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

Development of GROVE: A Guideline for RepOrting Vignette Experiments conducted in a healthcare context

OBJECTIVE

Experimental studies using vignettes investigate the impact of healthcare professional or patient/client characteristics, communication, and/or other behaviors on outcomes. To ensure methodological rigor and quality, guidance is needed for systematic reporting of such studies. We describe the development of the Guideline for RepOrting of Vignette Experiments (GROVE).

METHODS

A steering group comprising experts in vignette research oversaw guideline development using an iterative and expert-driven approach. The development process included reviewing relevant literature, developing draft reporting criteria, soliciting feedback from a working group of international experts, applying the draft criteria to completed or planned vignette studies, and iteratively revising criteria until final group consensus was reached. GROVE was registered with the EQUATOR network repository of reporting guidelines.

RESULTS

The final guideline encompasses the following criteria: 1. Rationale for a vignette design; 2. Vignette content; 3. Outcomes; 4. Vignette validity & realism; 5. Participants; and 6. Accessibility. Criterion 2 is further divided into five sub-criteria: 2.1. Healthcare scenario; 2.2. Manipulation & standardization; 2.3. Mode of delivery; 2.4. Expert involvement; and 2.5. Pilot testing.

CONCLUSION

GROVE offers authors guidance in reporting experimental vignette studies.

PRACTICE IMPLICATIONS

Transparent reporting of vignette studies will help readers evaluate the reliability and validity of study findings, replicate studies, and extract relevant information for reviews.

Understanding Health Care Disparities: A Focus on Diverse Women

As primary care clinicians, it is important to recognize the causes of health disparities in our patients who are women of color in order to advocate and work toward true equity in health outcomes. This article strives to introduce this concept by presenting areas of inequity such as maternal mortality, management of pain, cardiovascular health, and breast cancer outcomes. Lastly, we will introduce a framework and actionable steps that can be taken to counteract the biases known to influence patient care.

'Getting it write' in an era of online electronic health records access in primary care: A qualitative study exploring the needs and requirements of underserved patients and carers

OBJECTIVES

Most adult patients in England now have access to their primary care electronic health record (EHR), including free-text consultation notes, via the NHS App or other online services. As EHRs were not designed for patient audiences, this study aimed to explore patients' and carers' perspectives and understanding of simulated consultation notes.

METHODS

One interview and five focus groups were conducted with 26 patients and carers from a purposive sample of underserved communities in England between April and May 2023. Participants' understanding and views were elicited regarding five vignettes about patient consultation scenarios and corresponding simulated primary care EHR entries. Verbatim transcripts were analysed inductively using thematic analysis.

RESULTS

Most participants struggled to fully understand the simulated consultation notes, particularly medical acronyms, clinician shorthand and non-clinical abbreviations. Participants also identified issues which may cause unintended offence or anxiety, and made suggestions about how EHRs may be improved to meet the needs of patient audiences and maintain positive patient-clinician relationships.

CONCLUSIONS

Opening up online record access to include patient audiences necessitates a significant cultural shift in the way that consultation notes are written and used. Participants proposed technological and documentation adaptations to enhance understanding, support diverse patient needs and maintain positive patient-clinician relationships.

PRACTICE IMPLICATIONS

To fully realise the benefits of patient online records access, it is important for consultation notes to be written in a way that patients find meaningful, while maintaining their clinical integrity. To optimise NHS England's investment in this policy and avoid exacerbating health inequalities, it is essential to ensure all patients can access the benefits of online access to their EHR. Healthcare professionals need to be supported to manage the challenges of writing consultation notes for patient audiences, while continuing to maintain effective clinical care.

Navigating Inclusive Language in Veterinary Medicine: A Step Toward a More Equitable Workplace

Stigmatizing language, often rooted in unconscious bias, can reinforce power imbalances, perpetuate stereotypes, and compromise inclusivity. Inclusive language-defined as communication that respects diversity, acknowledges lived experiences and promotes equality-fosters a supportive and welcoming environment for all team members and clients. Its application extends to verbal interactions, written communication, policies, and educational materials. Strategies to implement inclusive language include adopting people-first phrasing, avoiding ableist expressions, respecting gender diversity, and embracing cultural humility. Organizations can further support inclusivity through training programs and leadership modeling. By prioritizing inclusive language, veterinary teams not only strengthen collaboration and equity but also enhance team dynamics, client satisfaction, and patient care. Recognizing the power of words and choosing them thoughtfully promotes a culture of belonging and respect, benefiting individuals and the organization as a whole.

Stigmatizing and Positive Language in Birth Clinical Notes Associated With Race and Ethnicity

Importance

Language used in clinical documentation can reflect biases, potentially contributing to health disparities. Understanding associations between patient race and ethnicity and documentation of stigmatizing and positive language in clinical notes is crucial for addressing health disparities and improving patient care.

Objective

To examine associations of race and ethnicity with stigmatizing and positive language documentation in clinical notes from hospital birth admission.

Design, Setting, and Participants

This cross-sectional study included birthing patients at 2 metropolitan hospitals in the Northeastern US between 2017 and 2019. Eligible participants were admitted for labor and birth and had at least 1 free-text clinical note. Analysis was conducted using natural language processing. Data were analyzed between March and December 2024.

Exposures

Patient race and ethnicity, categorized into mutually exclusive groups of Asian or Pacific Islander, Black, Hispanic, and White.

Main Outcome and Measures

Presence of 4 stigmatizing language categories (marginalized language or identities, difficult patient, unilateral or authoritarian decisions, and questioning patient credibility) and 2 positive language categories (preferred and/or autonomy, power and/or privilege).

Results

Among the 18 646 patients included in the study (mean [SD] age, 30.5 [6.2] years), 2121 were Black (11.4%), 11 078 were Hispanic (59.4%), and 4270 were White (22.9%). The majority (10 559 patients [56.6%]) were insured by Medicaid. Compared with White patients, Black patients had higher odds of having any stigmatizing language (model 2: odds ratio [OR], 1.25; 95% CI, 1.05-1.49; P < .001), after adjustment for demographic characteristics. Black patients also had higher odds of any positive language documented (model 2: OR, 1.18; 95% CI, 1.05-1.32; P = .006). Hispanic patients had lower odds of documented positive language (model 2: OR, 0.90; 95% CI, 0.82-0.99; P = .03). Asian or Pacific Islander patients had lower odds of language documented in the power and/or privilege category (model 2: OR, 0.71; 95% CI, 0.57-0.88; P = .002).

Conclusions and Relevance

In this cross-sectional study examining clinical notes of 18 646 patients admitted for labor and birth, there were notable disparities in how stigmatizing and positive language was documented across racial and ethnic groups. This underscores the necessity for improving documentation and communication practices to reduce the use of stigmatizing language.

The Family Snapshot-Innovation to integrate family context into daily interactions in the NICU

AIM

Current literature favours individualised decision making, an approach that requires understanding patients within their context and tailoring treatment and recommendations to their unique needs. In neonatology, family context becomes synonymous with patient context. In the neonatal intensive care unit (NICU), the team may be challenged to understand the intricacies of the family context, paramount for both families and clinicians. However, a significant gap exists between the intent to share information about the family context and the process of doing so. The transformational goal of this project was to embed an understanding of the family context into all interactions that occur in the NICU between clinicians and families, and between clinicians when discussing patients.

METHODS

We designed and implemented the Family Snapshot (FS), an innovation to bridge the gap between the intent and the process to share the family context.

RESULTS

Two groups of process measures have been collected to understand workflow integration: (1) whether the forms are being used and (2) how the forms are being used. Overall, completion of at least some part of the FS was >90%.

CONCLUSION

This manuscript describes our process, its feasibility and impact and presents two tools, the FS antenatal consultations and the FS tab.

