The language of a patient’s medical record can convey information not only about the patient’s state of health, but also the attitude of the clinician writing the report, with negative attitudes creating potential for stigma, new analysis finds .1
A team of researchers analyzed the linguistic characteristics of 600 encounter notes concerning 507 patients, written by 138 clinicians (assistants and residents) in an outpatient internal medicine setting in an urban university medical center. They found that physicians expressed both negative and positive attitudes towards their patients and that although most negative comments were not explicit, they could potentially convey bias and affect the quality of care the patient might receive. afterwards.
To better understand the analysis and its implications, we spoke with lead author Mary Catherine Beach MD, MPH. Dr Beach is Professor at the Johns Hopkins Berman Institute of Bioethics, Professor of Medicine at the Johns Hopkins School of Medicine, and Professor in the Department of Health, Behavior, and Society at the Johns Hopkins School of Public Health, Baltimore, Maryland.
What was the motivation behind the study?
I first noticed the use of stigmatizing language when conducting a study2 several years ago, reviewing the quality of pain management in people with sickle cell disease. As we went through patient charts and reviewed notes, we asked what pain patients reported, how much medication was given, how often it was reassessed, and how often pain relievers increased. when the previous dose did not work.
As we went through these charts, we were struck by the way doctors and nurses used language not to directly state but to imply that the patient was exaggerating the pain. For example, the doctor might write: “The patient says, ‘I am in as much pain as before. as true.
Once we noticed these linguistic patterns in this context, we realized that they could occur in other contexts as well. Now that our eyes had been opened, we started to see these models more widely. We therefore decided to perform a content analysis of the unstructured free text section of patient medical records at a primary care internal medicine facility and categorize the themes of negative language that could potentially be stigmatizing for the patient. .
Beyond the disbelief of the patients, which we had noticed in the context of sickle cell anemia, we found and began to categorize other themes of negative language that could be stigmatizing for the patient.
We have also found that doctors write positive things about their patients, so we decided not to do our analysis just on situations with stigmatizing language, but on any language that conveys more than the medical history and also what the whoever writes this history feels for the patient. .
Can you tell us more about what this type of “content analysis” involves?
Content analysis is a qualitative method which “focuses on the characteristics of language as communication with particular attention to the content or contextual meaning of the text” and involves “a thorough examination of the language with the aim of classify large amounts of text into an effective number of categories. which represent similar meanings.3 We sought to discern the theme or patterns of language that clinicians might use in their encounter notes and based on these patterns we defined language categories reflecting both negative and positive attitudes towards patients.
Was your research team made up entirely of physicians?
Our team included 2 doctors, 1 nurse-scientist, 1 pre-medical student and 1 computer scientist specializing in natural language processing.
What types of stigma language have you found?
We found that most negative comments were not explicit and generally fell into one or more of the following five categories: questioning the patient’s credibility; express disapproval of the patient’s reasoning or their own care; stereotypes based on race or social class; present the patient as difficult; and emphasizing the physician’s authority over the patient.