Patient chart notes are supposed to accurately reflect the current state, both mentally and physically, of patient status. Whether or not this is the case has never, in any large studies, been put to the test as to its veracity.
Fatigue and overwork have entered the equation, as it always has, and we should have remediation currently, but do we? Hurriedly rushing to complete chart notes is no excuse for including inaccuracy, not including information, or entering unintended bias in an attempt to meet the timely completion of a healthcare professional’s daily workload.
It would seem that electronic records would eliminate powerful and potentially damaging information, or lack thereof, from the chart record.
Patients too often never had access to their records, but that is changing in our new electronic health records decade where patients can access “patient portals” and review what has been immortalized. Formerly, patients had to request hard copies of patient summary visit notes, which weren’t always forthcoming.
One neurologist who didn’t know his summary would be read by a patient who came for a consult presented a dim view of the woman. He referred to her as a “mirthless woman” and proceeded to go downhill from there.
A recent study of 600 encounters with 138 physicians appeared in a prestigious medical journal. The study found six ways that physicians “express part of positive findings toward patients in medical records, including comments, approval, and personalization.”
However, in addition to these laudatory comments, the researchers also found five ways medical professionals “express negative feelings toward patients, including disapproval, discrediting, and stereotyping.”
How may the latter affect those healthcare professionals who read these chart notes in the future? The question almost doesn’t need to be asked because we already know the answer; negatively.
The Power Differential in Healthcare
The current study was revealing in its negative comments, which will affect future readers of these charts.
Negative themes noted in the 600 encounters notes included:
questioning patient credibility
expressing disapproval of patient reasoning or self-care
stereotyping by race or social class
portraying the patient as difficult
emphasizing patient authority over the physician authority over the patient
Physician authority over the patient? Isn’t this supposed to be a working relationship with the patient and the physician, who both come to an understanding? One is not in a position of one up, while the other is always in a one-down position, or are they? Is this an artifact of the study or reality-based in all areas?
It reminded me of a time when I was standing with a family next to the bed of a hearing-impaired woman who was gravely ill. Her hands had been tied to the bed rails, prohibiting her use of ASL. This was done despite a clear sign over her bed which indicated she was hearing-impaired.
A young physician came in and didn’t like that the family told him the patient had not signed consent for treatment and needed to use her hands to communicate. “I don’t care what you say,” he said. “You can talk to me until you’re blue in the face, and I’ll do as I want,” and with that, he stormed off.
After the woman died at another hospital to which she had been transferred once she developed sepsis, the hospital, which a surgeon owned, was charged with insurance fraud (they had an unnecessary surgical procedure gambit running with shelters for men), closed, and opened with a new name afterward. So much for change.
Which groups receive poorer quality of care than others according to certain factors in the medical record? They have included racial/ethnic identity, social class, older adults, individuals with low health literacy, obesity, and substance use disorders. There are also problems in a person’s language ability that can affect medical outcomes.
In one study, 655 emergency medical physicians used the term “sickler” which indicated the patient had sickle cell disease. Language, hearing, or reading ability also contributed to problems in the medical record.
The most recent study also stated that “Readers of stigmatizing (vs. normal) language had more negative attitudes toward the patient and opted to administer less analgesia, even though all clinically relevant information was the same.”
Bias, therefore, was shown even in the administration of pain-relieving medications (the ‘sicklers’) as a result of a note in the chart. Should patients have suffered this way? Undoubtedly, the answer is in the negative. But this was particularly noted in sickle cell disease, which would indicate a racial bias of the writer. Do medical professionals believe that Black patients need less pain medication than white patients? I would advise you review this in the medical literature or is it a question of medical training?
The documentation of any medical information must be devoid of anything but relevant medical information that contributes to the treatment and diagnoses of patients. The problem appears to stem from an inability of supervision in this area because of the crush of business that hospitals have brought on themselves.
How will electronic health records serve as a means to curb this type of behavior? Unless artificial intelligence reaches a level that can clearly distinguish between utilitarian information and unnecessary personal bias, it will continue. The continuance of this heinous behavior is one of which everyone in healthcare must become fully aware.
We must do our best to ensure that records are clearly scientific-based and avoidant of personal biases. There is no excuse for writing records that may damage the patient in the future. In fact, this diminishes the profession as a whole and must be countered; however, we must do it.