The language in a patient’s medical record can convey information not only about the patient’s medical condition but about the attitude of the clinician writing the report, with negative attitudes creating the potential for stigma, according to a new analysis.1
A team of researchers analyzed the linguistic features of 600 encounter notes about 507 patients, written by 138 clinicians (attendings and residents) in an ambulatory internal medicine setting at an urban academic medical center. They found that the physicians expressed both negative and positive attitudes toward their patients and that, although most negative language was not explicit, it could potentially transmit bias and affect the quality of care that the patient might subsequently receive.
To gain deeper insight into the analysis and its implications, we spoke to senior author Mary Catherine Beach MD, MPH. Dr Beach is a professor at Johns Hopkins Berman Institute of Bioethics, Professor of Medicine at Johns Hopkins School of Medicine, and a professor in the Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, Maryland.
What was the motivation behind the study?
I first noticed the use of stigmatizing language when I was conducting a study2 several years ago looking at pain management quality in people with sickle cell disease. As we went through the patients’ records and looked at the notes, we asked how much pain the patients reported, how much medication was given, how often it was reassessed, and how often the pain medication increased when the prior dose was not working.
While going through these records, we were struck by how physicians and nurses would use language not to directly state but to insinuate that the patient was exaggerating the pain. For example, the physician might write, “The patient states, ‘I am in as much pain as before.’” In this context, the use of quotes might have been an attempt to discredit, disbelieve, or not accept what the patient said as true.
Once we noticed these linguistic patterns in this context, we realized they might actually be occurring in other contexts as well. Now that our eyes had been opened, we began to see these patterns more broadly. So we decided to perform a content analysis of the unstructured, free text section of patient medical records from an internal medicine primary care setting and categorize themes of negative language that could be potentially stigmatizing to the patient.
Beyond the disbelief of patients, which we had noticed in the context of sickle cell anemia, we found and began to categorize other themes of negative language that could be stigmatizing to the patient.
We also found that physicians write positive things about their patients, so we decided not to make our analysis only about situations with stigmatizing language but about any language that conveys more than merely the medical history and also how the person writing that history feels about the patient.
Can you please speak more to what this type of “content analysis” involves?
Content analysis is a qualitative method that “focuses on the characteristics of language as communication with attention to the content or contextual meaning of the text,” and involves “examining language intensely for the purpose of classifying large amounts of text into an efficient number of categories that represent similar meanings.”3 We set out to discern theme or patterns of language that clinicians might be using in their encounter notes and on the basis of these patterns, we defined categories of language that reflected both negative and positive attitudes toward patients.
Did your research team consist only of physicians?
Our team included 2 physicians, 1 nurse-scientist, 1 premedical student, and 1 computer scientist with expertise in natural language processing.
What types of stigmatization language did you find?
We found that most negative language was not explicit and generally fell into 1 or more of 5 categories: questioning patient credibility; expressing disapproval of patient reasoning or self-care; stereotyping by race or social class; portraying the patient as difficult; and emphasizing physician authority over the patient.
What type of language did you find that questioned patient credibility?
There were several types of language patterns that suggested the clinician might disbelieve the patient report. Some implied lack of patient competency to remember and convey accurate information. Others questioned the patient’s sincerity.
Words that implied doubt included “apparently,” “supposedly,” “claims,” or “insists.” Here are a couple of examples:
- “Apparently he was sitting at home on the floor feeling fine when suddenly he felt fatigued all over his body.”
- “The patient insists she gets sick from vaccines.”
- “He claims that nicotine patches don’t work for him.”
The use of quotation marks can sometimes be interpreted as questioning the legitimacy of the quoted text. This tactic is sometimes called a “scare quote,”4 which signifies that a term being used is misleading. In one example, a physician wrote that the patient “takes albuterol for ‘chronic bronchitis.’” The quotation marks cast doubt upon the diagnosis of chronic bronchitis and also suggest that the patient has inaccurate beliefs about her condition.
What type of language did you find that conveyed disapproval of the patient?
Disapproval was suggested by terms that highlighted poor patient reasoning, decision-making, and behaviors, such as adherence or poor self-care. For example, ”she has stopped eating fruit in the last month because ‘it could have killed her’”—again, the quotation marks suggest that the patient’s health beliefs are unorthodox, or she is overreacting. Stating that a patient has “neglected to refill her blood pressure medication” is different from stating simply and neutrally that the patient has not taken her blood pressure medication.
Lastly, physicians sometimes used language that implied that they had to engage in tiresome repetition of some sort, for example, “I again explained…” or “despite repeated counseling…”
How were racial and/or social class stereotyping conveyed through the language you found in patients’ records?
These types of stereotypes were most often conveyed through direct quotes of either African American vernacular English, incorrect grammar, or nonstandard oversimplified medical term. For example, one clinician quoted the patient as stating that a surgical bandage had gotten “a li’l wet.” Another said the patient states that the lesion “busted open.”
