Our Police, Ourselves

Last week, the National Bureau of Economic Research (NBER) published a working paper by economist Roland Fryer on how police use violent force on civilians based on the race of those civilians.

Because police departments are not obliged to provide detailed encounter summaries in response to Freedom of Information Act requests and there is no standardized reporting of police use of force, Fryer’s team used a non-random sample of urban police departments with whom they were able to make contacts. Most of these departments were voluntarily a part of President Obama’s Police Data Initiative, a reform initiative focused on police accountability. In the methods section, Fryer is explicit about the bias that this selection introduces to the study and the limits it places upon its generalizability.

From these data sets, Fryer makes some interesting observations:

New York City Stop-And-Frisk Data

  • In New York, Black people are 17% more likely to experience police violence during a police stop compared to Whites. Hispanic people are 12% more likely.
  • This disparity was present across all use of force categories [(1) hands, (2) force to a wall, (3) handcuffs, (4) draw weapon, (5) push to the ground, (6) point a weapon, (7) pepper spray or (8) strike with a baton].

Police-Public Contact Survey (PCPS)

  • The PCPS is a nationally representative survey of civilians on their encounters with the police.
  • In the PCPS data set, Black people were 2.7 times more likely to report use of force by police and Hispanic people were 1.7 times more likely after accounting for demographic and encounter characteristics.
  • “Strikingly, both the black and Hispanic coefficients are statistically similar across these income levels suggesting that higher income minorities do not price themselves out of police use of force”

Houston Officer-Involved Shooting (OIS) Data

  • This was the result that has made the headlines. In Houston, police were no more likely to shoot a Black person during a police encounter than a White person.
  • Unlike in much of the press surrounding this research, in the paper itself Fryer is explicit about the limited scope of its conclusion: “To be clear, the empirical thought experiment here is that a police officer arrives at a scene and decides whether or not to use lethal force. Our estimates suggest that this decision is not correlated with the race of the suspect. This does not, however, rule out the possibility that there are important racial differences in whether or not these police-civilian interactions occur at all.”

This study joins a growing body of literature focused on racial bias in policing. These studies are reliant on the lay press for data which introduces its own set of biases, but unfortunately such weak data is what we’re stuck with until we get mandatory reporting of all police shootings.

These results do no necessarily conflict with Fryer’s result when you consider that Black people are more likely to be stopped by police than white people.

In other words, even if there is an equal chance of a police officer pulling the trigger during an encounter with a Black or White person, because Black people are stopped by police more often, they are shot by police more often.

I think this is an important conclusion to think about because it moves the narrative away from focusing solely on police shootings to a bigger picture view of how policing reflects broader social perceptions of Black criminality and suspiciousness.

Better de-escalation training can reduce the overall number of people killed by the police and by extension the number of Black people killed by police. Implicit bias training can reduce the excess targeting of Black communities which leads to excess Black deaths at the hands of police. These are great harm-reduction steps that we can take right now that will literally save lives.

However, affirming that Black Lives Matter means taking a step beyond reactive politics toward an understanding that police attitudes and behaviors are not anomalous, but a reflection of the society in which they operate. Police reforms are important, but so is rooting out and addressing the racial biases present in my own life and in my immediate community.

If this is something that you’re interested in as well, check out this curriculum on race and racism or this guide to developing a positive White identity through anti-racist action. And of course, feel free to chat with me about it. I’m @hkalodimos on Twitter.


Affirming the Value of Black Lives

In the wake of Alton Sterling and Philandro Castile’s untimely deaths at the hands of police, there is renewed focus on how we might remake our society into one which upholds and affirms the value of Black Lives. As healthcare providers, life’s value is not an abstraction, but a concrete goal toward which we strive every day. Every therapy we prescribe or perform is rooted in the value of life and our mission to preserve and prolong it.

Because of this, there is currently a lively discourse amongst physicians and other healthcare professionals about how we might respond to this epidemic of violence. I’m collecting some of these approaches in this post mostly in order to organize my thoughts, but I also want them to be available to anyone who is looking for a way to take action against the systemic racism which leads those who are labeled Black in this country to have a greater burden of illness.

If you have anything that you think I should add to this list, please let me know! Specifically, I want to know of any groups or individuals which are helping organize people around specific interventions.

Personal Interventions

Educate yourself

Change begins with you, right? A Letter to Our Patients on Racism is a great statement on how medical providers can meaningfully commit to anti-racism. While you’re at it, here are some great reading lists to better inform yourself of the causes and consequences of racism in American society:

If you have privilege, be an ally to those without it

At some point, I will pick and choose from these lists to make a shorter more manageable doc, but for now here are some resources that I frequently draw upon.

