Eric Jaeger - Implicit Bias in EMS (4/26/22)

Thanks everyone for coming. We have a great group here today. I appreciate that. And.

Give us about 30 seconds. We'll get started in a minute and I'll start with the introduction.

You'll be able to go, Peter.

Okay, awesome. Angus, thank you so much. All right, so welcome everybody. It's 1102. We have an amazing guest today. Very privileged to have Eric Jaeger come join us today from New Hampshire. A little bit of background Erickson. He does a lot of things here. He's just an incredible guy. So he's an RSI paramedic, an EMS educator at Exeter Hospital in New Hampshire. He served on the state of New Hampshire's EMS Protocol Committee for over 15 years. He's a big lecturer in EMS. He's on the circuit and he focuses on a few areas, including EMS care for patients with disabilities. And he'll plug his talk at EMS World in Orlando this year. I'd love to hear that one. I'll be there for sure. Death in Custody and implicit Bias. He actually holds a BS in Computer science from mit, a law degree from Boston College Law School, and when I ping people on Twitter and I said, does anyone have a lecture on implicit bias in ems? He was the only person who got back to me and within literally a day or two he agreed to join our call. So without any further do let me turn it over to you. Eric, thank you so much for joining us and we look forward to this topic.

Well, Peter, thank you so much for inviting me to talk about this topic. I think it's an incredibly important topic and I appreciate you sharing my background. So I'm going to skip right over that slide, other than to let people know my email address is there and I'll share it towards the end of the program as well.

I have no disclosures. The presentation and links are posted on my website. And again, I'll bring that up at the very end. I am going to be talking about a number of other amazing folks who have done work in this area and I won't have the opportunity to properly credit them as we go. So some of those links are also up on my website. I did want to make a special shout out to Professor Jamie Kennel at Oregon Health and Science University. Jamie has done a ton of work in this area and was kind enough to share with me a lot of his work, some of which I'll be talking about today.

My goal for this talk, I want you to know less at the end than you think you know. Now I am going to be challenging some of the Assumptions we hold. And I'm just asking that people keep an open mind.

I do think implicit bias may be the most important conversation EMS today, and I want to emphasize the word conversation. I get asked to talk about a lot of different topics. Airway management, for example. As an RSI paramedic, when I talk about airway management, I'm pretty confident I'm giving you the right answer to the question. Not because I'm that good, but because we have a ton of evidence and research and studies telling us what some of the right answers are to the questions. I don't think that's true in this area. I think implicit bias is a subject where I've got a lot of questions and I'm going to ask some of those questions today. But I. But I'm not going to pretend I'm an expert in this area or that I've got answers to all these difficult questions. I think it's incumbent on all of us on this call and in EMS more generally to try and work hard to address these issues.

What are my take home points on implicit bias? Implicit bias produces disparities that have a profound impact on the delivery of care by ems. And I hope to show you a little bit of that in the brief time I have today. Implicit bias is not amenable to easy solutions. We can't just whip some training onto our EMS folks and assume that we'll address that problem. And then addressing implicit bias, I think is the right thing to do from an ethical perspective. And I think the cool part is doing the right thing has the potential to meaningfully improve EMS care.

So what is implicit bias? Our brains evolved to see patterns. We can instantly recognize a friend in the sea of faces. Thousands of years ago. This served us well so that we could instantly recognize danger in the shadows. If you saw a shadow move in the forest and you weren't sure whether it was a predator, it was too late. It's a mental shortcut that allows us to make sense of a sea of data constantly threatening to overwhelm us. Where once this served to keep us safe, this same mechanism leads us astray today, causing us to unconsciously associate danger or worthiness or capability with certain groups rather than assessing them as individuals.

I want to be very clear and I think this is an important point when you talk to your folks about implicit bias. Implicit bias is not racism and it is not actual discrimination. I hold we'll talk about some of my implicit biases. I hold implicit or unconscious biases that are directly at odds with some of my consciously held and strongly held beliefs. And it's important to understand when we talk to EMS providers and I talk about this issue, I. I'm not suggesting anyone in the room is racist or engaged in actual explicit discrimination. We're talking about these underlying unconscious tendencies that nonetheless impact our actions.

And implicit bias really does impact so much of what we do.

