Race and Ethnicity and Clinician Linguistic Expressions of Doubt in Hospital Admission Notes

IMPORTANCE: Stigmatizing language in electronic health records (EHRs) can generate or reinforce negative stereotypes about patients from minoritized groups and erode their trust and experience. However, less is known about the use of such language to cast doubt on patient clinical history in hospital settings.

OBJECTIVE: To compare the prevalence of language expressing doubt about patient clinical history (eg, experiences and symptoms) in hospital admission notes by patient race and ethnicity.

DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, natural language processing tools were applied to analyze 54 936 admission notes from 1249 clinicians about patients aged 18 years or older at admission and hospitalized at an academic health system in the Northeast US between January 1, 2018, and February 28, 2023. Data were analyzed from September 1, 2022, to July 31, 2023.

EXPOSURE: Patient race and ethnicity (non-Hispanic Black, non-Hispanic White, and racial and ethnic minoritized groups excluding non-Hispanic Black [includes multiple racial and ethnic groups, such as Hispanic and Asian]) as recorded in the EHR based on self-report or registrar determination.

MAIN OUTCOME AND MEASURE: Binary indicator for at least 1 term casting doubt on patient clinical history was defined using epistemic stance, a linguistic construct expressing a writer’s degree of certainty in information. Terms were manually validated via iterative review of notes by the study team.

RESULTS: Among 56 325 admission notes (mean [SD] age of patients, 55.9 [19.0] years; 30 913 notes among female patients [54.9%]; 25 649 notes among non-Hispanic Black patients [45.5%], 26 442 notes among non-Hispanic White patients [46.9%], and 2985 notes among members of racial and ethnic minoritized groups excluding non-Hispanic Black patients [5.3%]), we analyzed 54 936 admission notes that had no missing data. Among all analyzed admission notes, 39 023 notes (71.0%) contained doubt language. Notes written about non-Hispanic Black patients had increased odds of containing at least 1 word or phrase of doubt (adjusted odds ratio, 1.21; 95% CI, 1.14-1.28; P < .001) compared with notes among non-Hispanic White patients. Compared with notes among non-Hispanic White patients, notes written about members of racial and ethnic minoritized groups excluding non-Hispanic Black patients had similar odds of containing at least 1 term of doubt.

CONCLUSION AND RELEVANCE: In this study, language casting doubt on patient clinical history was more likely to be found in notes of non-Hispanic Black patients. These results suggest that with the implementation of policies allowing patients full access to their health records, examining clinical documentation standards may be associated with improved patient experience.

Matt Slap Pilot Research Grant (Division of General Internal Medicine, University of Pennsylvania)
Resource Center for Minority Aging Research of the National Institutes of Health

Courtney R Lee, Jaya Aysola, Xinwei Chen, Eden Addisu, Ari Klein, Davy Weissenbacher, Graciela Gonzalez-Hernandez, Gary E Weissman