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

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.

Addressing Stigma-Related Health Disparities for Autistic Individuals Through Cultural Competemility: Insights from Research and Lived Experience

PURPOSE OF REVIEW

Autistic individuals experience disproportionate stigma across the life course in interpersonal, healthcare, and educational contexts. These experiences contribute to negative health and healthcare outcomes for this population. This paper seeks to describe autistic individuals' experiences of stigma and marginalization; discuss frameworks such as Campinha-Bacote's innovative concept of cultural competemility and its relevance to autistic populations; offer recommendations to healthcare providers based on this framework; and apply theory to practice in a case study.

RECENT FINDINGS

Autistic individuals increasingly understand autism as an important aspect of their identity. There are, however, few culturally informed healthcare efforts that reflect this understanding. As a result, efforts to address stigma-related health disparities for this population have limited effectiveness. In this manuscript, we highlight opportunities within clinical encounters, medical training, healthcare offices and systems, and research to provide higher quality culturally informed care to autistic populations and address stigma-related health disparities.

A Study of the Psychometric Properties of the Pediatric Symptom Checklist-17 for Children With Developmental Delays and Disorders

Primary care physicians (PCPs) frequently serve pediatric patients with developmental delays and disorders (DD/D). Although the most widely used primary care behavioral health screener, the Pediatric Symptom Checklist-17 (PSC-17), is validated for use with children without DD/D, it is unclear whether this measure accurately identifies behavioral health symptoms in youth with DD/D. Thus, the purpose of this study was to assess the psychometric properties of the PSC-17 for children with DD/D. Medical record data from 3596 pediatric patients at a primary care clinic were analyzed. Descriptive analyses, measurement invariance testing, and internal consistency evaluations were conducted to assess the psychometric properties of the PSC-17. The results of these analyses support the use of the PSC-17 for behavioral health screening for children with DD/D. Behavioral health screening in this population is critical, because the timely identification of behavioral health concerns can facilitate early intervention, which may enhance long-term functioning.

The last word: An analysis of power dynamics in clinical notes documenting against-medical-advice discharges

Against Medical Advice (AMA) discharges pose significant challenges to the healthcare system, straining patient-clinician relationships while contributing to avoidable morbidity and mortality. Furthermore, though these discharges culminate in patients' departure from hospitals, their effects reverberate long after, propagated by clinician notes stored in patients' medical records. These notes capture exceptionally fraught interactions between patients and providers, describing the circumstances surrounding breakdowns in clinical relationships. Additionally, they represent just one side of complex, contentious social interactions, for in describing AMA discharges, clinician notewriters quite literally have the last word. For these reasons, notes documenting AMA discharges provide insight into the ways in which clinicians conceptualize, characterize, and propagate power differentials in the contemporary healthcare system. Here, we present a qualitative thematic analysis of 185 notes documenting AMA discharges from a large urban US medical center, interpreting note dynamics through three sociological models of power analysis: (i) the distributive model of power promulgated by Max Weber, (ii) the collectivist power model characterized by Talcott Parsons and Hannah Arendt, and (iii) structural interpretations of power developed by Michel Foucault. We argue that in documenting AMA discharges, clinicians appear to conceive of their relationship with patients in almost exclusively distributive terms, which in turn contributes to an adversarial dynamic whereby both patients and clinicians ultimately suffer disempowerment. We furthermore argue that by facilitating clinicians' recognition of power's collectivist and structural dimensions, we may help transform breakdowns in patient-clinician relationships into opportunities for collaboration.

An idea to explore: Student-centered scientific and medical writing project and workshop for undergraduate students

Writing is usually integrated in the curriculum of science studies. However, students often lack the skills to write for various audiences or, to produce a well written manuscript. We developed a concise project of 15 European Credits to improve the writing skills in an early phase of the bachelor study. Students worked on texts from various journals and looked at the writing styles. They rewrote texts in a popular and more scientific way and practiced with clear, vivid language, avoiding clutter and hedge words, considering a proper use of grammar and interpunction. Medical writing was also introduced during the project. Grading was based on rewriting for a non-expert and expert audience. A rewritten text was presented to the public in the form of a student-initiated survey. This project shows an inverted approach creating student ownership and enthusiasm for writing. In addition, we created and tested successfully a concise two-day workshop based on this project. Based on the results we herewith present the work as an idea to explore.

