How to Reduce Stigma and Bias in Clinical Communication: a Narrative Review

A Study of the Psychometric Properties of the Pediatric Symptom Checklist-17 for Children With Developmental Delays and Disorders

Primary care physicians (PCPs) frequently serve pediatric patients with developmental delays and disorders (DD/D). Although the most widely used primary care behavioral health screener, the Pediatric Symptom Checklist-17 (PSC-17), is validated for use with children without DD/D, it is unclear whether this measure accurately identifies behavioral health symptoms in youth with DD/D. Thus, the purpose of this study was to assess the psychometric properties of the PSC-17 for children with DD/D. Medical record data from 3596 pediatric patients at a primary care clinic were analyzed. Descriptive analyses, measurement invariance testing, and internal consistency evaluations were conducted to assess the psychometric properties of the PSC-17. The results of these analyses support the use of the PSC-17 for behavioral health screening for children with DD/D. Behavioral health screening in this population is critical, because the timely identification of behavioral health concerns can facilitate early intervention, which may enhance long-term functioning.

The impact of physical changes to appearance on people with vertebral fragility fracture: a qualitative study

OBJECTIVES

The aim of this study was to explore the experiences of people with Vertebral Fragility Fracture (VFF) due to osteoporosis and the impact of the physical changes resulting from their condition.

DESIGN

Interpretive qualitative research using semi-structured individual interviews PARTICIPANTS: Eighteen people with VFF were interviewed; nine men and nine women. Participants ranged in age from 55 to 92 years and had between 1 and 10 previous vertebral fragility fractures.

SETTING

Interviews were offered in participants own homes, at the hospital or by Microsoft TEAMS or telephone. These were audio-recorded, transcribed verbatim, and analysed through reflexive thematic analysis.

RESULTS

Results are presented within four themes: loss of height; finding spinal curvature upsetting, the impact on looking good and whether having a stoop was inevitable or could be prevented by active engagement.

CONCLUSION

The findings show the negative impact on self-image caused by the physical manifestations of a VFF and that these can be as significant and distressing as pain and functional limitations. This information is useful for physiotherapists treating people with vertebral fragility fractures offering insight into the patients' experiences of these physical changes. CONTRIBUTION OF THE PAPER.

Adherence Labeling: Understanding the Origins, Limitations, and Ethical Challenges of "Diagnosing" Nonadherence

Promoting adherence to medical recommendations remains one of the oldest yet most persistent challenges of modern clinical practice. Although increasingly sympathetic to structural forces that affect health behavior, standard models frequently conceptualize nonadherence as a phenomenon of patient behavior, a self-evident quality belonging to patients that is responsible for a myriad of undesired outcomes. We contend, however, that this approach not only fails to consider the role of the clinician in the concept's origins in clinical encounters, but also has facilitated the use of adherence terms (eg, nonadherent, noncompliant, treatment resistant) as pejorative social labels to the detriment of the physician-patient relationship. Used without care, such terminology can alter the meaning assigned to patients' behaviors so that structural barriers to care such as poverty and systemic racism are reframed as problems of poor attitude or effort. This article explores the functions of adherence terms as social labels by reviewing their underlying logic in clinical settings and outlining pitfalls in the pathologization of nonadherence in research and practice. We propose the concept of adherence labeling-the assessment, classification, and dissemination of clinicians' perceptions of patients' adherence through social labels-as an alternative model to understand how adherence terms may inadvertently obstruct the care of marginalized patients.

Patient and clinician acceptability of automated extraction of social drivers of health from clinical notes in primary care

OBJECTIVE

Artificial Intelligence (AI)-based approaches for extracting Social Drivers of Health (SDoH) from clinical notes offer healthcare systems an efficient way to identify patients' social needs, yet we know little about the acceptability of this approach to patients and clinicians. We investigated patient and clinician acceptability through interviews.

MATERIALS AND METHODS

We interviewed primary care patients experiencing social needs (n = 19) and clinicians (n = 14) about their acceptability of "SDoH autosuggest," an AI-based approach for extracting SDoH from clinical notes. We presented storyboards depicting the approach and asked participants to rate their acceptability and discuss their rationale.

RESULTS

Participants rated SDoH autosuggest moderately acceptable (mean = 3.9/5 patients; mean = 3.6/5 clinicians). Patients' ratings varied across domains, with substance use rated most and employment rated least acceptable. Both groups raised concern about information integrity, actionability, impact on clinical interactions and relationships, and privacy. In addition, patients raised concern about transparency, autonomy, and potential harm, whereas clinicians raised concern about usability.

DISCUSSION

Despite reporting moderate acceptability of the envisioned approach, patients and clinicians expressed multiple concerns about AI systems that extract SDoH. Participants emphasized the need for high-quality data, non-intrusive presentation methods, and clear communication strategies regarding sensitive social needs. Findings underscore the importance of engaging patients and clinicians to mitigate unintended consequences when integrating AI approaches into care.

CONCLUSION

Although AI approaches like SDoH autosuggest hold promise for efficiently identifying SDoH from clinical notes, they must also account for concerns of patients and clinicians to ensure these systems are acceptable and do not undermine trust.

Mental Illness and Substance Use Disorder Stigma: Mapping Pathways Between Structures and Individuals to Accelerate Research and Intervention

Researchers, interventionists, and clinicians are increasingly recognizing the importance of structural stigma in elevating the risk of mental illnesses (MIs) and substance use disorders (SUDs) and in undermining MI/SUD treatment and recovery. Yet, the pathways through which structural stigma influences MI/SUD-related outcomes remain unclear. In this review, we aim to address this gap by summarizing scholarship on structural MI/SUD stigma and identifying pathways whereby structural stigma affects MI/SUD-related outcomes. We introduce a conceptual framework that describes how structural-level stigma mechanisms influence the MI/SUD treatment cascade via (a) interpersonal- and individual-level stigma mechanisms and (b) mediating processes among people with MI/SUD (i.e., access to resources, psychological responses, behavioral responses, social isolation). We consider intersections between MI/SUD stigma and stigma based on race/ethnicity, gender identity, and sexual orientation. Finally, we discuss the implications of this review for future research, interventions, and clinical practice.

Stigmatizing and Positive Language in Birth Clinical Notes Associated With Race and Ethnicity

Importance

Language used in clinical documentation can reflect biases, potentially contributing to health disparities. Understanding associations between patient race and ethnicity and documentation of stigmatizing and positive language in clinical notes is crucial for addressing health disparities and improving patient care.

Objective

To examine associations of race and ethnicity with stigmatizing and positive language documentation in clinical notes from hospital birth admission.

Design, Setting, and Participants

This cross-sectional study included birthing patients at 2 metropolitan hospitals in the Northeastern US between 2017 and 2019. Eligible participants were admitted for labor and birth and had at least 1 free-text clinical note. Analysis was conducted using natural language processing. Data were analyzed between March and December 2024.

Exposures

Patient race and ethnicity, categorized into mutually exclusive groups of Asian or Pacific Islander, Black, Hispanic, and White.

Main Outcome and Measures

Presence of 4 stigmatizing language categories (marginalized language or identities, difficult patient, unilateral or authoritarian decisions, and questioning patient credibility) and 2 positive language categories (preferred and/or autonomy, power and/or privilege).

Results

Among the 18 646 patients included in the study (mean [SD] age, 30.5 [6.2] years), 2121 were Black (11.4%), 11 078 were Hispanic (59.4%), and 4270 were White (22.9%). The majority (10 559 patients [56.6%]) were insured by Medicaid. Compared with White patients, Black patients had higher odds of having any stigmatizing language (model 2: odds ratio [OR], 1.25; 95% CI, 1.05-1.49; P < .001), after adjustment for demographic characteristics. Black patients also had higher odds of any positive language documented (model 2: OR, 1.18; 95% CI, 1.05-1.32; P = .006). Hispanic patients had lower odds of documented positive language (model 2: OR, 0.90; 95% CI, 0.82-0.99; P = .03). Asian or Pacific Islander patients had lower odds of language documented in the power and/or privilege category (model 2: OR, 0.71; 95% CI, 0.57-0.88; P = .002).

Conclusions and Relevance

In this cross-sectional study examining clinical notes of 18 646 patients admitted for labor and birth, there were notable disparities in how stigmatizing and positive language was documented across racial and ethnic groups. This underscores the necessity for improving documentation and communication practices to reduce the use of stigmatizing language.

A Critical Discourse Analysis of the Language of Stigmatization of Breast Cancer Patients in Nigeria

Breast cancer is a significant health concern globally, including in Nigeria, where its incidence is rising. An essential component of breast cancer care is the psychosocial wellbeing of patients, which is often shaped by the language used in healthcare and society. While some research has explored stigmatization of breast cancer patients, no study has focused on language as a tool for this stigmatization in Nigeria. This study examines how language perpetuates the stigmatization of breast cancer patients and explores ways to use language to improve their lives and health. Using Norman Fairclough's model of critical discourse analysis and a descriptive design, data was collected through interviews with 50 respondents at the University College Hospital in Ibadan, Nigeria. The study's discourse analysis revealed that stigmatization is perpetuated through language, including negative stereotypes, body shaming, spiritual interpretations, and derogatory terms. These discourses reflect broader social and cultural factors such as norms, beliefs, and power dynamics that reinforce stigmatization. The research highlights the effects of stigmatizing language, including denial, loss of femininity, shame, and fear of a new identity. The findings call for policies and interventions to reduce stigma, improve patient experiences, and raise public awareness of breast cancer.

The use of non-person-first language in neuro-ophthalmology referrals

OBJECTIVE

To investigate the prevalence of non-person-first language (PFL) in neuro-ophthalmology referrals to a single tertiary ophthalmology clinic.

DESIGN

Retrospective cross-sectional study.

METHODS

Participants included neuro-ophthalmology patients seen for their initial visit from July 2018 to December 2022. Ten randomly selected referrals from each day were screened. Non-PFL was further categorized as per American Medical Association and American Psychological Association guidelines. Associations between non-PFL and patient age and gender, referring provider gender and specialty, and year and length of referral, were evaluated using the χ2 test.

RESULTS

A total of 2105 referrals were included in the study and 81 (3.8%) used non-PFL, such as referring to a person with glaucoma as a "glaucoma patient". Error types included general (38.3%), stigma (25.9%), diabetes (19.8%), disability (13.6%), and obesity (2.5%). Non-PFL was significantly more likely in long referrals compared with medium and short referrals (9.9% vs 3.1% vs 1.3%; p < 0.001). Referral year was predictive of non-PFL (p = 0.0006), with a significant increase from 2018 (1.7%) to 2021 (6.1%) and decrease in 2022 (2.6%). Patient age was also predictive of non-PFL (p = 0.0359), with the highest prevalence among patients 40-69 years old (5.4%). Patient gender (p = 0.3350), referring provider gender (p = 0.3571), and referring provider specialty (p = 0.1280) were not predictive of non-PFL.

CONCLUSIONS

The highest proportions of non-PFL errors made were general and stigma errors. Non-PFL use was most prevalent in 2021, most commonly in referrals for patients aged 40-69 years. There exists a need for ongoing education and awareness around PFL use in physician-physician communication to enhance inclusive, nonstigmatizing care for neuro-ophthalmology patients.

Words matter: Destigmatizing the language of medicine through research, training, and future directions for emergency medicine

Background

In emergency medicine (EM), language choice significantly impacts patient care and can potentially cause harm, dehumanize patients, and introduce bias. Stigmatizing language in medical settings can affect patient dignity, trust, and outcomes. Despite its importance, there is limited education on avoiding stigmatizing language in EM. This concept paper addresses the need to raise awareness and develop strategies for use of inclusive language in the emergency department (ED).

Methods

A didactic session titled "Words Matter: Destigmatizing the Language of Medicine" was developed and presented at the 2024 Society for Academic Emergency Medicine (SAEM) Annual Meeting. The session involved a collaborative team of 12 individuals, including an EM resident, health equity fellow, and EM faculty. Content creation involved a comprehensive literature review and consensus-based decision making. The session featured current research related to stigmatizing language and interactive components, including case-based discussions and equity-focused alternative language choices.

Results

The didactic session, attended by approximately 70 participants, successfully highlighted the impact of stigmatizing language on health care disparities and patient trust. Interactive case studies allowed participants to identify and propose alternatives to stigmatizing language. The session provided actionable strategies for integrating inclusive language into practice and education. Postdidactic discussions emphasized the need for ongoing research and specific educational interventions to address stigmatizing language in EM.

Conclusions

Addressing stigmatizing language in EM is crucial for providing equitable and respectful patient care. The didactic session demonstrated effective methods for raising awareness and training health care professionals in using inclusive language. Future efforts should focus on developing standardized approaches for identifying and mitigating stigmatizing language, integrating these practices into training programs, and conducting longitudinal research to assess the impact on patient outcomes. Creating a culture of inclusive language in the ED will contribute to improved patient trust and care quality.

Health Care Practitioner Bias and Access to Inpatient Rehabilitation Services Among Survivors of Violence

Importance

Posthospital inpatient rehabilitation is essential for many patients with traumatic injuries. However, rehabilitation centers lack transparency and oversight in their admission practices and may be influenced by health care practitioner (HCP) use of stigmatizing language in patient medical records, leading to inequities in access to care.

Objectives

To examine differences in admission to inpatient rehabilitation centers for patients hospitalized for violent penetrating (VP) injuries compared with motor vehicle crash (MVC) injuries.

Design, Setting, and Participants

This mixed-methods retrospective qualitative study used data obtained from hospital records from 2015 to 2021. Data analysis occurred between July and December 2023. The study was performed at Boston Medical Center, an urban level I trauma center. The cohort included all patients hospitalized for VP or MVC injuries who were discharged to an inpatient rehabilitation center between 2015 and 2021.

Exposures

Injury type, categorized as VP or MVC.

Main Outcomes and Measures

The primary quantitative outcome was a denial for admission to an inpatient rehabilitation center. Qualitative content analysis identified similarities and differences across injury types in the manifestations of predetermined stigmatizing language categories in patients' medical records.

Results

Of 323 patients discharged to an inpatient rehabilitation center (median [IQR] age, 38 [25-59] years; 208 men [64.4%]; 29 Hispanic patients [9.0%], 118 non-Hispanic Black patients [36.5%], and 152 non-Hispanic White patients [47.1%]), 107 patients (33.1%) experienced at least 1 denial by a center before being placed (32 of 55 patients with VP injuries [58.2%] vs 75 of 268 patients with MVC injuries [28.0%]). Compared with patients with MVC injuries, patients with VP injuries had greater than 3 times the odds of experiencing a denial (odds ratio, 3.51; 95% CI, 1.93-6.48; P < .001). Medical records of patients with VP injuries had increased use of stigmatizing language that indicated culturally based or injury-related stereotyping, skepticism toward patient-reported symptoms, and heightened HCP-power dynamics contributing to unilateral decision-making.

Conclusions and Relevance

In this mixed-methods qualitative study of hospital patients discharged to rehabilitation centers, significant disparities in denials for admission were observed among survivors of violence, who were disproportionally Black or Hispanic. Stigmatizing language found in medical records suggested that bias within the referral process may have contributed to these disparities. These findings underscore the need for reformed clinical documentation practices and enhanced oversight of rehabilitation referral processes to promote equitable access to care.

Effects of Stigmatizing Language on Trainees' Clinical Decision-Making in Substance Use Disorders: A Randomized Controlled Trial

OBJECTIVES

Substance use disorder (SUD) continues to be one of the most stigmatized and under-treated conditions in the United States. Stigmatizing language used by healthcare workers can transmit bias to others within healthcare, including medical trainees. This study investigates how stigmatizing language and undergraduate medical education (UME) curricula may influence trainees' clinical decision-making for patients with SUD.

METHODS

Medical students from three Chicago-area medical schools were randomized to review either a stigmatizing or neutral version of a clinical scenario describing a patient experiencing opioid withdrawal. Participants (a) selected treatment plans for the fictional patient using two multiple-choice questions, (b) completed the Medical Condition Regard Scale (MCRS) to assess their attitudes, and (c) reported prior SUD experiences, both curricular and personal. Statistical analyses explored whether treatment decisions were influenced by attitudes, addiction medicine curricula, and exposure to the stigmatizing vignette.

RESULTS

Among the 366 medical students who completed this study, exposure to stigmatizing language (n = 191) led to clinical decision-making that would be less effective in treating opioid withdrawal for the fictional patient (p = 0.027; η2 = 0.013). Exposure to more SUD education during UME was correlated with more effective clinical decision-making for opioid withdrawal (β = 0.181; R2 = 0.033; p < 0.001) but was not correlated with attitudes toward patients with SUD (p = 0.231).

CONCLUSIONS

Stigmatizing language influences clinical decision-making when treating patients with SUD. Improving SUD education within UME may be an effective strategy for mitigating this effect within medical trainees.

Advancing Health Equity Through Substance Use Medical Record Data Sharing: Insights from Healthcare Providers

BACKGROUND

Better care is delivered when patients and providers share health information. Unfortunately, critical health data are often unavailable due to fragmentation within healthcare systems. Sensitive health information, like substance use disorder, is often sequestered in ways that do not meet patient data privacy choices and provider data access needs. This study explored healthcare providers' perspectives on barriers and facilitators to substance use data sharing and its impact on care.

METHODS

Focus groups were conducted with 31 healthcare providers from four treatment facilities. Discussions focused on privacy concerns, data-sharing workflows, and scenarios involving four Healthcare Effectiveness Data and Information Set (HEDIS) substance use disorder specific metrics. Open coding identified key concepts, and thematic analysis was employed to identify barriers and facilitators influencing data sharing and care outcomes.

RESULTS

Providers identified five main barriers: patient reluctance to share (48%), data access challenges (42%), poor provider coordination (29%), incomplete health information (26%), and complexity of privacy regulations (23%). Key facilitators included patient understanding (26%), patient-provider relationship (16%), and reliability of health information systems (16%).

DISCUSSION

This study sets the stage for understanding and addressing sensitive healthcare data access and privacy concerns through improved care coordination, systems interoperability, education, and policy reform.

Experiences of Blame Among Pregnant Black Women During Prenatal Care

OBJECTIVE

To measure the prevalence and identify correlates of self-reported experiences of provider-perpetrated blame and self-blame during maternal care among Black women in the US.

STUDY DESIGN

This exploratory cross-sectional pilot study surveyed 131 Black adult women who received maternal healthcare in the US within the past 5 years. Participants reported sociodemographics and experiences with maternal care, including provider-perpetrated blame and self-blame during their most recent pregnancy. Bivariate analyses (chi-squared and Kruskal-Wallis tests) were used to assess associations between individual-level characteristics, maternal care characteristics, and self-reported experiences of provider-perpetrated blame and self-blame during pregnancy.

RESULTS

49 (37.99%) of participants reported that at least one maternal care provider had indirectly or directly blamed them for their pregnancy complications, negative outcomes, or risk thereof and 37 (28.24%) reported self-blame. Neither type of blame was significantly associated with demographic characteristics (age, ethnicity, skin tone, education, income, employment). The two types of blame experiences were significantly associated with each other-57.14% (N = 28) of those who reported provider-perpetrated blame reported self-blame as well (p < 0.001). Both blame experiences were positively associated with receiving maternal care from a primary care physician, general practitioner, or family doctor (p < 0.01 for both blame types) and telehealth visits (p < 0.001 for both blame types). Both types of blame were also associated with perceptions that provider-communication was based in stereotypes or assumptions, lacking opportunities for questions, and provided insufficient information for informed decision-making (p < 0.001 for all comparisons).

CONCLUSIONS

Experiences of provider-perpetrated blame and self-blame may be highly prevalent in Black women's maternal care. These results suggest that Black women's experiences of provider-perpetrated blame and self-blame in maternal care are correlated with clinical characteristics as opposed to individual-level sociodemographics and may co-occur with negative and disenfranchising maternal care experiences linked to racial bias.

Secondary Qualitative Analysis of Stigmatizing and Nonstigmatizing Language Used in Hospital Birth Settings

OBJECTIVE

To more clearly understand the use of stigmatizing and nonstigmatizing language in electronic health records in hospital birth settings and to broaden the understanding of discrimination and implicit bias in clinical care.

DESIGN

A secondary qualitative analysis of free-text clinical notes from electronic health records.

SETTING

Two urban hospitals in the northeastern United States that serve patients with diverse sociodemographic characteristics during the perinatal period.

PARTICIPANTS

A total of 1,771 clinical notes from inpatient birth admissions in 2017.

METHODS

We used Krippendorff's content analysis of categorial distinction to identify stigmatizing and nonstigmatizing language. We based our categories for the content analysis on our pilot study and preexisting categories described by other researchers. We also explored new language categories that emerged during analysis.

RESULTS

We reviewed 1,771 notes and identified 10 categories that demonstrated stigmatizing language toward patients, nonstigmatizing language toward patients, and stigmatizing language among clinicians. We identified a new stigmatizing language category, Unjustified Descriptions of Social and Behavioral Risks. Positive or Preferred Language and Patient Exercising Autonomy for Birth are two new categories that represent language that empowers patients. Clinician Blame and Structural Care Barriers are new language categories that imply complex interprofessional dynamics and structural challenges in health care settings that can adversely affect the provision of care.

CONCLUSIONS

The results of this study provide a foundation for future efforts to reduce the use of stigmatizing language in clinical documentation and can be used to inform multilevel interventions to reduce bias in the clinical care in birth settings.

Biased Language in Simulated Handoffs and Clinician Recall and Attitudes

Importance

Poor-quality handoffs can lead to medical errors when transitioning patient care. Biased language within handoffs may contribute to errors and lead to disparities in health care delivery.

Objective

To compare clinical information recall accuracy and attitudes toward patients among trainees in paired cases of biased vs neutral language in simulated handoffs.

Design, Setting, and Participants

Surveys administered from April 29 to June 15 and from July 20 to October 10, 2023, included 3 simulated verbal handoffs, randomized between biased and neutral, and measured clinical information recall, attitudes toward patients, and key takeaways after each handoff. Participants included residents in internal medicine, pediatrics, and internal medicine-pediatrics and senior medical students at 2 academic medical centers in different geographic regions of the US. Data were analyzed from November 2023 to June 2024.

Exposures

Each participant received 3 handoffs that were based on real handoffs about Black patients at 1 academic center. These handoffs were each randomized to either a biased or neutral version. Biased handoffs had 1 of 3 types of bias: stereotype, blame, or doubt. The order of handoff presentation was also randomized. Internal medicine and pediatrics residents received slightly different surveys, tailored for their specialty. Internal medicine-pediatrics residents received the pediatric survey. Medical students were randomly assigned the survey type.

Main Outcomes and Measures

Each handoff was followed by a clinical information recall question, an adapted version of the Provider Attitudes Toward Sickle Cell Patients Scale (PASS), and 3 free-response takeaways.

Results

Of 748 trainees contacted, 169 participants (142 residents and 27 medical students) completed the survey (23% overall response rate), distributed across institutions, residency programs, and years of training (95 female [56%]; mean [SD] age, 28.6 [2.3] years). Participants who received handoffs with blame-based bias had less accurate information recall than those who received neutral handoffs (77% vs 93%; P = .005). Those who reported bias as a key takeaway of the handoff had lower clinical information recall accuracy than those who did not (85% vs 93%; P = .01). Participants had less positive attitudes toward patients per PASS scores after receiving biased compared with neutral handoffs (mean scores, 22.9 [3.3] vs 25.2 [2.7]; P < .001). More positive attitudes toward patients were associated with higher clinical information recall accuracy (odds ratio, 1.12; 95% CI, 1.02-1.22).

Conclusions and Relevance

In this survey study of residents and medical students, biased handoffs impeded accurate transfer of key clinical information and decreased empathy, potentially endangering patients and worsening health disparities. Handoff standardization is critical to addressing racial bias and improving patient safety.

Addressing Stigma-Related Health Disparities for Autistic Individuals Through Cultural Competemility: Insights from Research and Lived Experience

PURPOSE OF REVIEW

Autistic individuals experience disproportionate stigma across the life course in interpersonal, healthcare, and educational contexts. These experiences contribute to negative health and healthcare outcomes for this population. This paper seeks to describe autistic individuals' experiences of stigma and marginalization; discuss frameworks such as Campinha-Bacote's innovative concept of cultural competemility and its relevance to autistic populations; offer recommendations to healthcare providers based on this framework; and apply theory to practice in a case study.

RECENT FINDINGS

Autistic individuals increasingly understand autism as an important aspect of their identity. There are, however, few culturally informed healthcare efforts that reflect this understanding. As a result, efforts to address stigma-related health disparities for this population have limited effectiveness. In this manuscript, we highlight opportunities within clinical encounters, medical training, healthcare offices and systems, and research to provide higher quality culturally informed care to autistic populations and address stigma-related health disparities.

The Use of Non-Person-First Language in Consecutive General Ophthalmology Referrals

PURPOSE

To investigate the prevalence of non-person-first language (PFL) in consecutive general ophthalmology referrals to a single tertiary ophthalmology clinic.

DESIGN

Retrospective cross-sectional study.

METHODS

Participants included Ophthalmology patients seen for their initial visit to a single tertiary ophthalmology clinic from July 2018 to December 2022. Ten randomly selected referrals from each day were screened for non-PFL as per the American Medical Association and American Psychological Association guidelines. Non-PFL was further categorized into general, diabetes, stigma, obesity, or ageism subcategories. The Chi-square test was used to evaluate associations between non-PFL use and referring provider gender and specialty, length of referral, and patient age and gender.

RESULTS

A total of 2625 referrals were included in the study and 136 (5.2%) used non-PFL, such as referring to a person with diabetes as a "diabetic". Error types included Diabetes (38.2%), Stigma (30.9%), General (23.5%), Disability (8.8%), and Obesity (4.4%). Year of referral was predictive of non-PFL (P = .0016), with most occurring in 2020 (9.5%). Non-PFL was significantly more likely to occur in long length referrals compared to medium and short length referrals (16.2% vs. 5.1% vs. 3.5%, P < .001). Referring provider specialty was also predictive of non-PFL (P < .001) with most received by Family Medicine (8.3%), Optometry (4.4%), Emergency Medicine (0.62%), Ophthalmology (4.2%), Others (2.9%). Patient gender (P = .5563), patient age (P = .3466), and referring provider gender (P = .9057) were not predictive of non-PFL.

CONCLUSIONS

Non-PFL use was most prevalent in 2020, with the most common referral sources being Family Medicine and Optometry. The highest proportions of non-PFL errors made were diabetes and stigma errors. Increased use of PFL in physician-physician communication can decrease intersectional stigma and promote inclusive patient care for ophthalmology patients.

An idea to explore: Student-centered scientific and medical writing project and workshop for undergraduate students

Writing is usually integrated in the curriculum of science studies. However, students often lack the skills to write for various audiences or, to produce a well written manuscript. We developed a concise project of 15 European Credits to improve the writing skills in an early phase of the bachelor study. Students worked on texts from various journals and looked at the writing styles. They rewrote texts in a popular and more scientific way and practiced with clear, vivid language, avoiding clutter and hedge words, considering a proper use of grammar and interpunction. Medical writing was also introduced during the project. Grading was based on rewriting for a non-expert and expert audience. A rewritten text was presented to the public in the form of a student-initiated survey. This project shows an inverted approach creating student ownership and enthusiasm for writing. In addition, we created and tested successfully a concise two-day workshop based on this project. Based on the results we herewith present the work as an idea to explore.

The last word: An analysis of power dynamics in clinical notes documenting against-medical-advice discharges

Against Medical Advice (AMA) discharges pose significant challenges to the healthcare system, straining patient-clinician relationships while contributing to avoidable morbidity and mortality. Furthermore, though these discharges culminate in patients' departure from hospitals, their effects reverberate long after, propagated by clinician notes stored in patients' medical records. These notes capture exceptionally fraught interactions between patients and providers, describing the circumstances surrounding breakdowns in clinical relationships. Additionally, they represent just one side of complex, contentious social interactions, for in describing AMA discharges, clinician notewriters quite literally have the last word. For these reasons, notes documenting AMA discharges provide insight into the ways in which clinicians conceptualize, characterize, and propagate power differentials in the contemporary healthcare system. Here, we present a qualitative thematic analysis of 185 notes documenting AMA discharges from a large urban US medical center, interpreting note dynamics through three sociological models of power analysis: (i) the distributive model of power promulgated by Max Weber, (ii) the collectivist power model characterized by Talcott Parsons and Hannah Arendt, and (iii) structural interpretations of power developed by Michel Foucault. We argue that in documenting AMA discharges, clinicians appear to conceive of their relationship with patients in almost exclusively distributive terms, which in turn contributes to an adversarial dynamic whereby both patients and clinicians ultimately suffer disempowerment. We furthermore argue that by facilitating clinicians' recognition of power's collectivist and structural dimensions, we may help transform breakdowns in patient-clinician relationships into opportunities for collaboration.

Addressing Housing Issues Among People With Kidney Disease: Importance, Challenges, and Recommendations

Kidney disease disproportionately impacts people with low socioeconomic status, and low socioeconomic status is associated with worse outcomes for people with kidney disease. Unstable housing, which includes housing insecurity and homelessness, is increasing due to rising housing costs. There is mounting evidence that unstable housing and other health-related social needs are partially driving worse outcomes for people with low socioeconomic status. In this perspective, we consider the challenges to addressing housing for people with kidney disease, such as difficulty with identification of those with unstable housing, strict eligibility criteria for housing support, inadequate supply of affordable housing, and flaws in communities' prioritization of affordable housing. We discuss ways to tailor management for people experiencing unstable housing with kidney disease, and the importance of addressing safety, trauma, and emotional concerns as a part of care. We identify opportunities for the nephrology community to surmount challenges through increased screening, investment in workforce dedicated to community resource navigation, advocacy for investment in affordable housing, restructuring of communities' prioritization of affordable housing, and conducting needed research. Identifying and addressing housing needs among people with kidney disease is critical to eliminating kidney health disparities.

Examining Inclusive Language in Clinical Narratives in Medical Biochemistry Textbooks to Model Equitable Patient-Centered Care in Preclinical Undergraduate Medical Education

Purpose

When healthcare professionals use biased or stigmatizing language to describe people or conditions, it can impact the quality of care or erode the patient-physician relationship. It is not clear where healthcare professionals acquire biased and stigmatizing language in practice. This study focuses on examining language in educational materials used in training of medical students. Specifically, medical biochemistry textbooks were examined as they are often a first exposure to clinical narratives and communication standards. The aim of this project is to investigate whether medical biochemistry textbooks, widely recommended in preclinical UME, model inclusive language communication in clinical narratives.

Methods

To determine if educational materials follow inclusive writing guidelines, we conducted a modified document analysis on a sample of medical biochemistry textbooks when clinical scenarios were described. Three independent researchers separately reviewed the textbooks, coded the language using NVivo, and generated themes.

Results

Our results show that medical biochemistry textbooks contain language which is not in alignment with the best practices for inclusive language. Our analysis mapped codes to two primary themes of language misalignment. The first theme, "clinical language" (n = 92), included the following codes: difficult patient, general negative descriptive language, patient as failure, and questioning patient credibility. The second primary theme, "identity-first labeling" (n = 251), included 21 codes.

Conclusion

This study provides early evidence that the language used in medical biochemistry textbooks to describe people and conditions is not in alignment with inclusive language recommendations. This can reinforce the way future healthcare professionals speak to and about their patients.

Measuring Implicit Bias in ICU Notes Using Word-Embedding Neural Network Models

BACKGROUND

Language in nonmedical data sets is known to transmit human-like biases when used in natural language processing (NLP) algorithms that can reinforce disparities. It is unclear if NLP algorithms of medical notes could lead to similar transmissions of biases.

RESEARCH QUESTION

Can we identify implicit bias in clinical notes, and are biases stable across time and geography?

STUDY DESIGN AND METHODS

To determine whether different racial and ethnic descriptors are similar contextually to stigmatizing language in ICU notes and whether these relationships are stable across time and geography, we identified notes on critically ill adults admitted to the University of California, San Francisco (UCSF), from 2012 through 2022 and to Beth Israel Deaconess Hospital (BIDMC) from 2001 through 2012. Because word meaning is derived largely from context, we trained unsupervised word-embedding algorithms to measure the similarity (cosine similarity) quantitatively of the context between a racial or ethnic descriptor (eg, African-American) and a stigmatizing target word (eg, nonco-operative) or group of words (violence, passivity, noncompliance, nonadherence).

RESULTS

In UCSF notes, Black descriptors were less likely to be similar contextually to violent words compared with White descriptors. Contrastingly, in BIDMC notes, Black descriptors were more likely to be similar contextually to violent words compared with White descriptors. The UCSF data set also showed that Black descriptors were more similar contextually to passivity and noncompliance words compared with Latinx descriptors.

INTERPRETATION

Implicit bias is identifiable in ICU notes. Racial and ethnic group descriptors carry different contextual relationships to stigmatizing words, depending on when and where notes were written. Because NLP models seem able to transmit implicit bias from training data, use of NLP algorithms in clinical prediction could reinforce disparities. Active debiasing strategies may be necessary to achieve algorithmic fairness when using language models in clinical research.

Striving for health equity: Stigmatizing language in inpatient pharmacy notes - A pilot study

BACKGROUND

As pharmacy evolves, pharmacists have an increasing role in documentation. Publications examining the actions of other health professionals show that negative perception in written notes translates to patients receiving lower quality of care, resulting in worse health outcomes, suggesting that the use of stigmatizing language towards patients has concerning consequences.

OBJECTIVES

To identify the prevalence of stigmatizing language in inpatient pharmacy progress. notes based on patient specific characteristics and diagnoses.

METHODS

This retrospective pilot study reviewed inpatient pharmacy progress notes of a Midwestern (United States) tertiary academic institution from May to June 2023. Stigmatizing words and phrases associated with specified disease states were separated into the categories of general language, substance use disorders, and mental health. Notes of patients on internal medicine, family medicine, kidney/pancreas transplant, liver transplant, and gastroenterology services were included.

RESULTS

Stigmatizing language was found in 22% (n = 43) of notes. The words "abuse" and "dependence" had the highest prevalence. Patients diagnosed with substance use disorders experienced stigmatizing language at a high rate, exaggerated further if their note lacked a documented diagnosis.

CONCLUSIONS

This study demonstrated that stigmatizing language is present in pharmacy documentation. Providing context and resources of the proper documentation to reflect equitable healthcare is crucial for patient care.

Conceptualizing Domestic Violence Within Clinical Documentation

Domestic and family violence (DFV) is a global issue with significant impacts on victim-survivors. The emergency department (ED) serves as the initial point of contact for victim-survivors. Given the significant role that clinical notes play in the management of patients and the communication between healthcare professionals, understanding how healthcare practitioners describe and document abuse reported in emergency settings is crucial. Yet, there remains a gap in understanding how health professional document DFV in the medical records of women presenting to the ED. Therefore, this qualitative descriptive study explored how DFV is documented in patient records of women presenting to the ED. Clinical notes from healthcare workers, including medical practitioners, nurses, social workers, mental health clinicians and ambulance officers, were qualitatively analyzed. Overall, the study included 43 presentations from 32 women (aged 18-56 years old) who visited a regional ED, during which instances of DFV were noted. An inductive content analysis resulted in the identification of four categories, including (a) DFV articulated in direct speech, (b) Unambiguous DFV, (c) Unconfirmed DFV, and (d) Problematic relationship. Although most references to DFV in the clinical notes included direct quotations from the patient's descriptions of abuse or were documented unambiguously by healthcare professionals, a notable number of clinical notes exhibited a degree of caution or reluctance to acknowledge DFV dynamics when describing these events. These findings support the need for sustained and consistent professional training among healthcare professionals concerning the identification, documentation, and response to disclosures, suspicions, and allegations of DFV to better support victim-survivors presenting to the ED and other hospital settings.

Teaching Sex- and Gender-Sensitive Medicine Is Not Just a Matter of Content

Despite a growing integration of sex and gender-sensitive content in medical education around the globe, the focus on content often leads to a lack of consideration of the hidden curriculum. To foster an inclusive, sex- and gender-sensitive culture in medical education, we have to take a holistic approach that transcends a sole focus on explicit teaching content. This article provides reflections about the practice of teaching sex and gender-sensitive medicine focusing on the impactful yet implicit notions we convey about sex and gender in medical education. We propose action for leaders and teachers in medical education to explicitly address sex/gender in the hidden curriculum and within their institution, challenging the invisible practices of academia in the medical field.

Psychiatric nurses' perception of dignity in patients who attempted suicide

BACKGROUND

Maintaining the dignity of patients who attempted suicide is one of the caregivers' main ethical duties. Yet, in many cases, these patients are not treated with dignity. The concept of dignity is abstract, and there is no research on the dignity of suicidal patients. So, the present study is done to investigate psychiatric nurses' perception of dignity in patients who attempted suicide.

OBJECTIVE

The present study explores the concept of dignity in patients who attempted suicide from the perspective of psychiatric nurses.

RESEARCH DESIGN

The present study is a qualitative, descriptive work of research.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 20 psychiatric nurses from 2 hospitals affiliated with a university of medical sciences in the southeast of Iran were selected via purposeful sampling.

ETHICAL CONSIDERATIONS

The Research Ethics Committee of the Hamadan University of Medical Sciences approved the study's protocol, and ethical principles were followed in general.

FINDINGS

From the findings of the study, three main themes, namely " respect for personal; identity," "management of psychological tension," and "compassion-focused therapy," with 12 sub-themes were extracted.

DISCUSSION AND CONCLUSION

In the perspective of caregivers, patients who attempted suicide need to be cared for in supportive environments with compassionate and respectful behaviors to control their psychological tensions. These conditions would maintain such patients' dignity and result in appropriate behavioral outcomes. Policy-makers and administrators can use the present study's findings to create an appropriate clinical environment in which the dignity of patients who attempted suicide is properly maintained.

A Narrative Review on the Impact of Air Pollution on Heart Failure Risk and Exacerbation

Air pollution is a risk factor for many cardiovascular diseases, including heart failure (HF). Although the links between air pollution and HF have been explored, the results are scattered and difficult to piece together into a cohesive story. Therefore, we undertook a narrative review of all aspects of the relationship between HF and air pollution exposure, including risks of developing HF when exposed to air pollution, the exacerbation of HF symptoms by air pollution exposure, and the increased susceptibility that individuals with HF have for air pollution-related health risks. We also examined the literature on environmental justice as well as air pollution interventions for HF. We found substantial evidence linking air pollution exposure to HF incidence. There were a limited number of studies that examined air pollution exposure in clearly defined populations with HF to explore exacerbation of HF or the susceptibility of individuals with HF to air pollution health risks. However, there is substantial evidence that HF-related hospitalisations are increased under air pollution exposure and that the air pollution associated increase in HF-related hospitalisations is greater than hospitalisations for other chronic diseases, supporting links between air pollution and both exacerbation of HF and susceptibility of individuals with HF. There is emerging evidence for interventions that can decrease air pollution health risks for individuals with HF, and more studies are needed, particularly randomised controlled trials. Thus, although the air pollution-related health risks for HF incidence and hospitalisations are clear, further studies specifically targeted at identified data gaps will greatly improve our knowledge of the susceptibility of individuals with HF and interventions to reduce risks.

The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases

BACKGROUND

Engaging with human emotions is an integral but poorly understood part of the work of emergency healthcare providers. Patient factors (e.g., irritable behavior; mental illness) can evoke strong emotions, and evidence suggests that these emotions can impact care quality and patient safety. Given that nurses play a critical role in providing high quality care, efforts to identify and remedy factors that may compromise care are needed. Yet to date, few experiments have been conducted.

OBJECTIVE

To examine the effects of emotionally evocative patient behavior as well as the presence of mental illness on emergency nurses' emotions, patient assessments, testing advocacy, and written handoffs.

DESIGN

Experimental vignette research.

SETTING

Online experiment distributed via email between October and December 2020.

PARTICIPANTS

Convenience sample of 130 emergency nurses from seven hospitals in the Northeastern United States and one hospital in the mid-Atlantic region in the United States.

METHODS

Nurses completed four multimedia computer-simulated patient encounters in which patient behavior (irritable vs. calm) and mental illness (present vs. absent) were experimentally varied. Nurses reported their emotions and clinical assessments, recommended diagnostic tests, and provided written handoffs. Tests were coded for whether the test would result in a correct diagnosis, and handoffs were coded for negative and positive patient descriptions and the presence of specific clinical information.

RESULTS

Nurses experienced more negative emotions (anger, unease) and reported less engagement when assessing patients exhibiting irritable (vs. calm) behavior. Nurses also judged patients with irritable (vs. calm) behavior as more likely to exaggerate their pain and as poorer historians, and as less likely to cooperate, return to work, and recover. Nurses' handoffs were more likely to communicate negative descriptions of patients with irritable (vs. calm) behavior and omit specific clinical information (e.g., whether tests were ordered, personal information). The presence of mental illness increased unease and sadness and resulted in nurses being less likely to recommend a necessary test for a correct diagnosis.

CONCLUSIONS

Emergency nurses' assessments and handoffs were impacted by patient factors, particularly irritable patient behavior. As nurses are central to the clinical team and experience regular, close contact with patients, the effects of irritable patient behavior on nursing assessments and care practices have important implications. We discuss potential approaches to address these ill effects, including reflexive practice, teamwork, and standardization of handoffs.

TWEETABLE ABSTRACT

Simulated experimental study found that despite having received identical clinical information, emergency nurses believed that patients displaying irritable behaviours were less likely to return to work soon and were less likely to recover than patients who displayed calm behaviour.

Shifting into Action: from Data Segmentation to Equitable Interoperability for Adolescents (and Everyone Else)

BACKGROUND

Technological improvements and, subsequently, the federal 21st Century Cures Act have resulted in increased access to and interoperability of electronic protected health information (ePHI). These not only have many benefits, but also have created unique challenges for privacy and confidentiality for adolescent patients. The inability to granularly protect sensitive data and a lack of standards have resulted in limited confidentiality protection and inequitable access to health information.

OBJECTIVES

This study aimed to understand the challenges to safe, equitable access, and interoperability of ePHI for adolescents and to identify strategies that have been developed, ongoing needs, and work in progress.

METHODS

Shift, a national task force formalized in 2020, is a group of more than 200 expert stakeholder members working to improve functionality to standardize efforts to granularly identify and protect sensitive ePHI to promote equitable interoperability.

RESULTS

Shift has created high-priority clinical use cases and organized challenges into the areas of Standards and Terminology; Usability and Implementation; and Ethics, Legal, and Policy.

CONCLUSION

Current technical standards and value sets of terminology for sensitive data have been immature and inconsistent. Shift, a national diverse working group of stakeholders, is addressing challenges inherent in the protection of privacy and confidentiality for adolescent patients. The diversity of expertise and perspectives has been essential to identify and address these challenges.

Leveraging individual power to improve racial equity in academia

Academia in the United States continues to grapple with its longstanding history of racial discrimination and its active perpetuation of racial disparities. To this end, universities and academic societies must grow in ways that reduce racial minoritization and foster racial equity. What are the effective and long-lasting approaches we as academics should prioritize to promote racial equity in our academic communities? To address this, the authors held a diversity, equity, and inclusion (DEI) panel during the Society for Behavioral Neuroendocrinology 2022 annual meeting, and in the following commentary synthesize the panelists' recommendations for fostering racial equity in the US academic community.