For example, how we care for people with disabilities who may be experiencing behavioral issues.

How we react to transgender patients who ask to be referred to as they.

The decisions we make when we encounter police wrestling with a young black man who is acting suspiciously.

And even whether we suspect a heart attack in a person who is homeless experiencing chest pain. Let me tell you a story. I was a relatively new EMT basic working down in Lynn, Massachusetts. I got toned one day for a man lying on a stoop. I went with my even more junior EMT basic partner, and we encountered what we recognized as one of our homeless population lying on the stoop. We lifted him up onto the stretcher. I got in the driver's seat and drove to the hospital while she cared for him in the back. We were waiting in the triage line at the hospital and I happened to notice him reaching up and sort of grasping at his chest. And I said to him as we stood there in line, I said, sir, are you having chest pain? And his response floored me. He said, yes, I'm having chest pain. That's why I was lying down on the stoop. So that was a potent example for me of my own unconscious or implicit bias. When I got sent to that call, I saw a homeless man and failed to appreciate that what was actually happening was a medical emergency involving his chest pain and a potential heart attack.

A little bit more about my story. That's me right there with my son, Zenith Yeager. Zenith is a happy 22 year old boy, but he also has Dravet syndrome and has had epilepsy and seizures all his life. This is the reason why I got into EMS and in fact, the reason why I teach.

After I became a paramedic, I began to teach other paramedics about how to better care for seizure patients. And I've broadened that out now to teach paramedics how to better care for all patients with disabilities.

If you would think anybody would not be biased against people with disabilities, it would be me. I've got a kid with significant disabilities. I teach other paramedics how to care for patients with disabilities. And I'm very much aware of the implicit bias that exists against people with disabilities. The there's something called the Implicit association test and I urge you all to take it. It's easily found online. It's an online computer test that allows you to explore your own implicit or unconscious biases. And there are tests for gender, for race, for sexual orientation and for disabilities. I went and took the iat.

I took the IAT with regard to patients with disabilities. What did my IAT show? It showed that I have a moderate automatic preference for able bodied people compared with disabled people or that I have a tendency unconsciously to discriminate against people with disabilities. And I have to be honest with you, that was not a surprise at all to me.

Here's where I get my shameless plug. Peter mentioned and I just want to call out again. I am going to be talking at AMS World in Orlando, Florida. It's special needs masterclass, a four hour pre conference on Monday, October 10th from 8:00am to 12:00pm And I hope to see a bunch of folks there.

So let's explore a little bit more about how implicit bias actually works and actually impacts real world behavior. The Boston Symphony Orchestra in the 40s was 100% male. They knew there were high quality female musicians out there. They, they had invited a few to audition and it made absolutely no difference. While they might have hired one or two women, they remained nearly 100% male. Then they said, you know, the problem might be that all of our reviewers are male. Maybe if we do blind auditions. So in 1952 they instituted blind auditions where they put a screen up on the stage and each of the candidates would walk onto the stage. They wouldn't speak, they wouldn't say their name, they would sit down in a chair, they would play the piece of music. They all played identical pieces of music. Then they would walk back off the stage and the reviewers couldn't see the candidate. So they wouldn't know whether they were male or female.

And still nothing changed. They still hired nearly 100% male musicians until they made one more change. Anybody have any guess as to what that one more change might have been?

The shoes. Correct. They asked the candidates to remove their shoes. Sounds like someone's heard this story before. And everything changed because the candidates were walking on stage and the women were wearing high heels. It was very easy for the reviewers to discern who were the female candidates and who were the male candidates. No one is suggesting they were consciously biased or, or trying to discriminate against the female musicians. But even that subtle clue which told their brains which what gender the musicians were influenced the Outcomes.

This is a very short video I want to share with you about unconscious bias by Professor Richardson. She was a professor of law at UC Irvine School of Law. She's now the president of Colorado College.

So to understand unconscious racial bias, we need to understand a little bit about how our brains work. Our brains learn through associations. They make quick unconscious and automatic associations in response to a stimulus. And the reasons our brains do this is because they're efficient information processors. I'm sure when you walk into a room and you sit down at a chair, you don't spend even a second thinking about that strange object that you're sitting upon, because your brains have learned what a chair looks like and what you do with a chair. Your brains do that about everything, including people. And what our brains have learned is that certain people are associated with certain things. Although I myself am a woman, and I'm Korean and I'm black, I had all of the unconscious biases that most people of all races have.

