More than 500,000 patients leave US hospitals each year against medical advice (AMA), in the process facing risks for readmission and bad outcomes.
Now, add the risk of feeling stigmatized to the list, as researchers who took a closer look at the notes documenting those discharges found the language and tone physicians use often less than supportive and sometimes even angry and ridiculing. The notes often take on a paternalistic or judgmental stance or a defensive attitude, and that can bias future healthcare providers reading them against the patients, as well as discourage the patients from returning for care, the researchers said.
Mary Catherine Beach, MD, MPH
“Our analysis joins a growing body of evidence that linguistic choices made by clinicians in the medical record can convey negative attitudes toward patients,” the researchers wrote.
“In some ways, this paper is meant to be a call to arms, to rethink how we think about patients who don’t take our advice,” senior author Mary Catherine Beach, MD, MPH, professor of medicine at Johns Hopkins University School of Medicine, Baltimore, told Medscape Medical News.
While previous research has looked at patient characteristics associated with AMA discharges, much less attention has been focused on the interpersonal clinician-patient dynamics that end in an unadvised discharge, as this new research does.
‘He Said He Could Take His Own Advice’ and Other Stories
Beach and her colleagues analyzed the notes, looking at what was written and what was documented about the patient and the interaction, as well as howit was written in terms of word choices and how they convey the writer’s stance toward the patient or the events unfolding.
The data source was the clinical documentation from 362 hospitalizations that ended in an AMA discharge at an urban academic medical center.
Most (90%) of the 185 notes evaluated were written by hospitalists and other physicians, with the remainder written by nurses, social workers, and other healthcare providers.
Negative portrayals of patients often were evident through the healthcare providers’ descriptions of anger, ignorance, and unreliability of the patient. For instance, some notes described a patient’s threat to trash a room or patients yelling or becoming verbally abusive. One complained that the patient kept interrupting. One note was “conveyed with subtle ridicule” by stating that the patient said he “can take his own advice.”
Another included a description of what a physician called the patient’s long, curse-laden diatribe claiming he was not a “dope fiend.”
While the data for the study itself was collected in 2017, “My sense is that this is still a problem,” Beach said. “On the plus side, I think there is an increasing awareness in the health professions about the power of language.” However, “I don’t know if that’s made a demonstrable impact in how we document and talk about patients, but I think it probably will, and I think it has probably started to.”
How to Lessen Negativity
To lessen the stigma and negativity, Beach and her colleagues provide many examples of how to soften the language and what’s best left out when documenting the patient’s decision to leave.
Coping with AMA discharges are challenging, as Beach knows from her own experiences. “It’s frustrating for both sides,” she said. Often, the clinicians really care about the person they worked hard to get better, she said. When the patient decides to leave against professional advice, the physician can feel worried or unappreciated, she said. “Or they feel judgmental, like that person is making a terrible decision.”
Writing notes in more neutral language is the goal, she said. For instance, “you might consider putting in why the person decided to leave, if they told you,” she said, while omitting phrases like they demanded to leave or insist on leaving. Instead of writing “The nurse notified me of her demand to leave AMA,” better write “Patient wanted to leave immediately.”
If patients don’t want to talk about why they made the decision, “the best thing to do [in the notes] is to leave it alone,” Beach said, rather than saying they refused to say. “They don’t really owe us an explanation.”
Among the worst language the researchers found in the notes, Beach said, are those that told the departing patients they can’t come back, which she terms “awful.”
Healthcare providers who care for the patient in the future and read the stigmatizing language may form negative attitudes towards the patient and even manage pain less aggressively.
Beach said if she read notes documenting an abusive, angry person, she would like to think of herself as a good enough person that it would not affect her care of them. “But in reality, I would read that and think, ‘Oh no, I don’t really want to see that person.’”
Her bottom line: “Give them a little grace. When people are signing out at the hospital, they are often not at their best.”
The best example of positivity, Beach found, was this note about a departing patient: “Although she left her belongings in the room — and I do hope she returns to the hospital — we cannot hold her bed any longer.”
As for healthcare providers who are angry over the AMA discharge decision, she said: “Part of this just represents the way we view people who don’t take our advice.”
Expert: ‘Clinicians Are Looking for Recommendations’
Veronica Barcelona, PhD, MSN, RN
“This is a new area of research, and in my experience, clinicians are looking for clear recommendations on what language to avoid, and, more importantly, what language to use in its place,” said Veronica Barcelona, PhD, MSN, RN, assistant professor at Columbia University School of Nursing who has also researched the effects of stigmatizing language in electronic health records (EHRs).
She found that stigmatizing language in clinical notes affected birth outcomes, after analyzing data in the EHRs of nearly 19,000 women admitted to two US hospitals from 2017 to 2019 for childbirth.
Compared with patients whose EHRs had no stigmatizing language, those with any had a 36% higher risk for cesarean birth (adjusted odds ratio, 1.36; 95% CI, 1.23-1.50; P < .01), as well as higher risks for postpartum hemorrhage and chorioamnionitis.
Barcelona’s advised, “My recommendation is for clinicians to chart as if the patient is looking over their shoulder, not a lawyer, as many of us were taught in school. As patients have more access to reading their own electronic health records online, clinicians should focus on documentation practices that are patient-centered and respect patient autonomy.”
Beach and Barcelona had no disclosures.
The study was supported in part by Robert Wood Johnson Foundation and the National Institute on Minority Health and Health Disparities.