Clinical Documentation, Racism, and Health Inequity

Kenny Lin, MD, MPH
Posted on June 24, 2024

Poor treatment by a clinician leads to suspicion of the motives of the health care system, increasing one’s reluctance to seek necessary care and the risk of a having an uncomfortable health care interaction in the future. For many patients—particularly those who identify with one or more racial, sexual, gender, and religious minority groups—this vicious cycle often leads to worse health outcomes.

A Lown Right Care article in the June 2024 issue of American Family Physician addresses the consequences of stigmatizing clinical documentation. In the case scenario, a patient feels stereotyped by his new primary care physician, who incorrectly describes him as African American (he self-identifies as Dominican Hispanic) and noncompliant for not filling a prescription or seeing a subspecialist he could not afford. Drs. Alan Roth and Andy Lazris explain how this language could negatively affect encounters with other clinicians:

Patients who identify as Black are more likely than those who identify as White to have comments using negative words or connotations in their history and physical documentation and may be subject to systemic bias in physicians' perceptions of their credibility.… The stigmatizing language used to describe patients in medical records can influence other clinicians and physicians-in-training in their attitudes toward the patient and their medication-prescribing behavior. This is an important and potentially damaging pathway by which bias can be propagated from one clinician to another.

In a previous AFP editorial, Drs. Megan Healy and Khameer Kidia presented several strategies to reduce bias and avoid stigmatizing language in medical records and other clinical communications. These strategies include not using labels, not blaming patients for their conditions, and not beginning presentations with race, ethnicity, language, socioeconomic status, or other social identifiers that may activate unconscious bias.

In 2021, a controversial JAMA social media post questioned the existence of structural racism and made the incredible claim that “no physician is racist.” This unfortunate episode contrasted with AFP’s active approach to advancing health equity, including sharing and promoting antiracist practices. Nonetheless, the medical profession has a long way to go to align its behaviors with its ideals. In a first-person narrative published in last week’s New England Journal of Medicine, a Black health equity researcher visiting the emergency department receives callous treatment from two nurses and is mocked by a physician for suggesting that her area of expertise had something to do with the indifferent care she received. Making excuses for the health professionals involved (e.g., the emergency department was overcrowded, the nurses were tired and harried, the doctor was just having a bad day) amounts to being part of the problem. Instead, family physicians and other primary care clinicians can choose to be part of the solution to eliminating health inequities in kidney transplant, infertility care, skin conditions, asthma and lung diseases, cardiovascular disease, end-of-life care, and preventive care, among others.