Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record

Exploring healthcare providers’ perceptions regarding the prevention and treatment of chronic pain in breast cancer survivors: A qualitative analysis among different disciplines

Background

The prevention and treatment of chronic pain problems in breast cancer follow-up care require an adequate response from healthcare providers. Generally, this involves the uptake of evidence-based principles regarding pain management in everyday practice. However, despite the extensive literature on effective pain interventions, systematic and coordinated follow-up care is lacking for breast cancer survivors with pain problems in Flanders, Belgium.

Objective

This study aimed to gather insight into healthcare providers’ perceptions of pain prevention and treatment in breast cancer follow-up care, particularly with attention to the multilevel influences on pain follow-up.

Methods

We conducted four online focus groups with twenty-two healthcare providers from different disciplines such as oncologists, pharmacists, nurses, physiotherapists, and psychologists. Data analysis was guided by the Qualitative Analysis Guide of Leuven. This guide is inspired by the constant comparison method, based on Grounded Theory.

Results

The identified influencing factors were thematically grouped into four levels: at the level of the individual healthcare provider, in interaction with the patient, in interaction with colleagues, and at the context level. At each level, we distinguished factors related to healthcare providers’ perceptions such as awareness, knowledge, attitudes, beliefs, experiences, and intentions. For example, because of a lack of knowledge and certain beliefs among healthcare providers, referral to other disciplines often does not happen in the context of pain.

Conclusion

This study points out the need to explore the prevention and treatment of chronic pain after breast cancer from a multidimensional point of view. This involves not only the characteristics of individual healthcare providers but is also inherently interactional and system-like in nature. This analysis provides opportunities for the development of interventions that target the influencing factors of prevention and treatment of chronic pain in breast cancer survivors.

Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement

The clinical documentation of patients' mental status, behaviour and functioning is a fundamental aspect of inpatient mental health care. It is an important source of information-sharing with the interprofessional team and used by other clinicians within the circle of care to guide their decision-making process. Given the body of evidence highlighting concerns about the quality of nursing documentation and the growing literature demonstrating the presence of bias in healthcare, it is critically important that we examine the impact of this bias in nursing practice. The primary objective of this study was to determine whether clinical decisions and judgements change when nurses read documentation that is either biased or neutral. Using a quantitative, observational study that used surveys to collect data, participants were exposed to two patient vignettes and six clinical notes associated with each patient (notes were written with either biased or neutral language) and asked to make clinical decisions and judgements. Results from 199 nurse participants from a tertiary mental health hospital revealed a notable relationship between the type of notes read (biased vs. neutral) and clinical practice, namely, participants reading biased notes were less likely to offer health teaching when administering pro re nata (PRN) medication for sleep. We also found differences in decision-making and judgements based on the type of note read depending on years of experience and type of education. The results indicate that biased language in nursing documentation can influence other clinicians' decisions and judgements about patients, thereby indicating a cascade of bias.

Barriers to Buprenorphine Prescribing for Opioid Use Disorder in Hospice and Palliative Care

CONTEXT

Hospice and palliative care (HPC) clinicians increasingly care for patients with concurrent painful serious illness and opioid use disorder (OUD) or opioid misuse; however, only a minority of HPC clinicians have an X-waiver license or actively use it to prescribe buprenorphine as medication treatment for OUD.

OBJECTIVES

To understand barriers for HPC clinicians to obtaining an X-waiver and prescribing buprenorphine as medication treatment for OUD.

METHODS

We performed content analysis on 100 survey responses from members of the national Buprenorphine Peer Support Network, a group of HPC clinicians interested in buprenorphine, on X-waiver status, barriers to obtaining an X-waiver, and barriers to active prescribing.

RESULTS

Of 100 HPC clinicians surveyed, only 26 of 57 HPC clinicians with X-waivers had ever prescribed. Prominent barriers included discomfort managing concurrent pain, buprenorphine, and OUD; concerns about impacts on practice; unsupportive practice culture; insufficient practice support; patient facing challenges; and cumbersome regulatory policies.

CONCLUSION

Despite HPC clinicians' interest in buprenorphine prescribing for OUD, several steps are needed to facilitate the practice, including clinician education tailored to pain and to clinical challenges faced by HPC clinicians, mentorship on buprenorphine use, and cultural and practice changes to dismantle systemic stigma towards addiction. We propose evidence-based steps derived from our survey findings that individual clinicians, HPC leaders, and national HPC organizations can take to improve care for patients with painful serious illness and OUD.

How to Reduce Stigma and Bias in Clinical Communication: a Narrative Review

A growing body of literature demonstrates that healthcare providers use stigmatizing language when speaking and writing about patients. In April 2021, the 21st Century Cures Act compelled clinicians to make medical records open to patients. We believe that this is a unique moment to provide clinicians with guidance on how to avoid stigma and bias in our language as part of larger efforts to promote health equity. We performed an exhaustive scoping review of the gray and academic literature on stigmatizing medical language. We used thematic analysis and concept mapping to organize the findings into core principles for use in clinical practice. We compiled a list of terms to avoid and seven strategies to promote non-judgmental health record keeping: (1) use person-first language, (2) eliminate pejorative terms, (3) make communication inclusive, (4) avoid labels, (5) stop weaponizing quotes, (6) avoid blaming patients, and (7) abandon the practice of leading with social identifiers. While we offer guidance clinicians can use to promote equity through language on an individual level, health inequities are structural and demand simultaneous systems and policy change. By improving our language, we can disrupt the harmful narratives that allow health disparities to persist.

Discordance in Addressing Opioid Crisis in Rural Communities: Patient and Provider Perspectives

Providing patient-centered care to manage chronic pain and opioid use disorder (OUD) is associated with improved health outcomes. However, adopting a holistic approach to providing care is often challenging in rural communities. This study aims to identify and contrast challenges to providing patient-centered care from the perspective of patients and providers. A participatory design approach was adopted to elicit the perceptions of providers and patients with lived experiences of chronic pain and/or OUD in Jefferson County, Wisconsin. Two focus groups were conducted with each stakeholder group to identify problems that participants face with respect to chronic pain management and OUD and possible solutions. Four interviews were conducted with providers experienced in chronic pain management. Analysis of focus group sessions and interviews show consensus among patients and providers that lack of behavioral health and recovery resources create barriers to effectively manage OUD and chronic pain. However, there was discordance among the two groups about other barriers such as patient and provider attitudes, tapering approach, and access to medications for OUD. This tension among patients and providers can influence patients’ retention in therapy. More efforts are needed to mitigate stigma among providers in rural communities and support psychosocial needs of patients.