Medical student perceptions of psychiatric conditions and the impact of stigmatizing language

CONTEXT

Mental health conditions have been subject to significant societal stigma, which impacts the self-perception of people with mental illness and can impact their decision to seek treatment. General practitioners in the United States report overall negative attitudes toward people with severe mental illness; however, there are few studies into the beliefs of medical students on people with mental illnesses as well as the impact of stigmatizing language on these beliefs.

OBJECTIVES

The objectives of this survey were to evaluate the impact of stigmatizing language on medical students' responses to case presentations of mental illnesses, and to determine how these perceptions vary across the course of medical education.

METHODS

We conducted an online survey wherein medical student participants reviewed psychiatric case vignettes, which varied in their use of either person-centered language (PCL) or stigmatizing language. All current students at the authors' institution were sent the survey link via email. Participants rated the case for symptom severity, their likelihood to recommend hospitalization, their level of comfort and safety when interviewing the patient, the trustworthiness of the patient's report, and the likelihood that the condition would improve over the next year. For analysis, these responses were summed to yield a Student Perception Index Score from 1 to 60, with 60 being the "most stigmatizing" perspective (i.e., lowest comfort, most likely to hospitalize, etc.).

RESULTS

There were 87 total respondents, of which 44 answered the Stigmatizing vignettes and 43 answered the PCL vignettes, with roughly even respondents per year in school. Overall, there was not a significant difference between the PCL and stigmatizing language versions (p=0.73 for the major depression case; p=0.29 for the schizophrenia case). However, compared to first-year medical students, third-year students had significantly higher Student Perception Index Scores for the stigmatizing depression case (p=0.002), and fourth-year students had significantly higher stigma scores for the PCL depression case (p=0.02).

CONCLUSIONS

Although there was no overall difference between the average Index Scores for the PCL and stigmatizing versions of the case presentations, significant differences in the Index Scores of certain presentations for students undergoing clinical education indicate that some targeted education on mental health stigma may be beneficial for third- and fourth-year medical students. Teaching empathetic approaches to patients with mental illness, regardless of whether their presentation was "stigmatizing," emphasizes the holistic care expected through the osteopathic tenet describing the interconnectedness of mind, body, and spirit.

Discrimination, racism, and bias in childbirth pain management in the United States: a scoping review and directions for research and clinical care

Racial and ethnic disparities in obstetric analgesia care persist in the United States. There is a paucity of validated tools to measure how discrimination, racism, and bias affect obstetric anesthesia care. As a result, little is known about how racism and other forms of discrimination impact pain management during childbirth. In this scoping review, we evaluated 11 studies that quantitatively measured or qualitatively described experiences of discrimination, racism, or bias in childbirth pain management among birthing people in the United States. Studies focused on birthing people with marginalized identities due to race and ethnicity, disability status, history of opioid use disorder, and health insurance status. We provide nine recommendations for research and 14 recommendations for clinical practice to mitigate the impact of interpersonal, institutional, and structural discrimination in obstetric anesthesia care. Future research should prioritize quantitative analyses between structural discrimination and childbirth pain management, and employ an intersectional approach to improve care for birthing people with multiple marginalized identities. Clinical practice recommendations include developing rapport and trust with birthing people before labor analgesia is needed, diversifying the labor and delivery workforce, establishing patient-family advisory councils, and encouraging professional societies to advocate for equitable perinatal health policies.

The Use of Person-Centered Language in Scientific Research Articles Focused on Psychosis

Purpose

Societal stigma of psychosis leads to delayed treatment for individuals experiencing early symptoms, for fear of being labeled "crazy" or "psychotic." Delayed treatment can worsen the prognosis of individuals with psychosis. Proper adherence to person-centered language (PCL) guidelines can curb the widely held stigmatized preconceptions about psychotic conditions.

Methods

Our meta-epidemiological analysis began with a systematic search of literature in PubMed discussing psychosis from 2020-2022. From the 14,522 results, we randomly selected 500 articles in journals with at least 20 articles on psychosis (n=9,775), of which 241 articles met the inclusion criteria. These papers were screened for the usage of stigmatized language; article characteristics were also noted for further analysis.

Results

Our analysis revealed that 53.1% of articles screened included stigmatized language. The most common stigmatized phrase identified was "schizophrenia patient," found in 35.3% of papers. "Schizophrenic [patient/subject/etc]" and "psychosis patient" were each found in 12.4% of papers. The type of intervention (ie, pharmacologic, therapeutic, or observational) was the only variable that was found to be significant for PCL usage (P = 0.006).

Conclusions

The majority of medical articles screened did not adhere to PCL guidelines. The usage of stigmatized language in literature reinforces the use of these labels in medical education, doctor's offices, and popular culture. Given the impact of stigma on treatment delay - and the poor prognosis that may result - proper care should be taken to enforce PCL in medical literature. Reducing the fear of labeling is a necessary step in encouraging treatment for people experiencing early symptoms of psychosis.

The use of non-person-first language in neuro-ophthalmology referrals

OBJECTIVE

To investigate the prevalence of non-person-first language (PFL) in neuro-ophthalmology referrals to a single tertiary ophthalmology clinic.

DESIGN

Retrospective cross-sectional study.

METHODS

Participants included neuro-ophthalmology patients seen for their initial visit from July 2018 to December 2022. Ten randomly selected referrals from each day were screened. Non-PFL was further categorized as per American Medical Association and American Psychological Association guidelines. Associations between non-PFL and patient age and gender, referring provider gender and specialty, and year and length of referral, were evaluated using the χ2 test.

RESULTS

A total of 2105 referrals were included in the study and 81 (3.8%) used non-PFL, such as referring to a person with glaucoma as a "glaucoma patient". Error types included general (38.3%), stigma (25.9%), diabetes (19.8%), disability (13.6%), and obesity (2.5%). Non-PFL was significantly more likely in long referrals compared with medium and short referrals (9.9% vs 3.1% vs 1.3%; p < 0.001). Referral year was predictive of non-PFL (p = 0.0006), with a significant increase from 2018 (1.7%) to 2021 (6.1%) and decrease in 2022 (2.6%). Patient age was also predictive of non-PFL (p = 0.0359), with the highest prevalence among patients 40-69 years old (5.4%). Patient gender (p = 0.3350), referring provider gender (p = 0.3571), and referring provider specialty (p = 0.1280) were not predictive of non-PFL.

CONCLUSIONS

The highest proportions of non-PFL errors made were general and stigma errors. Non-PFL use was most prevalent in 2021, most commonly in referrals for patients aged 40-69 years. There exists a need for ongoing education and awareness around PFL use in physician-physician communication to enhance inclusive, nonstigmatizing care for neuro-ophthalmology patients.

Assessment of Compliance With ASCO Language of Respect Guidelines in Renal Cell Carcinoma Abstracts

PURPOSE

The ASCO Language of Respect (LOR) Guidelines were developed in 2020 to promote patient-respectful language in abstracts and presentations. We assessed adherence to LOR guidelines among renal cell carcinoma (RCC) abstracts presented at the 2023 and 2019 ASCO Annual Meetings.

METHODS

We systematically evaluated each statement in all RCC abstracts for compliance with the three clauses of LOR guidelines: "Do not blame patients," "Respect the role of patients," and "Do not dehumanize patients." Univariable and multivariable analyses were performed to identify factors associated with noncompliance.

