Stigmatizing Language in Patient Charts Linked to Diagnostic Errors

By Stacey Kusterbeck

You have probably seen — and possibly even used — terms such as “difficult patient” or “drug-seeking” in medical charts. But did you ever wonder if stigmatizing language puts patients at risk for diagnostic error? “We often think of the diagnostic process as a purely cognitive exercise. But it is heavily influenced by providers’ social biases and the practice environment,” asserts Katie Brooks, MD, an associate clinical professor of medicine at San Francisco General Hospital.

Brooks and colleagues wanted to assess if stigmatizing language was associated with the diagnostic process. The researchers used data from a previous study looking at diagnostic errors in hospitalized patients.¹ In that study, each chart was reviewed by clinicians to determine the presence or absence of a diagnostic error. The researchers analyzed 2,300 admissions of patients who either died or were transferred to the intensive care unit, and looked for stigmatizing language.² They categorized stigmatizing language into the following categories: questioning patient credibility, expressing disapproval of the patient, patient stereotyping, or labeling a patient as “difficult.”

About 8% of patients with diagnostic errors had stigmatizing language in their medical records, compared with about 4% of patients without diagnostic errors.

One case involved a young patient who presented with numbness and weakness in his extremities. In the chart, the provider commented on the patient’s inappropriate behavior (yelling and aggression toward providers) and noted his frequent requests for narcotics. The provider further stated that the patient’s presentation “is most likely due to malingering.” That patient had a delayed diagnosis of Guillain-Barré syndrome, a rare neurologic condition in which patients experience ascending paralysis. The patient ended up dying of respiratory failure caused by respiratory muscle weakness. “This is a particularly egregious example of stigmatizing language in a patient with a horrible outcome,” observes Brooks.

The stigmatizing language used in medical charts often is more subtle. “However, all cases portray the patient in a way that casts doubt on their character or symptomatology,” says Brooks. In this way, stigmatizing language can result in misdiagnosis, because of the provider’s anchoring bias or limiting the diagnostic workup. Loss of trust is another ethical concern if patients read the notes of providers who describe them in stigmatizing language. “When we use stigmatizing language, we are expressing decreased respect for our patients and their decisions,” adds Brooks. This hinders the provision of patient-centered care that honors patient autonomy.

It is unclear why and how stigmatizing language affects the diagnostic process. It is plausible that it simply is a marker of provider bias and discrimination, both of which influence diagnostic reasoning. It also is possible that the presence of stigmatizing language in the chart perpetuates bias against specific patients, influencing the care that other clinicians provide. “Either way, suboptimal care is delivered,” warns Brooks.

One way healthcare providers can address this issue is by calling out stigmatizing language when they see it. “This is a responsibility that should be shared by everyone in healthcare,” says Brooks.

Holland Kaplan, MD, an assistant professor at Baylor College of Medicine, has seen this stigmatizing language in patients’ medical records:

• “Drug-seeking behavior.” This term is used to describe patients seeking pain relief and can stigmatize individuals with chronic pain conditions. “It’s particularly problematic in certain groups with chronic pain conditions who are also members of groups that otherwise might experience discrimination, such as patients with sickle cell disease,” says Kaplan.

• “Non-compliant.” This term often is used to describe patients who do not follow treatment plans. “This can overlook underlying reasons for being unable to adhere to treatment plans, like socioeconomic factors or health literacy,” Kaplan says.

• “Frequent flyer.” This term refers to patients who frequently visit emergency departments, potentially dismissing their legitimate health concerns.

• “Difficult.” This word is used to describe patients perceived as challenging because of behavioral issues, which can lead to dismissive attitudes.

• “Poor historian.” This term is used when patients provide unclear or inconsistent medical histories. “It potentially overlooks communication barriers or cognitive issues,” says Kaplan.

• “Rock.” This term is used to describe patients on an inpatient service that have been admitted for a long period of time. These patients often are awaiting safe disposition and may not have active ongoing medical problems, however.

“Using stigmatizing language can perpetuate stereotypes and label patients in a way that they are defined by their condition rather than as a person with a certain condition,” says Kaplan. For example, a patient with diabetes might be referred to as a “diabetic.”

Since the 21st Century Cures Act was signed into law, patients can easily see their medical records. “This has made the consequences of using stigmatizing language in the medical record more severe,” says Kaplan. If patients see stigmatizing language in their medical record, it can lead to feelings of shame or self-blame that could discourage them from seeking medical care in the future.

Kaplan has observed that the use of stigmatizing language can serve as a type of “gallows humor,” serving as a coping mechanism for clinicians managing difficult, tragic situations. “However, it can also have impacts on how clinicians perceive and treat patients, which is inappropriate,” says Kaplan.

Within clinical settings, trainees observe how senior clinicians communicate about patients. “The ‘hidden curriculum’ in medical education consists of the unwritten, unspoken norms that are imparted to trainees in addition to the formal curriculum,” says Kaplan.

If trainees witness stigmatizing language being used casually or accepted without challenge, it appears as though it is appropriate or expected behavior. Medical training environments often have hierarchical structures where trainees may feel pressured to conform to the language and behaviors of their superiors.

“If senior clinicians use stigmatizing language without considering its impact, this can perpetuate stigmatizing attitudes and language,” says Kaplan. Ethicists can help to address this issue in these ways, offers Kaplan:

• Ethicists can model appropriate communication toward and about patients. This role modeling can take place during ethics consultation, family meetings, education sessions, committee meetings, and in the medical record.

• Ethicists can consciously avoid stigmatizing language, and deliberately use person-centered language in documentation. For example, ethicists might refer to “a person with schizophrenia” rather than “a schizophrenic.”

• Ethicists can gently educate and correct clinicians when they notice stigmatizing language being used in the medical record. Ethicists can suggest alternative, non-stigmatizing language that can be used instead.

• Ethicists can participate in curriculum creation and delivery for students, trainees, and faculty.

“Every training program should
have formal training on cultural competence, unconscious bias, and communication skills,” says Kaplan. “Ethicists are very well-positioned to provide this education.”

REFERENCES

1. Dalal AK, Schnipper JL, Raffel K, et al. Identifying and classifying diagnostic errors in acute care across hospitals: Early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study. J Hosp Med 2024;19:140-145.
2. Brooks KC, Raffel KE, Chia D, et al. Stigmatizing language, patient demographics, and errors in the diagnostic process. JAMA Intern Med 2024;184:704-706.