What type of language portrayed a “difficult patient?“
Some of the details suggested that the patient was ignorant, temperamental, or conveyed the physician’s frustration with the patient or the language was condescending or emotional (eg, “the patient was adamant” or “this seems to pacify him”).
How did the language convey unilateral decision making on the part of the physician?
In particular some language was paternalistic, with phrases such as, “I have instructed her” or “she was told to discontinue” or “I impressed upon her the importance of…” Phrases like these perpetuate the image of a power dynamic in which the physician presumes authority and portrays the patient as childish or ignorant.
Several of these language patterns involve the use of quotation marks. How do you think quotes should or should not be used in medical records?
I don’t come down on either side of the equation—“never use quotes” or “always use quotes.” If you do use quotes, make sure that your rationale is solid. For example, it is not only reasonable but extremely helpful to include the patient’s direct description of pain: “crushing chest pain,” “or “the worst headache I ever had.” These rapidly convey the suspicion that the patient might have a heart attack or subarachnoid hemorrhage. But stating that a lesion ruptured is different from quoting the patient stating that the lesion “busted open,” which offers no medically relevant information.
There is no simple formula for when and how to reword a direct quote. But a good rule of thumb is to ask yourself, what will show the most goodwill and respect toward the patient? How would you want someone you loved to be quoted and documented? The issue isn’t about policing language but rather putting care and respect into the records so that the next person who reads that record will regard the patient as someone to be respected and valued.
It helps to convey context for a patient’s refusal to adhere to a treatment plan. For example, writing, “She persevered on the fact that ‘a lot of stuff is going on at home with my family’ but that ‘you wouldn’t understand’” implies that this is a difficult patient. Providing some context or stating that the patient is experiencing home stressors that affect her ability to be adherent to her treatment regimen does not carry that implication.
I think that in psychiatry, it is often more necessary to quote the patient’s actual words, especially when you are conducting a mental status evaluation. But even in that setting, the important question is whether the quote you are using is conveying medically relevant and useful information.
How do you suggest that information about a patient’s nonadherence or anger, for example, be conveyed to the next clinician reader? What language do you recommend?
People always have reasons for their anger, mistrust of physicians or the medical establishment, or nonadherence. Sometimes, these reasons are not clear, sometimes you disagree with their reasons, but it is important to try to understand them and convey them in as neutral a way as possible. For example, “Mrs Smith has a complex family situation and finds it difficult to incorporate adhering to the treatment plan we put in place.”
What do you think contributes to the use of negative language toward patients?
I think that physicians’ stress and burnout are contributors. I also think it is natural and human to be frustrated, and that doesn’t necessarily come from a bad place. As physicians, we are invested in the wellbeing of our patients and we can feel frustrated when they are nonadherent to a helpful treatment regimen, for example. The problem is that sometimes we vent this frustration in the medical records.
How do you think physicians might address this?
I think the key is to see this type of writing as a wake-up call to remind ourselves that we are frustrated or burned out and take a second to think before writing.
Your analysis also included positive language. What types of positive language did you find?
We found that physicians’ positive language was more explicit than their negative language and included 6 categories: compliments, approval, self-disclosure, minimizing blame, personalization, and collaborative decision-making.
These positive sentiments also have the potential to influence the attitude of behavior of other clinicians who read those notes, and to contribute to improved clinician-patient interactions in the future.
What limitations did your analysis have?
My coauthors and I noted several limitations. One is that the data were collected from an ambulatory internal medicine setting at an urban academic center, and may not be generalizable to other specialties or settings. Moreover, we did not have data on the personal characteristics of the physician writers, such as age, gender, race/ethnicity, or training status (resident vs attending)—characteristics that may be important factors associated with how language is used. It would have been valuable to also know the racial/ethnic or gender concordance between the patient and the clinician.
It is also not known whether patients are able to detect the emotional and attitudinal tone of their clinicians, and their impact on the quality of subsequent care. Lastly, since we could not know the actual attitudes of the clinicians authoring the reports, or the attitudes and reactions of subsequent readers, we cannot verify all of our results and assumptions. We hope that this study will spur future research to investigate these questions.
- Park J, Saha S, Chee B, Taylor J, Beach MD. Physician use of stigmatizing language in patient medical records. JAMA Network Open. Published online July 14, 2021. doi:10.1001/jamanetworkopen.2021.17052
- Puri Singh A, Haywood C Jr, Beach MC, et al. Improving emergency providers’ attitudes toward sickle cell patients in pain. J Pain Symptom Manage. Published online November 17, 2015. doi: 10.1016/j.jpainsymman.2015.11.004
- Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. Published online November 1, 2005. doi.org/10.1177/1049732305276687
- Chait J. Scared yet? The New Republic. Published June 13, 2019. Accessed August 1, 2021.
This article originally appeared on MPR