Words Matter: The Impact of Stigmatizing Language in Healthcare Documentation
In nearly every medical visit conducted today, the clinician makes notes regarding the encounter in an electronic medical record. The patient or future clinicians can then access this information and may reference it to understand the previous care provided. However, clinician notes, whether intentionally or unintentionally, may contain negative language regarding the patient at the time of the visit. Such stigmatizing language may inflict mental anguish on the patient and more widely have the potential to influence the attitudes and behaviors of other clinicians, thereby affecting the overall quality of patient care.
Consider this scenario. A 64-year-old female patient presents to a clinic for a follow-up appointment for recalcitrant plantar fasciitis. She has undergone several episodes of treatment without achieving symptom resolution. Her most recent appointment was charted as below:
Today I saw Mrs. J with continued pain due to plantar fasciitis of her left foot. She is a “difficult patient.” She is “obese” and has “refused” to lose weight as directed. She “claims” that the pain medication I prescribed at her last visit “is not working for her.” She was “uncooperative with her physical exam” and became “defensive” when I suggested she needed to make significant changes to her “sedentary lifestyle.”
The language utilized in the chart notes was not only stigmatizing but also falls short of conveying the respect and empathy that every patient deserves. By applying negative labels, it implies a lack of personal responsibility, distracting from the patient’s actual medical needs and treatment plan. This situation highlights the critical importance of using respectful and nonstigmatizing language in medical records. Clinicians should prioritize objectively articulating the patient’s specific behaviors and needs, ensuring that their dignity is upheld rather than resorting to negative labels. This article will explore effective strategies for clinicians to recognize and eradicate stigmatizing language in their medical records.
Challenging the Stigma
A stigma is a set of negative and unfair beliefs that a society or group of people have about something, a mark of shame or discredit.1 Stigmas are widespread social constructs that unjustly categorize individuals or groups as inferior. These biases often emerge through the language we use, particularly in healthcare settings, where professionals may, even unintentionally, resort to derogatory terminology, blame patients for a lack of progress, or imply that an individual’s worth is contingent upon their health status.2 Such attitudes not only perpetuate discrimination and exclusion but also impede access to vital care and support. This damaging cycle negatively affects both the mental and physical well-being of those impacted.2 It is essential that clinicians become cognizant of the use of stigmatizing language in the medical record to better promote equity and significantly improve health outcomes for all.
The 21st Century Cures Act has significantly enhanced patient access to their medical records.3 While implementation of this legislation aimed to improve communication and facilitate shared decision-making, it also introduced potential challenges that may lead to misinterpretations or errors. It is essential for both patients and healthcare providers to navigate these changes thoughtfully.
The detrimental impact of stigmatizing language within medical records and its connection to healthcare professional (HCP) bias affecting patient outcomes has been of increasing interest as of late. Research has consistently demonstrated that when HCPs employ stigmatizing language, it can lead to significant and enduring consequences for patients and the healthcare system.2,4 These repercussions include:
- Loss of Patient Trust: Stigmatizing language undermines the trust between patients and providers.2,4 When patients feel judged or marginalized, they are less likely to seek necessary care, putting their health at risk.
- Obstacles to Effective Communication: Negative language creates barriers to open dialogue, preventing patients from sharing crucial health information.2,4 This lack of communication can hinder accurate diagnoses and the effectiveness of treatment plans.
