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      Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record

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          Abstract

          <div class="section"> <a class="named-anchor" id="d3232777e266"> <!-- named anchor --> </a> <h5 class="section-title" id="d3232777e267">Background</h5> <p id="Par1">Clinician bias contributes to healthcare disparities, and the language used to describe a patient may reflect that bias. Although medical records are an integral method of communicating about patients, no studies have evaluated patient records as a means of transmitting bias from one clinician to another. </p> </div><div class="section"> <a class="named-anchor" id="d3232777e271"> <!-- named anchor --> </a> <h5 class="section-title" id="d3232777e272">Objective</h5> <p id="Par2">To assess whether stigmatizing language written in a patient medical record is associated with a subsequent physician-in-training’s attitudes towards the patient and clinical decision-making. </p> </div><div class="section"> <a class="named-anchor" id="d3232777e276"> <!-- named anchor --> </a> <h5 class="section-title" id="d3232777e277">Design</h5> <p id="Par3">Randomized vignette study of two chart notes employing stigmatizing versus neutral language to describe the same hypothetical patient, a 28-year-old man with sickle cell disease. </p> </div><div class="section"> <a class="named-anchor" id="d3232777e281"> <!-- named anchor --> </a> <h5 class="section-title" id="d3232777e282">Participants</h5> <p id="Par4">A total of 413 physicians-in-training: medical students and residents in internal and emergency medicine programs at an urban academic medical center (54% response rate). </p> </div><div class="section"> <a class="named-anchor" id="d3232777e286"> <!-- named anchor --> </a> <h5 class="section-title" id="d3232777e287">Main Measures</h5> <p id="Par6">Attitudes towards the hypothetical patient using the previously validated Positive Attitudes towards Sickle Cell Patients Scale (range 7–35) and pain management decisions (residents only) using two multiple-choice questions (composite range 2–7 representing intensity of pain treatment). </p> </div><div class="section"> <a class="named-anchor" id="d3232777e291"> <!-- named anchor --> </a> <h5 class="section-title" id="d3232777e292">Key Results</h5> <p id="Par7">Exposure to the stigmatizing language note was associated with more negative attitudes towards the patient (20.6 stigmatizing vs. 25.6 neutral, <i>p</i> &lt; 0.001). Furthermore, reading the stigmatizing language note was associated with less aggressive management of the patient’s pain (5.56 stigmatizing vs. 6.22 neutral, <i>p</i> = 0.003). </p> </div><div class="section"> <a class="named-anchor" id="d3232777e302"> <!-- named anchor --> </a> <h5 class="section-title" id="d3232777e303">Conclusions</h5> <p id="Par8">Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations. </p> </div>

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          Most cited references24

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          Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities.

          Although the medical profession strives for equal treatment of all patients, disparities in health care are prevalent. Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making, so called "implicit bias". All of society is susceptible to these biases, including physicians. Research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics. We review the origins of implicit bias, cite research documenting the existence of implicit bias among physicians, and describe studies that demonstrate implicit bias in clinical decision-making. We then present the bias-reducing strategies of consciously taking patients' perspectives and intentionally focusing on individual patients' information apart from their social group. We conclude that the contribution of implicit bias to health care disparities could decrease if all physicians acknowledged their susceptibility to it, and deliberately practiced perspective-taking and individuation when providing patient care. We further conclude that increasing the number of African American/Black physicians could reduce the impact of implicit bias on health care disparities because they exhibit significantly less implicit race bias.
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            Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients

            Context Studies documenting racial/ethnic disparities in health care frequently implicate physicians’ unconscious biases. No study to date has measured physicians’ unconscious racial bias to test whether this predicts physicians’ clinical decisions. Objective To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes. Design, Setting, and Participants An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient. Main Outcome Measures IAT scores (normal continuous variable) measuring physicians’ implicit race preference and perceptions of cooperativeness. Physicians’ attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians’ explicit racial biases by questionnaire. Results Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians’ prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009). Conclusions This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.
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              A unified theory of implicit attitudes, stereotypes, self-esteem, and self-concept.

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                Author and article information

                Journal
                Journal of General Internal Medicine
                J GEN INTERN MED
                Springer Nature
                0884-8734
                1525-1497
                May 2018
                January 26 2018
                May 2018
                : 33
                : 5
                : 685-691
                Article
                10.1007/s11606-017-4289-2
                5910343
                29374357
                fc317034-0044-4c47-b8f8-f959e4272413
                © 2018

                http://www.springer.com/tdm

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