A new study published in JAMA Network Open explores the language used by physicians in patients’ medical health records. The researchers examine how both positive and negative language in medical records can affect the way patients are treated by medical professionals.
They encourage increased awareness of stigmatizing language in medical records to reduce negative attitudes towards patients and increase informative, competent care. The authors, led by Mary Catherine Breach, MD, MPH, of Johns Hopkins University, write:
“Patients are not treated equally in our health care system: some receive poorer quality of care than others based on their racial/ethnic identity, independent of social class. Others, such as older adults and individuals with low health literacy, obesity, and substance use disorders, may also be viewed negatively by health professionals in a way that adversely impacts their health care quality. Implicit bias among clinicians is one factor that perpetuates these disparities. Implicit bias is the automatic activation of stereotypes, which may override deliberate thought and influence one’s judgment in unintentional and unrecognized ways, and may affect treatment decisions.”
For example, in a study that investigated stigmatizing versus neutral language about a hypothetical patient with sickle cell disease, researchers found that stigmatizing language led to negative attitudes toward the patient, which in turn resulted in them providing the patient with fewer pain relievers despite their clinical information being the same as that of the patient who was introduced neutrally.
Researchers conducted a qualitative analysis of 600 randomly selected encounter notes from an ambulatory internal medicine setting at an urban academic medical center in the current study. Approximately 507 patients were written about in the notes, with the patients being predominantly Black (80%) females (69%).
The researchers examined the language used by physicians in the notes, identifying both positive and negative language as major themes.
The negative language used by physicians was separated into 5 categories: questioning patient credibility, disapproval, stereotyping, difficult patient, and unilateral decision making.
Researchers found that physicians questioned their patients’ credibility either by implying that they felt that the patient was not competent enough to recall or provide accurate information and by doubting their patients’ genuineness. They described how “doubt markers,” such as “supposedly,” “claims,” or “insists,” and quotes from the patients used in scare quotes were employed by physicians as a way to indicate uncertainty about the credibility of their patients.
Language indicating disapproval emphasized what physicians perceived as “poor patient reasoning, decision-making, and behaviors.” Physicians conveyed disapproval through language that used negative qualifiers like “unfortunately” and language that implied that they had to repeat themselves again and again to the patient, such as by stating, “I again explained. . .”
The negative language used by physicians went beyond the implicit into the explicit when physicians stereotyped patients based on racial identity or social class through their use of quotations of incorrect grammar or African American Vernacular English in patients’ notes. Racial bias has been shown to have major implications for the diagnosis and treatment of people of color.
Physicians also portrayed their patients as “difficult,” such as by conveying them as temperamental or ignorant and by expressing physician frustration. In addition, physicians used condescending and emotional language and quotes to portray their patients in a negative light.
The researchers provided examples of the “difficult patient” theme such as: “this seems to pacify him,” and “She will not consider taking it because ‘my heart is fine, I don’t want you all messing with my heart.’”
In their discussion of the “unilateral decision making” category, researchers highlight how the physician-patient power dynamic was emphasized in this type of language, as the patient was portrayed as ignorant and childish. In contrast, the physician painted themselves in a paternalistic or authoritative light by using language like, “I have instructed her. . .”
Physicians were also found to use positive language to describe their encounters with patients. The researchers categorized positive language into 6 groups: compliments, approval, self-disclosure, minimizing blame, personalization, and collaborative decision making.
Compliments included using positive adjectives, like “inspiring” or “kind,” to describe patients and were often at the beginning of the notes.
Physicians typically showed approval of patients in relation to their overcoming difficulties or their active participation in their care.
Positive emotions about patients were at times self-disclosed by physicians, such as through language like “Patient expressed her gratitude for care the last few years and expressed her thanks. I . . . expressed my gratitude as well for being an inspiring patient.”
In some notes, physicians attempted to minimize blame against patients for not following their treatment plans by promoting understanding through emphasizing particular challenges or barriers that may be preventing the patient from fully engaging in their care.
Attempts to humanize the patient by providing personal details about the patient’s life from the patient’s perspective, such as hobbies or important loved ones, were included in some of the encounter notes.
The final positive language category was identified as “collaborative decision-making,” which contrasts the unilateral decision-making category that fell under the negative physician language theme. Whereas the unilateral decision-making category indicated a paternalistic physician making treatment decisions on behalf of their patient, language in the collaborative decision-making category indicated that treatment decisions were made together by physician and patient.
Psychiatry has been shown to struggle to implement shared decision-making fueled by the misguided belief that patients are not competent enough to participate in the decision-making process.
Awareness of the language used in medical records is critical. With the rise of electronic health records in the United States, which make medical records available across health settings, the way notes are worded can influence how other medical professionals reading the notes perceive treat their patients.
In addition to negatively impacting how clinicians perceive and treat their patients, stigmatizing language can adversely affect the patients’ willingness to participate in treatment. If patients have negative interactions with clinicians due to the stigmatized language used in their notes, it may result in a cycle of self-fulling prophecy where the patient is perceived as “difficult” or disengaged and treated by medical professionals as such, which increases the negative feelings of the patient, who then transfers negative past experiences onto other clinicians.
Further, ambulatory internal medicine clinics tend to be high-stress environments, which can lead to implicit biases being activated, frustration, and burnout, which in turn, can result in the use of negative language in patient notes as a way for medical professionals to vent their frustrations.
The researchers suggest that addressing the stress and frustration inherent to such environments is key to improving the language used in medical records, in addition to working to make clinicians more aware of the language that they are using in their notes.
The researchers described having difficulty arriving at a consensus as to whether some of the language used in the notes were negative or positive – partly due to some of the statements being perceived as normal to the medical profession. They gave the example of how clinicians are often taught to write using the patients’ own words in their notes, but that in practice, patient quotes tend to be used as scare quotes, which are used to portray a negative attitude, in records.
They also highlight the complexities of the positive language used by physicians, particularly compliments and praise, as using any emotional language could lead to further disparities in the treatment of patients, which leads to the argument that medical records should use only neutral language. Additionally, compliments used towards marginalized groups like people of color may reflect racist attitudes that imply that people of color are not expected to exhibit traits like being “pleasant.”
Despite the issues associated with the use of compliments and praise in patients’ records, minimizing blame, personalization, and collaborative decision-making are all positive ways that medical professionals can engage in patient-centered care and attitudes that promote the dignity and respect of the patient.
A major limitation of this study was that although patients were able to access their electronic health records during the time the notes were written, most had not yet engaged with the electronic system, indicating that the majority of the clinicians had not written the notes with the understanding that patients might read them. Another limitation was that the notes were collected from an ambulatory, internal medicine setting at an urban academic medical center, so the findings may not be able to be generalized to other medical settings. Further, there was no information on the physicians’ demographics, like age, race/ethnicity, etc., which may have influenced how language was used in their notes. Lastly, the researchers point to the assumptive nature of their work, as they could not know the physicians’ attitudes while writing the notes or how the readers interpreted them.
In their conclusion, Breach and colleagues emphasize that increased awareness and consciousness of how professionals write and read medical notes is crucial to reduce treatment disparities and increase respectful treatment of patients. They suggest that research should be conducted to explore more deeply how often stigmatizing language is used, how it changes depending on the patient and clinician, or the relationship between physician and patient, as well as how stigmatizing language affects overall treatment outcomes.
Park, J., Saha, S., Chee, B., Taylor, J., & Beach, M. C. (2021). Physician use of stigmatizing language in patient medical records. JAMA Network Open, 4(7), 1-11. doi:10.1001/jamanetworkopen.2021.17052 (Link)