Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Race are You

Massachusetts has decided to have EMS ask patients to identify themselves by race during patient contact. Is this a good idea?

For St. Patrick’s Day we need to start asking patients some questions to find out how they will be celebrating the day. Since we only seem to have any complexion when blushing or when compared with people from Iceland, there may be some confusion about what skin color actually is.

Excuse me, but what race do you consider yourself to be?

Or –

On a scale of zero to ten, how black are you?

How many drops of black blood make a person black (and is this the racial version of homeopathy)?

When do we hook up the lie detector to the patient?

The implied message is that this information is important for determining appropriate care. After all, that is why we ask patients questions.

Are you white enough/black enough/hispanic enough/oriental enough/other enough to receive the best care that I can provide? Does the answer determine if we give the Tuskegee Treatment to some patients?

Then there are the patients who claim that we must be blind if we cannot tell what they are.

What about Tiger Woods, or Vin Diesel, or someone else, who has made it clear that they do not want to discuss their ancestry? Will this make us the miscegenation police?

What if we disagree with the answer provided by the patient?

Mr. Hitler, we don’t have Aryan as an option, besides your neighbors tell us that your ancestry is actually Jewish. You must provide us with answers. And remember, this is for posterity so be honest.

We’re from the government and we’re here to help.

Kelly Grayson writes in None of Our Business

I’m not saying there’s no racism in EMS. We have the same biases as any other group. And honestly, when you see one ethnic and demographic group abusing the system day after day, it’s hard not to become jaded.

But some of us blame the system that makes that group more likely to inappropriately utilize our services, instead of focusing on their skin tone.

But even that second group keeps their racism to themselves until after they drop off the patient at the ED.

That has generally been my experience. Whether is is professionalism that prevents those who express racist feelings from mistreating patients, I have no idea.

I do notice that some people will go to great lengths in treating someone who appears to be of a different race differently, just to create the impression of not treating that person differently. This is anecdotal, of course, and a neurotic devotion to appearances over reality. In politics and law appearances do seem to trump reality.

In Foolishness In Massachusetts, Too Old To Work, Too Young To Retire writes –

In other words, it’s just the kind of stupidity that we’d expect from officious officials who know nothing about the industry that they are regulating.

I could state that this covers it. I could point to a lot of the other points he makes. I could.

However, in response to those claiming that more data will be helpful, there are still some things that critics of this policy have not mentioned.

When I was in San Francisco, we joked that the most important data point was –

With what gender do you most strongly identify? 🙂

Even that is not a simple one, or the other, choice. Not that we will find TOTWTYTR’s friendly PC officious officials accommodating these patients. Maybe I shouldn’t give them ideas.

There are a few specific illnesses, such as beta-thalassemia (due to a genetic mutation prevalent in those with ancestors from the Mediterranean), for whom this might be useful to a number cruncher in extracting data, but is Mediterranean ancestry one of the available categories?

I am going to take a wild guess and go with – No.

There are plenty of theories about the racial predispositions for various diseases, but if the questions do not really address patient care issues, what is the point? We flatter ourselves that we understand the racial/genetic basis for diseases, but this is just an exercise in appealing to the least intelligent demographer.

Potential genetic predisposition.

That is the most that can be said about the usefulness of this question, which will most likely be misused by everyone who makes reference to the data.

Are these politically motivated questions?

Are these medically motivated questions and how do we draw the sample for genetic testing?

How much time do we spend obtaining consent for genetic testing?

What about people who answer the race question with –

None.

or

Other.

or

Human.

or

I prefer not to view the world in such inappropriately narrow terms.

What kind of training do they provide to EMS for dealing with the people who will be offended by the question?

It is bad enough that we are accused of responding to some patients slowly because of the patient’s race. Not that the people making this complaint would have any idea how to accurately report response times, because it always seems as if it takes forever for the ambulance to get there. Now we appear to be telling patients that we want to know their race before we will treat them. In what way is this not a bad idea?

For more information on drawing faulty conclusions from poorly collected data, look at two recent studies using the National Trauma Data Bank® and my reviews of the flaws with the data.