So many of you may have heard of the IAT or the implicit association test. When I took the implicit association test, what it demonstrated is that I associated white men with positive things and black men with negative things. I associated with women with the home and men with the workplace. And I do not consciously subscribe to these biases. So I don't have an explicit bias, but I had an implicit bias, and that's the difference between the two. So being a conscious racist and having unconscious racial biases are not equivalent things. So unconscious biases tend to influence us in situations that are ambiguous. And so when a situation is ambiguous, your brain will fill in the missing pieces. And often it will do this with the unconscious associations that it's learned. And as a result of that, you might treat two people engaged in identical behaviors differently.

So, fascinatingly, Professor Richardson was talking about unconscious bias there in the context of the criminal justice system. But I think her comments where she mentions that unconscious bias has the greatest tendency to influence us in situations where we're stressed out or where information is scarce, or where it's ambiguous applies directly to US operating as EMS professionals at 3am in the dark in situations where we've got scant information.

But I guess one question you could ask is, does any of this matter in ems? We're in the business of saving lives, right? We often don't have time to pay attention to all the subtleties. Sometimes we have to be a bull in a china shop. Even if we commit small acts of bias, does it really matter?

And I'm going to show you that I think it really does matter and it cuts across probably virtually everything we do. This is a study that was published in 2018. It was the work of Professor Jamie Kennel.

And it's been reported on by NPR, among others. He looked at 100,000 EMS patients. So work on pain medication and racial disparities has been done in hospital and in EDS. He did this work specifically looking at our world EMS. He looked at 100,000 EMS patients in Oregon between 2015 and 2017, and he found that black patients were 40% less likely to get pain medication than white patients. He noted at the time that paramedics often work in time pressured situations with ambiguous clinical information and scarce resources. In these situations, we are much more likely to make decisions based on stereotypes.

It extends to people with disabilities. Implicit bias against people with disabilities is among the strongest of any forms of bias higher than gender, race, religion, sexuality, weight and political orientation. Only age child shows more political bias.

It extends to the LGBTQ community. The CDC recently reported that one in four LGBTQ youth attempted suicide in the first six months of 2021. I was stunned when I heard that statistic. Dr. Scott Hadland has recently noted that when we discriminate against LGBTQ people on topics like same sex, marriage, workplace, trans athletes in education, queer teens are listening, internalizing and suffering.

I'm going to talk to you briefly also about death in custody, where we begin to look at the potential deadly impact of implicit bias. This, by the way, Peter mentioned that I do a complete talk on death in custody, which I think is another incredibly important conversation in EMS.

Elijah McClain died, unfortunately in Aurora, Colorado in August of 2019. He was walking home from a convenience store. Someone called 911 to report a black male being suspicious. And so the police stopped him for being suspicious. They restrained him prone on the ground while they struggled with him. They described him as being on something, pouring sweat and having superhuman strength.

Elijah McClain was not, however, on drugs that night or ever had not committed any crime on that night or ever. Paramedics showed up a short time later, administered 500 milligrams of ketamine, and unfortunately, he died a short time later.

The city of Aurora convened a blue ribbon panel to look at Elijah McClain's death and try and understand what lessons could be learned from it and what we need to do differently going forward. Included on that panel was Dr. Melissa Costello, an ED physician, and she produced a portion of the report that I'm going to read to you from here. She looked at a number of issues involving the care of Elijah McClain and similar patients. But she also focused on whether implicit bias was playing a role in clouding decision making. She noted that evidence shows we overestimate young black men as taller, heavier, stronger, more muscular and more capable of causing physical harm than young white men. Our perceptions of black people as more threatening impact judgments about the force necessary to restrain black suspects and influence others to excuse officers use of force against black suspects.

She said. The research shows that providers perceive black patients to be less compliant and less cooperative than white patients.

The AMA has also produced a report looking at a variety of issues related to excited delirium and the use of drugs to chemically restrain individuals outside of the hospital settings and published a new policy in June 2021. And in their report, they also addressed implicit bias, noting who is most likely to die from first responder actions, including administration of chemic sedation otherwise healthy black males in their mid-30s who are viewed as aggressive, impervious to pain, displaying bizarre behavior and using substances. Characterizations that may be best less on evidence and more in generalizations. Misconceptions, bias and racism.

