Physicians are more likely to describe black patients as uncooperative, study finds

Medical records contain a wide variety of information, from a patient’s diagnosis and treatments to their marital status, alcohol consumption, and exercise habits.

They also record whether a patient follows the doctors’ advice. A healthcare provider may add a note that the patient is “not cooperating” or “not adhering,” which signals that the patient has not been cooperating and exhibits problematic behaviors.

Two large new studies have found that these terms, while not in common use, are far more likely to appear on the medical records of black patients than those of patients of other races.

“In medicine, we tend to label people derogatory when we don’t really ‘see’ them,” said Dean Schillinger, a physician who directs the Center for Vulnerable Populations at the San Francisco General Hospital and Trauma Center, and was not involved in the research. “The labeling process provides a convenient shortcut that leads some physicians to blame patients for their illnesses.”

The first study, published by the scientific journal Health Affairs, found that the probability that black patients had at least one negative description present in their electronic health records was 250% higher than for patients of other races.

The study was based on an analysis of more than 40,000 notes taken on 18,459 adult patients at a large urban medical center in Chicago between January 2019 and October 2020.

About 8% of all patients had one or more derogatory terms present on their charts, the study found. The most commonly used negative terms of description in the forms were “refused”, “did not accept”, “did not comply” and “agitated”.

“It’s not so much a question that a doctor should never use these terms as it is why we’re applying these words so much more often to black patients,” said Michael Sun, lead author of the study and a third-year medical student. at the Pritzker School of Medicine, University of Chicago.

“Do we really believe that black patients fail to comply with medical instructions as often as white patients?”

Rather than assuming that the patient lacks motivation or is not engaged, the medical team should ask whether the patient is experiencing financial difficulties, transportation difficulties, or other obstacles to adhering to treatment, for example illiteracy or problems understanding the English language. .

The researchers found that records of patients treated at clinics are much less likely to contain negative terms than records from hospitals and emergency rooms, perhaps because clinical service providers have a more frequent relationship with their patients and are better acquainted with the circumstances. their.

Regardless of race, unmarried patients and those dependent on government health plans such as Medicare and Medicaid are much more likely to receive negative descriptions than those who are married or with private health plans.

Patients who are in poor general health, with multiple underlying chronic health problems, are also twice as likely to receive negative ratings on their medical records, the survey found.

The second study, published in JAMA Network Open, analyzes the electronic medical records of nearly 30,000 patients in a large urban academic center between January and December 2018.

The study was looking for what the researchers termed “reproving language” and compared the negative terms used to describe patients from different racial and ethnic backgrounds, as well as those with three chronic illnesses: diabetes, substance abuse and pain disorders. severe.

Overall, 2.5% of the notes contained terms such as “did not adhere”, “did not comply”, “failed” or “did not do”, “refused” or “refusal”, and, on certain occasions, “combative” or ” questioning”. But while 2.6% of the notes on white patients contained terms like these, they were present in 3.15% of the notes on black patients.

Looking at approximately 8,700 notes on patients with diabetes, 6,100 notes on patients with substance abuse disorder, and 5,100 notes on patients with chronic pain, the researchers determined that patients with diabetes, mostly with Type 2 diabetes, often associated with being overweight and defined as a “lifestyle” disease, were most likely to be described negatively.

Nearly 7% of diabetes patients were described as not meeting prescriptions, or as having “uncontrolled” forms of the disease, or as “failing” in their treatment.

A note might describe that a patient “refused the diabetes diet,” for example, or “failed to adhere to the insulin regimen.” The more severe the disease, the more likely the patient is to have notes with negative descriptions.

In contrast, only 3.4% of patients with substance abuse disorders were described in negative terms, and less than 1% of patients with chronic pain had negative descriptions.

The medical record is the first thing a hospital health care provider sees, before they even see the patient, said Dr Gracie Himmelstein, lead author of the study, and it creates a strong first impression.

“Before I meet the patient for the first time in the emergency room, the first thing I do is ask for their chart, read past admissions notes and try to assess their medical history,” said Himmelstein, a resident physician at the University of California at Los Angeles. Angeles, who conducted the research as part of his doctoral thesis at Princeton University.

“What I’m looking for is to determine what the medical problems are, but in doing that I’m also reading a narrative of the interaction between the patient and previous doctors.”

Rather than relying on vague and possibly biased terms like “failed,” clinicians should try to understand why a patient is not cooperating and point out specific reasons in the medical record, Himmelstein said.

“If a patient is not, in quotes, adhering to the treatment regimen, what’s going on?” she said. “People have difficulties administering insulin. It can be prohibitively expensive. There can be medical literacy difficulties. We need to identify exactly where the problem is.”

Labels have consequences, warned Schillinger. While some of the notes provide essential information, the terms used can cloud the physician’s—and future physicians’—judgment and decisions, reduce their compassion and empathy. And that can cause patients to lose trust in healthcare providers.

“Patients whose doctors judge, blame or criticize them are much less likely to trust their doctors and the health care system as a whole,” said Schillinger.

“Having trusted healthcare providers — who earn their patients’ trust by not judging them unfairly — is critical to ensuring the best possible health and closing health disparities.”

Translation by Paulo Migliacci.