RESULTS

Among 101 abstracts from 2023, the majority involved clinical research (66.3%) and had a character count at limit, defined as within 5% of the 2,600-character limit (51.5%). In 60.4% of abstracts, at least one statement violated the LOR guidelines. Proportions of abstracts with one or more statements with dehumanizing, blaming, or disrespectful language were 46.5%, 21.8%, and 1.0%, respectively. Among all variables examined, including research and author characteristics, abstracts at character limit emerged as the only category with significantly higher rates of noncompliance (62.3% v 35.0%, P = .013). Multivariable analyses showed an odds ratio of 3.3 (95% CI, 1.4 to 7.6, P = .006) for abstracts at character limit to have at least one noncompliant statement. Notably, even among abstracts not at character limit, 46.9% contained statements violating the guidelines. Between 2019 and 2023, the rate of statements that violated the LOR guidelines decreased from 71.0% to 60.4%.

CONCLUSION

A significant proportion of RCC abstracts contain language inconsistent with LOR guidelines. Although character limit is a likely contributor, our report highlights the need for our professional societies and abstract reviewers to cultivate greater awareness and adherence to patient-respectful language.

Words matter: Destigmatizing the language of medicine through research, training, and future directions for emergency medicine

Background

In emergency medicine (EM), language choice significantly impacts patient care and can potentially cause harm, dehumanize patients, and introduce bias. Stigmatizing language in medical settings can affect patient dignity, trust, and outcomes. Despite its importance, there is limited education on avoiding stigmatizing language in EM. This concept paper addresses the need to raise awareness and develop strategies for use of inclusive language in the emergency department (ED).

Methods

A didactic session titled "Words Matter: Destigmatizing the Language of Medicine" was developed and presented at the 2024 Society for Academic Emergency Medicine (SAEM) Annual Meeting. The session involved a collaborative team of 12 individuals, including an EM resident, health equity fellow, and EM faculty. Content creation involved a comprehensive literature review and consensus-based decision making. The session featured current research related to stigmatizing language and interactive components, including case-based discussions and equity-focused alternative language choices.

Results

The didactic session, attended by approximately 70 participants, successfully highlighted the impact of stigmatizing language on health care disparities and patient trust. Interactive case studies allowed participants to identify and propose alternatives to stigmatizing language. The session provided actionable strategies for integrating inclusive language into practice and education. Postdidactic discussions emphasized the need for ongoing research and specific educational interventions to address stigmatizing language in EM.

Conclusions

Addressing stigmatizing language in EM is crucial for providing equitable and respectful patient care. The didactic session demonstrated effective methods for raising awareness and training health care professionals in using inclusive language. Future efforts should focus on developing standardized approaches for identifying and mitigating stigmatizing language, integrating these practices into training programs, and conducting longitudinal research to assess the impact on patient outcomes. Creating a culture of inclusive language in the ED will contribute to improved patient trust and care quality.

Health Care Practitioner Bias and Access to Inpatient Rehabilitation Services Among Survivors of Violence

Importance

Posthospital inpatient rehabilitation is essential for many patients with traumatic injuries. However, rehabilitation centers lack transparency and oversight in their admission practices and may be influenced by health care practitioner (HCP) use of stigmatizing language in patient medical records, leading to inequities in access to care.

Objectives

To examine differences in admission to inpatient rehabilitation centers for patients hospitalized for violent penetrating (VP) injuries compared with motor vehicle crash (MVC) injuries.

Design, Setting, and Participants

This mixed-methods retrospective qualitative study used data obtained from hospital records from 2015 to 2021. Data analysis occurred between July and December 2023. The study was performed at Boston Medical Center, an urban level I trauma center. The cohort included all patients hospitalized for VP or MVC injuries who were discharged to an inpatient rehabilitation center between 2015 and 2021.

Exposures

Injury type, categorized as VP or MVC.

Main Outcomes and Measures

The primary quantitative outcome was a denial for admission to an inpatient rehabilitation center. Qualitative content analysis identified similarities and differences across injury types in the manifestations of predetermined stigmatizing language categories in patients' medical records.

Results

Of 323 patients discharged to an inpatient rehabilitation center (median [IQR] age, 38 [25-59] years; 208 men [64.4%]; 29 Hispanic patients [9.0%], 118 non-Hispanic Black patients [36.5%], and 152 non-Hispanic White patients [47.1%]), 107 patients (33.1%) experienced at least 1 denial by a center before being placed (32 of 55 patients with VP injuries [58.2%] vs 75 of 268 patients with MVC injuries [28.0%]). Compared with patients with MVC injuries, patients with VP injuries had greater than 3 times the odds of experiencing a denial (odds ratio, 3.51; 95% CI, 1.93-6.48; P < .001). Medical records of patients with VP injuries had increased use of stigmatizing language that indicated culturally based or injury-related stereotyping, skepticism toward patient-reported symptoms, and heightened HCP-power dynamics contributing to unilateral decision-making.

Conclusions and Relevance

In this mixed-methods qualitative study of hospital patients discharged to rehabilitation centers, significant disparities in denials for admission were observed among survivors of violence, who were disproportionally Black or Hispanic. Stigmatizing language found in medical records suggested that bias within the referral process may have contributed to these disparities. These findings underscore the need for reformed clinical documentation practices and enhanced oversight of rehabilitation referral processes to promote equitable access to care.

Impact of a Web-Based Curriculum on Internal Medicine Resident Use of Stigmatizing Language for Substance Use Disorder

BACKGROUND

Addiction is a chronic, treatable disorder, yet it carries considerable stigma. Stigmatizing language biases how clinicians view patients with substance use disorders (SUDs) and negatively affects patient care. While national medical organizations have recommended educational initiatives to reduce the stigma associated with SUDs, studies of initiatives are lacking. We aimed to improve documentation of SUDs and reduce measured stigma by teaching standardized, non-stigmatizing language.

METHODS

We created an online, 25-minute interactive curriculum about vocabulary for addiction and why language matters. Before and 8 weeks after completing the curriculum, internal medicine residents viewed a video encounter between a physician and a "challenging" simulated patient with opioid use disorder, then completed a case write-up and a SUD stigma survey. We analyzed the frequency of usage of stigmatizing terms and quantified participants' stigma levels.

RESULTS

During the fall of 2020, UPMC Internal Medicine residents completed the curriculum. In all, 98 participants (out of ~150) completed the pre-curriculum assessment, and 39 completed the entire course. In pre-curriculum write-ups, stigmatizing terminology was used 4 times more often than clinical terminology (30 terms per 100 write-ups versus 7.6, P = .032). Clinical terminology was used 134% more often post-curriculum than pre-curriculum (24 terms per 100 write-ups vs 7.6), but this result was not significant. There was no difference between measured stigma levels pre- and post-curriculum. In total, 34/45 (75.6%) participants who completed the post-curriculum survey said that they learned new information, and 32/45 (71.1%) would recommend it to others.

CONCLUSIONS

There were trends toward improvement in language, including decreased use of stigmatizing terminology and increased usage of clinical terminology, though not statistically significant. The curriculum was well-received, but the study was limited in participation by the COVID-19 pandemic. However, the simple design of the curriculum-a short, web-based module-allows for easy delivery to workers across the healthcare sector.

Advances, Nuances, and Future Directions in Neonatal Toxicology Testing

Toxicology testing is a commonly used tool applied to the identification and management of infants with prenatal substance exposure. Although such testing has the potential to aid in the clinical management of newborns, clinicians who order such testing are frequently unaware of the limitations and harms of testing and the impact of the test results on the pregnant person-newborn dyad. In this review, we summarize the types and limitations of neonatal toxicology tests and identify areas for improvement, including policy change and advocacy, to drive equitable care for newborns and families with perinatal substance exposure. Clinicians ordering toxicology testing for neonates must understand their facility's testing capabilities, the screening vs confirmatory nature of that available testing, how to proceed with confirmatory testing of a screening test, and how to accurately interpret the result of that test.

