From the Editor
After the hospitalization ends, a detailed summary. A quick note outlining the psychotherapy session. Written comments about the patient’s care as she or he begins work with another clinician. Medical records include all of the above.
But do they also include stigmatizing language?
In this week’s first selection, the authors consider such language in a new paper for JAMA Network Open. Jenny Park (of Oregon Health and Science University) and her co-authors look at 600 notes, and find the categories of positive and negative language using a qualitative analysis. They write: “Language has a powerful role in influencing subsequent clinician attitudes and behavior. Attention to this language could have a large influence on the promotion of respect and reduction of disparities for disadvantaged groups.”
Ancient Egyptian medical records – stigmatizing language then too?
In our other selection, Dr. Katherine A. Termini (of Vanderbilt University) writes about self-disclosure. In a very personal essay, the psychiatrist discusses her own mental health problems – and her decision not to tell others in the medical profession. She then writes about changing her mind. “I encourage you to ask yourself: How have I contributed to this stigma and what can I do about it? If physicians step forward to tell their personal experiences with mental illness to an audience of colleagues willing to listen empathetically, we can make progress on the arduous task of destigmatizing mental health.”
Selection 1: “Physician Use of Stigmatizing Language in Patient Medical Records”
Jenny Park, Somnath Saha, Brant Chee, et al.
JAMA Network Open, 14 July 2021
Patients are not treated equally in our health care system: some receive poorer quality of care than others based on their racial/ethnic identity, independent of social class. Others, such as older adults and individuals with low health literacy, obesity, and substance use disorders may also be viewed negatively by health professionals in a way that adversely impacts their health care quality. Implicit bias among clinicians is one factor that perpetuates these disparities. Implicit bias is the automatic activation of stereotypes, which may override deliberate thought and influence one’s judgment in unintentional and unrecognized ways, and may affect treatment decisions.
Literature from the field of social psychology finds that attitudes can be reflected through people’s language. For example, a national study of 655 emergency medicine physicians found that those who used the term ‘sickler’ were more likely to have negative attitudes toward patients with sickle cell disease and that these negative attitudes were associated with lower physician adherence to national guidelines for pain management and medication-prescribing behavior. Biased language can in turn affect the attitudes of others hearing or reading that language. Kelly et al found that physicians who read a vignette with the term ‘substance abuser,’ as opposed to ‘having a substance use disorder,’ agreed more that the person was personally culpable and should be punished, and agreed less that the person needed treatment.
Perhaps most concerning, biased language can influence the quality of care patients receive. A 2018 randomized controlled vignette study examined how language in the medical record of a hypothetical patient with sickle cell disease would influence physicians who read the note.
So opens a paper by Park et al.
Here’s what they did:
- They conducted a qualitative analysis of encounter notes from electronic medical records.
- To do this, they “abstracted all patient medical records that had been written by physicians (attendings and residents) in 2017 at an ambulatory internal medicine setting at an urban academic medical center.”
- Of the more than 10 000 notes, they randomly selected 600.
- The qualitative analysis – a content analysis – involved a review of 100 notes, a discussion of emerging themes with the team, and then a further review of the remaining notes.
Here’s what they found:
- “A total of 138 clinicians (attendings and residents) wrote the 600 encounter notes about 507 patients.”
- Demographics. Most patients were female (69%) and Black/African American (80%).
- Categories. The authors identified five major categories of negative language: questioning credibility, disapproval, stereotyping, difficult patient, unilateral decisions. For example, “unilateral decision making” –“Sometimes physicians used language that conveyed a paternalistic tone, using phrases like ‘I have instructed her’ or ‘I impressed upon her the importance of.’ This language upholds the image of a power dynamic where the physician presumes authority and portrays the patient as childish or ignorant.” See table below.
- Categories, continued. The authors identified six major categories of positive language: compliments, approval, self-disclosure, minimizing blame, personalization, collaborative decision making. For example, “compliments” –“This category included explicit descriptions of patients using positive adjectives. For example, physicians described patients as being ‘charming,’ ‘inspiring,’ ‘pleasant,’ and ‘kind.’ These compliments were usually located at the beginning of the medical notes.”
A few thoughts:
- This is a good study.
- This is a very relevant study.
- Reading through the physician comments, the examples of negative language are often subtle but still present.
- As more and more providers embrace “open notes” – allowing patients quick and easy access to their notes – will our language naturally change?
- What are the larger implications? The authors see several. “Just as we have developed a greater understanding about microaggressions and micro-inequities, this study’s findings suggest that we must raise consciousness about how we write and read medical records.” Nice point.
