Words matter in medical records. The most recent reminder of this truism comes from studies in Health Affairs and JAMA Network that have drawn attention to the potential for racial and ethnic bias in physician documentation.
The disproportionate use of negative terms like "noncompliant" to describe Black and Brown patients could affect the impression that future caregivers have of the patient, according to the studies and subsequent media coverage. Additionally, with patients now having almost universal online access to their physician's notes, reading apparently derogatory descriptions about themselves most certainly degrades trust.
While bias as a result of language in medical records is a clear potential issue, perhaps it is time to review more broadly the way that clinicians describe patients in medical records.
The reason for a visit is often called a "complaint," as in, "The patient complains of fever." It's not unusual that, when overhearing a medical student present a patient's history on rounds, the patient has piped up, "I'm not complaining. I am just telling you what is wrong with me." Unlike the rest of the world, in the exam room, complaints are expected and welcomed.
We also speak of patients "failing" treatments, as in, "The patient failed physician therapy and now presents for surgery." Except the reality is that if the patient did not get significant pain relief from the prescribed physical therapy, it was the treatment that failed the patient, not the other way around.
If a patient reports that they are not a substance user, we often use the term "deny," as in, "The patient denies using drugs or alcohol." The use of "deny" in most of the world has an undercurrent of non-belief, as if the clinician is saying "maybe so or maybe not." Even if the physician does not intend to portray suspicion, a patient or another clinician reading the record could believe that. In the case of substance use or abuse, the patient is potentially not telling the truth, depending on the circumstances. We also use "deny" for reporting the lack of various symptoms, as in, "The patient denies cough." Who knows better than the patient if they are coughing? A physical exam doesn't need to be portrayed in the medical record as a cross-examination, does it?
When a patient cannot or does not want to follow the recommendations of the physician, that patient might be called "noncompliant." We might as well call them "disobedient." The word reeks of condescension and promotes the infantilizing of patients, which is never appropriate. Its use negates the idea of shared decision-making between a physician and patient, where the decisions on testing and treatments are made together—and fully informed. Ironically, shared decision-making results in the patient being more likely to be "compliant" with the plan.
The use of OpenNotes, where physician notes in medical records are available online for patients, has increased over the past several years and is now cemented in place with the 21st Century Cures Act. Initially, such access worried physicians, with concerns—ultimately needless—that these online records would result in a flurry of (nonbillable) calls to the office, with patients asking about a slightly abnormal lab value or the meaning of a medical term. That fear does not appear to have materialized in any significant way in part because patients are not yet fully aware that the notes are being shared.
We all learned to use particular language as part of our medical training. Perhaps it is time to refresh that language.