Experiences of stigma in hospitals with addiction consultation services: A qualitative analysis of patients' and hospital-based providers' perspectives

BACKGROUND

Addiction consultation services (ACS) provide evidence-based treatment to hospitalized patients with substance use disorders (SUD). Expansion of hospital-based addiction care may help to counteract the stigma that patients with SUD experience within the health care system. Stigma is among the most impactful barriers to seeking care and adhering to medical advice among people with SUD. We aimed to understand how the presence of an ACS affected patients' and hospital-based providers' experiences with stigma in the hospital setting.

METHODS

We conducted a qualitative study utilizing focus groups and key informant interviews with hospital-based providers (hospitalists and hospital-based nurses, social workers, pharmacists). We also conducted key informant interviews with patients who received care from an ACS during their hospitalization. An interprofessional team coded and analyzed transcripts using a thematic analysis approach to identify emergent themes.

RESULTS

Sixty-two hospital-based providers participated in six focus groups or eight interviews. Twenty patients participated in interviews. Four themes emerged relating to the experiences of stigma reported by hospital-based providers and hospitalized patients with SUD: (1) past experiences in the health care system propagate a cycle of stigmatization between hospital-based providers and patients; (2) documentation in medical charts unintentionally or intentionally perpetuates enacted stigma among hospital-based providers resulting in anticipated stigma among patients; (3) the presence of an ACS reduces enacted stigma among hospital-based providers through expanding the use of evidenced-based SUD treatment and reframing the SUD narrative; (4) ACS team members combat the effects of internalized stigma by promoting feelings of self-worth, self-efficacy, and mutual respect among patients with SUD.

CONCLUSIONS

An ACS can facilitate destigmatization of hospitalized patients with SUD by incorporating evidence-based SUD treatment into routine hospital care, by providing and modeling compassionate care, and by reframing addiction as a chronic condition to be treated alongside other medical conditions. Future reductions of stigma in hospital settings may result from promoting greater use of evidence-based treatment for SUD and expanded education for health care providers on the use of non-stigmatizing language and medical terminology when documenting SUD in the medical chart.

Say what you mean, mean what you say: The importance of language in the treatment of obesity

OBJECTIVE

Obesity is a highly stigmatized disease, and despite the understanding of the processes involved, negative language reinforcing outdated views of obesity persists within the scientific literature. This is the first study, to the authors' knowledge, to determine how widespread stigmatizing language is within publications on obesity and examine its impact on patients.

METHODS

Two standard terms within obesity publications were identified, and a literature search was carried out to determine their prevalence. A parallel qualitative analysis was conducted with patients with obesity to determine perceptions of these terms.

RESULTS

Of the 3,020 papers screened, 2.4% included the term fail, and 16.8% contained morbid used in conjunction with obesity. Sixteen patients participated in the qualitative analysis. They felt that negative language, particularly failure, implied a personal responsibility for lack of weight loss. Clinically meaningful terminology fostered a more constructive relationship with health care providers.

CONCLUSIONS

Although most journals object to overtly stigmatizing language, using phrases or words that carry negative connotations is less clearly discouraged. It is important to recognize that language that implies a moral responsibility for weight loss or the development of obesity contradicts the well-established evidence base that obesity results from complex biological processes.

Digital Scarlet Letters: Sexually Transmitted Infections in the Electronic Medical Record

ABSTRACT

The harms of implicit bias in clinical settings are acknowledged but poorly understood and difficult to overcome. We discuss how structural components of electronic medical record (EMR) user interfaces may contribute to sex and gender-based discrimination against patients via constant, duplicative presentation of stigmatizing sexually transmitted infection (STI) data irrespective of clinical significance. Via comparison with symbolism and representative quotes in Hawthorne's 1850 novel The Scarlet Letter, we propose a metaphor to examine how EMRs function as a platform for moral judgment, which may display an indelible "scarlet letter" for pregnant patients with STI history. We consider whether current depictions of STIs in EMRs are structurally unjust and may contribute to biased treatment by directing attention to violations of hegemonic sex/gender norms regarding sexual behavior and thus triggering moral judgments of maternal fitness. We conclude with recommendations for how to address these challenges to improve ethical stewardship of sensitive sexual/reproductive health data.

Exploration of note writing by mental health nurses using a video scenario

AIMS AND OBJECTIONS

We aimed to explore the content and language of nursing documentation and gain insight into the internal processes of nurses while notetaking.

BACKGROUND

Documentation is a core competency of mental health nursing, has clinical and ethical importance and is the integral to the efficient and effective care provided to patients. However, issues related to the content and quality of nursing notes continues to be a concern and there remains gaps in our understanding about the internal processes that nurses engage in when writing notes.

DESIGN

We used a mixed method design that included a content analysis with note review and interviews.

METHODS

After watching a video, psychiatric nurses (n = 27) wrote a note and then were interviewed about their note taking process. We used the COREQ guidelines for reporting our data.

RESULTS

Participants relied on four main themes when determining what to include in their notes-what happened and what the patient said or did, plus anything different than baseline, and safety concerns. Analyses revealed the presence of bias in the notetaking and participants were not familiar with effective strategies to mitigate these during the documentation process. Lastly, we found that notes are typically consistent in using some of the SOAPE format with notes focused on direct observations and the use of 'facts', while assessment and construction of treatment plans are used to a lesser extent.

CONCLUSIONS

Our results provide insight into the decision-making process of nursing staff regarding their documentation practices: overall they appear unaware of the importance of their notes, and believe that capturing the facts about their patients is important, while devaluing their own input and interpretations.

RELEVANCE TO CLINICAL PRACTICE

Our results provide evidence that mental health nurses may need additional training regarding documentation, more specifically about what to include, word choice and bias.

