Doctors’ notes are meant to be an objective record of their interactions with patients. Among other uses, the notes provide important context for any other providers who treat those patients in the future.
But these notes aren’t as objective as doctors might think. For example, a doctor might write that a patient was “agitated” at an appointment, or “nonadherent” with the treatment plan they discussed the last time.
These words are negative descriptors, and according to a new study, they are applied unequally across racial lines: Black patients had 2.54 times the odds of white patients of having at least one negative term in their notes.
The study’s lead author, Michael Sun, is a third-year medical student at the University of Chicago’s Pritzker School of Medicine. Building on earlier research that’s shown how implicit bias can affect doctor-patient relationships, Sun and his co-authors wanted to see if they could document that bias in a large set of notes. “What are we really saying about our patients?” Sun said.
The team collected electronic health records for more than 18,000 patients who had received care in Chicago as outpatients, inpatients, or in the emergency department. The notes spanned January 2019 through September 2020, allowing the researchers to compare records before and after the start of the Covid-19 pandemic. In all, there were more than 40,000 sets of notes.
With the help of a panel from the Health Equity Commission of the Society of General Internal Medicine, the researchers chose a set of 15 negative words that doctors sometimes use. These included terms like “angry,” “aggressive,” “challenging,” “exaggerate,” and “noncompliant.” Then the researchers trained a machine learning model to comb through the records and find instances where patients were described in these ways. The researchers didn’t have enough data to compare additional racial groups, but the difference between Black and white patients was clear.
Sun said he wished this results, published Wednesday in the journal Health Affairs, surprised him. “To be quite honest, I’m not surprised at all,” he said. In a 2020 nationwide survey, more than 10% of Black adults reported experiencing discrimination or unfair treatment while seeking health care within the previous year.
“This study makes an important step forward” by showing that certain stigmatizing words are more likely to appear in the records of Black patients, said Mary Catherine Beach, a professor at both the Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health.
In a 2021 study, Beach and co-authors found that words such as “claims,” “insists” and “apparently” were more likely to appear in the medical records of Black patients. They also found that doctors’ notes for Black patients and for women were more likely to include quotes (for example, “The patient had a ‘reaction’ to the medication”).
“These words may be stigmatizing even if they do not reflect individual bias on the part of the clinicians who write them,” Beach said. That’s because the language stays in the patient’s electronic record, where it may influence how future doctors perceive the patient. In a study using fictional medical notes, doctors in training were less aggressive in managing the pain of a patient who was described with stigmatizing language.
“As a profession, we need to think carefully,” Beach said, and choose words that “reduce blame and recognize the complexity and injustice inherent in our system.”
Sun said he did find one reason for hope in his study. The researchers expected that doctors might have used more negative words after the start of the pandemic, given the extra stress they were under. Yet the results showed the opposite: After March 1, 2020, there were fewer negative terms for all patients.
The researchers speculated that factors such as nationwide protests around the deaths of George Floyd and other Black people killed by police, as well as health disparities highlighted by the pandemic, may have made doctors more sensitive to racism. The results hint that mere awareness might be enough to help doctors change their language. Sun and his co-authors are hoping to continue this line of research and learn more about the causes and effects of biased language in medical notes.
Sun said that as the child of Korean American immigrants, he’s always been interested in language and the ways it’s used. Yet even doing this research hasn’t inoculated him against using stigmatizing terms as he begins to see patients of his own. Sun recalled one patient that he saw after most of the work on this paper was completed. When he began writing his notes, “The first word that I reached for to characterize our conversation was ‘difficult,’” Sun said. “And when that thought crossed my mind, I was shocked.”
At the same time, Sun said, his research has shown him that making a change can be simple. He can choose to use different words, and more words, to give context about what the patient was experiencing that day in the hospital. “It’s about intervening when we can and making small changes that are fully within our power, every single day,” Sun said, “to tell the full story of our patient.”
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