As more patients gain access to their medical records and healthcare providers' notes, clinicians should practice using more "human-centered" and empathetic language when documenting patient encounters in the EHR, according to Jonathan Cartsonis, MD, and Michael Zirulnik, PhD.
In an op-ed for Vice, Dr. Cartsonis, a rural health professor at University of Arizona's College of Medicine in Phoenix, and Dr. Zirulnik, a communication scholar and consultant at The Varsity Project, described the risks that come with transparency of patients' medical records. Patients' increased access to clinical notes is attributed largely in part to OpenNotes, an international movement that encourages healthcare providers to share clinical notes with patients online through secure patient portals, according to Drs. Cartonis and Zirulnik.
"Medical practitioners often use professional language that is pejorative, paternalistic, accusatory, and aggressive — revealing a power dynamic between [physician] and patient that can disrupt therapeutic relationships and affect how patients are cared for," Drs. Cartsonis and Zirulnik wrote.
The co-authors offered various instances of medical language laced with "troubling" terms. One example of a medical note may read, "'The patient denied skipping doses of the prescribed antibiotic though non-compliance is suspected…'." Drs. Cartsonis and Zirulnik argued that while the words "denied" and "noncompliance" are terms used in the medical profession, they can be interpreted as describing patients "and their accounts, as unreliable and untrustworthy."
To avoid any unintentional accusatory implications from terms used in clinical notes, clinicians should use empathetic and human-centered language. Drs. Cartsonis and Zirulnik provided the following alternative example to the previous clinical note: "Patient states they took all of their doses. I suspect that doses of medication have been missed, as clinical findings do not correlate with outcomes."
The use of humane language may translate to improved health outcomes, such as the provider discovering patient factors such as the individual may have dementia or be experiencing personal or financial stressors that have affected the individual's ability to purchase or consume the recommended medication.
To improve patient happiness and medical care, the healthcare providers will "have to reconsider what language we teach in medical schools, and what colloquialisms we'll support in the practice of medicine," Drs. Cartsonis and Zirulnik concluded.