Spine immobilization in penetrating trauma: more harm than good?
Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
J Trauma. 2010 Jan;68(1):115-20; discussion 120-1.
PMID: 20065766 [PubMed – in process]

My commentary on this study is in –

Spine Immobilization in Penetrating Trauma: More Harm Than Good?
Rogue Medic
01/21/2010
Article

Correction on Spine Immobilization in Penetrating Trauma: More Harm Than Good
Rogue Medic
03/15/2011
Article

Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis.
Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
Ann Surg. 2010 Dec 20. [Epub ahead of print]
PMID: 21178760 [PubMed – as supplied by publisher]

Full Text in PDF format from www.medicalscg

My commentary on this study is in –

Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part I, Part II, and Part III
Rogue Medic

02/20/2011
Part I

02/22/2011
Part II

03/01/2011
Part III

.

Comments

  1. First off, hats off to you to once again educating me, I know now that miscegenation is a word, and what it means. I can go to sleep easily tonight, having expanded my knowledge. That being said, I know from looking at multiple ePCR vendors, that “race/ethnicity” is in all I’ve seen, I believe it’s actually a NHTSA data point they have to include to meet the standard(s).

    That being said, I’ve always argued that it has absolutely no bearing whatsoever on whatever treatment EMS may or may not provide as a result as we have no guidelines, protocols, or anything of the like that allow/condone our differential treatment based solely on race/ethnicity.

    I’ve not been yelled at or otherwise disciplined for my refusal to fill out this wholly useless demographic point that serves absolutely no point. That’s not to say that won’t change in the future, but for now I’m ok. I also remember seeing on multiple different paper chart forms across the country a similar set of checkboxes that allowed you to choose the patient’s race/ethnicity. Call me even more paranoid than Kelly Grayson, but maybe it’s just the government encroaching more and more everyday.

    • Can’t Say, clowns will eat me,

      First off, hats off to you to once again educating me, I know now that miscegenation is a word, and what it means. I can go to sleep easily tonight, having expanded my knowledge.

      Not only is it a word, but it is one that only seems to exist to help us to categorize people as different. Once we label people as different/other/less than me, it becomes easier to justify mistreating them. Hitler combined this with a duty to authority in persuading plenty of otherwise good people to abuse and kill their neighbors. Jews, gays, communists, gypsies, anarchists, mentally ill, developmentally disabled, prostitutes, and many other untermenschen.

      That being said, I know from looking at multiple ePCR vendors, that “race/ethnicity” is in all I’ve seen, I believe it’s actually a NHTSA data point they have to include to meet the standard(s).

      Another reason for EMS not to be a part of NHTSA (National Highway Traffic Safety Administration). Do they track the race of people driving on the roads they administer?

      That being said, I’ve always argued that it has absolutely no bearing whatsoever on whatever treatment EMS may or may not provide as a result as we have no guidelines, protocols, or anything of the like that allow/condone our differential treatment based solely on race/ethnicity.

      Most people understand that.

      I’ve not been yelled at or otherwise disciplined for my refusal to fill out this wholly useless demographic point that serves absolutely no point. That’s not to say that won’t change in the future, but for now I’m ok. I also remember seeing on multiple different paper chart forms across the country a similar set of checkboxes that allowed you to choose the patient’s race/ethnicity.

      One problem is that even though we will only be collecting data arbitrarily, we have begun to think that we are collecting good data. The number crunchers will tell us that we can use this and the law of large numbers to draw meaningful conclusions. This is like studying treatment, but allowing everyone to use whatever treatment they want and to give those treatments names based on their individual opinions. Research is not supposed to introduce variables, but control for variables. This is only giving the appearance of useful data collection.

      Call me even more paranoid than Kelly Grayson, but maybe it’s just the government encroaching more and more everyday.

      So, for your race, I should put down more paranoid than Kelly Grayson?

      We’re going to need another box. 🙂

      • I guess working for a Fortune 5 company makes me more paranoid about corporations than my government, but that’s just me. Corporations track way more stuff about individuals and will throw you under the bus just as quickly as a Government.

        Either way, I don’t see the big issue that requires such a fire storm on this topic. NEMSIS makes it a required data-point, so MA OEMS is mandating its collection. For once they supplied training to go with a mandate, hallelujah! The training on collecting this data point (as you pointed out, it’s a fuzzy data point like gender or a middle name) is better than no training, but it wasn’t the best training. It also didn’t appear to be written by people who have worked in the field. All good reasons to correct this.