Presenting complaint: use of language that disempowers patients

Caitríona Cox and Zoë Fritz argue that outdated medical language that casts doubt, belittles, or blames patients jeopardises the therapeutic relationship and is overdue for change

The Use of Person-centered Language in Medical Research Articles Focusing on Hearing Loss or Deafness

BACKGROUND

Hearing loss represents one of the most common disabilities worldwide. Despite its prevalence, there is a degree of stigmatization within the public's perception of, or attitude toward, individuals diagnosed with hearing loss or deafness. This stigmatization is propagated by the way hearing loss is referenced, especially in writing. Although the medical community is familiar with hearing loss, medical research is not consistently compliant with nonstigmatizing terminology, like person-centered language (PCL). This study aims to quantify the use of PCL in medical research related to hearing loss.

METHODS

A cross-sectional analysis of articles related to hearing loss was performed using PubMed as the primary search engine. The search encompassed articles from January 1, 2016, to November 17, 2020. Journals had to have at least 20 search returns to be included in this study. The primary search resulted in 2392 articles from 31 journals. The sample was then randomized and the first 500 articles were chosen for data extraction. Article screening was performed systematically. Each article was evaluated for predetermined non-PCL terminology to determine adherence to the American Medical Association Manual of Style (AMAMS) guidelines. Articles were included if they involved research with human participants and were available in English. Commentaries and editorials were excluded.

RESULTS

Four hundred eighty-two articles were included in this study. Results from this study indicate that 326 articles were not adherent to AMAMS guidelines for PCL (326/482; 68%). Emotional language (i.e., burden, suffer, afflicted) was employed to reference hearing loss in 114 articles (114/482; 24%). Non-PCL adherent labels (i.e., impaired and handicapped) were identified in 46% (221/482) of articles related to hearing loss or deafness. Sixty-seven articles (67/482; 14%) used person-first language in reference to the word "deaf" and 15 articles (15/482; 3%) used "deaf" as a label.

CONCLUSIONS

Based on the findings from this cross-sectional analysis, the majority of medical research articles that address hearing loss contain terminology that does not conform to PCL guidelines, as established by AMAMS. Many respected organizations, like the American Medical Association, have encouraged the use of PCL in interactions between patient and medical provider. This encompasses communication in person and in writing. This recommendation stems from the understood role that language plays in how we build impressions of others, especially in a medical context. Implementing PCL to destigmatize language used in reference to deafness or hearing loss is essential to increase advocacy and protect the autonomy of these individuals.

Society for Maternal-Fetal Medicine Consult Series #62: Best practices in equitable care delivery-Addressing systemic racism and other social determinants of health as causes of obstetrical disparities

The Centers for Disease Control and Prevention define social determinants of health as "the conditions in the places where people live, learn, work, and play" that can affect health outcomes. Systemic racism is a root cause of the power and wealth imbalances that affect social determinants of health, creating disproportionate rates of comorbidities and adverse outcomes in the communities of racial and ethnic minority groups. Focusing primarily on disparities between Black and White individuals born in the United States, this document reviews the effects of social determinants of health and systemic racism on reproductive health outcomes and recommends multilevel approaches to mitigate disparities in obstetrical outcomes.

How Would You Treat This Patient With Acute and Chronic Pain From Sickle Cell Disease? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Sickle cell disease is prevalent in large numbers of patients in the United States and has a significant global impact. Its complications span numerous organs and lead to reduced life expectancy. Acute and chronic sickle cell pain is a common cause of patient suffering. The American Society of Hematology published updated guidelines on management of acute and chronic pain from sickle cell disease in 2019. Several of the recommendations are conditional and leave specific decisions to the treating physician. These include conditional recommendations about the use of ketamine for acute pain and the initiation and discontinuation of long-term opioid therapy for chronic pain. Here, 2 hematologists discuss these guidelines and make contrasting recommendations for the management of acute and chronic pain for a patient with sickle cell disease.

Use of Person-Centered Language Among Scientific Research Focused on Sickle Cell Disease

BACKGROUND

Sickle cell disease (SCD) is a lifelong illness affecting many individuals in the United States. Proper management of SCD is imperative, however, the unpredictability of pain crises may lead to frequent emergency department (ED) visits. This SCD feature has led to health-related stigmatization via labels and other terminology within clinical settings, which may be translated through medical research. Thus, it is important for medical literature to adhere to person-centered language (PCL) to diminish such stigmas from transcending into the clinical setting.

OBJECTIVE

Our aim was to determine current adherence to PCL related to individuals with SCD in existing literature.

METHODS

This was a cross-sectional design study. Published studies on SCD that used human participants were selected between January 1, 2015 and April 14, 2021. Two investigators performed screening and data procedures in a masked, duplicate fashion, with conflicts and discrepancies resolved via an arbiter. χ² Tests and linear and logistic regressions were used for data analysis.

RESULTS

After excluding editorials and commentaries, 200 articles were retained. We found that 186 publications (94%) adhered to PCL. Among articles with non-PCL, labeling occurred in 2 articles (1%) and emotional language implying suffering was identified in 10 articles (5%).

CONCLUSIONS

Our study suggests a widespread adherence to PCL in recent SCD literature. However, findings suggest a major disconnect between education and practice, as recent publications document the use of non-PCL terminology within EDs. Health care providers should be aware of biases and institutional resources should be allocated toward raising awareness.

The Influence of the Electronic Health Record on Achieving Equity and Eliminating Health Disparities for Children

The electronic health record (EHR) has been heralded as a transformative approach to modernizing health care and advancing health equity. Access to the EHR can facilitate shared clinical decision-making and improved communication with patients, families, and among health care providers. Recent legislative and regulatory efforts have been passed to increase the transparency as well as the initiatives to increase the meaningful use of the EHR. Yet despite these well-intended efforts, challenges to addressing health equity through the EHR persist. This article reviews three distinct challenges to addressing health equity related to the EHR. We discuss (1) both the implicit and explicit bias that exist in EHR documentation, (2) the gaps that remain between screening for social determinants of health and the effective inclusion and billing of that screening into the EHR, and (3) the disparities that exist with the use of patient portals. Addressing these three areas will enhance the opportunities to advance health equity through the use of the EHR and bring us one step closer to eliminating health disparities in pediatric health care. [Pediatr Ann. 2022;51(3):e112-e117.].