Speak to your friends, family, and coworkers

Discussing race is difficult, but important. Here are some tips to make the conversation productive.

  • Connect before you correct. Always start the conversation by centering on your connection with the person and acknowledgement of their good qualities. At the very least, most people have good intentions.
  • Spend more time listening than speaking. Monologues do not change minds. Spend time early in the conversation coming to understand not only what a person’s beliefs are, but what experiences they’ve had that have informed those beliefs.
  • Respond to the person, not to the straw man. When listening to someone, consider the most generous interpretation of their words and respond to that.
  • Do not try to “win” the conversation. The purpose of this conversation is not to embarrass the other person or force them to admit they are racist. It’s to come to a better understanding of each other’s points of view. If you are approaching the conversation with malice, you better believe that the other person is going to shut down.

Law Enforcement Interventions

Advocate for comprehensive police reform

  • Summary: No single intervention is going to fix all the problems with our current law enforcement system, however, Campaign Zero has put together a thoughtful list of reforms which when taken together promote and more just and peaceful society.
  • What you can do: Read over their reform proposals and then use the Take Action Tool on their website to speak with your local representatives about the laws being considered in your state or to advocate for the reforms you feel most passionate about. If you’re feeling generous, you should donate here!

Promote police implicit bias training

Promote Crisis Intervention Teams

  • Summary: Crisis Intervention Teams are focused on safely and appropriately responding to people experiencing a mental health crisis without resorting to violence. While not directly addressing the issue of racism in policing, it is a reform effort to making law enforcement more humane and community-oriented.
  • What you can do: The National Alliance on Mental Illness has a page dedicated to how you can help establish a Crisis Intervention Team in your city. As before you can also contact your city council person and advocate for this intervention.

Make law enforcement-related deaths a notifiable condition 

  • Summary: By mandating reporting of these deaths, researchers will be able to gather more accurate public health data about patterns in this type of violence. Dr. Nancy Krieger has been the most vocal advocate of this approach and you can read her full argument in PLoS Medicine (Open Access).
  • What you can do: I’m not aware of any formal organizing around this issue, but you can contact the APHA or your medical society and advocate for this approach.

Healthcare Interventions

Commit to and promote the practice of trauma-informed care

  • Summary: Patients that have been traumatized by police violence, repeated racist encounters, or other events are often at higher risk of illness. Trauma-informed care is a practice of acknowledging past traumas and helping patients heal while avoiding re-traumatizing them.
  • What you can do: The Substance Abuse and Mental Health Services Administration has some great resources here, but to really engage you will likely have to seek out local training for your physician group.

Ensure hospital staff is trained in de-escalation strategies

  • Summary: The recent shooting of Alan Pean while he was hospitalized for a manic episode brought national attention to hospital security staff that is often unprepared to safely manage agitated patients.
  • What you can do: Find out what policies your hospital has for managing agitated patients and if they haven’t instituted de-escalation training for security personnel, advocate for it.

Physician-Activist Groups To Join or Follow



Unintended Pregnancy: Common Ground in the Abortion Debate

Screen Shot 2016-03-13 at 4.27.03 PMThis chart is a big deal because unintended pregnancy is a big deal.

The physical and emotional stress of unintended pregnancy is reason enough to desire its reduction. However, it’s also notable that unintended pregnancy is associated with inadequate prenatal care, smoking and drinking during pregnancy, and giving birth to premature or low birth-weight infants. Thus, by creating conditions in which a women can choose if and when she becomes pregnant, you can improve the health and well-being of both women and children.

Because of this, the National Survey of Family Growth has been a frequent cause for consternation among public health-minded folks as it has previously shown an unintended pregnancy rate that just wouldn’t budge. Results from 2001 allowed for some hope when there was a modest decline in the rate, but when 2008 results showed an increased rate of unintended pregnancy, those hopes were dashed.

Two weeks ago, the New England Journal of Medicine published the latest data on unintended pregnancy in the United States showing a 18% decline in the rate of unintended pregnancy between 2008 and 2011 to an all-time-low of 45 unintended pregnancies for every 1000 women between the ages of 15 and 44. This is still far too many unintended pregnancies, but it’s progress.

tThe report also contains lots of interesting information about the use of abortion in the United States. The percentage of unintended pregnancies that ended in abortion ticked up slightly from 40% to 42%. However, because the rate of unintended pregnancy dropped over this same time period the abortion rate actually decreased from 19.4 to 16.9 per 1000 women aged 15-44 between 2008 and 2011. 

