Negative Patient Descriptors Documenting Racial Bias In The Electronic Health Record

Michael Sun, Tomasz Oliwa, Monica E. Peek, and Elizabeth L. Tung
Peer-Reviewed Article
January 2022


Medical notes about Black patients were more than twice as likely to contain stigmatizing language compared to white patients.


Many studies have identified systemic bias in the health care system and examined its impact, though few have analyzed whether stigmatizing language in providers’ medical notes is disproportionately associated with patient race or ethnicity. This study analyzed providers’ electronic health record (EHR) notes related to health history and physicals for over 18,000 patients across a five-month period in 2020 within three different health care settings (outpatient, inpatient, emergency department) at a large urban academic medical center. The study analyzed language about the patient or patient’s behavior using 15 negative descriptors found in the literature, such as “difficult patient” or “combative.”


Overall, eight percent of patients had one or more negative descriptors recorded in their medical note. The most common descriptors were “refused,” and “(not) adherent.” Adjusting for socio-demographic and health characteristics, the medical notes of Black patients were 2.54 times as likely to have one or more negative descriptors than white patients. Findings also noted other types of biases, including socio-economic bias evidenced by how the medical notes of patients with Medicaid had 2.66 adjusted higher odds of a negative descriptor compared to patients with private or employer-based insurance.


The study provides evidence of how stigmatizing language in medical notes is applied disproportionately to Black patients and Medicaid enrollees. Stigmatizing language can contribute negatively to their downstream health care treatment and planning. The study authors describe several policy interventions to address the use of this stigmatizing language including provider bias trainings and a call to review professional language standards in the medical field.

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