SOAPs and SUDs: Patients With Substance Use Disorders and What Clinicians Should Know About the Cures Act

The 21st Century Cures Act of 2016 mandates that patients have access to their clinical notes, labs, and imaging through electronic portals and requires information sharing among healthcare entities. We provide practical tips to healthcare professionals on best practices in documenting substance use in the era of transparent electronic medical records, as well as provide guidance on the application of the Cures Act information blocking exceptions for their patients who use substances.

An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities

Racism and discrimination are the root of many pediatric health inequities and are well described in the literature. Despite the pervasiveness of pediatric health inequities, we have failed to adequately educate and prepare general pediatricians and pediatric subspecialists to address them. Deficiencies within education across the entire continuum and in our health care systems as a whole contribute to health inequities in unacceptable ways. To address these deficiencies, the field of pediatrics, along with other specialties, has been on a journey toward a more competency-based approach to education and assessment, and the framework created for the future is built on entrustable professional activities (EPAs). Competency-based medical education is one approach to addressing the deficiencies within graduate medical education and across the continuum by allowing educators to focus on the desired equitable patient outcomes and then develop an approach to teaching and assessing the tasks, knowledge, skills, and attitudes needed to achieve the goal of optimal, equitable patient care. To that end, we describe the development and content of a revised EPA entitled: Use of Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. We also highlight the ways in which this EPA can be used to inform curricula, assessments, professional development, organizational systems, and culture change.

Effect of Exposure to Visual Campaigns and Narrative Vignettes on Addiction Stigma Among Health Care Professionals: A Randomized Clinical Trial

IMPORTANCE

Stigma toward people with opioid use disorder (OUD) is pervasive in clinical settings, impeding delivery of high-quality care. To date, no study has evaluated the effect of different stigma-reduction messages or messengers among health care professionals.

OBJECTIVE

To evaluate the effect of OUD-related messages delivered by different messengers on stigma and attitudes toward people with OUD among health care professionals.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial examined the effects of OUD-related messages delivered by a visual campaign alone or in combination with a written narrative vignette from the perspective of 1 of 3 messengers. Health care professionals in the US were recruited from 2 national online survey panels (Ipsos KnowledgePanel and SurveyHealthcareGlobus). A total of 1842 participants completed a web-based survey measuring stigma toward people with OUD from November 13 to 30, 2020.

INTERVENTIONS

Eight groups were exposed to 1 of 2 message frames. One frame (Words Matter) emphasized the harm of stigmatizing language, and the other (Medication Treatment Works) focused on the effectiveness of medications approved by the US Food and Drug Administration for the treatment of OUD. Message frames were communicated through either a visual campaign alone or a visual campaign in combination with a written narrative vignette from the perspective of a simulated patient with OUD, a clinician, or a health care system administrator.

MAIN OUTCOMES AND MEASURES

Dimensions of stigma toward people with OUD were measured on 5-point Likert scales that included items about desire for social distance from people with OUD, perception of individual blame for OUD, perspective of OUD as a medical condition, and support for increased governmental spending on OUD treatment. The level of warmth felt toward people with OUD was measured by a feeling thermometer (range, 0-100 points).

RESULTS

Among 1842 participants, the mean (SD) age was 47 (13) years; 1324 participants (71.9%) were female, 145 (7.9%) were Hispanic, 140 (7.6%) were non-Hispanic Black, 1344 (73.0%) were non-Hispanic White, and 213 (11.6%) were of other non-Hispanic race (ie, individuals who did not self-report race as Black or White and did not self-report ethnicity as Hispanic). Compared with nonexposure, exposure to the combination of visual campaign and narrative vignette communicating the importance of nonstigmatizing language from the perspective of a patient with OUD was associated with a lower probability (difference, -16.8 percentage points, 95% CI, -26.1 to -7.4; P < .001) of unwillingness to have a person with OUD marry into the family (a measure of social distance preference) and a 7.2-point (95% CI, 3.2-11.1; P < .001) higher warmth rating. Participants exposed to the combined visual campaign and patient vignette about the value of medication treatment for OUD also had significantly lower levels of stigma compared with those in the nonexposed control group (eg, unwillingness to have a person with OUD as a neighbor: difference, -15.3 percentage points; 95% CI, -24.6 to -6.0; P = .001).

CONCLUSIONS AND RELEVANCE

In this study, messages about nonstigmatizing language and effective medication for OUD reduced stigma among health care professionals. Stigma-reduction efforts targeting health care professionals may improve health care system capacity to serve people with OUD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05127707.

Use of Race in Kidney Research and Medicine: Concepts, Principles, and Practice

Black Americans and other racially and ethnically minoritized individuals are disproportionately burdened by higher morbidity and mortality from kidney disease when compared with their White peers. Yet, kidney researchers and clinicians have struggled to fully explain or rectify causes of these inequalities. Many studies have sought to identify hypothesized genetic and/or ancestral origins of biologic or behavioral deficits as singular explanations for racial and ethnic inequalities in kidney health. However, these approaches reinforce essentialist beliefs that racial groups are inherently biologically and behaviorally different. These approaches also often conflate the complex interactions of individual-level biologic differences with aggregated population-level disparities that are due to structural racism (i.e., sociopolitical policies and practices that created and perpetuate harmful health outcomes through inequities of opportunities and resources). We review foundational misconceptions about race, racism, genetics, and ancestry that shape research and clinical practice with a focus on kidney disease and related health outcomes. We also provide recommendations on how to embed key equity-enhancing concepts, terms, and principles into research, clinical practice, and medical publishing standards.

Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record

Little is known about how racism and bias may be communicated in the medical record. This study used machine learning to analyze electronic health records (EHRs) from an urban academic medical center and to investigate whether providers' use of negative patient descriptors varied by patient race or ethnicity. We analyzed a sample of 40,113 history and physical notes (January 2019-October 2020) from 18,459 patients for sentences containing a negative descriptor (for example, resistant or noncompliant) of the patient or the patient's behavior. We used mixed effects logistic regression to determine the odds of finding at least one negative descriptor as a function of the patient's race or ethnicity, controlling for sociodemographic and health characteristics. Compared with White patients, Black patients had 2.54 times the odds of having at least one negative descriptor in the history and physical notes. Our findings raise concerns about stigmatizing language in the EHR and its potential to exacerbate racial and ethnic health care disparities.