I want to be clear that and it's very difficult in this short talk to parse it out, but it's not always implicit bias that leads to disparities in care, including among people of different nationalities and races. There are other issues we need to be aware of. So, for example, language barriers and limited English proficiency is something that impacts EMS care for people who don't speak English and isn't explained. Those disparities aren't necessarily the same as implicit bias. So we do need to do more work here. And I don't mean to suggest by our talk today that everything's about implicit bias.

How should we address implicit bias? Give me one second. My computer's telling me the power is going to die.

The classic problem. Right? I apologize. So how should we address implicit bias?

I really think this is an all hands on deck moment for ems. I think there's work that needs to be done by EMS officials at the state level, by EMS agency leadership, by medical directors, by hiring managers, and by EMS educators.

Implicit bias. Here's the problem with it. It's deeply embedded in culture.

And we know that culture eats everything. Culture trumps training and mission statements and values and policy. Changing cultural aspects of EMS is exceptionally challenging and we probably all encountered circumstances where we tried to make similar changes that.

Took a dedicated effort. I think there are many parts to the whole solution, so I think training is needed. Data analysis, diversification of EMS Hiring protocols and policies, leadership and public accountability.

Training? Yeah, absolutely. It's what I do for a living. Training for EMS providers, unfortunately though, is not yet proven to reduce implicit bias, at least in a way that's sustainable. Implicit bias is resilient. It's sort of baked into our brains. I do think training is an important aspect. I think we need training for leadership like this talk here today.

To help leaders understand the challenge and equip them with tools for addressing implicit bias in their own organizations. And I think we need to develop a toolkit for educators to help address this challenging topic. I think EMS educators are great at talking about airway management, but the reality is this is a topic that they're probably neither knowledgeable about, comfortable talking about, and we need to equip them with better tools.

This is a mic drop moment for me. I saw this online. The statement there are two types of EMS agencies, those that are improving their racial treatment disparities and those that haven't looked for racial disparities in their data yet. That was pretty telling to me. Basically says if you think you don't have these implicit bias issues that are leading to true disparities in care in your organization, it's because you have failed to look at your data to discern them.

I think we must begin to collect the data, separating it out by ensuring that our providers are collecting information on race, gender, sexual orientation so that we can ultimately report on that data and use it to help guide our actions.

ASEP now published an article in 2020 talking about the the need to diversify the EMS workforce in order to combat implicit bias. And I think it's both EMS workforce and leadership. They set A diverse EMS workforce representative of the patients it serves is crucial to promote understanding and eliminate disparities in care experienced by minority patients. I agree completely. I'm a little concerned though that this is a long term solution to the problem. And given the current struggle, we're all having to hire enough providers in ems. I think it's going to be challenging to recruit folks from the underserved and vulnerable communities that are impacted by implicit bias.

Policies can for sure make a difference. So the Las Vegas Metropolitan Police Department in 2011 established a policy to combat implicit bias. They found that during foot pursuits they had a significant number of excessive force incidents. And so they create a policy that said during foot pursuits the arresting officer must be different than the officer that gave chase and as a consequence, excessive force incidents fell by 23%. So carefully crafted policies can make a difference.

Leadership needs to be involved. And I think this is your state bureau of ems, your state medical control board, whatever form that might take. I think agency level leadership needs to acknowledge implicit bias. They need to be talking about this topic. They need to request data collection and analysis so we can understand the disparities in how we care for our patients. And agency level leadership needs to support training on this topic. We need medical director leadership, creating expectations in our organizations and providing training.

And then the last topic I want to mention is public accountability. This can take many different forms. Professor Kennel shared with me that out in Oregon, one of the positive outcomes from their work on implicit bias was they worked together with AMR to form a community advisory board that helps guide AMR and their equity work. Members are selected from communities of color that AMR serves and that community advisory board has access to all of the CQI data and reports that I've mentioned to you that we need to collect and develop.

I haven't talked very much about actions that individual providers can take to combat their own implicit bias. I just didn't have time in today's conversation. I'm going to share with you one final clip though, from Professor Richardson video that I think is one of the key concepts.

