How Bias And History Shape Black Patients' ER Experiences

The emergency department is the one place in health care mandated by law to provide care regardless of insurance, status, or ability to pay. It’s supposed to be our “safety net.”

For tens of millions of people, it is a point of critical access. Ideally, you walk through the ER doors expecting to be treated with equal dignity, regardless of skin color, gender identity, or religious or political affiliation. As Black patients, however, we enter with a complex reality of going in expecting the same standard of care as anyone else, while carrying the heavy knowledge that it may very well not be granted.

As George Bernard Shaw observed in 1909, “The tragedy of illness at present is that it delivers you helplessly into the hands of a profession which you deeply mistrust.” More than a century later, that mistrust is not just lingering; it is being actively reinforced in our local emergency rooms. For countless African Americans, this “safety net” has become a site of profound trauma. It is a space where bias and ongoing disparities converge to impact the quality of life — and survival.

The reality of this experience is rooted in a fundamental power imbalance. When faced with an extreme emergency — a life-threatening injury or sudden, agonizing illness — families often have no choice but to rely on a system that they know does not always work to serve them. This reliance on an often-unresponsive or even hostile institution is not a matter of preference; it is a necessity. Patients are forced into the hands of a profession that many have been taught, through generations of lived experience and oral history, to approach with extreme caution. You hope for the best and proceed with a side-eye.

Historical Trauma

To understand why Black patients often enter the emergency room with deep-seated suspicion, one must look beyond current statistics. The history of American medicine is built on the exploitation of Black bodies. As documented in the 2007 book “Medical Apartheid” by Harriet Washington, the foundational figures of American research, such as J. Marion Sims, built their reputations on the suffering of enslaved women. Sims, often hailed as the father of modern gynecology, performed dozens of “exquisitely painful, distressingly intimate” surgeries on enslaved women without anesthesia to perfect treatments and create medical tools for procedures for white women.

As Washington notes, the development of early anesthetics such as ether often came at a brutal cost to Black subjects. She outlines several instances in which young boys were forced to inhale the substance against their will. This rarely was an endeavor to improve health care for Black populations; instead, it underscored a systemic devaluation of Black life, where individuals were viewed as expendable clinical material, left to carry the physical trauma of experimentation long after the research had concluded.

When Black patients express mistrust of medical research or institutions, they are often labeled as “paranoid.” But as the historical record reveals, this is not a baseless fear of imaginary harm.

Many in the Black community who have historic mistrust of science and the medical profession often cite the “Tuskegee experiment” and Henrietta Lacks.

In the Tuskegee Study, Black men from the 1930s-1970s thought they were being treated for ailments including syphilis, but never were given a cure; instead, they were studied by researchers.

Lacks died of cervical cancer in 1951 while being treated at The Johns Hopkins Hospital in Baltimore. Her tissue biopsy was sent to a researcher’s lab, and unlike the cells of other patients, her cells — dubbed HeLa cells — multiplied and live on to this day. These cells and the advances created from them have made billions for corporations.

Decades passed before the Lacks family learned of this exploitation; since then, they have successfully sought compensation, reaching settlements with multiple pharmaceutical firms, including two this year.

Systems Failure

African Americans have a long, resilient history of creating their own systems for survival. Facing systemic exclusion from mainstream health care, Black communities relied on midwives and healers for essential care. To combat these barriers, leaders and churches built their own hospitals and clinics, while Black physicians founded the National Medical Association to advocate for equity after being barred from the American Medical Association for decades.

While the ways Black patients are treated, and mistreated, have changed from the open abuse of the past to more subtle biases we see today, the core issue remains the same: American medicine must do better.

Some argue that these issues belong in the past. Advocates, however, maintain that such is impossible while the same disparities persist today.

We are now seeing “algorithmic racism,” in which medical algorithms use race as a biological variable. When race is entered into an algorithm to determine care, it creates different — and often discriminatory — outcomes for identical cases. Algorithms often use historical health care spending or electronic health record (EHR) codes to predict health needs. Since marginalized groups historically receive less spending, the system wrongly assumes they are healthier and prioritizes white patients for resources.

“Even within the health care system and the medical algorithms that drive decisionmaking for patient care, we know that there’s racial bias built into that too,” says Rhonda Smith, executive director of California Black Health Network.

“Race is a social construct, not a biological one,” Smith says. “So that should never be a factor in how patient care is delivered.”

When physicians face clinical uncertainty, implicit bias often fills the gap.

“When you don’t know what to do, that’s when your biases are going to come out,” says Dr. Tiffani Johnson, an ER pediatrician and researcher at the UC Davis Medical Center (UCDMC).

Data shows that Black and Latino children who come into the ER are significantly more likely to undergo invasive testing that wasn’t medically necessary, while white patients are statistically more likely to receive subspecialty consults or appropriate pain medication.

Furthermore, Black girls experiencing abdominal pain are more likely to be tested for sexually transmitted diseases due to the harmful bias that views them as being sexually active at an earlier age. Black patients across the board receive lower triage scores, leading to longer waits and less urgent care.