Developing machine learning-based models to help identify child abuse and neglect: key ethical challenges and recommended solutions

Child abuse and neglect are public health issues impacting communities throughout the United States. The broad adoption of electronic health records (EHR) in health care supports the development of machine learning-based models to help identify child abuse and neglect. Employing EHR data for child abuse and neglect detection raises several critical ethical considerations. This article applied a phenomenological approach to discuss and provide recommendations for key ethical issues related to machine learning-based risk models development and evaluation: (1) biases in the data; (2) clinical documentation system design issues; (3) lack of centralized evidence base for child abuse and neglect; (4) lack of "gold standard "in assessment and diagnosis of child abuse and neglect; (5) challenges in evaluation of risk prediction performance; (6) challenges in testing predictive models in practice; and (7) challenges in presentation of machine learning-based prediction to clinicians and patients. We provide recommended solutions to each of the 7 ethical challenges and identify several areas for further policy and research.

Linking electronic health records and in-depth interviews to inform efforts to integrate social determinants of health into health care delivery: Protocol for a qualitative research study (Preprint)

Background

Health systems are attempting to capture social determinants of health (SDoH) in electronic health records (EHR) and use these data to adjust care plans. To date, however, methods for identifying social needs, which are the SDoH prioritized by patients, have been underexplored, and there is little guidance as to how clinicians should act on SDoH data when caring for patients. Moreover, the unintended consequences of collecting and responding to SDoH are poorly understood.

Objective

The objective of this study is to use two data sources, EHR data and patient interviews, to describe divergences between the EHR and patient experiences that could help identify gaps in the documentation of SDoH in the EHR; highlight potential missed opportunities for addressing social needs, and identify unintended consequences of efforts to integrate SDoH into clinical care.

Methods

We are conducting a qualitative study that merges discrete and free-text data from EHRs with in-depth interviews with women residing in rural, socioeconomically deprived communities in the Mid-Atlantic region of the United States. Participants had to confirm that they had at least one visit with the large health system that serves the region. Interviews with the women included questions regarding health, interaction with the health system, and social needs. Next, with consent, we extracted discrete data (eg, diagnoses and medication orders) for each participant and free-text clinician notes from this health system’s EHRs between 1996 and the year of the interview. We used a standardized protocol to create an EHR narrative, a free-text summary of the EHR data. We used NVivo to identify themes in the interviews and the EHR narratives.

Results

To date, we have interviewed 88 women, including 51 White women, 19 Black women, 14 Latina women, 2 mixed Black and Latina women, and 2 Asian Pacific women. We have completed the EHR narratives on 66 women. The women range in age from 18 to 90 years. We found corresponding EHR data on all but 4 of the interview participants. Participants had contact with a wide range of clinical departments (eg, psychiatry, neurology, and infectious disease) and received care in various clinical settings (eg, primary care clinics, emergency departments, and inpatient hospitalizations). A preliminary review of the EHR narratives revealed that the clinician notes were a source of data on a range of SDoH but did not always reflect the social needs that participants described in the interviews.

Conclusions

This study will provide unique insight into the demands and consequences of integrating SDoH into clinical care. This work comes at a pivotal point in time, as health systems, payors, and policymakers accelerate attempts to deliver care within the context of social needs.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36201

Examination of Stigmatizing Language in the Electronic Health Record

IMPORTANCE

Stigmatizing language in the electronic health record (EHR) may alter treatment plans, transmit biases between clinicians, and alienate patients. However, neither the frequency of stigmatizing language in hospital notes, nor whether clinicians disproportionately use it in describing patients in particular demographic subgroups are known.

OBJECTIVE

To examine the prevalence of stigmatizing language in hospital admission notes and the patient and clinician characteristics associated with the use of such language.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of admission notes used natural language processing on 48 651 admission notes written about 29 783 unique patients by 1932 clinicians at a large, urban academic medical center between January to December 2018. The admission notes included 8738 notes about 4309 patients with diabetes written by 1204 clinicians; 6197 notes about 3058 patients with substance use disorder by 1132 clinicians; and 5176 notes about 2331 patients with chronic pain by 1056 clinicians. Statistical analyses were performed between May and September 2021.

EXPOSURES

Patients' demographic characteristics (age, race and ethnicity, gender, and preferred language); clinicians' characteristics (gender, postgraduate year [PGY], and credential [physician vs advanced practice clinician]).

MAIN OUTCOME AND MEASURES

Binary indicator for any vs no stigmatizing language; frequencies of specific stigmatizing words. Linear probability models were the main measure, and logistic regression and odds ratios were used for sensitivity analyses and further exploration.

RESULTS

The sample included notes on 29 783 patients with a mean (SD) age of 46.9 (27.6) years. Of these patients, 1033 (3.5%) were non-Hispanic Asian, 2498 (8.4%) were non-Hispanic Black, 18 956 (63.6%) were non-Hispanic White, 17 334 (58.2%) were female, and 2939 (9.9%) preferred a language other than English. Of all admission notes, 1197 (2.5%) contained stigmatizing language. The diagnosis-specific stigmatizing language was present in 599 notes (6.9%) for patients with diabetes, 209 (3.4%) for patients with substance use disorders, and 37 (0.7%) for patients with chronic pain. In the whole sample, notes about non-Hispanic Black patients vs non-Hispanic White patients had a 0.67 (95% CI, 0.15 to 1.18) percentage points greater probability of containing stigmatizing language, with similar disparities in all 3 diagnosis-specific subgroups. Greater diabetes severity and the physician-author being less advanced in their training was associated with more stigmatizing language. A 1 point increase in the diabetes severity index was associated with a 1.23 (95% CI, .23 to 2.23) percentage point greater probability of a note containing stigmatizing language. In the sample restricted to physicians, a higher PGY was associated with less use of stigmatizing language overall (-0.05 percentage points/PGY [95% CI, -0.09 to -0.01]).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, stigmatizing language in hospital notes varied by medical condition and was more often used to describe non-Hispanic Black patients. Training clinicians to minimize stigmatizing language in the EHR might improve patient-clinician relationships and reduce the transmission of bias between clinicians.

