Language in medical records may be due for an update

Common phrases like "presenting complaint" or "the patient denies" can sound judgmental or doubtful of patients, researchers from The Healthcare Improvement Studies Institute (THIS) in the U.K. said.

• "One patient stated: 'I did not deny these things. I said I didn’t feel them. Completely different. Language matters,'" the authors wrote about one person's response shown a doctor's notes of an outpatient visit.
• Another patient balked at the phrase “Patient claims pain is 10/10” instead of “patient experiencing 10/10 pain” because it implied a degree of disbelief, the researchers wrote.
• One study cited in the analysis looked at language examples such as "not tolerating oxygen mask" versus "refuses oxygen mask" and showed the non-neutral term was linked with negative attitudes toward the patient and less prescribing of pain medications.

What they're saying: "Much of the language highlighted here is deeply ingrained in medical practice and is used unthinkingly by clinicians. However, we believe that it is now outdated," write the University of Cambridge researchers.

The big picture: This is part of a number of efforts calling attention to how patients are described in medical records.

• A study published earlier this year in Health Affairs found Black patients were more than two-and-a-half times as likely as white patients to have negative descriptors such as "resistant," "challenging" or "non-compliant." Those clinical descriptions were likely to be copied into subsequent notes and amplify biases as a case works its way through the medical system, the authors wrote.
• At times, the language used in records can belie physician bias that can impact the quality of care they receive, another study published in JAMA Open Network found.
• Clinical terminology embedded in medical records can include overtly racist phrases that were in use decades ago.
• The American Medical Association published a health equity language guide aimed at encouraging physicians to factor how systemic discrimination and biases contribute to patients' ailments.

Be smart: While medical descriptions have typically been viewed as communication between physicians, patients are increasingly going to have access to them making it important in the physician's communication with patients as well.

• For instance, rules stemming from the 21st Century Cures Act that go into effect in October will allow patients to access far more parts of the electronic records for free, said Catherine DesRoches, associate professor at Harvard Medical School.
• "The law will apply to everything in your record that an organization is legally required to share under HIPAA," DesRoches said.

But, but, but: While some clinicians say the goal of eliminating bias is laudable, changing clinical language could actually create more confusion.

• Using terms such as "the patient claims," for instance, differentiates information that has been provided versus information that has been validated by the provider.
• Requiring clinicians to rethink language will likely "add needless burden" in an already overstretched health care system, one physician wrote in a comment on the BMJ article.

My thought bubble: It'd be easy to dismiss questions around language as political correctness.

• But the discussion is factoring in more and more policy discussions, not just because of transparency but because the health system increasingly relies on artificial intelligence and natural language processing. (Both are being used, for example, to help identify cases of child abuse from pediatric electronic medical records.)

The bottom line: Words matter.