Physician Use of Stigmatizing Language in Patient Medical Records, Park et al, 2021

Physician Use of Stigmatizing Language in Patient Medical Records

Jenny Park; Somnath Saha; Brant Chee, Janiece Taylor; Mary Catherine Beach

JAMA Netw Open. 2021

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781937

Key Points

Question What types of stigmatizing language are written by physicians about patients in their medical records?

Findings This qualitative study of 600 encounter notes from 138 physicians found 6 ways that physicians express positive feelings toward patients in medical records, including compliments, approval, and personalization. This study also found 5 ways that physicians express negative feelings toward patients, including disapproval, discrediting, and stereotyping.

Meaning These findings suggest that physicians should increase their awareness of stigmatizing language in patient records to ensure that their notes are informative and respectful.

 

They do a lot more than that. They flag patients that they don't like or they disbelieve. And these apparent snap judgements are life sentences because none of them ever get removed, as far as I can tell, nor is there any appeal.

 

Full abstract.

Abstract

Importance
Negative attitudes toward patients can adversely impact health care quality and contribute to health disparities. Stigmatizing language written in a patient’s medical record can perpetuate negative attitudes and influence decision-making of clinicians subsequently caring for that patient.

Objective
To identify and describe physician language in patient health records that may reflect, or engender in others, negative and positive attitudes toward the patient.

Design, Setting, and Participants
This qualitative study analyzed randomly selected encounter notes from electronic medical records in the ambulatory internal medicine setting at an urban academic medical center. The 600 encounter notes were written by 138 physicians in 2017. Data were analyzed in 2019.

Main Outcomes and Measures
Common linguistic characteristics reflecting an overall positive or negative attitude toward the patient.

Results
A total of 138 clinicians wrote encounter notes about 507 patients. Of these patients, 350 (69%) were identified as female, 406 (80%) were identified as Black/African American, and 76 (15%) were identified as White. Of 600 encounter notes included in this study, there were 5 major themes representing negative language and 6 themes representing positive language. The majority of negative language was not explicit and generally fell into one or more of the following categories: (1) questioning patient credibility, (2) expressing disapproval of patient reasoning or self-care, (3) stereotyping by race or social class, (4) portraying the patient as difficult, and (5) emphasizing physician authority over the patient. Positive language was more often more explicit and included (1) direct compliments, (2) expressions of approval, (3) self-disclosure of the physician’s own positive feelings toward the patient, (4) minimization of blame, (5) personalization, and (6) highlighting patient authority for their own decisions.

Conclusions and Relevance
This qualitative study found that physicians express negative and positive attitudes toward patients when documenting in the medical record. Although often not explicit, this language could potentially transmit bias and affect the quality of care that patients subsequently receive. These findings suggest that increased physician awareness when writing and reading medical records is needed to prevent the perpetuation of negative bias in medical care.

 

Possibly, although I suppose one can stereotype about others from their own race and gender too, perhaps it would be interesting to know which characteristics use more if the positive or negative language overall

 

An example of a negative phrase in a patient file is: Patient X claims to have such and such. The word "claims" casts doubt on the patient's credibility and character in general. It generates questions about the patient's motives. It implies many things.

 

Having seen my NHS notes a while back, it's full of 'She thinks she has [such and such]' or 'She feels [such and such]'. Why not simply 'She says'? It seems intended to belittle the patient's intelligence and credibility, and I can't help wondering why they do this.

 

I was told by a health care worker there is a prevalent attitude or belief that the public is not intelligent, in fact quite the opposite.

I also heard this same opinion from another health care worker. From this n=2 sample, and my own experience, I would guess this opinion is fairly common. But I don't think it's restricted to health care workers.

ETA: deleted a "this".

 

Not in reference to your own situation @EzzieD or, I'm sure the experience of many here, but this style can be "OK" in intent and isn't necessarily judgemental of the patient.