Pediatric Discharge From the Emergency Department Against Medical Advice

In this Ethics Rounds we present a conflict regarding discharge planning for a febrile infant in the emergency department. The physician believes discharge would be unsafe and would constitute a discharge against medical advice. The child's mother believes her son has been through an already extensive and painful evaluation and would prefer to monitor her well-appearing son closely at home with a safety plan and a next-day outpatient visit. Commentators assess this case from the perspective of best interest, harm-benefit, conflict management, and nondiscriminatory care principles and prioritize a high-quality informed consent process. They characterize the formalization of discharge against medical advice as problematic. Pediatricians, a pediatric resident, ethicists, an attorney, and mediator provide a range of perspectives to inform ethically justifiable options and conflict resolution practices.

Addressing Bias and Stigma in the Language We Use With Persons With Opioid Use Disorder: A Narrative Review

BACKGROUND: Despite an increase in access to medications for opioid use disorder, less than 20% of individuals with opioid use disorder (OUD) receive treatment. Stigmatizing language has been identified as a potential trigger for explicit and implicit biases that may adversely affect treatment enrollment and quality of care for persons with OUD. AIMS: To conduct a narrative review of the literature on stigmatizing language and OUD, examine how treatment outcomes are affected, and present strategies to reduce bias and promote OUD treatment. METHOD: A narrative review of the literature between 2010 and 2019 was conducted using CINAHL, PubMed, and PsycINFO. Key search terms were opioid use disorder (or substance use disorder), stigma, and language. Fifty-two articles were screened for inclusion, and 17 articles were included in this review. RESULTS: The articles reviewed provide consensus that stigmatizing language toward persons with OUD fosters explicit and implicit bias and impedes engagement in treatment. Four themes emerged: (1) stigma and language, (2) stigma and language used by health care professionals, (3) stigma and language used by the general public, and (4) stigma and language used by people with OUD. CONCLUSIONS: Stigmatizing language is dehumanizing and plays a pivotal role in bias and discrimination that may contribute to unsatisfactory treatment outcomes among persons with OUD. Health care professionals, nursing in particular, must assume an intentional stance against stigma perpetuated toward persons with OUD through advocacy in education, practice, policy, and the media.

'More than words' - Interpersonal communication, cognitive bias and diagnostic errors

During the diagnostic process, clinicians may make assumptions, prematurely judge or diagnose patients based on their appearance, their speech or how they are portrayed by other clinicians. Such judgements can be a major source of diagnostic error and are often linked to unconscious cognitive biases - faulty quick-fire thinking patterns that impact clinical reasoning. Patient safety is profoundly influenced by cognitive bias and language, i.e. how information is presented or gathered, and then synthesised by clinicians to form and communicate diagnostic decisions. Here, we discuss the intricate links between interpersonal communication, cognitive bias, and diagnostic error from a patient's, a linguist's and clinician's perspective. We propose that through patient engagement and applied health communication research, we can enhance our understanding of how the interplay of communication behaviours, biases and errors can impact upon the patient experience and diagnostic error. In doing so, we provide new avenues for collaborative diagnostic error research striving towards healthcare improvements and safer diagnosis.

Medical Information Mining-Based Visual Artificial Intelligence Emergency Nursing Management System

This study aims to design a set of the visual artificial intelligence system based on medical information mining for hospital emergency care management. A visual artificial intelligence emergency first aid nursing management system is designed by analyzing the needs of the emergency first aid nursing management system. The results show that system personnel allocation, comparative management, record management, query management analysis, basic setup analysis, nursing management basis, and nonfunctional requirements all need to be optimized for the emergency first aid management system. In this study, the comparative management module, log management module, and the query management module are designed, and the emergency first aid management system of different APP terminal functions in different modules is described in detail. The nursing document query business is tested, and the corresponding time of query of nursing assessment sheet, nurse shift record, nurse record, and physical sign observation sheet is 375.50 ms, 351.48 ms, 336.36 ms, and 245.57 ms, respectively. It shows that the visual artificial intelligence emergency nursing management system based on medical information mining can provide convenience for clinical work to a large extent and has potential application value in hospital emergency nursing work.

A Value-Added Health Systems Science Intervention Based on My Life, My Story for Patients Living with HIV and Medical Students: Translating Narrative Medicine from Classroom to Clinic

In 2018-2019, at the Keck School of Medicine of the University of Southern California (KSOM), we developed and piloted a narrative-based health systems science intervention for patients living with HIV and medical students in which medical students co-wrote patients' life narratives for inclusion in the electronic health record. The pilot study aimed to assess the acceptability of the "life narrative protocol" (LNP) from multiple stakeholder positions and characterize participants' experiences of the clinical and pedagogical implications of the LNP. Students were recruited from KSOM. Patients and staff were recruited from the Maternal, Child, and Adolescent/Adult Center for Infectious Disease and Virology (MCA) at Los Angeles County+USC Medical Center. Ten patients, seventeen students, and ten MCA staff participated in the pilot study. Qualitative methods were used to gather data from students', patients', and staff's perspectives. Three themes emerged from the thematic analysis: (1) patients' life narratives conveyed their unique life experiences and voices; (2) the protocol could result in wide-ranging effects on HIV care; (3) the LNP enabled students to contribute value to patients' healthcare. Across groups, participants considered the LNP an acceptable intervention. The LNP, its limitations, and implications for HIV care, narrative medicine, and health information technology are presented.

Spheres of Influence and Strategic Advocacy for Equity in Medicine

As the extent of health disparities in the USA has been revealed, particularly during the COVID-19 pandemic, physicians have increasingly attended to their roles as advocates for their patients and communities. This article presents "spheres of influence" as a concept that can help physicians think strategically about how to build upon their clinical work and expertise to promote equity in medicine. The physician's primary sphere of influence is in direct patient care. However, physicians today often have many other roles, especially within larger health care institutions in which physicians often occupy positions of authority. Physicians are therefore well-positioned to act within these spheres in ways that draw upon the ethical principles that guide patient care and contribute materially to the cause of equity for colleagues and patients alike. By making changes to the ways they already work within their clinical spaces, institutional leadership roles, and wider communities, physicians can counteract the structural problems that undermine the health of the patients they serve.