Addressing Housing Issues Among People With Kidney Disease: Importance, Challenges, and Recommendations

Kidney disease disproportionately impacts people with low socioeconomic status, and low socioeconomic status is associated with worse outcomes for people with kidney disease. Unstable housing, which includes housing insecurity and homelessness, is increasing due to rising housing costs. There is mounting evidence that unstable housing and other health-related social needs are partially driving worse outcomes for people with low socioeconomic status. In this perspective, we consider the challenges to addressing housing for people with kidney disease, such as difficulty with identification of those with unstable housing, strict eligibility criteria for housing support, inadequate supply of affordable housing, and flaws in communities' prioritization of affordable housing. We discuss ways to tailor management for people experiencing unstable housing with kidney disease, and the importance of addressing safety, trauma, and emotional concerns as a part of care. We identify opportunities for the nephrology community to surmount challenges through increased screening, investment in workforce dedicated to community resource navigation, advocacy for investment in affordable housing, restructuring of communities' prioritization of affordable housing, and conducting needed research. Identifying and addressing housing needs among people with kidney disease is critical to eliminating kidney health disparities.

Examining Inclusive Language in Clinical Narratives in Medical Biochemistry Textbooks to Model Equitable Patient-Centered Care in Preclinical Undergraduate Medical Education

Purpose

When healthcare professionals use biased or stigmatizing language to describe people or conditions, it can impact the quality of care or erode the patient-physician relationship. It is not clear where healthcare professionals acquire biased and stigmatizing language in practice. This study focuses on examining language in educational materials used in training of medical students. Specifically, medical biochemistry textbooks were examined as they are often a first exposure to clinical narratives and communication standards. The aim of this project is to investigate whether medical biochemistry textbooks, widely recommended in preclinical UME, model inclusive language communication in clinical narratives.

Methods

To determine if educational materials follow inclusive writing guidelines, we conducted a modified document analysis on a sample of medical biochemistry textbooks when clinical scenarios were described. Three independent researchers separately reviewed the textbooks, coded the language using NVivo, and generated themes.

Results

Our results show that medical biochemistry textbooks contain language which is not in alignment with the best practices for inclusive language. Our analysis mapped codes to two primary themes of language misalignment. The first theme, "clinical language" (n = 92), included the following codes: difficult patient, general negative descriptive language, patient as failure, and questioning patient credibility. The second primary theme, "identity-first labeling" (n = 251), included 21 codes.

Conclusion

This study provides early evidence that the language used in medical biochemistry textbooks to describe people and conditions is not in alignment with inclusive language recommendations. This can reinforce the way future healthcare professionals speak to and about their patients.

Measuring Implicit Bias in ICU Notes Using Word-Embedding Neural Network Models

BACKGROUND

Language in nonmedical data sets is known to transmit human-like biases when used in natural language processing (NLP) algorithms that can reinforce disparities. It is unclear if NLP algorithms of medical notes could lead to similar transmissions of biases.

RESEARCH QUESTION

Can we identify implicit bias in clinical notes, and are biases stable across time and geography?

STUDY DESIGN AND METHODS

To determine whether different racial and ethnic descriptors are similar contextually to stigmatizing language in ICU notes and whether these relationships are stable across time and geography, we identified notes on critically ill adults admitted to the University of California, San Francisco (UCSF), from 2012 through 2022 and to Beth Israel Deaconess Hospital (BIDMC) from 2001 through 2012. Because word meaning is derived largely from context, we trained unsupervised word-embedding algorithms to measure the similarity (cosine similarity) quantitatively of the context between a racial or ethnic descriptor (eg, African-American) and a stigmatizing target word (eg, nonco-operative) or group of words (violence, passivity, noncompliance, nonadherence).

RESULTS

In UCSF notes, Black descriptors were less likely to be similar contextually to violent words compared with White descriptors. Contrastingly, in BIDMC notes, Black descriptors were more likely to be similar contextually to violent words compared with White descriptors. The UCSF data set also showed that Black descriptors were more similar contextually to passivity and noncompliance words compared with Latinx descriptors.

INTERPRETATION

Implicit bias is identifiable in ICU notes. Racial and ethnic group descriptors carry different contextual relationships to stigmatizing words, depending on when and where notes were written. Because NLP models seem able to transmit implicit bias from training data, use of NLP algorithms in clinical prediction could reinforce disparities. Active debiasing strategies may be necessary to achieve algorithmic fairness when using language models in clinical research.

Striving for health equity: Stigmatizing language in inpatient pharmacy notes - A pilot study

BACKGROUND

As pharmacy evolves, pharmacists have an increasing role in documentation. Publications examining the actions of other health professionals show that negative perception in written notes translates to patients receiving lower quality of care, resulting in worse health outcomes, suggesting that the use of stigmatizing language towards patients has concerning consequences.

OBJECTIVES

To identify the prevalence of stigmatizing language in inpatient pharmacy progress. notes based on patient specific characteristics and diagnoses.