A disparity in pain management is rooted in a long-standing medical notion that Black people possess a higher tolerance for pain and therefore require less treatment. This harmful myth, furthered by J. Marion Sims and others, continues to shape modern clinical practice, as evidenced by persistent data.

A review of records from 1990 to 2018 found that Black patients consistently received less analgesia (relief or reduction of pain without loss of consciousness) than their white counterparts. This trend remains stark as a 2024 analysis of more than 4.7 million emergency department visits revealed that Black patients with acute trauma or high pain scores were still significantly less likely to be treated with pain medications than white peers, demonstrating that outdated racial stereotypes continue to influence current clinical outcomes.

Prescription For Change

UC Davis recently eliminated a race-based clinical algorithm that put Black and Latino patients at a historical disadvantage. Like most hospitals, UCDMC long used a race-based “correction” on a standard kidney function test (eGFR) that automatically boosted scores for Black patients based on the assumption they had more muscle mass. On paper, that made Black kidneys look healthier than they were, delaying referrals to specialists, monitoring, and eligibility for transplant, while Black patients still were more likely to die of kidney disease and arrive at hospitals needing emergency dialysis.

In 2024, medical students in Dr. Jann Murray-Garcia’s “Race and Health” course began to question the logic and history behind this practice, asking why race was being used as a biological variable at all and pushing faculty to scrutinize the evidence. Dr. Murray-Garcia encouraged her students to explore that “curiosity” and Dr. Rachel Lucatorto, an internist, teaching physician and ally, helped move the institution to act. Their evidence-based push helped make UCDMC one of the first academic medical centers to drop the race adjustment and adopt a race-neutral test as soon as national guidelines changed.

“Race is not a genetic phenomenon,” Dr. Murray-Garcia says. “It's not even a geographic or ancestry phenomenon. … Race is a social construction that served a sociopolitical purpose, such as in education and racial residential segregation, in appraisals for our homes and educational inequity, suspension rates. We are still living with these historical scripts. My class is very unique in that we look at the historical context of health inequities and how those scripts are still manifested clinically.”

Dr. Murray-Garcia also points to an algorithm that was used for years to decide whether women who’d previously had a C‑section could safely try for a vaginal birth. Until 2021, the algorithm quietly penalized Black and Latina patients, assigning them negative assessment points simply for their race or ethnicity and steering more of them toward repeat surgeries.

When researchers finally went back and reran the same data without race and Latino ethnicity in the formula, the model worked just as well. This exposed how “race-based” medicine can obscure the true drivers of Black maternal deaths, such as unequal care and hospital quality, in favor of biology.

Advocacy for change isn’t limited to algorithms; it also involves challenging the physical environment of the ER.

Dr. Johnson also has seen change at work. The medical center brought in a canine security unit in summer 2020 following the national protests that followed the deaths of George Floyd, Ahmaud Arbery and Breonna Taylor to “maintain a calm and secure environment” during night shifts. Not long after the dog was introduced, Dr. Johnson, a nocturnist on the pediatric side of the ER, took care of a child with severe injuries caused by another police dog.

“It got me thinking about the civil rights movement and the ways in which canines have been deployed against peaceful protesters and the legacy of trauma around canine units for Black folks,” Dr. Johnson recalls.

She also thought about how the canine’s presence could prove triggering for patients experiencing mental health crises, as well as those with substance use issues who associate dogs with prior negative encounters with law enforcement. She was concerned that fearful patients would be deterred from seeking necessary care.

Some of her white male colleagues took a different approach in getting leadership to reconsider and got the police dogs removed from the emergency department. For Dr. Johnson, it underscored the importance of partnering with colleagues who don’t look like her, but share her values and who can sometimes be more effective advocates in certain rooms.

Building A Healthier Future

Beyond immediate patient empowerment, some leaders look toward long-term, structural reimagining. Smith argues it will take more than statements and training to change history; that it will require equipping people with the tools to protect themselves in real time.

“If we’re able to empower our community … to do all the things that I [talk] about — like knowing what their patient rights are, making sure those rights are exercised and respected and protected — I do believe that racism will become less of an issue,” she says.

“At the very least, they will know how to navigate through those situations and know how to handle those situations, instead of retreating or retaliating in a way that doesn’t serve them well.”

Dr. Johnson wants to leverage the lessons of the past and the concept of Afrofuturism to build a future where children and families can thrive. She’ll focus on both during an upcoming sabbatical.

“I want to learn from our ancestors — how they were able to build programs with far fewer resources than we have now — and apply those lessons to the current challenges we’re facing, so we can reimagine better futures for children and families,” she says.

“I’m really excited about this next arc of my career, where I’m moving beyond just documenting the harm to asking, ‘How do we build better futures that don’t rely on systems that have been harmful?’”

She and other advocates and stakeholders say the status quo is a state of emergency and it’s time we treat it like one.