Humans are natural pattern recognition machines. We have an evolved instinct not only to recognize different patterns but also to categorize and store these patterns in order to make future predictions. In fact, this ability to recognize and represent patterns to draw a variety of intuitive inferences could be the defining and most original characteristic of our brain. Furthermore, just as in the case of all evolved instincts, these categorizations most often do not occur on a conscious level but occur mostly automatically and subconsciously. Additionally, just as in any other evolutionary adaptations, the role of this system is not necessarily to uncover any real “truths” about the world but to primarily serve our evolutionary drive to reproduce and survive. Therefore, in our modern world, this gift of pattern matching has the potential to become a curse as these patterns ossify into culturally ingrained stereotypes.
A stereotype is defined as a “widely held but fixed and oversimplified image or idea of a particular type of person or thing.” According to the stereotype content model, we categorize people along two axes: warmth and competence. These two axes are independent of each other. Therefore, groups are broadly categorized into four quadrants. Groups such as children, people with disabilities, and older adults [upper left of quadrant] are often pitied and shown sympathy but held in high regard. This group involves activation of the ventromedial prefrontal cortex (vmPFC) region in the brain which is involved in the impact of emotion on decision making. Group members in this category elicit a desire to help. In contrast, groups such as the poor, the homeless, welfare recipients are on average categorized with low warmth and low competence [bottom left] and are often treated as a monolithic, homogenous population without individual variation. Regions of the brain associated with aggression and disgust (amygdala and insula) are activated in response to group members in this quadrant. Interestingly, the insula also triggers disgust when eating something bitter and it is hypothesized that the brain reused this feature for social disgust. Just as in any model, the real world is far more complex and does not present with clean and discrete boundaries, but nevertheless, this model can serve as the framework for decision making biases in the emergency department.
The emergency department is an essential part of the US healthcare system. In fact, according to a recent analysis, an increasing amount of care is delivered in emergency departments across America. Approximately half of all medical care is delivered in the emergency department. Moreover, certain groups are significantly more apt to get care in these departments compared to others. More specifically, African-Americans, Medicare, and Medicaid recipients and people with disabilities are significantly more likely to have emergency department visits than patients in other groups. In other words, the emergency department largely serves groups perceived to be on average on the left side of the stereotype content model. As individuals in these groups are often medically vulnerable, being cognitively unaware of our subconscious stereotypes can lead to missing subtle but important clues in the patient presentation. In a high-risk environment such as the Emergency Department, this can have potentially catastrophic consequences. Overlooking subtle signs of trauma in a frequent alcoholic or under-appreciating the extent of a skin infection in a disheveled homeless patient are examples of not uncommon risk-laden scenarios that are prone to stereotyping. Conversely, on the other end of the spectrum, older adults and those with disabilities are stereotyped as helpless and providers often fall in the pitfalls of over-testing and overtreatment. We either overtreat to extend the quantity of life in the elderly or we overtest to rule out low probability events in the disabled.
Legendary artificial intelligence pioneer Marvin Minsky stated, “in general we are least aware of what our brains do best.” Stereotyping is not a lazy shortcut but a natural and innate function that served a function in our evolutionary history. We all have multiple stereotypes in our brains that are culturally reinforced and groups in different categories evoke different feelings. Often operating at the most subtle levels, these feelings influence decision making sometimes in catastrophic ways but also in insidious ways. Since emergency departments serve as the social safety net and see a disproportionate number of vulnerable individuals and these stereotypes are largely subconscious in origin and operate outside the realm of conscious thought, it is not sufficient or maybe not even feasible for us providers to be aware of the impact of these stereotypes. Therefore, there must be processes, policies, cognitive tools in place that mitigate the risk posed by these stereotypes.