I really can’t emphasize enough how important it is to recognize that one of the most effective tools we have for reducing the rate of abortion is to reduce the rate at which women need abortions by providing effective and affordable birth control to all women who desire it. In these times when political common ground is scarce, this strikes me as an area where people with different value systems can agree on a policy that would be a win for everyone.

Finally, the report also emphasizes a fact that I believe doesn’t get enough play which is that abortion is incredibly common amongst all types of women. Amongst Catholic women, 48% of unintended pregnancies end in abortion. Evangelical Christians, the religious group which utilizes abortion the least, still terminate 32% of their unintended pregnancies. Although people from these groups are often fighting to restrict access to abortion, there is a deep irony to the fact that this is a procedure that they themselves use at roughly the same frequency as the general population.

Even if it is ironic, it is not surprising. After all, abortion is a safe procedure which allows women to be in control of whether or when they raise a child. Of course women from all walks of life avail themselves of it.

Facts to take with you:

  1. 45% of all pregnancies are unintended
  2. 42% of unintended pregnancies end in abortion
  3. 21% of all pregnancies end in abortion
  4. 1 in 3 women will have an abortion at some point in their life

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Behavior change and patient empowerment

(The following is a response to an event co-hosted by NEJM Catalyst and LDI CHIBE on “Patient Engagement: Behavioral Strategies for Better Health.” It has been cross-posted to the Leonard Davis Institute’s Health PolicySense blog)

As a medical student going into primary care, I value health behavior change not only as a disease prevention strategy, but as a way of empowering patients. In many areas of our health care system, we ask our patients to be passive recipients of care: to take their pills obligingly, get their colonoscopies on the appointed date, and to consent to the surgeries we recommend. In health behaviors such as diet and exercise, patients are instead active promoters of their own wellbeing.

This altered power balance in which the patient has control and the provider has only influence can make health care practitioners who are used to being in charge feel deeply uncomfortable. However, with a third of all premature deaths in America attributable to health behaviors, there is tremendous opportunity here to better our nation’s health by partnering with patients to promote more healthy behaviors.

Continue reading “Behavior change and patient empowerment”

A Brief Intervention for Behavior Change

This essay is based on a talk I gave to medical students and faculty at the Perelman School of Medicine at the University of Pennsylvania on how physicians can help patients achieve behavior change.

Developing instincts

heart_attackThis image is enough for most of you in the audience to start building your differential diagnosis. When this older gentleman shows up in your emergency department sweating profusely and complaining of chest pain, you’re going to instinctively reach for an aspirin and an EKG.

Much of our medical training is focused on these kinds of situations where procedural memory helps us act quickly and effectively. This is important because when we’re in a time limited and stressful situation, it can be difficult to think clearly and so we need to develop good instincts.

Yet let me turn the clock back twenty years, well before his coronary arteries are overrun with plaque. What happens when this same patient shows up to your outpatient practice and during a routine exam you find out that he smokes a pack of cigarettes a day?

You’ve got 5 minutes until you see your next patient. Once again, you’re time limited and stressed. What do you do? Are you still ready to act?

Continue reading “A Brief Intervention for Behavior Change”

Why do we pay more to treat illness than prevent it?

(The following has been cross-posted to the Leonard Davis Institute’s Health PolicySense blog)

David Asch, Mark Pauly, and Ralph Muller have a great piece in this month’s New England Journal of Medicine on how we as a society think about preventive versus cancer care. They observe that whenever preventive care strategies are studied, there is an obsessive concern with the return on investment of these strategies and that this same scrutiny is not applied to cancer care.

The entire article is well worth reading, but in summary their argument is that this difference occurs because:

  1. Cancer care is more profitable for healthcare providers than preventive care.
  2. There are more well-defined and evidence-based strategies for cancer treatment than for preventive care.
  3. Seeking reward for treating illness is a much stronger motivator than avoiding penalty for failing to prevent illness.

Continue reading “Why do we pay more to treat illness than prevent it?”

Rationing through self-triage, my patient perspective

As I fell off the curb, my first thought was about my deductible.

Earlier in the year, I had tried to save a little money and chose a high deductible plan. This meant that I would have to pay the full cost of any doctor visit (including my primary care provider) until I had spent down my $6500 deductible. With an emergency department visit costing hundreds of dollars, I worried that my clumsiness had effectively wiped out whatever premium savings I had achieved with this choice.

In choosing a high-deductible plan, I had gambled that I could get through a year without illness and in the process fallen victim to my own optimism bias. As my ankle rolled inward and I heard an extremely unsetting *snap*, I felt very stupid about it.

Continue reading “Rationing through self-triage, my patient perspective”