Effects of Stigmatizing Language on Trainees' Clinical Decision-Making in Substance Use Disorders: A Randomized Controlled Trial

OBJECTIVES

Substance use disorder (SUD) continues to be one of the most stigmatized and under-treated conditions in the United States. Stigmatizing language used by healthcare workers can transmit bias to others within healthcare, including medical trainees. This study investigates how stigmatizing language and undergraduate medical education (UME) curricula may influence trainees' clinical decision-making for patients with SUD.

METHODS

Medical students from three Chicago-area medical schools were randomized to review either a stigmatizing or neutral version of a clinical scenario describing a patient experiencing opioid withdrawal. Participants (a) selected treatment plans for the fictional patient using two multiple-choice questions, (b) completed the Medical Condition Regard Scale (MCRS) to assess their attitudes, and (c) reported prior SUD experiences, both curricular and personal. Statistical analyses explored whether treatment decisions were influenced by attitudes, addiction medicine curricula, and exposure to the stigmatizing vignette.

RESULTS

Among the 366 medical students who completed this study, exposure to stigmatizing language (n = 191) led to clinical decision-making that would be less effective in treating opioid withdrawal for the fictional patient (p = 0.027; η2 = 0.013). Exposure to more SUD education during UME was correlated with more effective clinical decision-making for opioid withdrawal (β = 0.181; R2 = 0.033; p < 0.001) but was not correlated with attitudes toward patients with SUD (p = 0.231).

CONCLUSIONS

Stigmatizing language influences clinical decision-making when treating patients with SUD. Improving SUD education within UME may be an effective strategy for mitigating this effect within medical trainees.

Stigmatizing Language in Substance Use-related International Classification of Diseases Codes

OBJECTIVES

Healthcare-associated stigma is a critical barrier for treatment engagement for patients with substance use disorders. Although there are efforts to combat stigmatizing language in clinical documentation, little is known about the presence of substance use-related stigmatizing language in structured diagnosis codes ubiquitous in clinical medicine.

METHODS

We examined the presence of substance use-related stigmatizing terms contained within the International Classification of Diseases, 10th revision, clinical modification (ICD-10-CM) diagnosis code descriptions. Stigmatizing terms were compiled from guidelines authored by the National Institute on Drug Abuse, while ICD-10-CM codes were obtained from the United States Centers for Disease Control and Prevention.

RESULTS

We evaluated 74,259 ICD-10-CM code descriptions and identified 173 substance use-related codes with stigmatizing language. The stigmatizing terms detected were "abuse" (157 code descriptions), "alcoholic" (16), and "drug abuser" (2). The term "abuse" was used in relation to multiple substances including alcohol, opioids, cannabis, sedatives, hypnotics and anxiolytics, cocaine, stimulants, hallucinogens, inhalants, other psychoactive substances, tobacco, and other medicinal products.

CONCLUSIONS

Stigmatizing language is used in multiple ICD-10-CM code descriptions. Subsequent iterations should bring ICD-10-CM code descriptions in line with current recommendations for destigmatized descriptors to avoid the perpetuation of stigma in healthcare.

Implicit bias in the patient descriptor "homeless" and its association with emergency department opioid administration and disposition

BACKGROUND

Biased language in provider documentation of marginalized patient populations has been shown to negatively influence patient management. There has been debate over the use of "homeless" as a descriptor of people experiencing homelessness (PEH), as it is a potentially biased term with negative connotations. This study explores the relationship between the use of the word "homeless" in Emergency Department (ED) provider documentation and admission rates, as well as intravenous (IV) vs. oral (PO) opioid administration rates.

METHODS

This single-center retrospective study analyzed electronic medical record (EMR) data from 2 academic EDs in Southern California. ED physician encounter notes from the calendar year 2021 were included if the patient had a history of unstable housing documented elsewhere in the medical record in the past year. Patients were categorized as HIN+ if the term "homeless" was featured in the note. Multivariate logistic regression analysis was performed to determine if HIN+ was associated with admission vs discharge for 7 common ED diagnoses, as well as for the administration of IV vs PO opioids.

RESULTS

The cohort consisted of 2751 PEH with 5049 unique ED encounter notes. Of these, 920 patients with 1333 unique notes were HIN+. Regardless of diagnosis, charting "homeless" in the note (HIN+) was a strong predictor of discharge rather than admission (OR: 0.70, CI: 0.60-0.82). This was especially true for those with a diagnosis of heart failure exacerbation (OR: 0.45, CI: 0.23-0.87) and alcohol withdrawal (OR: 0.47, CI: 0.24-0.90). HIN+ patients were also less likely to receive IV opioids (OR: 0.41, CI: 0.24-0.69).

CONCLUSIONS

ED physician use of the term "homeless" in medical documentation was associated with a lower likelihood of being admitted to the hospital for certain conditions and more likely to receive PO rather than IV opioids compared with those patients not labeled as "homeless". This study reinforces prior studies in how biased language may alter medical decision making.

Consultation Liaison Case Conference: Inpatient Psychiatric Consultation for Patients With Sickle Cell Disease

We present the fictional case of a 29-year-old man with sickle cell disease referred to psychiatry for evaluation of depression during an acute pain episode. Consultation-liaison psychiatrists with expertise in sickle cell disease provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching points include the high prevalence of mood and cognitive disorders in this population, as well as pertinent issues related to chronic pain, opioids, and stigma.

Inequities time-to-follow-up care and administrative action after low back pain diagnosis in active duty service members

ABSTRACT

As healthcare systems adopt data-driven methods to determine resource allocation for treating low back pain (LBP), it is critical to evaluate equity in time-to-follow-up care after an index visit and long-term occupational outcomes. This retrospective observational study included medical records of 525,252 active duty US service members who received an LBP index diagnosis from June 2016 to February 2022. Poisson generalized additive models evaluated time-to-LBP follow-up visit (primary outcome) and administrative action receipt (eg, disability evaluation; secondary outcome). Service members assigned female in the medical record compared to service members assigned male had lower cumulative hazards of follow-up visit at 1-week, but higher hazards by 4 weeks. Asian and Pacific Islander, Black, and Latino service members compared to white service members had lower cumulative hazards of follow-up visit during the acute/subacute period (up to 7, 19, 31, weeks, respectively), then higher cumulative hazards. Service members whose race and ethnicity was recorded as Other had lower hazards across time. Service members assigned female in the medical record compared to service members assigned male had lower cumulative hazards of administrative action receipt, as did Asian and Pacific Islander, Black, and Latino service members and service members whose race and ethnicity was recorded as Other compared to white service members. Overall, inequities in LBP follow-up visit timing warrant system-level programming to mitigate healthcare barriers acutely and subacutely after an LBP index visit, as well as system-level evaluation of pathways to administration action receipt.

Clinician perspectives on electronic health record behavioral alerts and hospital workplace violence prevention: A mixed methods study at 20 organizations

BACKGROUND

Workplace violence prevention programs are important for safety, but little is known about how they are perceived by clinicians or whether electronic health record (EHR) behavioral alerts are perceived as effective.

OBJECTIVE

To understand perspectives on the use of EHR behavioral alerts as part of workplace violence prevention programs in hospitals.

METHODS

Mixed methods study utilizing semi-structured focus groups with a structured survey. Focus group participants were members of a national hopsitalist consortium.

RESULTS

Twenty-eight individuals from 20 different organizations participated in focus groups, with 24 (86%) completing the survey. There was broad uncertainty in best practices for inpatient workplace violence prevention. There was also wide variation in EHR behavioral alert use across multiple domains, including how and why the alerts are placed and how they are used by the end user. Finally, focus groups had mixed sentiments on the potential impacts of these alerts; among participants who responded to surveys, half (50%) noted that alerts caused deviations in care and 21% indicated they witnessed instances where behavioral alerts led to adverse patient outcomes. Most (67%) survey respondents did not think EHR behavioral alerts prevented workplace violence. The majority (88%) of respondents also reported that patient demographic factors impacted whether an alert was placed.