- Deterioration of Mental Health: The use of stigmatizing terms can instill feelings of shame and isolation, exacerbating mental health disorders and negatively impacting overall well-being.2,4
- Worsening Health Disparities: Stigmatizing language reinforces existing disparities in healthcare, disproportionately affecting marginalized groups and resulting in inequitable treatment that worsens their health outcomes.2,4
- Delayed Diagnosis and Treatment: Patients who experience stigma may delay seeking medical help, resulting in delayed diagnoses and treatment initiation; this delay can lead to the progression of medical conditions, increased healthcare costs, and reduced treatment success.2,4
- Poor Treatment Concordance: Patients who feel stigmatized are more likely to disengage from their treatment plans and miss follow-up appointments, adversely affecting their long-term health.2,4
- Broader Implications for the Healthcare System: The cumulative impact of negative patient experiences places strain on the healthcare system, resulting in increased costs and a higher burden of untreated conditions.2,4
Strategies to Reduce the Use of Stigmatizing Language
There are several ways clinicians can reduce the use of stigmatizing language to improve communication and support the delivery of patient-centered, culturally competent healthcare.5,6 Clinicians are urged to embrace person-first language as a vital practice in their interactions with patients. By distinguishing the individual from their health condition, we not only humanize the patient but also foster an atmosphere of respect that acknowledges their inherent dignity.5,6 For example, instead of labeling someone as “diabetic,” it is more appropriate to say, “person with diabetes.” Clinicians should prioritize the use of inclusive language and neutral terms that empower individuals from marginalized communities.5,6 Rather than using the term “gay lifestyle,” it is preferable to refer to “sexual orientation.” Additionally, it is essential to avoid derogatory phrases such as “frequent flyer” and “noncompliant,” as they imply inferiority and carry implicit bias.5,6 Instead, clinicians should note that a patient is “not currently taking medications as prescribed,” promoting a culture of understanding and support.5,6
It is essential for clinicians to respect and validate the patient’s experience throughout the healthcare process. Objective documentation is paramount. When clinicians utilize quotation marks around statements made by patients or resort to terminology such as “alleges” or “claims,” they inadvertently diminish the patient’s status as the authority on their own health.5,6 This practice can create an atmosphere of distrust regarding the patient’s accuracy and honesty as a historian of their medical background.5,6
The significance of demonstrating cultural competence in healthcare cannot be overstated. Clinicians should actively seek to understand the diverse backgrounds and experiences of their patients to provide effective, patient-centered care. A key aspect of this endeavor is the practice of empathy and active listening. By listening to patients without judgment, clinicians can recognize and appreciate the individuality of each situation, ultimately enhancing the patient-provider relationship and improving overall care.5,6
The presence of stigmatizing language in medical records can perpetuate bias and discrimination.5,6 As a response, health care organizations are increasingly encouraging clinicians to participate in language-sensitivity training. Through workshops and training that specifically focus on language awareness, clinicians can learn to identify and eliminate stigmatizing language in their communication and documentation, ultimately promoting a more respectful and equitable healthcare environment for all patients.5,6
In Summary
Clinicians should self-monitor the use of stigmatizing language in their documentation. This article emphasizes the importance of effective and empathetic communication. It is crucial to avoid language that could undermine the patient-provider relationship or reinforce biases. By actively acknowledging and addressing instances of stigmatizing language, clinicians can cultivate a more inclusive and patient-centered healthcare environment. This commitment to respectful communication not only enhances the quality of care but also contributes to improved health outcomes for diverse patient populations.
Dr. Cole is the Director of Wound Care Research at Kent State University College of Podiatric Medicine and a Podiatry Today Editorial Board member.
References
1. Stigma. Merriam-Webster. https://www.merriam-webster.com/dictionary/stigma. Accessed January 13, 2025.
2. Himmelstein G, Bates D, Zhou L. Examination of stigmatizing language in the electronic health record. JAMA Netw Open. 2022;5(1):e2144967. doi:10.1001/jamanetworkopen.2021.44967
3. 21st Century Cures Act. US Food and Drug Administration. https://www.fda.gov/regulatory-information/selected-amendments-fdc-act/21st-century-cures-act#:~:text=Cures%20enhances%20our%20ability%20to%20modernize%20clinical,of%20novel%20medical%20products%2C%20including%20medical%20countermeasures. Accessed January 13, 2025.
4. Dolezal L. Shame anxiety, stigma and clinical encounters. J Eval Clin Pract. 2022;28(5):854-860. doi:10.1111/jep.13720
5. Healy M, Richard A, Kidia K. How to reduce stigma and bias in clinical communication: a narrative review. J Gen Intern Med. 2022;37(10):2533-2540. doi:10.1007/s11606-022-07510-0
6. The Joint Commission. Implicit bias in healthcare. April 2016. Accessed October 24, 2023. https://www.jointcommission.org/-/media/tjc/documents/newsletters/quick-safety-issue-23-apr-2016-final-rev.pdf
