Improving Health Equity by Eliminating Biased and Stigmatizing Language in Medical Notes

Karla Silverman, Center for Health Care Strategies
A Black man in his 30s, sitting on the table in a doctor's office as the doctor takes notes on a clipboard.

"Patient states she has been 'in pain for 24 hours,' but does not appear to be in pain now."

"Patient is non-compliant."

What do you think is being conveyed in the first sentence? Did the patient report they were in pain for 24 hours, but now they don’t seem to be in pain anymore? Or did the patient say they were in pain for 24 hours, but they don’t appear to be in pain now, and the provider thinks the patient was exaggerating? Or does the provider not believe that the patient was ever in pain at all?

In the second example, imagine that a medication prescribed to you made you feel sick, and you stopped taking it and this is what was written in your medical notes. How would that make you feel? Some providers and clinical staff routinely call patients “non-compliant” when they do not follow doctor’s instructions, including not taking a prescribed medication. But the use of the term “non-compliant,” is about as far from a collaborative, person-centered approach to care as you can get and is even described in one article as ”authoritarian, suggesting that patients must obediently comply with the doctor’s recommendations.”  

This type of stigmatizing language in medical notes can make patients and families feel devalued and can cause individuals to be less likely to trust their medical providers and engage in care. Avoiding negative and judgmental language and using words that promote inclusivity and respect are critical for supporting health equity.

Long-Term Negative Impact of Biased Language in Patient Records

Health care providers are trained to use neutral non-biased language in medical records, but studies of provider notes continue to show that bias exists. A study published in JAMA Network shows that when they use negative language about patients it falls into a few general 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; and (5) emphasizing physician authority over the patient. Evidence demonstrates that health care providers also exhibit implicit bias in their day-to-day interactions. Implicit bias is when a person unconsciously makes assumptions about another person that leads to a negative assessment of that person based on characteristics such as race, ethnicity, age, ability, gender, or sexual preference. Biases in written notes include disapproval, questioning of patient credibility, labeling a patient as difficult, stereotyping, and unilateral decision-making. Certain groups ─ including non-Hispanic Black people, people of color, people with substance use disorder diagnoses, and pregnant and birthing people ─ are described with negative or stigmatizing language at higher rates than other groups.

Not surprisingly, a provider using negative and stigmatizing language in their medical notes can make patients feel judged and less likely to engage in future care. Unfortunately, a biased characterization written by one provider in an electronic medical record often follows that patient to future health care visits. Providers read each other’s notes. Studies show that when providers are shown negative language about patients that other providers have written, they are more likely to view the patient negatively even before they have met them, and to take that patient’s pain less seriously.

Improving Medical Notetaking with Equity in Mind

While providers and clinicians can’t single-handedly extinguish the implicit bias and negative attitudes that are present in the health care system toward some patients, individual providers can recognize stigmatizing language when they see or hear it and take steps to ensure their notes do not include it. They can also model best notetaking practices for others in the medical field.

Here are three things that health care providers can do to improve their patient notes:

1. Avail yourself to existing tools and guidance.

Many tools exist to help providers and clinical staff become better at documenting in medical records. Best practices include strategies such as: (1) trusting patients and avoiding communicating disbelief; (2) learning to recognize and avoid stigmatizing language; and (3) focusing on positive themes and humanizing details. Guidance is available that can also help providers rethink processes they were trained in ─ such as when or when not to use quotes ─ to capture what a patient said in their own words without stereotyping or implying blame toward patients.

2. Understand which populations and medical conditions are often described negatively.

Acknowledging which groups have historically been subject to stereotyping, negative language, and disbelief of their stories is critical. Researchers from the University of Chicago analyzed over 40,000 history and physical notes in patient electronic medical records in an urban hospital setting and found that Black patients were 2.5 times more likely than white patients to have at least one negative description in their medical record. At Mass General Brigham, a large health care system in Massachusetts and New Hampshire, researchers found roughly 18% of notes for more than 30,000 patients with a substance use disorder diagnosis contained stigmatizing language.   

3. Model best practices, such as person-first language, for other providers.

Modeling best practices for other clinicians is something that health care providers and care team members can start doing today. Using person-first language that centers on the person, not their conditions, can reverse the dehumanizing impact that results from describing people as their illnesses. Patients are people. They have lives and families and hopes and dreams and the sum totality of them is not an illness or an addiction. So, we say a “patient with diabetes” instead of “a diabetes patient” or a person who is HIV + instead of an HIV patient, or a person with bipolar depression instead of a manic-depressive patient.

Moving Forward

Despite the old nursery rhyme, words can cause harm. In the face of the poor health outcomes that our country faces today ─ the mental health crisis, the opioid epidemic, and high rates of chronic conditions ─ it’s important to step back and consider that some patients are being blamed for their conditions, or their situations, through words in their medical records. The result: many patients who perceive this bias may not engage in the care they need.

Providers can make critical changes in how they document in their patient notes. They can be alert to the use of negative and disbelieving language in medical charts. They can replace harmful descriptions with humanizing details about the person they are providing care for. Addressing patients with dignity and respect and eliminating biased and stigmatizing notes in patient charts are key steps toward helping patients engage in care.