Although it might read poorly, there is sometimes a more benign explanation to this. It relates to the difference between symptoms and signs. Similar to subjective vs objective.

In the ideal medical world, things happen in proper order, with a structure that serves everyone well. History, examination, differential diagnosis, investigations, definitive diagnosis, treatment, follow-up. History is the story elicited from the patient, often directed with particular questions from the doctor, sometimes simply open-ended. The doctor does the other steps, often out-sourcing to colleagues: lab, x-ray, referral etc. (Not being in clinical medicine, I hope I've got this right, in case any professors of medicine are reading. )

So, the patient complains of symptom(s): "headache", "cough", "breathless", "sore" etc. These would often be stated with non-medical terms. The doctor examines and determines objective clinical evidence of signs of disease and dysfunction and decides "pneumonia right lower lobe" for example.

So sometimes you'll see notes that read along the lines of "the patient says/believes they have diagnosis X". The implication is that it hasn't been (yet) validated by the doctor and given the official stamp. This also applies to other doctors. An official communication or record indicating a diagnosis generally becomes an established part of the problem list. But sometimes there is hearsay. This might be because the patient is relaying what another doctor has diagnosed or they came from another country without their medical records, etc. Then you might see something like "patient A is said to have diagnosis X". That can also be code for "I'm unconvinced by what this other doctor has written"...

Something of a special case that I and some others here would experience is when you're a doctor, but now you're the patient. You know the lingo and you're used to thinking and talking in this language. Doctors don't like it when you do that. For example, on one occasion I described very precisely, observable physiological changes - only to be told I was fixating / hypervigilant / internalising / catastrophising etc. I shudder to think how my clinical notes read for that encounter...

 

I guess that that comes from asking the question "what do you think is wrong with you?" what do you feel?" It is likely that the patient never mentions thoughts or feelings.

 

I do know what you mean, they feel they need to couch things in vague terms unless/until they can get some lab test result that shows something really blatantly obvious, which unfortunately never happened for me.

It would have at least been better, though, if what they quoted me as 'thinking' or 'feeling' was what I actually said! With every NHS doctor I've seen, my notes are so outstandingly wrong that it looks like they confused me with some other patient, or just made it all up, and all in full stigmatising and belittling glory. I've had to write letters asking them to correct the mistakes and request that the letter be put in my notes. But, they never correct the mistakes and even if the letters are in my notes, it's unlikely a doctor would read them, only the ones from other doctors. An awful and unhelpful situation for sure. Interestingly, this doesn't happen with the private doctor I see - she takes care to get everything right.

 

I think it reads poorly even when the doctor writes, 'She/he said...'. After all, medical consultations aren't police inquiries.

Why can't they write, for example, 'she experiences tremors and pins and needles in her hands', 'he experiences severe headaches', 'they have had a number of bad falls in the last month' etc.? Using the term 'experiences' covers the subjective aspect of pain and fatigue and other debilitating symptoms which don't have an objective test, but implies the healthcare professional believes the patient's testimony. Why would a doctor not feel able to report a patient's objective experiences, such as falls, in a way that portrays they can accurately remember them (unless the patient has a condition that affects such memory and recall)?

 

Is it possible (in addition to the judgements that the article describes) they are also categorising them using Bradshaws needs - normative (has professional diagnosis of /clinical observation of), felt (she says she feels, she says she has), expressed (wants referral to..treatment with..)?

 

Ditto.

I have had someone else's notes plonked into the middle of mine. One of the miscarriages in my records isn't mine, and when I told my doctor he suggested that I might have forgotten! How many women forget miscarriages, particularly since I was going through IVF at the time?

I've had internal organs miscounted, to the extent that they have been removed (in real life) and then (allegedly) grown back and been perfectly heathy, then been removed again (allegedly). The longest time between removal and (alleged) reappearance was about 30 years. The shortest time was 6 years.

