care) for the same symptoms (2012). Not only do these biased treatments prevent access to current quality treatment, they discourage patients deemed
‘undeserving’ from seeking care in the future (Tang et al. 2015). Patient records, visual recognition of ‘repeat offenders’, and embarrassment or anger at treatment act as deterrents for future admission into ERs, regardless of the validity of future concerns.
While differences in admission decisions can theoretically be attributed to the increased likelihood of underclass patients to contract diseases due to their living situations (i.e., fundamental-cause theory), studies in non-emergency medical settings reveal despite identical symptoms, racially distinctive black features and characteristics specific to low-income groups were both sufficient deterrents for appointment offers (Kugelmass 2016). This also eliminates the possibility of spurious factors such as less serious symptoms influencing provider decisions. In 2003, sociologist Geiger proposed medical disparities can be attributed to differences
in willingness to seek treatment differs between black minorities and other ethnicities. However, in a more recent study, Schnittker et al. showed for most symptoms white Americans and African Americans display similar willingness to seek treatment; in fact, African Americans are more willing to seek treatment in some cases and have significantly higher treatment expectations than white Americans (2005). These findings indicate negative predispositions of African Americans towards physicians are not especially prevalent, negating the past research claiming this factors into lower quality treatment and further providing the validity of structural
discrepancies infringed by providers. Traditional sociological health disparity research fails to address both SES and race. In fact, most research omits SES stratification within racial groups, effectively ignoring the effects race and income have on each other (Williams and Sternthal 2010). Such omission has led to criticism about the lack of intersectionality in this field (Homan et al. 2021). This study aims to remedy this gap by providing a more comprehensive study of all the factors which affect disparities in the health field. By narrowing the field to a subset of medicine which is disproportionately relevant to low-income households, it is possible to simultaneously study both race and SES without fear of erroneously attributing the cause of health disparities to one or the other. Furthermore, this study follows the process of emergency medicine from the beginning to end, fully capturing the multitude of checkpoints in which discrimination can be enacted – an approach unseen in previous sociological studies on health disparities.
Conclusions and Future Considerations
Large-scale data analyses, observational studies, and experiments are all needed to encapsulate the full extent of discrimination in the health field. However, data analyses and experiments have limited applications in emergency medicine. Whereas most specialties of medicine have standard conditions and procedures which are overrepresented in literature (e.g., kidney transplants in nephrology), permitting analysis through databases, emergency medicine deals with a too diverse range of conditions to allow for generalization and all-inclusive conclusions (Daw 2015). Furthermore, few demographic databases can be cross-referenced with
meta-databases of health information and account for the intersectionality between race and SES, making this method unsuitable for this research question. In addition, true emergency situations are unpredictable, and are thus not amenable to techniques common in experiments such as subliminal priming (Stepanikova 2012). Time-constraints placed on case studies are useful in studying the role of stress in medical decisions; however, entirely replicating the fast-paced nature of emergency medicine is nearly impossible, limiting the usefulness of experimentation. Rather, ethnographic studies combined with interviews, similar to Lara-Millán’s 2014 study, are most applicable to future research on ERs, allowing for the observation in natural emergency settings. Future ethnographic studies following a limited number of patients throughout the whole journey from ambulance (or as soon as they walk into the ER), to ER, to consultation with a physician, combined with interviews from both providers and the patients would provide greater insight into health disparities. However, there are considerable ethical and practical restrictions as patients in emergency situations cannot consent to inclusion in studies until after obtaining a certain degree of treatment, posing the risk of wasting observational hours on patients who do not provide consent. Hence, a slightly less encompassing alternative would be to split observational hours between ambulances and the specific ERs they feed into, following providers instead of patients. By elucidating the effects of different theories on the way sociological research on health disparities is conducted, past studies exemplify the importance of framing health disparities as the result of a power imbalance perpetuated by advantaged groups (Reynolds 2021). Past research is especially useful in displaying the role of both implicit and explicit biases in a variety of healthcare processes related to obtaining emergency medical care, exhibiting the extent to which discrimination shapes medical decisions. Analyzing such research ensures future studies of health disparities in ERs take into account the complex intersection of different forms of inequalities and are applicable to interactions between different levels of providers rather than merely physicians (Homan et al. 2021). In fact, this web of discrimination best explains the negative system of checks and balances present in medicine; even if patients can persist through discrimination on one level, they will face bias on the other levels, leading to the persistent nature of health disparities. Thus, future studies should consider combinatory effects of different forms of discrimination, as well as the cyclical nature of various aspects of this process – both of which play a role in perpetuating health inequalities in American ERs.
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