Loaded Language in Medical Records May Hamper Patient Care

Physicians who use stigmatizing language in their patients' medical records may negatively affect the care those patients get for years to come.

Be careful what you write, physicians.

Recording disparaging medical notes about your patients could adversely affect the care they receive or how aggressively their pain is managed, according to a study published this month in the Journal of General Internal Medicine.

"This record may be the only source of information a new clinician has about some patients," says Mary Catherine Beach, MD, the study's lead author, said in comments accompanying the study.

"We have to question the assumption that the medical record always represents an objective space," Beach says.

The study gave more than 400 medical students and residents one of two vignettes about a hypothetical patient, a 28-year-old African-American man with sickle cell disease and chronic hip pain.

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

For example:

• "He has about 8-10 pain crises a year, for which he typically requires opioid pain medication in the ED."
   
• "He is narcotic dependent and in our ED frequently."

For example:

• "He spent yesterday afternoon with friends and wheeled himself around more than usual, which caused dehydration due to the heat."
   
• "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."

For example:

• "His girlfriend is by his side but will need to go home soon."
   
• "His girlfriend is lying on the bed with shoes on and requests a bus token to go home."

The study 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.

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.

Beach said medical residents had more negative attitudes than medical students toward the hypothetical patient.

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

Physicians-in-training who identified as African-American generally had more positive attitudes toward the patient.

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

The researchers said they were encouraged by one result of the study.

"When prompted, the participants seemed able to reflect on how the words used in the chart notes communicated respect and empathy for the patient," said study co-author Anna Goddu, a Johns Hopkins School of Medicine student. "To us, this seems like a promising point of intervention."