Where We Stand
Section: Health Care Delivery
Policy: Person-Centered Language in Medical Records
Appendix Z
Language used to describe patients in medical documentation can perpetuate bias, influence clinical decision-making, and contribute to healthcare disparities.1 Language and communication about our patients must align with our commitment to equitable, patient-centered care. The Oregon Medical Association (OMA) strongly endorses the use of person-first, equity-focused language in patient medical records. Our stance reflects a commitment to ensuring that all individuals are treated with dignity, respect, and humanity. Person-first language in healthcare prioritizes the individual over their condition, aiming to treat patients with respect and reduce stigma emphasizing their humanity and discouraging bias.
The Impact of Stigmatizing Language in Medical Records
Research demonstrates that stigmatizing language in medical records such as "non-compliant" or "substance abuser," negatively impact the attitudes and behaviors of clinicians, perpetuating bias and reducing the quality of care. Such language may transmit and reinforce these biases amongst other clinicians and potentially affect treatment decisions.2 When stigmatizing language is present in medical documentation, clinicians are more likely to form negative attitudes toward the patient, offer less aggressive pain management, and make punitive judgments.2
Person-First Language for Health Equity
OMA advocates for person-first language in medical records to counter these negative biases. This approach emphasizes the person before the diagnosis or condition, helping to preserve the patient’s dignity and avoiding the depersonalization often caused by labels. For example, rather than referring to a patient as a "diabetic" or a "substance abuser," we encourage clinicians to describe the patient as "a person living with diabetes" or "a person with a substance use disorder." This subtle shift in language fosters more compassionate care and aligns with the OMA goal of reducing health disparities.
It is also essential to recognize that while person-first language is generally appropriate, certain individuals may prefer identity-first language. For example, individuals within the autistic and deaf communities may opt for terms such as 'Autistic person' or 'Deaf person,' reflecting a sense of identity and culture. Preferences can vary even within communities, underscoring the need for clinicians to engage in patient-centered communication and inquire about individual language preferences to ensure respectful and personalized care.3
Avoiding Blame and Bias in Documentation
Stigmatizing language, such as terms like "non-compliant" or "uncooperative" often places undue responsibility or blame on patients for their health conditions without considering external factors, such as social determinants of health. This language can overlook barriers such as transportation, financial challenges, or access to healthcare and undermine trust between patients and clinicians.
OMA advocates for documentation practices that recognize the structural barriers affecting patients' choices. For instance, instead of labeling a patient as "non-compliant," clinicians could document, "Patient unable to attend clinic due to lack of transportation." This allows healthcare teams to better understand and address the root causes of health inequities and promotes solutions-oriented care.
As medicine shifts towards a collaborative, patient-centered model, clinicians should use language that supports and respects patient autonomy. Communication should refrain from conveying personal disapproval of patient choices or unnecessarily questioning their credibility, ensuring interactions that empower and validate patients' perspectives and lived experiences.
Reducing the Transmission of Bias
Medical records serve as the primary communication tool among clinicians. The language used within them can perpetuate bias across care teams, disproportionately impacting economically or socially marginalized communities. Patients of color, especially Black patients4, are disproportionately more likely to have stigmatizing language documented in their records. Such language can lead to diminished trust, compromised patient and healthcare team relationships, and poorer health outcomes5. Using respectful, objective language minimizes the transmission of bias and ensures that care is fair, equitable, and free from stigma.
Citations
- Kelly, John F, and Cassandra M Westerhoff. “Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms.” The International journal on drug policy vol. 21,3 (2010): 202-7. doi:10.1016/j.drugpo.2009.10.010
- P Goddu, Anna et al. “Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record.” Journal of general internal medicine vol. 33,5 (2018): 685-691. doi:10.1007/s11606-017-4289-2
- Healy, Megan et al. “How to Reduce Stigma and Bias in Clinical Communication: a Narrative Review.” Journal of general internal medicine vol. 37,10 (2022): 2533-2540. doi:10.1007/s11606-022-07609-y
- Himmelstein, Gracie et al. “Examination of Stigmatizing Language in the Electronic Health Record.” JAMA network open vol. 5,1 e2144967. (2022), doi:10.1001/jamanetworkopen.2021.44967
- Fernández, Leonor et al. “Words Matter: What Do Patients Find Judgmental or Offensive in Outpatient Notes?.” Journal of general internal medicine vol. 36,9 (2021): 2571-2578. doi:10.1007/s11606-020-06432-7