LIMITATIONS

The study focused on clinician experience at academic hospitals.

CONCLUSIONS AND RELEVANCE

Reports of uncertainty in best practices for deploying EHR behavioral alerts, along with perceptions of variability in implementation and potential biases in alert usage, raise concerns about their effectiveness and potential for worsening disparities. Standardized, evidence-based practices that safeguard healthcare workers without compromising patient care and equity are needed.

Structural Competency: A Faculty Development Workshop Series for Anti-racism in Medical Education

Introduction

In response to accreditation bodies requiring health disparities curricula, medical educators are tasked with incorporating structural competency, the understanding of how social and structural barriers like structural racism impact health, into their teaching. Most have not received training in this area, yet there remains a scarcity of faculty development curricula to address this gap. We describe the creation, implementation, and evaluation of a faculty development workshop series rooted in the framework of structural competency.

Methods

We delivered four 90-minute workshops at an urban academic medical center from March through April of 2021. Workshops were offered to interdisciplinary faculty. We evaluated this workshop series with a pre- and postintervention survey assessing attitudes and confidence, and a postintervention satisfaction survey. Data analysis was conducted using a paired t test.

Results

A total of 206 participants attended at least one workshop within the series, and 20 participants completed both pre- and postintervention surveys. Participants overwhelmingly recommended these workshops to their colleagues and had significant increases in overall attitudes (3.3 vs. 3.6, p = .001) and level of confidence (3.2 vs. 3.9, p < .001) incorporating structural competency.

Discussion

Our application of structural competency to faculty workshops and teaching tools feasibly engages faculty in instruction to incorporate concepts of structural racism and the downstream effects of social determinants of health into clinical teaching. It represents an innovative tool as we seek to enhance clinical teaching to improve care for racially and ethnically minoritized communities.

CARE-SD: classifier-based analysis for recognizing provider stigmatizing and doubt marker labels in electronic health records: model development and validation

OBJECTIVE

To detect and classify features of stigmatizing and biased language in intensive care electronic health records (EHRs) using natural language processing techniques.

MATERIALS AND METHODS

We first created a lexicon and regular expression lists from literature-driven stem words for linguistic features of stigmatizing patient labels, doubt markers, and scare quotes within EHRs. The lexicon was further extended using Word2Vec and GPT 3.5, and refined through human evaluation. These lexicons were used to search for matches across 18 million sentences from the de-identified Medical Information Mart for Intensive Care-III (MIMIC-III) dataset. For each linguistic bias feature, 1000 sentence matches were sampled, labeled by expert clinical and public health annotators, and used to supervised learning classifiers.

RESULTS

Lexicon development from expanded literature stem-word lists resulted in a doubt marker lexicon containing 58 expressions, and a stigmatizing labels lexicon containing 127 expressions. Classifiers for doubt markers and stigmatizing labels had the highest performance, with macro F1-scores of 0.84 and 0.79, positive-label recall and precision values ranging from 0.71 to 0.86, and accuracies aligning closely with human annotator agreement (0.87).

DISCUSSION

This study demonstrated the feasibility of supervised classifiers in automatically identifying stigmatizing labels and doubt markers in medical text and identified trends in stigmatizing language use in an EHR setting. Additional labeled data may help improve lower scare quote model performance.

CONCLUSIONS

Classifiers developed in this study showed high model performance and can be applied to identify patterns and target interventions to reduce stigmatizing labels and doubt markers in healthcare systems.

A comparison of written case notes and the delivery of care in dementia specialist mental health wards

Introduction: Stigmatising language concerning people living with dementia can cause potentially harmful and dehumanising consequences. Language used about people living with dementia in mental health wards may focus on medical perspectives and suggest custodial relationships with patients rather than person-centred accounts of individuals. This language could have a devastating impact on the provision of person-centred care. This study investigated the relationship between accounts of people living with dementia written in healthcare case notes and clinical practice at three dementia specialist wards in Wales, UK. Language guidance was provided to ward staff to assess whether stigmatising language could be reduced and whether this influenced the provision of person-centred care.Methodology: Dementia Care Mapping was adapted to analyse case note entries for enhancing and detracting accounts of people living with dementia at three data collection points. These were compared to the results of routine DCM observations of care across the three wards. The healthcare case notes of 117 people living with dementia, encompassing 4, 522 entries over ten months were analysed. DCM observations of 38 people living with dementia within the three wards were compared against the case note results. Person-centred language guidance was shared with care staff following each data collection point.Results: Following the provision of person-centered language guidance, the use of personally enhancing language was observed to increase across all three wards. Non-person-centred case note entries predominantly focussed on Labelling language, whilst language concerning Invalidation and Objectification also occurred frequently compared to other DCM domains. Person centred language typically concerned Acknowledgement. A relationship between case note entries and practice was evident in some domains although findings were inconsistent.Discussion and Implications: The findings highlight the importance of addressing stigmatising language in healthcare and suggest that further studies to support the anti-stigma agenda in dementia care are required.

Avoiding Patient Abandonment: A Pathway to Ethical Resolution in Situations of Untenable Patient-Surgeon Relationships

BACKGROUND

A trusting partnership between patient and surgeon lies at the core of a successful therapeutic relationship. However, there are conditions that can jeopardize this partnership and create an ethical dilemma for the surgeon, who is guided by a moral obligation to care for the patient without causing unnecessary harm. The authors present a discussion of several pathways to achieve ethical resolution to therapeutic relationships that have grown untenable, with a focus on patients with comorbid psychiatric illness. The principal objective of these pathways is to prevent further delivery of futile interventions while avoiding patient abandonment.

METHODS

A review of the literature was performed, and principles of clinical ethics were applied to provide guidelines for care in situations of untenable patient-surgeon relationships.

RESULTS

There are no published ethical guidelines for resolving a therapeutic impasse in surgical patients with psychiatric illness. The authors applied ethical principles of treatment futility, nonmaleficence, beneficence, and patient abandonment to develop a framework for navigating difficult postoperative patient relationships.

CONCLUSIONS

Managing postoperative surgical patients with comorbid psychiatric conditions presents a unique challenge. In severe cases, therapeutic discharge may be ethically permissible and necessary to disrupt a maladaptive treatment cycle to prevent future patient harm. Specific precautions must be taken to avoid patient abandonment.

Natural Language Processing (NLP): Identifying Linguistic Gender Bias in Electronic Medical Records (EMRs)

With the rise of feminism, women report experiencing doubt or discrimination in medical settings. This study aims to explore the linguistic mechanisms by which physicians express disbelief toward patients and to investigate gender differences in the use of negative medical descriptions. A content analysis of 285 electronic medical records was conducted to identify 4 linguistic bias features: judging, reporting, quoting, and fudging. Sentiment classification and knowledge graph with ICD-11 were used to determine the prevalence of these features in the medical records, and logistic regression was applied to test gender differences. A total of 2354 descriptions were analyzed, with 64.7% of the patients identified as male. Descriptions of female patients contained fewer judgmental linguistic features but more fudging-related linguistic features compared to male patients (judging: OR 0.69, 95% CI 0.54-0.88, p < 0.01; fudging: OR 1.38, 95% CI 1.09-1.75, p < 0.01). No significant differences were found in the use of reporting (OR 0.95, 95% CI 0.61-1.47, p = 0.81) and quoting (OR 0.99, 95% CI 0.72-1.36, p = 0.96) between male and female patients. This study highlights how physicians may express disbelief toward patients through linguistic biases, particularly through the use of judging and fudging language. Both male and female patients may face different types of systematic bias from physicians, with female patients experiencing more fudging-related language and less judgmental language compared to male patients. These differences point to a potential mechanism through which gender disparities in healthcare quality may arise, underscoring the need for further investigation and action to address these biases.

