Stigmatizing language should be avoided whenever possible.

I read an article in the Journal of the American Medical Association (JAMA) a few weeks ago that intrigued me; it was titled Physician Use of Stigmatizing Language in Patient Medical Records.

When I teach my documentation course to providers who have gotten in trouble with their medical boards, I instruct them that they must tell the truth – but should also consider how their words may resonate with the patient. As of April 2021, according to a provision of mandated medical transparency afforded by the 21st Century Cures Act, it is required that patients have access to their own medical record. Does this, and should this affect how the provider documents the encounter? And does the way we document affect other caregivers?

The study’s findings were that the majority of negative language was not explicit, and fell into one or more of five 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; or
    5. Emphasizing physician authority over the patient.

They found that positive language was often more explicit, and fell into these categories:

    1. Direct compliments;
    2. Expressions of approval;
    3. Self-disclosure of the provider’s positive feelings toward the patient;
    4. Minimization of blame;
    5. Personalization; and
    6. Highlighting patient authority for their decisions.

The premise is that negative perception of groups of patients may affect the quality of care provided to them and may be reflected in the language used to describe the encounter in the medical record. Two examples offered were the use of the word “sickler” to describe an implicit negative attitude toward patients with sickle cell disease, and using the phrase “substance abuser,” as opposed to a patient “having a substance use disorder.” The article alluded to participants in the study expressing attitudes that these patients were personally culpable and less deserving of treatment and compassionate care. They posit that bias can be perpetuated throughout the medical record and can sway how future caregivers perceive and treat patients.

This article made me think of a paradigm shift I have seen recently (and have embraced) wherein members of the news media refer to “the enslaved,” as opposed to “slaves.” The former expression conveys a sense that something was forcibly perpetrated on the individual, in contradistinction to them actively or volitionally accepting the role of servitude. Another language shift we all have experienced is shunning the expression “committed suicide.” The generally accepted term now is “died by suicide.” The word “commit” evokes criminality, like “committing murder or adultery.”

How we document things and the language we use matters. The article details “doubt markers,” which are ways of conveying suspicion or distrust about the authenticity of symptoms or the patient’s adherence to prescribed treatment. Words like “supposedly,” “claims to,” or “alleges” can call into question the legitimacy of the premise. The authors also mention a tactic known as “scare quotes,” which is using quotation marks to cast doubt on the diagnosis or the scenario (e.g., “she takes albuterol for ‘chronic bronchitis’”). The article authors state that this practice also can convey disapproval or negative judgment of the patient’s actions or thought processes.

Other behaviors disparaged in the study were racial or social class stereotyping: adjectives that impart condescension or frustration, and paternalistic language (e.g., “I impressed upon him the importance of…”).

Positive language practices included use of positive adjectives (e.g., “this is a pleasant 83-year-old…”), explicit approval of positive patient behaviors (e.g., “hard work following instructions” or “good insight into disease process”), and self-disclosure of positive sentiments towards the patient. If a provider felt positive towards the patient, they might minimize blame by expressing barriers to following a treatment plan in a more favorable light (e.g., “limited short-term memory making it difficult to carry out recommended interventions”). Providers also sometimes included details about the patient’s life or activities, judged through the lens of their own interests or background (e.g., “she has a strong faith, which she feels uplifts and strengthens her.”)

How does this impact the provider-patient relationship, that the patient has access to their own electronic medical record? An article regarding the impression patients have of outpatient notes found that 10 percent of patients reported feeling judged and/or offended by something they read in their notes. These patients often had diagnoses in the social determinants of health (SDoH) category (e.g., unemployment, financial hardship). The specific issues were errors and surprises, labeling, and disrespect. Does this mean that clinicians should stop documenting words like “obese,” “anxious,” “depressed,” and/or “elderly?”

My advice is that practitioners must tell the story and tell the truth. If a patient is morbidly obese or clinically depressed, this must be reported, and the condition addressed. However, it may take a few extra moments to critically analyze documentation from the perspective of the reader and try to avoid offense. Dr. Fernandez, author of the outpatient note study, was quoted as saying, “I try to mirror the concept of: what would it feel like if I was reading this out loud to the patient?”

We must acknowledge that we all have implicit biases. As healthcare providers, it is our responsibility to try to minimize the effect our biases have on our decision-making and strive to rise above our prejudices. When we document, we should be aware of how we say things; we do not want to negatively influence subsequent caregivers to provide lesser care.

Stigmatizing language should be avoided whenever possible, not just to avoid upsetting the patient, but to change how we think about and treat patients.

Programming Note: Listen to Dr. Erica Remer Tuesdays on Talk Ten Tuesdays, 10 Eastern, when she co-hosts with Chuck Buck

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