By: Julia Raney, Devika Bhushan, Peter Leahy, Tiffany Lee, Ria Pal, Samuel Ricardo Saenz, Michael Gisondi, Kim Hoang, Carrie Johnson, Cynthia Kapphahn, and Natalie Kirilcuk
Stigmatizing language negatively affects quality of care and patient experience.
We define ‘stigmatizing language’ as language that casts doubt on the patient experience, implies culpability, promotes stereotypes and bias, or defines the patient by their disease (e.g. ‘addict’ vs ‘patient with substance use disorder’).
Imagine listening to the following history presented by a trainee:
17-year-old African American, ex-gang banger, drug dealer, admitted to the Pediatric Intensive Care Unit after a rollover motor vehicle crash… his luck finally caught up with him and now he is a quadriplegic.
Sadly, this excerpt is from a real patient presentation, though the identifying characteristics were changed to anonymize the case. Providers on the care team were profoundly upset when they heard the language used to describe this patient. The presentation implied that the patient deserved his injuries and clearly displayed racism, classism, judgment, and a lack of empathy. Upon review, similar language summarized the case in the electronic health record.
Several Studies Demonstrate the Impact of Stigma in Medicine.
A World Health Organization study conducted in 14 countries found that patients with alcohol use disorder and other types of addiction felt highly stigmatized. Further, these patients feared that personal disclosure or public knowledge of their condition would negatively impact employment or broader social standing.
Feelings of shame and guilt often translate to delays in health-seeking behavior. Patients who delay engagement with the health care system can present to care much later and sicker, with advanced conditions that are harder to treat. Perhaps some of these patient concerns about judgment and discrimination are justified, however. In one study, health care workers were shown to view individuals with substance-related conditions as irresponsible, aggressive, dangerous, and untrustworthy.
Language used about patients, either verbally or recorded in the medical record, can influence the extent to which such stereotypes are automatically activated for providers and can influence clinical decisions. For instance, a study by Kelly et al explored how the words ‘substance abuser’ versus ‘patient with substance use disorder’ influenced mental health providers’ perceptions of theoretical patients. Participants were asked to rate the extent to which they agreed with the causes of various fictional patients’ substance-related conditions. Providers who read cases with the term ‘substance abuse’ were more likely to regard the patients as personally culpable for their condition than those who read the term ‘substance use disorder’. Consequently, they recommended punitive therapies over reformative interventions.
A 2018 John Hopkins study of medical students and residents found that when trainees were randomized to read clinical vignettes of an identical patient presenting in a sickle cell pain crisis, use of neutral or stigmatizing language profoundly impacted providers’ perceptions. Residents and medical students who read stigmatizing language, such as ‘narcotic dependent’ vs ‘typically requires opiate pain medications,’ reported less empathy towards the patient. Importantly, this translated to significant differences in the type of pain medications (opioid versus non-opioid) that the providers recommended. Again, these differences in assessment and plan were based solely on the wording of the cases.
Three Steps to Remove Stigmatizing Language from Clinical Practice
We offer the following three steps to help providers reduce their use of stigmatizing language:
- Be mindful of conditions or social determinants of health that are frequently described using stigmatizing language.
Bias is more likely to affect patient care when the provider is under time or cognitive stress (promoting the use of heuristics) or when the patient is from a marginalized social group or one that is different from the provider’s own. In these situations, we recommend reflecting on the following questions:
- Am I distracted, stressed, or fatigued as I communicate about this patient?
- Do I dislike or disbelieve this patient?
- Am I making assumptions about this patient because of her race, gender, and sexual orientation, which happen to be different from mine?
Be careful of bias resulting from countertransference, which is when a provider’s feelings or emotions can inappropriately enter into the relationship with and impact the care of a patient. Countertransference can result when providers feel parental towards, overly identify with, are sexually attracted to, or otherwise exhibit strong positive or negative emotional reactions towards a patient.
- Question language that might perpetuate bias.
Identify biased language when presenting, copying forward, or documenting a case. Consider:
- Does my history consist solely of facts or also of assumptions?
- Are the details in the history necessary to describe the clinical presentation? (From the introductory example, previous membership in a gang and the patient’s race are not pertinent in the ‘one-liner’ summary.)
- Am I using “quotations” judiciously in ways that are crucial to the patient’s care?
- Would I feel comfortable with my patient hearing or reading this?
- Replace stigmatizing language with neutral terms.
Choose neutral language to describe the patient, the circumstances of their presentation, and the social context of their illness. Ask yourself, “How would my patient feel if they read my note in the medical record?” Here are several examples:
It bears mentioning that most providers use stigmatizing language not out of malice, but out of convenience — and sometimes, a lack of awareness of one’s own biases. Stigmatizing words can be linguistic shortcuts and are common, therefore they come to mind easily when composing notes or presentations. Biasing language may erroneously be used to communicate stigmatizing assumptions around social determinants of health between providers. The initial phrases that a provider chooses to document in the electronic medical record may follow a patient for a lifetime and negatively affect the way they are perceived by other providers and their future medical care.
It’s time that we all reflect on and recognize how crucially our word choice can impact patient care and take the necessary steps to communicate with objective, non-judgmental language.
About the authors:
The authors of this post are participants in the 2019 Leadership Education Advances Diversity program at Stanford University School of Medicine: Julia Raney, MD (Pediatrics), Devika Bhushan, MD (Academic Pediatrics), Peter Leahy, MD (Medical Biochemical Genetics), Tiffany Lee, MD (Medicine/Anesthesia), Ria Pal, MD (Child Neurology), Samuel Ricardo Saenz, MD, MPH (Psychiatry), as well as their program mentors: Michael Gisondi, MD (Emergency Medicine), Kim Hoang, MD (Pediatrics), Carrie Johnson, MBA (Pediatrics), Cynthia Kapphahn, MD, MPH (Adolescent Medicine), and Natalie Kirilcuk, MD (Colorectal Surgery).
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