"You're not taught to think about the words you use and then it just perpetuates"- a qualitative examination of medical students' perspectives of stigmatising language in healthcare

BACKGROUND

Stigmatising language is used commonly in healthcare, affecting healthcare providers' perceptions of patients and care delivery. Using person-first language is best practice, however, it does not reflect reality.

METHOD

This study examined medical students' perspectives on stigmatising language in healthcare. Twenty-one medical students at the RCSI University of Medicine and Health Sciences participated in four focus group interviews; a thematic analysis of the data was conducted.

RESULTS

Seven themes were identified: prevalence of stigmatising language, its impact on students and patients, being sensitive versus medically accurate, evolving nature of recommendations for language use, barriers to changing practice, power dynamics and cultural context influencing language use, stigmatising language being a societal issue. Participants provided recommendations for improving language use in healthcare: open discussions and student feedback on language in the learning environment, lecturers signposting person-first language, training workshops on person-first language for clinicians and lecturers, and social intelligence skills training.

CONCLUSION

Study findings highlight the impact of stigmatising language in healthcare. To address this issue and inform guidance for future generations of professionals, medical students recommended more open dialogue and improved social intelligence.

Guidelines for Patient-Centered Documentation in the Era of Open Notes: Qualitative Study

BACKGROUND

Patients in the United States have recently gained federally mandated, free, and ready electronic access to clinicians' computerized notes in their medical records ("open notes"). This change from longstanding practice can benefit patients in clinically important ways, but studies show some patients feel judged or stigmatized by words or phrases embedded in their records. Therefore, it is imperative that clinicians adopt documentation techniques that help both to empower patients and minimize potential harms.

OBJECTIVE

At a time when open and transparent communication among patients, families, and clinicians can spread more easily throughout medical practice, this inquiry aims to develop informed guidelines for documentation in medical records.

METHODS

Through a series of focus groups, preliminary guidelines for documentation language in medical records were developed by health professionals and patients. Using a structured focus group decision guide, we conducted 4 group meetings with different sets of 27 participants: physicians experienced with writing open notes (n=5), patients accustomed to reviewing their notes (n=8), medical student educators (n=7), and resident physicians (n=7). To generate themes, we used an iterative coding process. First-order codes were grouped into second-order themes based on the commonality of meanings.

RESULTS

The participants identified 10 important guidelines as a preliminary framework for developing notes sensitive to patients' needs.

CONCLUSIONS

The process identified 10 discrete themes that can help clinicians use and spread patient-centered documentation.

Inclusive Language to Support Health Equity and Belonging in Dentistry

Inclusive language in dentistry is essential for delivering high-quality, equitable care that respects and empathizes with patients from diverse backgrounds. It involves using language that avoids exclusion and bias, focusing on person-first terms, and understanding the preferences of individuals and communities. This approach not only promotes health equity and belonging but also strengthens trust and communication between providers and patients and among members of the dental health care team. Education, training, and consistent deliberate practice in inclusive language among health care professionals are crucial for integrating these principles into oral health care.

Anaphylaxis in pediatric patients: single-center study in a private hospital

This study aimed to characterize the profile of probable anaphylaxis cases treated at a private pediatric hospital emergency department in São Paulo. It investigated triggering factors, the presence of cofactors, treatments administered, and follow-up for these cases through interviews with the patients' families. A single-center cross-sectional study analyzed medical records of children and adolescents treated between 2016 and 2020. Allergist physicians evaluated cases with symptoms consistent with anaphylaxis to identify probable cases, and the parents or legal guardians of these cases were interviewed to gather detailed information about the episodes. A total of 69 probable cases of anaphylaxis (PCA) were identified among 460,434 visits. Of the 51 PCAs evaluated, most presented with cutaneous and respiratory symptoms, with a male predominance (63%), and 27% were under 2 years old. Foods, particularly nuts and peanuts, were the primary triggers. Nearly one-third of the patients did not undergo investigation following the episode, and intramuscular adrenaline (37%) and auto-injectable adrenaline (4%) were underutilized as treatments. Eight cases exhibited recurrence of symptoms after initial improvement, suggesting a potential biphasic reaction. In conclusion, this study revealed that the majority of PCAs occurred in male children, with nuts and peanuts as the main triggers. The management of PCAs was suboptimal, characterized by the underutilization of intramuscular adrenaline as the first-line treatment and low rates of auto-injectable adrenaline prescriptions during follow-up. Increasing awareness and education about anaphylaxis in children, along with emphasizing the importance of proper treatment, are crucial to reducing the risk of morbidity and mortality in this vulnerable population.

How Racialized Approaches to Opioid Use Disorder and Opioid Misuse Management Hamper Pharmacoequity for Cancer Pain

@JCO_ASCO paper focuses on racialized approaches to OUD and opioid misuse as underappreciated drivers of disparities in cancer and recs a path forward.

Stigmatizing and affirming provider language in medical records on hospitalized patients with opioid use disorder

BACKGROUND

Stigma within the healthcare environment limits access to treatment for opioid use disorder (OUD), even as OUD results in significant morbidity and mortality. Language in clinical documentation affects patient experience and future care through the transmission of stigma or positive regard. With the passage of the 21st Century Cures Act, patients have full access to their medical records online.

OBJECTIVES

The objective of our study was to understand providers' use of stigmatizing and affirming language in the electronic health record (EHR) for OUD patients with long hospital stays.

METHODS

We selected patients with a first-time referral to the Duke University Hospital OUD consult service who met diagnostic criteria for OUD with a hospital stay ≥28 days from July 2019 to February 2022. Two reviewers independently evaluated each admission and discharge note for stigmatizing or affirming language and the group met weekly to validate coding reliability.

RESULTS

Forty-eight patients (96 notes) met our inclusion criteria. We identified 434 occurrences of stigmatizing and 47 occurrences of affirming language. One-third (34%) of stigmatizing language appeared in system-generated fields (drop-down categories and diagnosis codes) and the rest was authored by providers.

CONCLUSIONS

Stigmatizing language was present in both provider- and system-generated language and was nine times more frequent than affirming language in the medical records of hospitalized patients with OUD. While provider education may reduce stigmatizing language, institutional level changes to the EHR and International Classification of Disease codes are necessary to decrease stigmatizing language within medical records.

Secondary Qualitative Analysis of Stigmatizing and Nonstigmatizing Language Used in Hospital Birth Settings

OBJECTIVE

To more clearly understand the use of stigmatizing and nonstigmatizing language in electronic health records in hospital birth settings and to broaden the understanding of discrimination and implicit bias in clinical care.

DESIGN

A secondary qualitative analysis of free-text clinical notes from electronic health records.

SETTING

Two urban hospitals in the northeastern United States that serve patients with diverse sociodemographic characteristics during the perinatal period.

PARTICIPANTS

A total of 1,771 clinical notes from inpatient birth admissions in 2017.

METHODS

We used Krippendorff's content analysis of categorial distinction to identify stigmatizing and nonstigmatizing language. We based our categories for the content analysis on our pilot study and preexisting categories described by other researchers. We also explored new language categories that emerged during analysis.

RESULTS

We reviewed 1,771 notes and identified 10 categories that demonstrated stigmatizing language toward patients, nonstigmatizing language toward patients, and stigmatizing language among clinicians. We identified a new stigmatizing language category, Unjustified Descriptions of Social and Behavioral Risks. Positive or Preferred Language and Patient Exercising Autonomy for Birth are two new categories that represent language that empowers patients. Clinician Blame and Structural Care Barriers are new language categories that imply complex interprofessional dynamics and structural challenges in health care settings that can adversely affect the provision of care.