- The authors also give comment on underlying reasons why clinicians may be negative towards patients – and then write negative notes about patients. “Attendings and residents who staff ambulatory internal medicine clinics are often under time pressure and other stress, which can contribute to bias activation, emotional frustration and burnout, all of which might exacerbate any tendencies clinicians might have to vent negative attitudes toward patients in the medical record. Addressing the underlying stress and frustration that many clinicians have in their practices may be among the most important ways to reduce expressions of disrespect toward patients.”
- In terms of limitations, the authors note several, including the setting: “our data were collected from an ambulatory, internal medicine setting at an urban academic medical center, which may limit generalizability of these findings to other specialties or settings.” But would the findings be different if, say, we considered mental health notes? Certainly, in my experience, the language with substance use disorders remains negative and judgmental. People with an alcohol use disorder have “a habit,” as an example.
- Besides avoiding the negative language outlined above, clinicians may find the following essay by Dr. John Torous (of Harvard University) to be helpful for writing in the era of Open Notes. (I particularly like suggestion 6.) https://www.psychologytoday.com/ca/blog/digital-mental-health/202010/opening-mental-health-notes-7-tips-prepare-clinicians
The full JAMA Network Open paper can be found here:
Selection 2: “My Lie by Omission”
Katherine A. Termini
JAMA, 13 July 2021
‘How many pills did you take?’
‘I’m not sure. A couple handfuls.’
‘Well, how many were in a handful?’
‘I really don’t know. I didn’t count, I just took them.’
‘Okay, so you’re saying you tried to kill yourself but don’t even know how many pills you took.’
Following with a scoff, the doctor moved onto questioning my mother.
At 16, those words were an icy stab in the sterile environment of the medical unit. It seemed the medical team viewed me as nothing more than a teenage girl seeking attention, rather than a suffering human in need of help. Such stigma against mental illness is indisputably apparent in the US health care system and often has detrimental consequences on patient care. My experience became a fundamental moment in my own personal narrative, sparking an ambition to combat this stigma. After finding a supportive community in college, I never expected the negative perceptions to follow me into my medical career, filling me with dread at admitting the reality of my attempted suicide.
So begins a paper by Dr. Termini.
She discusses her desire to disclose her mental health problems in college: “The importance of my suicide attempt on my personal history became especially salient during college. I openly shared this background with peers, so my story could mitigate the misconceptions of those with mental illness. I hoped to convey that suicidal ideation was not the tropes portrayed in media; it was neither romantic nor maniacal. It was perplexing, paralyzing, and sometimes all-consuming, but it was not necessarily infinite. The desire to decrease bias and help others guided me to volunteer on a suicide hotline, which eventually led me to medicine.”
She notes the decision to apply to medical school, but not to disclose:
“I initially planned to share this story in my personal statement and interviews. However, I was advised by mentors to avoid the subject of my mental health history. Conversely, narratives of childhood injury or diabetes were often utilized as examples of personal statements. It struck me that there was something disparate about my story, and I was reminded of the judgment and isolation I experienced during my hospital admission. Determined to enter medicine, I reworked my personal statement and delivered one that was lackluster and unoriginal. I considered my lie by omission to be another hoop to jump through, like the Medical College Admission Test. I told myself that I could begin tearing down some of this bias once I was actually in medical school.”
Except that she didn’t: “I witnessed clinicians make disparaging or dubious comments on patients’ suicidal ideations or their resolves to end their lives. It seemed as if a patient’s verbalized doubts about dying made their symptoms, concerns, and fears less absolute. In those moments, I wanted to explain the conflicted state those patients may find themselves in and how one moment can tip the scales. I wanted to scream that ambivalence does not mean their suffering does not exist or deserve compassion. I wanted to lecture on the capacity of a patient to feel a gloom so profound that they fear they will never escape the clutches of its gravity yet also feel a grief for leaving life behind. But I did none of these things, despite my conviction that my perspective holds value.”
Why the silence? “The simple answer is fear – fear of what a confession would do to my career, fear of being perceived as somehow incapable of providing quality care, fear of finding myself on the receiving end of that bias once again.”
She continues: “I decided to specialize in psychiatry, which added another layer of anxiety. Would peers see my story as confirmation of the misconception that psychiatrists pursue the field because they also require treatment? Despite a decade of stability, would I still somehow seem unwell to a room of psychiatrists during residency interviews? What if I said the wrong thing, failed to successfully articulate how my suicide attempt changed me in positive ways? What if I am viewed as naive or unprofessional for considering it a core part of my narrative.”
A few thoughts:
- This is a moving essay.
- This piece is also highly self-critical. Is it too self-critical? “By shrouding my professional journey’s origin, I robbed it of its heart. I considered myself an advocate, someone aspiring to overcome the mental health stigma in our profession. I could not reconcile this with the need to hide my own mental health history.”
- This is a courageous essay – published, no less, in JAMA.
The full JAMA paper can be read here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.