When I read my records I see that pain is repeatedly minimised or not mentioned at all. Copious bleeding from a gastric bleed was repeatedly minimised. I've had entire operations missed out of my records. I've had laparoscopies in which findings which were important and relevant to my future health were made and yet they were recorded in a way that just said "Laparoscopy" and nothing else, so the important findings were not recorded. I had adenomyosis - not recorded. Fibroids - not recorded. Adhesions - recorded in letters but not recorded in any summary so will never be found.

I tried getting things corrected but nothing happened.

When receptionists look me up on their computer systems they scowl at me when they find me, presumably because I've been flagged in some way - but naturally nobody would ever admit this and the flags are life sentences.

 

Thank you, yes agree. That mostly seems to happen as a matter of course which was a pleasant surprise to me and my GP has that sort of open system too. The hospital encounter I mentioned above was noticeably not one that was sent out.

I think the message is getting there that patients can, do and should read their notes (although translation can be an issue at times). Most people I've worked with seem to use the principle that everything you write will be read by patient and family, if not plastered over the front page of The Herald, so proceed accordingly. The stories above show much to be done in many regions / specialties.

The point about summary judgement with no right of appeal that lasts in perpetuity is a major problem. Particularly when one side just won't hear the facts due to fundamental disconnect. It then flows on to a lifetime of negative experiences for patient and family.

On a brighter note, working in paediatrics I sometimes indulge a little more free rein with my reports. Eg in a preamble to all my official, proper and hopefully logically structured opinion, there might very occasionally be a bit of: "Janey came for her ultrasound with us this morning. She wasn't at all keen on this, but together she and I scanned Teddy's belly and found he was full of cotton wool. Janey was then surprised that she herself did not contain cotton wool, but agreed with me that there was clear evidence of sugar and spice and everything nice (unlike her sister). At the end she said she would be very happy to come and see us again in a month."

In my experience, this sort of thing adds a lot to family and team morale and strengthens the relationship and humanises the process.

 

I was trained not to use stigmatising language. I would verbatim jot phrases people said and put them in quote marks. If needs be I would clarify to make sure I had it right. I would jot down signs and symptoms directly into their psych notes (paper version, electronic later) People were allowed to believe what they liked, it’s their illness and belief system. In NZ, people are allowed full access to their psych notes, they can get a photocopy but third party info will be removed unless that party has consented for it to remain. We usually offer another mental health professional to sit with the client, if they wish, to explain terms, provide emotional support and if needs be collate corrections. If we get something wrong we change it. Of course it can be distressing to read the psychiatrist’s opinion but we have to sit and explain why we made this diagnosis. They have the right to disagree and have it recorded in their notes. They may also read through and give additional information/history and this will be recorded. This can be very useful as often parts of their history is not taken due to time constraints, weren’t enquired about. This can change the diagnosis sometimes or add new insights. This helps the therapeutic relationship.

In addition, we do not use any descriptors other than age, identified ethnicity and gender.

 

Yes, this is a real problem, everything that is written down becomes part of the person’s health record. Everything I write down (and every other health professional) becomes a contemporaneous medicolegal document (this is a very important part of medical law, you can’t go back and change things, if you cause an error and cover up evidence)

But the health professional can misrepresent what was said, twist meanings, make things up and all sorts. I have seen things written when I asked the client about it (or their family etc) they have been shocked and it is an opportunity to set the record straight. In NZ, if the person feels misrepresented they have a right to complain via the Health and Disability Rights Code, every health practice have these clearly posted in waitrooms. There are forms available online and at receptions, and must be passed to the manager of that service, a formal process of investigation occurs. If there is a misunderstanding, things are often worked out and the health professional apologises, if not it can be moved to the next level whether within the service or a complaint to the Health and Disability Commission.

So to a degree every interview with a health professional is a medicolegal assessment. But appreciate some are more deleterious than others due to the power of that professional and their profession to make diagnoses and recommendations that have very negative outcomes for the patient. Independent opinion and legal proceedings is often the only option.