        Granted the sheer paranoia surrounding the motive is pretty crazy. Heaven forbid we should identify an area that needs improvement, although if it is a touchy subject we could leave it alone. Tough questions are best left unanswered I guess 🙂

        I only agree in part that ethnicity does not affect patient care. Ethnicity isn’t likely to effect my choice in medications or treatments (although religion may effect my choice in treatments). Some ethnic groups have qualms about male-female interaction and many ethnic groups (although probably more correctly, “cultural”) have different social mores than the majority of responders. We should be cognizant to these and how they may affect our delivery of patient care.

        If we had good data collection for this data point, albeit fuzzy, certain retrospective chart reviews could be made. Targeted education for population subgroups, etc. End of the world? Hardly. Invasion of privacy? Nope (just because I didn’t ask doesn’t change your race).

        • Christopher,

          I guess working for a Fortune 5 company makes me more paranoid about corporations than my government, but that’s just me.

          I work for a Fortune 5 Billion company that makes that tiny little division of Hallmark seem huge.

          Corporations track way more stuff about individuals and will throw you under the bus just as quickly as a Government.

          Does it really matter who does this?

          Either way, I don’t see the big issue that requires such a fire storm on this topic.

          Hardly a fire storm.

          NEMSIS makes it a required data-point, so MA OEMS is mandating its collection.

          As with JCAHO/TJC (Joint Commission for Accrediting Healthcare Organizations, now just The Joint Commission) and Press Ganey, we are being distracted from patient care for the irrelevant, patient care-wise.

          For once they supplied training to go with a mandate, hallelujah! The training on collecting this data point (as you pointed out, it’s a fuzzy data point like gender or a middle name) is better than no training, but it wasn’t the best training. It also didn’t appear to be written by people who have worked in the field. All good reasons to correct this.

          And, according to TOTWTYTR, the training has been taken down.

          Granted the sheer paranoia surrounding the motive is pretty crazy. Heaven forbid we should identify an area that needs improvement, although if it is a touchy subject we could leave it alone. Tough questions are best left unanswered I guess 🙂

          No. Tough questions should not be left unanswered, but we should be able to clearly define the question before we start having the government, or anyone else, try to answer it. Nonsensical answers, based on irrelevant data, are probably a lot worse than no answers at all.

          I only agree in part that ethnicity does not affect patient care. Ethnicity isn’t likely to effect my choice in medications or treatments (although religion may effect my choice in treatments). Some ethnic groups have qualms about male-female interaction and many ethnic groups (although probably more correctly, “cultural”) have different social mores than the majority of responders. We should be cognizant to these and how they may affect our delivery of patient care.

          The same is true of any parent/spouse observing the assessment of their child/spouse. We should handle it as respectfully as possible. We do not need to know what ethnic group they might classify themselves as in order to do this. We may only increase their stress level by asking these questions. For example, You’re Muslim? Well, are you Sunni or Shiite? I need to know. You’re life depends on the answer. This question would not even acknowledge any other Muslim sects.

          When we require that EMS begin to address things that are not a part of EMS, we set ourselves up for failure. Failure in EMS can be fatal for the patient, regardless of what racial identity the patient may have chosen during the multiple choice test administered by EMS.

          If we had good data collection for this data point, albeit fuzzy, certain retrospective chart reviews could be made. Targeted education for population subgroups, etc.

          We could also address the patient’s income, or religion, or whether the patient is a Red Sox fan (think of the perennial stress).

          End of the world? Hardly.

          Why do you keep acting as if this is something new, or extreme, rather than just plain wrong?

          Invasion of privacy? Nope (just because I didn’t ask doesn’t change your race).

          Just because the police search your car, doesn’t change whether you were transporting illegal substances. 😕

          • Does it really matter who does this?

            My point was only that people seem to view this as evil because the government asked them. NC required us to do this back during the Bush Administration, but I don’t remember any sort of outcry then.

            Hardly a fire storm.