METHODS

This retrospective pilot study reviewed inpatient pharmacy progress notes of a Midwestern (United States) tertiary academic institution from May to June 2023. Stigmatizing words and phrases associated with specified disease states were separated into the categories of general language, substance use disorders, and mental health. Notes of patients on internal medicine, family medicine, kidney/pancreas transplant, liver transplant, and gastroenterology services were included.

RESULTS

Stigmatizing language was found in 22% (n = 43) of notes. The words "abuse" and "dependence" had the highest prevalence. Patients diagnosed with substance use disorders experienced stigmatizing language at a high rate, exaggerated further if their note lacked a documented diagnosis.

CONCLUSIONS

This study demonstrated that stigmatizing language is present in pharmacy documentation. Providing context and resources of the proper documentation to reflect equitable healthcare is crucial for patient care.

Conceptualizing Domestic Violence Within Clinical Documentation

Domestic and family violence (DFV) is a global issue with significant impacts on victim-survivors. The emergency department (ED) serves as the initial point of contact for victim-survivors. Given the significant role that clinical notes play in the management of patients and the communication between healthcare professionals, understanding how healthcare practitioners describe and document abuse reported in emergency settings is crucial. Yet, there remains a gap in understanding how health professional document DFV in the medical records of women presenting to the ED. Therefore, this qualitative descriptive study explored how DFV is documented in patient records of women presenting to the ED. Clinical notes from healthcare workers, including medical practitioners, nurses, social workers, mental health clinicians and ambulance officers, were qualitatively analyzed. Overall, the study included 43 presentations from 32 women (aged 18-56 years old) who visited a regional ED, during which instances of DFV were noted. An inductive content analysis resulted in the identification of four categories, including (a) DFV articulated in direct speech, (b) Unambiguous DFV, (c) Unconfirmed DFV, and (d) Problematic relationship. Although most references to DFV in the clinical notes included direct quotations from the patient's descriptions of abuse or were documented unambiguously by healthcare professionals, a notable number of clinical notes exhibited a degree of caution or reluctance to acknowledge DFV dynamics when describing these events. These findings support the need for sustained and consistent professional training among healthcare professionals concerning the identification, documentation, and response to disclosures, suspicions, and allegations of DFV to better support victim-survivors presenting to the ED and other hospital settings.

Psychiatric nurses' perception of dignity in patients who attempted suicide

BACKGROUND

Maintaining the dignity of patients who attempted suicide is one of the caregivers' main ethical duties. Yet, in many cases, these patients are not treated with dignity. The concept of dignity is abstract, and there is no research on the dignity of suicidal patients. So, the present study is done to investigate psychiatric nurses' perception of dignity in patients who attempted suicide.

OBJECTIVE

The present study explores the concept of dignity in patients who attempted suicide from the perspective of psychiatric nurses.

RESEARCH DESIGN

The present study is a qualitative, descriptive work of research.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 20 psychiatric nurses from 2 hospitals affiliated with a university of medical sciences in the southeast of Iran were selected via purposeful sampling.

ETHICAL CONSIDERATIONS

The Research Ethics Committee of the Hamadan University of Medical Sciences approved the study's protocol, and ethical principles were followed in general.

FINDINGS

From the findings of the study, three main themes, namely " respect for personal; identity," "management of psychological tension," and "compassion-focused therapy," with 12 sub-themes were extracted.

DISCUSSION AND CONCLUSION

In the perspective of caregivers, patients who attempted suicide need to be cared for in supportive environments with compassionate and respectful behaviors to control their psychological tensions. These conditions would maintain such patients' dignity and result in appropriate behavioral outcomes. Policy-makers and administrators can use the present study's findings to create an appropriate clinical environment in which the dignity of patients who attempted suicide is properly maintained.

A Narrative Review on the Impact of Air Pollution on Heart Failure Risk and Exacerbation

Air pollution is a risk factor for many cardiovascular diseases, including heart failure (HF). Although the links between air pollution and HF have been explored, the results are scattered and difficult to piece together into a cohesive story. Therefore, we undertook a narrative review of all aspects of the relationship between HF and air pollution exposure, including risks of developing HF when exposed to air pollution, the exacerbation of HF symptoms by air pollution exposure, and the increased susceptibility that individuals with HF have for air pollution-related health risks. We also examined the literature on environmental justice as well as air pollution interventions for HF. We found substantial evidence linking air pollution exposure to HF incidence. There were a limited number of studies that examined air pollution exposure in clearly defined populations with HF to explore exacerbation of HF or the susceptibility of individuals with HF to air pollution health risks. However, there is substantial evidence that HF-related hospitalisations are increased under air pollution exposure and that the air pollution associated increase in HF-related hospitalisations is greater than hospitalisations for other chronic diseases, supporting links between air pollution and both exacerbation of HF and susceptibility of individuals with HF. There is emerging evidence for interventions that can decrease air pollution health risks for individuals with HF, and more studies are needed, particularly randomised controlled trials. Thus, although the air pollution-related health risks for HF incidence and hospitalisations are clear, further studies specifically targeted at identified data gaps will greatly improve our knowledge of the susceptibility of individuals with HF and interventions to reduce risks.

