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Stigmatizing language in chart notes creates negative impressions
Clinical Question
Does negative language affect residents' and medical students' attitudes toward specific patients and influence their treatment decisions?
Bottom line
Think of how antagonistic common medical jargon is. Patients "complain." They "admit" or "deny." They "refuse" or are "noncompliant." The words we use can transmit, via a hidden curriculum, implicit bias to medical personnel in training. This study compared stigmatizing language with neutral language used to describe a patient with sickle cell disease that cast doubt on the patient's pain ("still a 10" vs "still a 10/10"), portrayed the patient negatively ("hung out at McDonald's" vs "spent the afternoon with friends"), or implied patient responsibility with references to uncooperativeness ("he refuses his oxygen mask" vs "he is not tolerating the oxygen mask"), Medical students and residents had more negative attitudes toward the hypothetical patient when described with stigmatizing language and suggested less aggressive management of the patient's pain. It's time to revise the medical scripts that convey negativity and bias about the patients in our care. 1b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Foundation
Setting: Other
Synopsis
In this study, medical students (n = 233) and emergency or general internal medicine residents (n= 180) were randomly assigned, concealed allocation unknown, to read 1 of 2 chart notes with medically identical information about a hypothetical patient with sickle cell disease: one using neutral language (eg, "He has about 8 to 10 pain crises per year, for which he typically requires opioid pain medication in the ED") or stigmatizing language (eg, "He is narcotic dependent and in our ED frequently"). After reading the note, both the residents and medical students completed the Positive Attitudes toward Sickle Cell Patients Scale (range 7 - 35) and the residents selected a treatment for the patient from 4 options. Attitudes were significantly lower, on average, for participants presented stigmatizing language (25.1 vs 20.3; P < .001). Attitudes were progressively lower with years of training (correlation coefficient -.95). Residents were more likely to select less aggressive treatment (eg, a low-dose opioid or a nonsteroidal anti-inflammatory drug instead of higher dose opioid, along with less likelihood of redosing) if exposed to stigmatizing language (P <.001). Participants reading the stigmatizing note also were more likely to identify the physician who wrote the note as having a more negative attitude toward the patient.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
Not sure the utility of information. However, if stigmatizing language causes residents to choose lower dose of opioids or NSAID, you could argue for using it? Because evidence for opioids is not that great.
The language we use is a fascinating area of study. Thanks for informing us
Remembering that the patient has a right and access to their one chart can be an instigating factor to help us as physicians midlife our language to best foster a strong patient-doctor relationship
Examples used by study suggest two different patients. Opioid dependent suggests they are are daily users vs presenting for pain management during a crisis.
As if this doesn’t happen often now-another way medicine undermines its legacy of providing care and kindness.RRH
we constantly have to re-visit and reflect on our own patient - physician interaction and in a positive way bias free ! It all comes down to RESPECT ion our interpersonal communications.
Surprising this continues to go on - perhaps some departmental oversight / linked with CME could be implemented to address this. Part of a QA initiative:)
Seems to me that psychiatry struggles with a stigma free language to describe psychiatric disorders. Terms that we use regularly, if read by a patient, can be interpreted as being stigmatizing and insulting - ex. Borderline Personality disorder / Narcissistic Personality Traits. At times our diagnostic terms may be causing more harm than good.
It’s about time we all remember to avoid such language in charts and consults. My favourite is:
“This 50 year old obese woman”
stigmatizing language
1) agree with previous comment that description of patient re. narcotic use is not "medically identical information"
2) we also need to acknowledge the pendulum may swing too far in the "language police" direction. The medical chart is primarily for care providers, and accurate medical terms should not be expunged because they may be misunderstood by laypeople. in the above examples, borderline PD is a concise way to convey a specific psychiatric Dx, as is obese in referring to a specific BMI.
Judgement calls are needed about language. A diagnosis of chf May reference Sob . A resident reads it as informative.Another reading notes to the family may get a pejorative accusation.
Stigmatizing Language
While it is true that language may be stigmatizing, it takes two to tango. Mature readers do have a responsibility to recognize that not all writers share the same views or express themselves equally objectively. Offensive language is, well, offensive. However, who defines when offensive stagmatization is present or intended? A fine balance of respectful language, insightful reading, freedom of speech and healthy skeptisicm of all that one reads, are all necessary to communicate the truth. I have certainly strggled to avoid language that stigmatizes (eg, "this patient has a BMI over 30 rather than this obese patient). However, I hope that concens about micro-aggressions don't get carried away.
We are all biased, and our biggest bias is thinking that we are not biased
agree that we should be careful about languages but I also think we should be careful about implicit biases in regard to treatment. This article assumes that opioids are the best treatment when recent studies suggest otherwise.
On occasions the stigmatizing comments are meant to explain the situations as in cases of non compliance with medications, being aggressive or hostile towards the staff. So the way I see it is that it is not meant to be stigmatizing but more of accurate, descriptive or warning rather than choosing softer words that does not convey the real image that is intended to be
Good poem