If I could leave you with just one piece of advice, and this is going to be the hardest piece of advice, believe me, I know that it would be to slow down. So slowing down, being aware of the circumstances when you might act on your unconscious biases, obtaining more information, are all things that you can do to try to reduce the impact of these unconscious biases on your behaviors and judgments.

So that's really all I had for you today. Thank you very much for the invitation to talk. My take on points are the same. I began with that implicit bias produces disparities that have a profound impact on the delivery of care by ms, that it's not amenable to easy solutions, and that addressing implicit bias is both the right thing to do and something that has the potential to meaningfully improve care. Thank you very much.

Wow, Eric, that was so incredible. You know, we've done over 50 of these talks and this by far stands out to me as the best one without any negativity to the other ones. But this is so important in ems. And you know what was fascinating to me is that your own personal experiences with your son didn't change your own implicit biases. And I think that's an important thing. We have a lot of people on this call who I'm sure are thinking similar things. We have state People on the call, we have the state Bureau of EMS people. We have folks really at the highest level of the state here. We have data people on this call, medical directors, EMS leadership. And I have a feeling that this will be truly one of the most impactful talks that we've heard. I'm sure this video will be watched by many people and I would love to see. Does anyone have any comments for Eric before we move over to.

Dr. Pepe's lecture webinar? Anyone from the state or anyone with any experience with this, I want to comment on that.

I think, I think it was a true mic drop moment. Let me see if I can get. Dr. Schepke, can you, you know, are you there? Are you on today? I saw your name.

Hey, Ken, I would love to hear your thoughts on this.

I'll tell you, we have a whole office here, Department of Health, that deals just with this type of topic. And it's very interesting for me to see that perspective and realize that we probably all have a bit of this and it's a problem that I think you, I know we struggle. We try and figure out how do we deal with some of these health inequities and basically differences in care that people get. And I think you've touched on some topics that really sounded bring home why this is so hard to fix just with training and it's. I think it's useful. I'm going to have some of my folks watch this video, actually, so hopefully it'll help get us to some point where we get some answers to make some headway on this topic. I appreciate, appreciate the talk.

Thank you very much.

I just wanted to say in closing, Peter, that I think you touched on what perhaps is the most important piece of this equation. I have found in talking with EMS providers that being able to walk in and talk about your own implicit bias is an entry point. These are difficult conversations to have with some of our fire EMS folks. And as I do with all these conversations, I don't want to walk in there telling them they're doing things wrong. I want to walk in there and help them understand how to do things better. And I have found that by making clear that implicit bias is not the same thing as actual racism and that by exposing my own implicit biases that it provides an entry point for the conversation.

Awesome.

Thank you for that. And we appreciate that in those comments. And what I'm going to do is, you know, the two people who I'm going to ping also maybe offline, is Angus Jamison, who's now our state medical director who's highly data driven, one of the most data driven people I know and Also Chief Tom DiBernardo who's up at the state, who's helping us with data driven decision making. And I thought those two are really going to make an impact in our state. So both Angus and Tom, I don't know if any of you can make a comment right now before we move over to Dr. Pepe's talk, but I know we have data.

What we should and could be doing outside of the hospital.

Hey, Peter, you want to mention something before we.

Yeah, yeah, thanks. I think there's some really interesting questions in the chat as well. I just want to say thanks for, for making what's sometimes a very difficult topic to speak about and wrap your head around and understand and really find an actionable way of approaching it. I appreciate you making it much more sort of concrete and just, I really appreciate the way it was framed and the way you discussed it in a very frank way. So thank you for that. I also want to say go Exeter as an academy alum and my sister used to be in attending at that hospital.

Terrific.

So thanks very much for joining us today.

Thank you for your comments.

All right, well, we're going to move over to Dr. Pepe's webinar. Eric, I'll give you the last word, any final comments you want to make to our group and then we'll move over to Dr. Pepe.

No, I thank you very much for the invitation and I appreciate people's enthusiasm to address this very important topic. And I'm available if people should want any of the materials. Just reach out. Thank you.

Thank you so much. All right, everyone, stay tuned and everyone's welcome to stay for the Eagles and let's take it away to Dr. Pepe. Thanks everyone.