CONCLUSIONS

The results of this study provide a foundation for future efforts to reduce the use of stigmatizing language in clinical documentation and can be used to inform multilevel interventions to reduce bias in the clinical care in birth settings.

Biased Language in Simulated Handoffs and Clinician Recall and Attitudes

Importance

Poor-quality handoffs can lead to medical errors when transitioning patient care. Biased language within handoffs may contribute to errors and lead to disparities in health care delivery.

Objective

To compare clinical information recall accuracy and attitudes toward patients among trainees in paired cases of biased vs neutral language in simulated handoffs.

Design, Setting, and Participants

Surveys administered from April 29 to June 15 and from July 20 to October 10, 2023, included 3 simulated verbal handoffs, randomized between biased and neutral, and measured clinical information recall, attitudes toward patients, and key takeaways after each handoff. Participants included residents in internal medicine, pediatrics, and internal medicine-pediatrics and senior medical students at 2 academic medical centers in different geographic regions of the US. Data were analyzed from November 2023 to June 2024.

Exposures

Each participant received 3 handoffs that were based on real handoffs about Black patients at 1 academic center. These handoffs were each randomized to either a biased or neutral version. Biased handoffs had 1 of 3 types of bias: stereotype, blame, or doubt. The order of handoff presentation was also randomized. Internal medicine and pediatrics residents received slightly different surveys, tailored for their specialty. Internal medicine-pediatrics residents received the pediatric survey. Medical students were randomly assigned the survey type.

Main Outcomes and Measures

Each handoff was followed by a clinical information recall question, an adapted version of the Provider Attitudes Toward Sickle Cell Patients Scale (PASS), and 3 free-response takeaways.

Results

Of 748 trainees contacted, 169 participants (142 residents and 27 medical students) completed the survey (23% overall response rate), distributed across institutions, residency programs, and years of training (95 female [56%]; mean [SD] age, 28.6 [2.3] years). Participants who received handoffs with blame-based bias had less accurate information recall than those who received neutral handoffs (77% vs 93%; P = .005). Those who reported bias as a key takeaway of the handoff had lower clinical information recall accuracy than those who did not (85% vs 93%; P = .01). Participants had less positive attitudes toward patients per PASS scores after receiving biased compared with neutral handoffs (mean scores, 22.9 [3.3] vs 25.2 [2.7]; P < .001). More positive attitudes toward patients were associated with higher clinical information recall accuracy (odds ratio, 1.12; 95% CI, 1.02-1.22).

Conclusions and Relevance

In this survey study of residents and medical students, biased handoffs impeded accurate transfer of key clinical information and decreased empathy, potentially endangering patients and worsening health disparities. Handoff standardization is critical to addressing racial bias and improving patient safety.

Prevalence of Person-First Language in Idiopathic Intracranial Hypertension: A Systematic Review of Case Reports

BACKGROUND

Person-first language (PFL) is a linguistic prescription, which places a person before their disease. It is considered an important tool to reduce stigma. However, PFL is not routinely used across the scientific literature, particularly in patients with overweight or obesity. Patients with idiopathic intracranial hypertension (IIH) face various stigmas through high rates of poverty, female gender, and frequent rates of comorbidities. Non-PFL language use intersects and worsen the health inequities faced by these patients.

METHODS

A systematic review of case reports. MEDLINE and EMBASE were searched for all case reports with "pseudotumor cerebri" [MESH] OR "Idiopathic Intracranial Hypertension" as key word between January 1974 and August 2022. The primary criterion was the article's inclusion of patients with overweight or obesity. The secondary criterion was the article's discussion regarding obesity as risk factor. Articles not meeting primary or secondary criteria were excluded.

RESULTS

Approximately 514/716 (71.8%) articles used non-PFL language. The publication year was predictive of non-PFL language: 1976-1991 (82.3%) vs 1992-2007 (72.3%, P = 0.0394) and 2008-2022 (68.3%, P = 0.0056). Non-PFL was significantly higher in obesity compared with other medical conditions (60.3% vs 7.3%, P < 0.001). The patient gender ( P = 0.111) and ethnicity ( P = 0.697), author's specialty ( P = 0.298), and primary English-speaking status ( P = 0.231), as well as the journal's impact factor ( P = 0.795), were not predictive of non-PFL.

CONCLUSIONS

Most literature focused on IIH use non-PFL when discussing overweight or obesity, regardless of the patient's gender and ethnicity, journal's impact factor, senior author's specialty, and English-speaking status. Non-PFL use is much more common when discussing obesity compared with other medical conditions. Appropriate use of PFL can decrease stigma and, more importantly, decrease the intersectionality of health stigma faced by patients with IIH.

Delivery of Hand Care to Patients With High Anxiety Burden

PURPOSE

To determine whether patients presenting with Patient-Reported Outcome Measurement Information System (PROMIS) anxiety scores at >95th percentile of the US population undergo elective hand surgery at rates different from patients with less anxiety. Secondarily, we aimed to assess surgeon notation of these patients' emotional states and incidences of postoperative complications.

METHODS

This single-center retrospective cohort study analyzed data from new adult patients presenting for hand care between January 2019 and December 2020. Patients with initial PROMIS anxiety scores ≥70 were identified as the high anxiety burden (HAB) group. For each patient with HAB presenting with carpal tunnel syndrome, trigger finger, and distal radius fractures (n = 45), three controls were matched (n = 135). After matching, bivariate statistical analysis compared outcome variables of interest between patient groups. Sentiment analysis was used to explore if patient anxiety was realized and considered in surgical decision making.

RESULTS

After matching, patients with HAB averaged baseline PROMIS scores in every assessed domain that were ≥1 SD worse than unaffected patients. Patients with HAB and control patients were offered surgery at a comparable rate (58% vs 47%). Among those offered surgery, patients with HAB were less likely to undergo surgery (73% vs 92%). Postoperative complications occurred more frequently in the patients with HAB (32% vs 8%). Sentiment analysis of office notes revealed that the patients with HAB had their emotional state explicitly noted more often (40% vs 24%), but the majority of patients with HAB did not have this addressed in records.

CONCLUSIONS

Patients with HAB both underwent surgery offered less frequently and when undergoing surgery, experienced more complications. Surgeons are likely to miss opportunities to positively influence extreme patient anxiety as most patients with HAB were treated without mention of their emotional state. Future investigations should explore whether preoperative anxiety alleviation could diminish these disparities.

TYPE OF STUDY/LEVEL OF EVIDENCE

Symptom Prevalence III.

"Against Medical Advice" Discharges After Respiratory-Related Hospitalizations: Strategies for Respectful Care

Against medical advice (AMA) discharges are practically and emotionally challenging for both patients and clinicians. Moreover, they are common after admissions for respiratory conditions such as COPD and asthma, and they are associated with poor outcomes. Despite the challenges presented by AMA discharges, clinicians rarely receive formal education and have limited guidance on how to approach these discharges. Often, the approach to AMA discharges prioritizes designating the discharge as "AMA," whereas effective coordination of discharge care receives less attention. Such an approach can lead to stigmatization of patients and low-quality care. Although evidence for best practices in AMA discharges remains lacking, we propose a set of strategies to improve care in AMA discharges by focusing on respect, in which clinicians treat patients as equals and honor differing values. We describe five strategies, including (1) preventing an AMA discharge; (2) conducting a patient-centered and truthful discussion of risk; (3) providing harm-reducing discharge care; (4) minimizing stigma and bias; and (5) educating trainees. Through a case of a patient discharging AMA after a COPD exacerbation, we highlight how these strategies can be applied to common issues in respiratory-related hospitalizations, such as prescribing inhalers and managing oxygen requirements. We argue that, by using these strategies, clinicians can deliver more respectful and higher quality care to an often-marginalized population of patients with respiratory disease.

