Words Do Matter

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Stigmatizing notes can affect patient care

Medical records are more accessible (e.g., patient portals) and enduring (e.g., digital) than ever before. This transparency has prompted the College to articulate the expectation that documentation in medical records be professional and not contain discriminatory or inappropriate remarks about patients.

The expectation, stated within the College’s recently approved Medical Records Documentation policy, makes the point that patients can, and often do, obtain copies of their medical records and clinical notes and that reading unprofessional comments about themselves can undermine their relationship with their doctor.

But stigmatizing words can do more harm than even souring a patient on their physician. A Johns Hopkins study found that physicians who use stigmatizing language in their patients’ medical records may affect the care those patients get for years to come.

When doctors read notes and descriptions from previous medical visits, says the study published in the May 2018 edition of  The Journal of General Internal Medicine, the language in those notes may play a role in how that patient is treated, as well as the kind of care they receive from other doctors who read the medical record.

Dr. Mary Catherine Beach, a professor at the Johns Hopkins Bloomberg School of Public Health, designed the study to determine whether the language and descriptions used in patient records can perpetuate bias among physicians. More than 400 physicians-in-training — medical students and residents — were presented with one of two vignettes about a hypothetical patient, a 28-year-old Black man with sickle cell disease and chronic hip pain.

While the vignettes contained medically identical information, one used neutral language to describe the patient and his condition, while the other vignette contained nonessential language that implied various value judgements. 

Dr. Beach and her research colleagues found that physicians-in-training who read the stigmatizing patient chart notes were significantly more likely to have a negative attitude toward the patient than those who read the chart containing more neutral language.

And not only did their attitudes change — so did their treatment plans. Those physicians-in-training who had read the stigmatizing chart note decided to treat the patient’s pain less aggressively.

 “The medical record may be the only source of information a new clinician has about some patients,” says Dr. Beach. “We have to question the assumption that the medical record always represents an objective space.”

Even physicians-in-training who recognized the language as stigmatizing were more likely to form more negative opinions about the patient and to treat that patient’s pain less aggressively.

“There is growing evidence that the language used to communicate in health care reflects and influences clinician attitudes toward their patients,” says Anna Goddu, a Johns Hopkins University School of Medicine student who co-authored the study. “Medical records are an important and overlooked pathway by which bias may be propagated from one clinician to another, further entrenching health care disparities.”

Participants who identified as black or African-American generally had more positive attitudes toward the patient.

“That affirms what some other studies have shown,” says Dr. Beach, “specifically, that African-American clinicians have more positive attitudes toward patients with sickle cell disease.”

Goddu says that, while the topic deserves more research, she hopes this study opens some eyes.

“I hope our study makes clinicians think twice before including certain, nonessential points about a patient’s history or demeanor in the medical record,” she says.

Importance of Language

The study’s participants were introduced to the hypothetical Mr. R., an African-American man whose condition necessitates the use of a wheelchair. Both vignettes begin with Mr. R. visiting the hospital emergency department with vaso-occlusive crisis, common among patients with sickle cell disease. Among the standard treatments for this condition are opioids to treat pain and oxygen to combat the effects of sickled red blood cells’ inability to oxygenate organs. 

Examples of the differing notes on the hypothetical patient:

Stigmatizing LanguageNeutral Language
“He is narcotic dependent and in our ED frequently.”“He has about 8-10 pain crises a year, for which he typically requires opioid pain medication in the ED.”
“Yesterday afternoon, he was hanging out with friends outside McDonald’s where he wheeled himself around more than usual and got dehydrated due to the heat.”“He spent yesterday afternoon with friends and wheeled himself around more than usual, which caused dehydration due to the heat.”
“The pain has not been helped by any of the narcotic medications he says he has already taken”“The pain is not alleviated by his home pain medication regimen.”
“He appears to be in distress.”“He is in obvious distress.”
“His girlfriend is lying on the bed with shoes on and requests a bus token to go home.”“His girlfriend is by his side but will need to go home soon.”

More Suggestions

“the patient claimed”
“the patient insisted”
“the patient demanded”
“the patient denied”
“the patient reported”
“the patient stated”

“the patient is obese”
“the patient’s BMI is …”

“the patient is a substance abuser”
“the patient is narcotic seeking”
“the patient has a substance use disorder”

“patient refuses to wear oxygen mask”
“patient not tolerating oxygen mask”