The use of person-centered language in scientific research articles focusing on opioid use disorder

BACKGROUND

Opioid Use Disorder (OUD) affects approximately 1% of the population. Despite the prevalence of OUD, it remains a highly stigmatized disorder. Using person-centered language (PCL) - and thereby emphasizing the significance of the person rather than their diagnosis - is a potential strategy to reduce stigma in medical research related to addiction. Thus, we aimed to determine adherence to PCL in OUD-related publications according to the American Medical Association's guidelines.

METHODS

We performed a systematic search for articles published between January 1, 2016 through December 31, 2020 using the PubMed database. Articles were randomized and screened until we reached 300 articles that met inclusion criteria. Three-hundred articles were screened to meet this goal. Articles were then screened for non-PCL terms, determined a priori.

RESULTS

The majority (240/300; 80 %) of OUD-related publications were not adherent to the AMA guidelines on PCL. Additionally, the use of emotional language (i.e. suffer, afflicted, etc.) was employed in 48 % (145/300) of articles. Stigmatizing terminology was found in 73 % (218/300) of the OUD related articles in this study. Our study demonstrated a statistically significant correlation between senior author affiliation and adherence to reporting guidelines (i.e., PRISMA, STROBE, etc.).

CONCLUSION

A majority of OUD-related publications are not adherent to AMA guidelines on PCL. Language used in these publications is often repeated and replicated in medical education and clinical practice, which directly impacts patient-provider relationships. PCL-adherent language is a tool that both medical researchers and clinicians can use to combat stigma that individuals with OUD may experience.

A Cascade of Structural Barriers Contributing to Racial Kidney Transplant Inequities

Stark racial disparities in access to and receipt of kidney transplantation, especially living donor and pre-emptive transplantation, have persisted despite decades of investigation and intervention. The causes of these disparities are complex, are inter-related, and result from a cascade of structural barriers to transplantation which disproportionately impact minoritized individuals and communities. Structural barriers contributing to racial transplant inequities have been acknowledged but are often not fully explored with regard to transplant equity. We describe longstanding racial disparities in transplantation, and we discuss contributing structural barriers which occur along the transplant pathway including pretransplant health care, evaluation, referral processes, and the evaluation of transplant candidates. We also consider the role of multilevel socio-contextual influences on these processes. We believe focused efforts which apply an equity lens to key transplant processes and systems are required to achieve greater structural competency and, ultimately, racial transplant equity.

Correlates of PrEP Uptake Among Young Sexual Minority Men and Transgender Women in New York City: The Need to Reframe "Risk" Messaging and Normalize Preventative Health

Pre-exposure prophylaxis (PrEP) is an effective form of HIV prevention, but young sexual minority men face myriad barriers to PrEP uptake. Participants (n = 202) completed a survey on healthcare experiences and beliefs about HIV and PrEP. While 98% of the sample knew about PrEP, only 23.2% reported currently taking PrEP. Participants were more likely to be taking PrEP if they received PrEP information from a healthcare provider and endorsed STI-related risk compensation. Conversely, PrEP uptake was less likely among those with concerns about medication use and adherence. While there were no racial/ethnic differences in PrEP uptake, there were differences in correlates of PrEP use for White participants and participants of color. To facilitate PrEP uptake, clinicians should provide PrEP education and screen all patients for PrEP candidacy. Additionally, public health messaging must reframe HIV "risk", highlight benefits of STI testing, and emphasize the importance of preventive healthcare for SMM.

Words Matter: What Do Patients Find Judgmental or Offensive in Outpatient Notes?

BACKGROUND

Sharing outpatient notes with patients may bring clinically important benefits, but notes may sometimes cause patients to feel judged or offended, and thereby reduce trust.

OBJECTIVE

As part of a larger survey examining the effects of open notes, we sought to understand how many patients feel judged or offended due to something they read in outpatient notes, and why.

DESIGN

We analyzed responses from a large Internet survey of adult patients who used secure patient portals and had at least 1 visit note available in a 12-month period at 2 large academic medical systems in Boston and Seattle, and in a rural integrated health system in Pennsylvania.

PARTICIPANTS

Adult ambulatory patients with portal accounts in health systems that offered open notes for up to 7 years.

APPROACH

(1) Quantitative analysis of 2 dichotomous questions, and (2) qualitative thematic analysis of free-text responses on what patients found judgmental or offensive.

KEY RESULTS

Among 22,959 patient respondents who had read at least one note and answered the 2 questions, 2,411 (10.5%) reported feeling judged and/or offended by something they read in their note(s). Patients who reported poor health, unemployment, or inability to work were more likely to feel judged or offended. Among the 2,411 patients who felt judged and/or offended, 2,137 (84.5%) wrote about what prompted their feelings. Three thematic domains emerged: (1) errors and surprises, (2) labeling, and (3) disrespect.

CONCLUSIONS

One in 10 respondents reported feeling judged/offended by something they read in an outpatient note due to the perception that it contained errors, surprises, labeling, or evidence of disrespect. The content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved medical lexicon, reduce the transmission of bias to other clinicians, and reinforce healing relationships.

This is our lane: talking with patients about racism

Racism has significantly impacted communities of color for centuries. The year 2020 is a reminder that racism is an ongoing public health crisis. Healthcare institutions have an important role in dismantling racism because of their ability to implement innovative solutions that advance diversity, address social determinants of health, and promote health equity. Healthcare professionals have the unique opportunity to support patients by discussing patients' experiences of bias and racism. Asking about discrimination, however, can be difficult because of the sensitive nature of the topic and lack of appropriate education. This review highlights the importance of addressing patients' experiences of racism, utilizing the frameworks of trauma-informed care, structural competency, provider bias, and intersectionality. Furthermore, this review provides ways to engage in meaningful dialogue around discrimination and includes important patient-centric resources.

Cross-Sectional Analysis of Patient-Centered Language Use in Journals Publishing Research Focused on Heart Failure

Purpose

Detrimental effects of using non-patient-centered language (nPCL) have been reported for diabetes, mental illness, and obesity, and both the American Medical Association (AMA) and International Committee of Medical Journal Editors (ICMJE) recommend using patient-centered language in medical literature. Heart failure is a common yet stigmatized disease, and nPCL may further propagate stigma. This study analyzed current use of nPCL in journals focused on heart failure research and also examined whether the journals steer authors to adhere to AMA or ICMJE guidelines regarding nPCL.