Implementation of Cultural Awareness and Cognitive Bias Training Within Graduate Nursing Programs

BACKGROUND

Cognitive bias negatively affects patient outcomes, resulting in medical errors, sentinel events, and legal claims. The brunt of bias-induced inequities and disparities has fallen on Black and Brown people, women, and the LGBTQ+ communities. Faculty training programs have rapidly increased in number, whereas student training has lagged.

METHOD

A three-part curricular series was developed for students seeking nurse practitioner (NP) training. The series addressed racial bias, microaggression, and gender bias using vignettes and guided pre- and debriefing.

RESULTS

The series was initially implemented to 70 students from four different specialty areas of study. Students resoundingly reported the content as valuable and challenging and the environment as a safe space to learn, be vulnerable, and be empathetic to the experiences of others.

CONCLUSION

This three-part series has been implemented across eight NP majors and has become a required component of the NP on-campus intensive experience. [J Nurs Educ. 2024;63(11):777-780.].

The Use of Non-Person-First Language in Consecutive General Ophthalmology Referrals

PURPOSE

To investigate the prevalence of non-person-first language (PFL) in consecutive general ophthalmology referrals to a single tertiary ophthalmology clinic.

DESIGN

Retrospective cross-sectional study.

METHODS

Participants included Ophthalmology patients seen for their initial visit to a single tertiary ophthalmology clinic from July 2018 to December 2022. Ten randomly selected referrals from each day were screened for non-PFL as per the American Medical Association and American Psychological Association guidelines. Non-PFL was further categorized into general, diabetes, stigma, obesity, or ageism subcategories. The Chi-square test was used to evaluate associations between non-PFL use and referring provider gender and specialty, length of referral, and patient age and gender.

RESULTS

A total of 2625 referrals were included in the study and 136 (5.2%) used non-PFL, such as referring to a person with diabetes as a "diabetic". Error types included Diabetes (38.2%), Stigma (30.9%), General (23.5%), Disability (8.8%), and Obesity (4.4%). Year of referral was predictive of non-PFL (P = .0016), with most occurring in 2020 (9.5%). Non-PFL was significantly more likely to occur in long length referrals compared to medium and short length referrals (16.2% vs. 5.1% vs. 3.5%, P < .001). Referring provider specialty was also predictive of non-PFL (P < .001) with most received by Family Medicine (8.3%), Optometry (4.4%), Emergency Medicine (0.62%), Ophthalmology (4.2%), Others (2.9%). Patient gender (P = .5563), patient age (P = .3466), and referring provider gender (P = .9057) were not predictive of non-PFL.

CONCLUSIONS

Non-PFL use was most prevalent in 2020, with the most common referral sources being Family Medicine and Optometry. The highest proportions of non-PFL errors made were diabetes and stigma errors. Increased use of PFL in physician-physician communication can decrease intersectional stigma and promote inclusive patient care for ophthalmology patients.

Variation in Mentions of Race and Ethnicity in Notes in Intensive Care Units Across a Health Care System

BACKGROUND

Social constructs like race can affect how patients are perceived and impact care. This study investigated whether mentions of race in notes for critically ill patients differed according to patients' race.

METHODS

This retrospective cohort study included intensive care unit notes for adults (≥18 years old) admitted to any of 6 intensive care units at University of California, San Francisco, from 2012 through 2020. Notes were linked to National Provider Identifier records to obtain note writer characteristics. Logistic regression analysis with robust SEs clustered on note writers was adjusted for patient-, note- and clinician-level characteristics. Any race or ethnicity mention was the outcome of interest.

RESULTS

Among 5573 patients with 292 457 notes by 9742 unique note writers, 3225 patients (57.9%) self-reported their race as White, 997 (17.9%) as Asian, 860 (15.4%) as Latinx, and 491 (8.8%) as Black. Note writers documented race/ethnicity for 20.8% of Black, 10.9% of Latinx, 9.1% of White, and 4.4% of Asian patients. Black patients were more likely than White patients to have race mentioned in notes (adjusted odds ratio, 2.05 [95% CI, 1.49-2.82]).

CONCLUSIONS

Black patients were more than twice as likely as White patients to have race mentioned in notes. Note language containing information on social constructs has consequences for clinicians and patients reading notes and for algorithms trained on clinical notes.

Equity and justice in medical education: mapping a longitudinal curriculum across 4 years

BACKGROUND

In 2024 in the United States there is an attack on diversity, equity, and inclusion initiatives within education. Politics notwithstanding, medical school curricula that are current and structured to train the next generation of physicians to adhere to our profession's highest values of fairness, humanity, and scientific excellence are of utmost importance to health care quality and innovation worldwide. Whereas the number of anti-racism, diversity, equity, and inclusion (ARDEI) curricular innovations have increased, there is a dearth of published longitudinal health equity curriculum models. In this article, we describe our school's curricular mapping process toward the longitudinal integration of ARDEI learning objectives across 4 years and ultimately creation of an ARDEI medical education program objective (MEPO) domain.

METHODS

Medical students and curricular faculty leaders developed 10 anti-racism learning objectives to create an ARDEI MEPO domain encompassing three ARDEI learning objectives.

RESULTS

A pilot survey indicates that medical students who have experienced this curriculum are aware of the longitudinal nature of the ARDEI curriculum and endorse its effectiveness.

CONCLUSIONS

A longitudinal health equity and justice curriculum with well-defined anti-racist objectives that is (a) based within a supportive learning environment, (b) bolstered by trusted, structured avenues for student feedback and (c) amended with iterative revisions is a promising model to ensure that medical students are equipped to effectively address health inequities and deliver the highest quality of care for all patients.

Occurrence of Stigmatizing Documentation Among Hospital Medicine Encounters With Opioid-Related Diagnosis Codes: Cohort Study

BACKGROUND

Physician use of stigmatizing language in the clinical documentation of hospitalized adults with opioid use is common. However, patient factors associated with stigmatizing language in this setting remain poorly characterized.

OBJECTIVE

This study aimed to determine whether specific demographic factors and clinical outcomes are associated with the presence of stigmatizing language by physicians in the clinical documentation of encounters with opioid-related ICD-10 (International Statistical Classification of Diseases, Tenth Revision) codes.

METHODS

Hospital encounters with one or more associated opioid-related ICD-10 admission diagnoses on the hospital medicine service during the 2020 calendar year were analyzed for the presence of stigmatizing language in history and physical and discharge summaries. Multivariable adjusted logistic regression models were used to determine associations of age, race, gender, medication for addiction treatment use, against medical advice discharge, homelessness, comorbid polysubstance use, comorbid psychiatric disorder, comorbid chronic pain, cost, and 30-day readmission with the presence of stigmatizing language.

RESULTS

A total of 221 encounters were identified, of which 64 (29%) encounters had stigmatizing language present in physician documentation. Most stigmatizing language was due to use of "substance abuse" rather than the preferred term "substance use" (63/66 instances). Polysubstance use and homelessness were independently associated with the presence of stigmatizing language (adjusted odds ratio [aOR] 7.83; 95% CI 3.42-19.24 and aOR 2.44; 95% CI 1.03-5.90) when controlling for chronic pain and other covariates.

CONCLUSIONS

Among hospital medicine encounters with an opioid-related diagnosis, stigmatizing language by physicians in clinical documentation was common and independently associated with comorbid polysubstance use and homelessness.