During her treatment for acute leukemia, my friend Susan came to me for help and advice while she was in the hospital receiving chemotherapy. I also did her laundry. She went to one of the specialists at a major tertiary care center and had access to the lengthy consultation written by the oncologist. Susan had a career as a highly respected and much-loved elementary school principal in our county school district.
Her first comment was that in the narrative section discussing her as a patient, the word principal was misspelled (as principle). Of course, as a former teacher, this would catch her eye. I am not sure if this error reduced her opinion of the physician’s standing or intellect in her estimation. I stood up for the doctor, whom I did not know, by telling her that the note was likely dictated and some program or transcriptionist inadvertently used the wrong spelling of that word (which has a different meaning), and it was not proof-read before being placed into the medical record.
I suspect many people, some of whom may be excellent physicians, misuse or misspell this word. Susan would remind you that your school’s principal is your pal. The next thing she asked about was the doctor’s description of her as well-groomed. She could not understand why this was relevant or present in the record. “Why did my doctor say this about me?”
I tried to explain this to Susan. The medical record serves as a communication tool for the medical team to convey thoughts, facts, and conjectures to each other. These notes existed for centuries before they routinely became available to patients and their families in the 21st century.
The mention of Susan’s profession and general appearance was likely to give the referring physicians and others on her case, a mental snapshot of her as a person. A person’s profession, grooming, and clothing choices send out messages to the world and into the brains of the doctors and nurses. We all understand the level of education that one must have to become a principal. “Good” grooming is quite subjective but generally signifies that one is clean and dressed presentably.
What did Susan’s doctor mean in his note when he referred to her as well-groomed? Most likely, this was shorthand for all who would read his note later to know that this lady had her wits about her, cared about her appearance, and had the means to take care of herself. How someone takes care of herself can tell us a lot, but looks can be deceiving.
In a much-publicized case in DC, paramedics mistook a normally well-groomed man for another drunk when he was picked up in the streets of Georgetown after being mugged and beaten on his way home from a restaurant. Arbitrary and wrong assumptions were made by paramedics that resulted in the patient being brought to an emergency department ill-suited for the head injury he was discovered to have hours later. The report of “another drunk” was given to the receiving staff, and he was placed on a gurney to wait for evaluation. He should have prioritized getting that head CT scan immediately to exclude traumatic brain injury.
I explained some of this reasoning to Susan as she digested this comment in addition to the dreadful diagnosis of acute leukemia that was discussed in the consultation. She learned a lot about her diagnosis and closely followed her lab results. She had so much faith in her physicians and in the intentions of God. She followed the treatment plans her medical team ordered and passed away in 2021 at the age of 71.
In an insightful article in The New Yorker, “The Curious Side Effects of Medical Transparency,” noted author and practicing internist, Danielle Ofri, discusses the effects of having physician notes and test results available to the patient and their family members even before the physician gets to read and review them. Rather than set off alarm bells and anxiety attacks in her patients, even the thoughtful and lyrical Dr. Ofri has found herself making drastic edits.
In Changing How We Think about Difficult Patients, I discuss how some of the language we use describing and labeling patients has become terribly negative. Even the shorthand way clinicians refer to their patients, such as the cancer patient in bed ten or the seizure in bed twenty, robs people of their humanity and individuality. When we identify a person as a certain diagnosis, knowing what we know about confirmation bias, we inadvertently look for evidence that confirms what we already believe to be true and dismiss evidence that goes against our previously held belief. Humans like to be right, even if they are confirming something that is incorrect.
A study from the January 26, 2018 Journal of General Internal Medicine researched if words matter and the impact of stigmatizing language and the transmission of bias in the medical record. The results strongly back up my intuition about this problem. The researchers conclude,
“Our results suggest that language used in medical records to describe patients can directly influence subsequent physicians-in-training who read the notes, in terms of both their attitudes towards the patient and their medication-prescribing behavior…We must question the assumption that the medical record always represents an objective space. Clinicians must be vigilant to guard against contributing to bias as they write chart notes about their own patients and as they read chart notes written by others. The language in medical records should be more carefully considered to avoid perpetuating clinician biases and the health care disparities that may arise from them.”
The notes we write, and the verbal reports we give to our colleagues at the end of a shift contain much information. They also contain a lot of labeling and words charged with negative judgment and disapproval. Labeling a person by their visit frequency or most obvious diagnosis will certainly stop our curiosity from looking for another reason for a new sign or symptom. It also affects their downstream treatment in the same way that labeling someone as “non-compliant” or “difficult.”
So not only do we miss diagnoses and affect future treatment, we can now look forward to offending the patient or the family members with the language we use in the medical record. We cannot begin to change the terms we use or our thoughts about our patients until we become aware that we are using them. We need to take a close look at the language of our notes. The MedEd Portal of March 2021 features an article titled “Words Matter: An Antibias Workshop for Health Care Professionals to Reduce Stigmatizing Language.” There is a treasure trove of information and advice in that article.
We should not beat ourselves up when we discover that our notes include some biased or stigmatizing language. Our senior residents, instructors, and attending physicians taught us to think this way. We can now question those beliefs and decide to change them. We can soften the language of our notes and consider how a non-medical person might receive a particular comment.
We can convey useful information to the next clinician without terms of condescension or judgment. Our patients benefit, and we do too. Being judgmental and sanctimonious towards our patients feels terrible. Being more positive makes causes us to feel more understanding and compassion.
Watch what you write in those notes. Adopt more objective language that conveys precisely the meaning you intend. Then your patients and their families will understand those words and trust that their doctor has their best interest at heart.
Joan Naidorf is an emergency physician and author of Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals.