Doctors and providers routinely add notes to medical records indicating whether the patient is likely to follow up on their medical advice. Charts may contain key descriptors like “noncompliant” or “non-adherent,” which shows the provider that the patient has a history of exhibiting problematic behaviors.
However, a new study shows that doctors are more likely to ascribe these characteristics to black patients than those that are white.
“Seeing” Patients
The study looked at more than 40,000 notes added to the medical records of 18,459 adult patients at a medical center in Chicago from January 2019 to October 2020. Around 8% of all patients had derogatory terms in their records, with the most common being “refused,” “not adherent,” “not compliant” and “agitated.”
“It’s not so much whether you should never use these words, but why are we applying these words with so much more frequency to black patients?” said Michael Sun, the lead author of the study and a third-year medical school student at the University of Chicago’s Pritzker School of Medicine. “Do we really believe black patients are truly not compliant, so many more times than white patients?”
Sun and the other authors of the study argue that providers should consider additional factors that may affect the patient’s ability to follow through on medical advice, such as financial barriers, transportation issues, and scheduling conflicts, rather than labeling patients as non-compliant.
“In medicine, we tend to label people in derogatory ways when we don’t truly ‘see’ them — when we don’t know them or understand them,” said Dr. Dean Schillinger, director of the Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, who was not involved in the studies. “The process of labeling provides a convenient shortcut that leads some physicians to blame the patient for their illnesses.”
The researchers also found that outpatient clinics were far less likely to use these negative descriptions in medical records compared to those found in hospitals and ER clinics. That may be due to the fact that these clinics are more familiar with the circumstances their patients are facing.
Single and unmarried patients were also more likely to have negative terms in their medical records than married patients. Doctors were also more likely to apply these terms to uninsured patients and those on government health plans like Medicare and Medicaid than those with private health insurance.
Patients with chronic health conditions were more than twice as likely to have these words in their charts than healthy patients.
Around 2.5% of all notes contained terms like “nonadherence,” “noncompliance,” “failed” or “failure,” “refuses” or “refused,” and, on occasion, “combative” or “argumentative.” Just 2.6% of white patients had these terms on their charts compared to 3.15% of black patients.
When looking at 8,700 notes on patients with diabetes, 6,100 notes on patients with substance abuse issues, and 5,100 notes on those with chronic pain, the researchers found that diabetes was often referred to as a “lifestyle”. Nearly 7% of patients with diabetes were described as noncompliant, having an “uncontrolled” disease, or to have “failed.”
Just 3.4% of patients with substance use disorders had negative terms in their medical records and fewer than 1% of patients with chronic pain had notes with negative descriptions.
The authors warn that these terms can follow patients around for years.
Dr. Gracie Himmelstein, the paper’s first author, said the patient’s chart is often the first thing the provider sees. It creates a strong first impression that can be hard to counteract.
“Before I even go meet a patient in the emergency room, the first thing I do is call up their record and read through the previous admission notes and get a sense of their history,” said Dr. Himmelstein, a resident physician at the University of California, Los Angeles, who carried out the research as part of her doctoral thesis at Princeton University. “I’m looking to see what their medical problems are, but as I do so, I’m also reading a narrative of their interactions with previous physicians.”
She wants doctors to think about what kinds of obstacles their patients may be facing when seeking medical care.
“If the patient is, quote-unquote ‘noncompliant’ with the regimen, what is going on?” she said. “It’s hard for people to manage insulin. It can be prohibitively expensive. There can be issues around health literacy. We need to pinpoint where that problem is.”
These terms can affect how a patient is treated for years to come. It can also affect the provider’s judgment and lead to a lack of empathy.
“Patients whose physicians tend to judge, blame or vilify them are much less likely to have trust in their doctors, and in the medical system overall,” Dr. Schillinger said. “Having health care providers who are trustworthy — who earn their patients’ trust by not judging them unfairly — is critical to ensuring optimal health and eliminating health disparities.”
