Stigmatizing Language in Medical Records Affects Patient Care, Study Shows

Physicians who use stigmatizing language in their patients’ medical records could be affecting the care they receive for years to come, according to a new Johns Hopkins study.

Titled “Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record,” and published in the Journal of General Internal Medicine, the study aimed to determine whether the language and descriptions used in patient records could perpetuate bias among doctors.

The study analyzed the notes and descriptions physicians had written during visits to a hypothetical patient at a large urban medical center. Researchers then assessed how the language used in the notes influenced the patient’s care and pain management.

Researchers at the Johns Hopkins School of Medicine used an experimental vignette study design, in which 413 residents and medical students were randomized to read one of two chart notes presenting medically identical information about a hypothetical 28-year-old patient with sickle cell disease (SCD) and chronic pain in his left hip.

While the briefings were identical, one used non-essential language that appeared to stereotype the patient and cast doubt on his pain, and the other used neutral language — for example, one chart insisted the patient’s pain is “still a 10” while the other, which used neutral phrasing, said he “still has 10/10 pain.”

When introduced to the hypothetical Mr. R, an African-American man whose condition required the use of a wheelchair, both vignettes began with the patient visiting the emergency department (ED) with a vaso-occlusive crisis, common in sickle cell patients.

Standard treatments for this condition are opioids to treat pain, and oxygen to fight the effects of the sickled red blood cells’ inability to oxygenate organs.

While one medical report documented the situation as “he has about 8-10 pain crises a year, for which he typically requires opioid pain medication in the ED,” the other, which used stigmatizing language, described the same Mr. R as “narcotic dependent and in our ED frequently.”

Another example of stigmatizing language in Mr. R’s medical record stated: “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.”

Here’s the same sentence in the version that used neutral, non-stereotypical language: “He spent yesterday afternoon with friends and wheeled himself around more than usual, which caused dehydration due to the heat.”

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

Not only did their attitude change, their treatments did as well. Physicians-in-training who read the stigmatizing notes would treat the patients’ pain less aggressively.

These findings are significant because every clinician’s encounter with a patient is documented. These charts include symptoms, patient history, vital signs, assessments, and treatment plans.

“This record may be the only source of information a new clinician has about some patients,” Mary Catherine Beach, MD, who designed the study, said in a press release. “We have to question the assumption that the medical record always represents an objective space.”

“There is growing evidence that the language used to communicate in healthcare reflects and influences clinician attitudes toward their patients,” said Anna Goddu, a Johns Hopkins Medical School 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 healthcare disparities,” she said.

One result, however, was encouraging. When prompted, participants were able to reflect on how the words used in the chart notes communicated respect and empathy for the patient and when they did not.

“To us, this seems like a promising point of intervention,” Goddu said.

Also, medical residents were found to have more aggressive attitudes than medical students toward the hypothetical patient.

“Attitudes seem to become more negative as trainees progress,” Beach said. “It may be that trainees are influenced by negative attitudes and behaviors among their peers and seniors in the clinical setting.”

Of the 413 study participants (54% response rate), 42.8% were female, 43.5% were residents, and 14% were Hispanic/Latino. Most respondents were white (54.7%), 26.9% were Asian, and 10.4% were black or African-American.

Participants who identified themselves as black or African-American were also generally seen to have more positive attitudes toward the patients, which reportedly correlates with results of previous studies.

“That affirms [that] specifically African-American clinicians have more positive attitudes toward patients with sickle cell disease,” Beach said.

This study contributes to the growing evidence that language used to communicate in healthcare reflects and influences clinician attitudes toward their patients.

Examples of other research includes one study that found residents were more likely to mention black race vs. white when the patient had stereotypically negative behavior, and another study, specific to sickle cell disease, found that physicians use the term “sickler” to describe SCD patients in a derogatory form.

The authors are hopeful that their study drives more research into the subject and raises awareness among healthcare practitioners about their own biases toward patients, which sometimes may come out as involuntary nonobjective writing.