            Your coverage wasn’t the object of the statement 🙂

            No. Tough questions should not be left unanswered, but we should be able to clearly define the question before we start having the government, or anyone else, try to answer it. Nonsensical answers, based on irrelevant data, are probably a lot worse than no answers at all.

            I agree fully, however, they’re not getting productive feedback (or they’ll likely shut their ears off at the first hint of feeling ‘attacked’). Perhaps a better way to get this information is to begin linking EMS and Hospital records, as it is recorded in-hospital. You can throw in the bonus for both parties with record-linkage to help improve patient outcomes.

            Why do you keep acting as if this is something new, or extreme, rather than just plain wrong?

            I’m not surprised by this since it has been required everywhere I’ve worked, just with no explanation as to how to get the information. Provided it doesn’t take time away from patient care, I see no issue with its collection. To be honest, I take more issue with collecting billing/insurance information than ethnicity.

            Just because the police search your car…

            I was alluding to the sentiment, also not directed at your post, that asking someone their ethnicity was somehow inappropriate.

            In a perfect world we’d be devoid of unnecessary paper pushing and just drop off John and Jane Doe (ok that was ethnically insensitive…) at the hospital. Alas I doubt that will ever be the case.

            • Christopher,

              Perhaps a better way to get this information is to begin linking EMS and Hospital records, as it is recorded in-hospital. You can throw in the bonus for both parties with record-linkage to help improve patient outcomes.

              That works for me.

              The only way I provide this information is by obtaining a billing sheet from the hospital, which generally includes some sort of attempt at pigeon-holing the patient racially.

              I’m not surprised by this since it has been required everywhere I’ve worked, just with no explanation as to how to get the information. Provided it doesn’t take time away from patient care, I see no issue with its collection. To be honest, I take more issue with collecting billing/insurance information than ethnicity.

              It is not required where I work. There is a space for the information, but there is no punishment for leaving it blank.

              I was alluding to the sentiment, also not directed at your post, that asking someone their ethnicity was somehow inappropriate.

              I think that it distracts from the things we should be doing and therefore is inappropriate.

              This is not different from the JCAHO/TJC questions that nurses are required to ask patients on admission.

              How often does this lead to delaying the recognition of the real problem?

              How much does this encourage hospitals to hire people who are good at filling out the forms, but wouldn’t recognize an unstable patient?

              Should that be the path that EMS follows?

              In a perfect world we’d be devoid of unnecessary paper pushing and just drop off John and Jane Doe (ok that was ethnically insensitive…) at the hospital. Alas I doubt that will ever be the case.

              I agree.

    • The ePCR we use at my agency has a spot for race. We always leave it blank–in fact, doing so is specifically part of our procedures for filling out an ePCR.

  2. As someone who’s seen the inside of Mass. DPH, I suspect this isn’t intended to change treatment at all. You and many others have pointed out that race is almost never a medically relevant fact. In the aggregate, however, data about the race of patients could be used to identify disparities in care. They like disparity-hunting, and with some reason.

    We can argue about the appropriateness of using EMS providers to collect relatively politically-charged public health data, but this isn’t just a matter of mindless compliance with standards.

    • Matt,

      As someone who’s seen the inside of Mass. DPH, I suspect this isn’t intended to change treatment at all.

      The law of unintended consequence is entirely about the results being unintended.

      You and many others have pointed out that race is almost never a medically relevant fact. In the aggregate, however, data about the race of patients could be used to identify disparities in care.

      Maybe, but probably not.

      For the data to be useful, the data would need to be accurate. Why should anyone believe that this is a way to collect accurate data?

      They like disparity-hunting, and with some reason.

      Would they be identifying true disparities, or just the appearance of disparities.

      As with Caesar’s wife, would we be required to punish the innocent, just to create the appearance of being above suspicion, when the only reason for the suspicion would be a blind faith in this superstition?

      We can argue about the appropriateness of using EMS providers to collect relatively politically-charged public health data, but this isn’t just a matter of mindless compliance with standards.

      Provide some evidence that the data will be accurate.

      Provide some evidence that the data will provide reliable information.

      This is just compliance to satisfy the prejudice of someone who thinks that the data will mean something, even though there is no good reason to come to this conclusion.