Shifting into Action: from Data Segmentation to Equitable Interoperability for Adolescents (and Everyone Else)

BACKGROUND

Technological improvements and, subsequently, the federal 21st Century Cures Act have resulted in increased access to and interoperability of electronic protected health information (ePHI). These not only have many benefits, but also have created unique challenges for privacy and confidentiality for adolescent patients. The inability to granularly protect sensitive data and a lack of standards have resulted in limited confidentiality protection and inequitable access to health information.

OBJECTIVES

This study aimed to understand the challenges to safe, equitable access, and interoperability of ePHI for adolescents and to identify strategies that have been developed, ongoing needs, and work in progress.

METHODS

Shift, a national task force formalized in 2020, is a group of more than 200 expert stakeholder members working to improve functionality to standardize efforts to granularly identify and protect sensitive ePHI to promote equitable interoperability.

RESULTS

Shift has created high-priority clinical use cases and organized challenges into the areas of Standards and Terminology; Usability and Implementation; and Ethics, Legal, and Policy.

CONCLUSION

Current technical standards and value sets of terminology for sensitive data have been immature and inconsistent. Shift, a national diverse working group of stakeholders, is addressing challenges inherent in the protection of privacy and confidentiality for adolescent patients. The diversity of expertise and perspectives has been essential to identify and address these challenges.

The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases

BACKGROUND

Engaging with human emotions is an integral but poorly understood part of the work of emergency healthcare providers. Patient factors (e.g., irritable behavior; mental illness) can evoke strong emotions, and evidence suggests that these emotions can impact care quality and patient safety. Given that nurses play a critical role in providing high quality care, efforts to identify and remedy factors that may compromise care are needed. Yet to date, few experiments have been conducted.

OBJECTIVE

To examine the effects of emotionally evocative patient behavior as well as the presence of mental illness on emergency nurses' emotions, patient assessments, testing advocacy, and written handoffs.

DESIGN

Experimental vignette research.

SETTING

Online experiment distributed via email between October and December 2020.

PARTICIPANTS

Convenience sample of 130 emergency nurses from seven hospitals in the Northeastern United States and one hospital in the mid-Atlantic region in the United States.

METHODS

Nurses completed four multimedia computer-simulated patient encounters in which patient behavior (irritable vs. calm) and mental illness (present vs. absent) were experimentally varied. Nurses reported their emotions and clinical assessments, recommended diagnostic tests, and provided written handoffs. Tests were coded for whether the test would result in a correct diagnosis, and handoffs were coded for negative and positive patient descriptions and the presence of specific clinical information.

RESULTS

Nurses experienced more negative emotions (anger, unease) and reported less engagement when assessing patients exhibiting irritable (vs. calm) behavior. Nurses also judged patients with irritable (vs. calm) behavior as more likely to exaggerate their pain and as poorer historians, and as less likely to cooperate, return to work, and recover. Nurses' handoffs were more likely to communicate negative descriptions of patients with irritable (vs. calm) behavior and omit specific clinical information (e.g., whether tests were ordered, personal information). The presence of mental illness increased unease and sadness and resulted in nurses being less likely to recommend a necessary test for a correct diagnosis.

CONCLUSIONS

Emergency nurses' assessments and handoffs were impacted by patient factors, particularly irritable patient behavior. As nurses are central to the clinical team and experience regular, close contact with patients, the effects of irritable patient behavior on nursing assessments and care practices have important implications. We discuss potential approaches to address these ill effects, including reflexive practice, teamwork, and standardization of handoffs.

TWEETABLE ABSTRACT

Experimental evidence links irritable patient behaviors to lower quality emergency department nurse handoffs, which may compromise patient safety @(lindamisbell) @(Nathan_Huff_1).

Leveraging individual power to improve racial equity in academia

Academia in the United States continues to grapple with its longstanding history of racial discrimination and its active perpetuation of racial disparities. To this end, universities and academic societies must grow in ways that reduce racial minoritization and foster racial equity. What are the effective and long-lasting approaches we as academics should prioritize to promote racial equity in our academic communities? To address this, the authors held a diversity, equity, and inclusion (DEI) panel during the Society for Behavioral Neuroendocrinology 2022 annual meeting, and in the following commentary synthesize the panelists' recommendations for fostering racial equity in the US academic community.