Methods

Following systematic search of PubMed for heart failure-related articles published from May 1, 2018, to April 30, 2020, cross-sectional analysis was performed. Each selected article was inspected for an array of nPCL terms and frequency of nPCL usage. Chi-squared tests and multivariable logistic regressions were used to assess relationships between study characteristics and nPCL use.

Results

Of the 195 articles fully analyzed, 108 (55.4%) contained a nPCL term, the most frequently used being "heart failure patient" (78.7%), "burden" (23.1%), and "suffer" (15.7%). Use of nPCL was disproportionately more common in original research articles (63.5%) and less common in case reports (18.2%). Articles that did not detail any treatment or intervention used the most nPCL (71.1%). No statistically significant association was found between a journal's impact factor and its adherence to AMA or ICMJE recommendations.

Conclusions

nPCL is widely used in publications reporting on heart failure. We encourage authors and journals to reduce nPCL to help decrease the stigma patients with this disease often encounter.

Physician Use of Stigmatizing Language in Patient Medical Records

IMPORTANCE

Negative attitudes toward patients can adversely impact health care quality and contribute to health disparities. Stigmatizing language written in a patient's medical record can perpetuate negative attitudes and influence decision-making of clinicians subsequently caring for that patient.

OBJECTIVE

To identify and describe physician language in patient health records that may reflect, or engender in others, negative and positive attitudes toward the patient.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study analyzed randomly selected encounter notes from electronic medical records in the ambulatory internal medicine setting at an urban academic medical center. The 600 encounter notes were written by 138 physicians in 2017. Data were analyzed in 2019.

MAIN OUTCOMES AND MEASURES

Common linguistic characteristics reflecting an overall positive or negative attitude toward the patient.

RESULTS

A total of 138 clinicians wrote encounter notes about 507 patients. Of these patients, 350 (69%) were identified as female, 406 (80%) were identified as Black/African American, and 76 (15%) were identified as White. Of 600 encounter notes included in this study, there were 5 major themes representing negative language and 6 themes representing positive language. The majority of negative language was not explicit and generally fell into one or more of the following categories: (1) questioning patient credibility, (2) expressing disapproval of patient reasoning or self-care, (3) stereotyping by race or social class, (4) portraying the patient as difficult, and (5) emphasizing physician authority over the patient. Positive language was more often more explicit and included (1) direct compliments, (2) expressions of approval, (3) self-disclosure of the physician's own positive feelings toward the patient, (4) minimization of blame, (5) personalization, and (6) highlighting patient authority for their own decisions.

CONCLUSIONS AND RELEVANCE

This qualitative study found that physicians express negative and positive attitudes toward patients when documenting in the medical record. Although often not explicit, this language could potentially transmit bias and affect the quality of care that patients subsequently receive. These findings suggest that increased physician awareness when writing and reading medical records is needed to prevent the perpetuation of negative bias in medical care.

The Use of Person-Centered Language in Medical Research Journals Focusing on Psoriasis: Cross-sectional Analysis

BACKGROUND

Person-centered language places a person's identity before any disability or medical condition they may have. Using person-centered language reduces stigma and improves the patient-physician relationship, potentially optimizing health outcomes. Patients with psoriasis often feel stigmatized due to their chronic skin condition.

OBJECTIVE

We seek to evaluate the use of person-centered language in psoriasis literature and to explore whether certain article characteristics were associated with non-person-centered language.

METHODS

We performed a systematic search on PubMed for recently published articles in journals that regularly publish psoriasis studies. After article reduction procedures, randomization, and screening, we reached our target sample of 400 articles. The following non-person-centered language terms were extracted from each article: "Psoriasis Patient," "Psoriasis subject," "Affected with," "Sufferer," "Suffering from," "Burdened with," "Afflicted with," and "Problems with." Screening and data extraction occurred in a masked duplicate fashion.

RESULTS

Of the 400 included articles, 272 (68%) were not adherent to person-centered language guidelines according to the American Medical Association Manual of Style. The most frequent non-person-centered language term was "Psoriasis Patient," found in 174 (43.5%) articles. The stigmatizing language was associated with the type of article and funding status, with original investigations and funded studies having higher rates of stigmatizing language.

CONCLUSIONS

Articles about psoriasis commonly use non-person-centered language terms. It is important to shift away from using stigmatizing language about patients with psoriasis to avoid potential untoward influences. We recommend using "patients with psoriasis" or "patient living with psoriasis" to emphasize the importance of person-centered care.

Health Professional Stigma as a Barrier to Contingency Management Implementation in Opioid Treatment Programs

Contingency management (CM) has robust evidence of effectiveness as an adjunct to medication for opioid use disorders. However, CM implementation in opioid treatment programs has been limited by a myriad of well-documented barriers. One relatively unexplored barrier that may hinder CM implementation is health professional stigma toward patients with opioid use disorders. Qualitative interviews were conducted with 43 health professionals (21 leaders, 22 front-line counselors) from 11 different opioid treatment programs across Rhode Island to explore their familiarity with CM and to elucidate barriers and facilitators to CM implementation. Interviews were transcribed and coded by 3 independent raters using a reflexive team approach. Transcripts were analyzed for both a priori and emergent themes. Health professional stigma was identified as an emergent major theme with 4 distinct subthemes: (a) distrust of patients (44%, N = 19); (b) infantilizing views about patients (19%, N = 8); (c) belief that patients do not deserve prizes (19%, N = 8); and (d) recognition of patient self-stigma and community-based stigma (23%, N = 10). In addition, we identified multiple instances of health professional use of potentially stigmatizing language toward patients with opioid use disorders via terms such as drug abuser, addict, and clean or dirty urine screens (70%, N = 30). Stigma themes were identified in 86% of the transcripts, highlighting potential targets for multilevel implementation strategies. Findings of this study suggest that multiple types of health professional stigma should be considered and proactively addressed in efforts by psychologists to implement CM and other evidence-based interventions in opioid treatment programs.