Clinicians who use stigmatizing language in their patients’ medical records might be affecting the future care those patients receive, according to a new study.

Healthcare disparities can prevent patients from getting the diagnostic and treatment services they need. Clinician bias plays a role in these healthcare disparities.

When practitioners review notes and descriptions entered on previous visits, the language used in those notes might play a role in the treatment of that patient. Stigmatizing language may even affect how aggressively doctors manage that patient’s pain on subsequent encounters.

Words Matter in Medicine

The researchers wanted to determine whether the language used in patient records can perpetuate bias among physicians. They enrolled 413 physicians-in-training into the study. Participants were medical students and residents in emergency medicine and internal medicine programs at an urban academic medical center.

The team of researchers, led by Dr. Mary Catherine Beach, presented the participants with one or two vignettes about a hypothetical, male 28-year-old patient with sickle cell disease and chronic hip pain.

The hypothetical patient was Mr. R, an African-American man. The severity of his condition required him to use a wheelchair.

Both vignettes begin with Mr. R visiting the hospital emergency department (ED) with vaso-occlusive crisis, a painful and common complication of sickle cell disease. Rapid initiation of opioids is the standard treatment to treat pain associated with vaso-occlusive crisis; oxygen combats poor oxygenation due to sickled red blood cells.

The vignettes contained medically identical information; the only difference between the two vignettes was the language. One vignette used neutral language about the patient and his condition. The other contained nonessential language suggestive of various value judgments.

Examples of the differing notes on the hypothetical patient include:

"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."

"He is in obvious distress."

"He appears to be in distress."

The scientists used the Positive Attitudes towards Sickle Cell Patients Scale to measure attitudes towards the hypothetical patient among all participants. They issued two multiple-choice questions to evaluate pain management decisions among residents participating in the study.

The researchers found that physicians-in-training exposed to the stigmatizing language had more negative attitudes towards the patient, at 20.6 stigmatizing vs. 25.6 neutral responses. Furthermore, reading the stigmatizing language was more likely to lead to less aggressive pain management.

The researchers also found that medical residents had more negative attitudes towards the hypothetical patient than did the medical students.

This suggests that attitudes become increasingly negative as training progresses. Study participants who identified as African-American or black had more positive attitudes towards Mr. R. than did their counterparts.

Clinicians document every patient encounter in a chart note, detailing symptoms, patient history, vital signs, test results, assessments and treatment plans. In some cases, medical records are all doctors have to go on when assessing a patient’s condition.

Many clinicians view medical records as objective — the results of this study suggests that the notes in medical records may propagate and perpetuate bias.

Even the participants who recognized the language as stigmatizing were more likely to form a negative opinion about the patient and provide less aggressive treatment for the patient’s pain.

There was a bit of good news in the study, though.

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

The researchers published their study in the in the May edition of The Journal of General Internal Medicine.