We in healthcare education invest a great deal of time in teaching our learners how to communicate with patients. Use PEARLS to convey empathy. Lean into the patient. Never stand above the patient. Soften your tone and slow down when delivering bad news. How much do we think and teach about writing effective, compassionate and ethical notes? Ethical, compassionate charting that is free from bias is a topic that has recently received some attention since patients now have access to our electronic notes as soon as we sign them.
Fact #1: Words have power and the chart is no exception. The chart note “has a plot and perhaps a subplot … It demonstrates the power, and perhaps the prejudice, of providers and the cooperation, compliance, or obstinacy of patient or family … The chart note author is also a character in the unfolding narrative” (Dubler and Liebman, 2011).
Fact #2: We all have biases. The majority of the time, it’s unconscious, so we aren’t tapped into it. We don’t notice it when it inadvertently manifests itself in our words or written paragraphs. Bias also includes use antiquate terms to describe physical exam findings (like the racist term Mongolian spots) – they are such a part of the majority culture, that we don’t even realize it.
Combine these two facts and we have the potential to significantly harm and alienate our patients and their families. Why? Because the language that we use in the chart paints a picture before others even see the patient and before they can make a judgement for themselves. It has the potential to covertly signal whether the patient is trustworthy, deserving, or “good.” The subtle words we choose to write in the chart can suggest infantilization, dominance, or antagonism. The “characters” in our narrative have no power over their story because we as transcribers prioritize bits of the patient’s information and make it our own. The chart note is another way in which the power asymmetry between healthcare professional and patient is reinforced. Real-time transparency through the 21st Century Cures Act has put an exclamation point on this issue. We are not the purely objective scientists we claim to be. We arrive at the patient interaction with the baggage of our own cultures, shortcomings and biases.
Take for example the phrase “…delightful, but refuses everything we offer him.” It has a duplicitous meaning. Delightful, on the surface, sounds benign, but in reality, it’s an infantilizing term — one that we typically use to describe young children. “Refuses everything” implies that our dominance and authority has been questioned. Instead a more even-handed charting practice would be to describe precisely what the patient is declining, followed immediately with an explanation as to why the patient might refuse. If we don’t dig deeper to find meaning behind the patient’s actions, we run the risk of the patient being viewed as difficult or oppositional indefinitely in the chart, thus negatively influencing the views of all the healthcare providers who follow up with the patient in the future. The cycle never ends.
Another example is “…not sure if the medication will help him, given his continual non-compliance…” We learned this term in medical school and have not been able shake it. Those more savvy healthcare providers have substituted this term for the more benign “non-adherence,” but we all know it means the same thing. Non-compliance again implies our dominance in the clinical interaction. Of course we have clinical expertise, but creating an alliance with our patient is likely to engender better outcomes — AND it’s more rewarding for us. A better way to convey the communication with this patient might be: “Barriers to following the medical regimen, which we discussed today, include…” Why? Because there is usually a barrier (or several) to being able to adhere to medical advice. Oftentimes, our questioning might reveal that the patient has differing cultural values, financial barriers, or low health literacy. I could list all of the social determinants here.
In addition, it is important to re-examine how we think about adherence. We often think of it in dichotomous terms. “You either follow my directions or you don’t.” In reality, adherence is often more complex and a matter of degree. It improves at times or may get worse, depending on the varied life circumstances and stressors that our patients experience. When we are tapped into their stressors, we approach the chart with a deeper understanding. The chart can be a tool for partnership with the patient when we document with humility and compassion. Recognizing our role in crafting a version of the patient narrative or in the utilization of antiquated terms is important to moving towards equity and bias-free charting.
Being aware of the language we use in the chart requires us to be aware of our own emotions and biases. The ability to change lifelong habits and rethink the way we document also requires work, which sounds daunting. Can we really add on more work with documentation? We will offer a re-frame: Healthcare professionals signed up to take care of patients because it taps into the empathic spirit of our character — it gives our work meaning when patients know that we are on their side of the court. Re-imagining our charting process using more just and ethical language affirms for our patients and ourselves that commitment to empathy.
Dr. Tariq is a Professor in the Department of Internal Medicine and Associate Dean for Student Affairs at the University of Arkansas for Medical Sciences. She spent 15 years teaching the Practice of Medicine II course and currently teaches content on social determinants of health and the health consequences of systemic racism. She serves as faculty in the division of diversity, equity and inclusion and regularly leads workshops on implicit bias.
Dr. Laura Guidry-Grimes is Assistant Professor of Medical Humanities and Bioethics at the University of Arkansas for Medical Sciences, and she serves as a clinical ethics consultant for UAMS and Arkansas Children’s Hospital. She participates in several initiatives of the Division of Diversity, Equity and Inclusion, including leading implicit bias training.
Bibliography
- Herrera, Pablo A., L. Monada, Denise Defey. “Understanding Non-Adherence from the Inside: Hypertensive Patients’ Motivations for Adhering and Not Adhering.” Qualitative Health Research 27.7 (2017): 1023-1034.
- Dubler, Nancy, Liebman, Carol. Bioethics Mediation: A Guide to Shaping Shared Solutions. United Hospital Fund of New York, 2011.