Goddu AP, O'Conor KJ, Lanzkron S, et al. Do words matter? Stigmatizing language and the transmission of bias in the medical record. J Gen Intern Med. 2018; doi: 10.1007/s11606-017-4289-2. [Epub ahead of print].

For hematologists providing care for children and adults with sickle cell disease (SCD), we frequently must counsel our colleagues not to use terms that are considered pejorative, such as sickler or frequent flyer when describing individuals with SCD. Individuals with SCD consider the term sickler to be derogatory, particularly because the term reduces their existence to a disease.1  Based on the belief that such terms dehumanize the individual with SCD, the SCD community has worked hard to limit their use. There are data to support such care with terminology: Dr. Jeffrey Glassberg and colleagues conducted a survey of 655 emergency department physicians from 49 U.S. states.2  The results serve as compelling evidence that the term sickler is associated with negative physician attitudes and lower adherence to evidence-based guidelines for acute care in the emergency department.2 

In a randomized controlled trial of medical students and residents (n=413), Dr. Anna P. Goddu and colleagues tested the hypothesis that after reading a medical record note using stigmatizing language, trainees would treat the patient’s pain less aggressively than trainees who read a chart note using neutral language. The definition of stigmatizing language was defined as having any one of the following three features: 1) casting doubt on the patient’s pain (e.g. “insisting that his pain is ‘still a 10’” vs. still has 10/10 pain); 2) portraying the patient negatively (with irrelevant or unnecessary indicators of lower socioeconomic status such as “hanging out with friends outside McDonald’s”); and 3) implying patient responsibility with references to uncooperativeness (e.g., “he refuses his oxygen mask” vs. “he is not tolerating the oxygen mask”). Reading the stigmatizing language in the medical record resulted in a hypothetical, less aggressive management of the patient’s pain when compared to reading a note that was neutral but that contained the same pertinent medical information (5.56 stigmatizing vs. 6.22 neutral; p=0.003) when using two multiple choice questions (complain range of 2-7, representing intensity of pain treatment). Reading the stigmatizing language also resulted in more negative attitudes about the patient with SCD in acute pain (20.6 stigmatizing vs. 25.6 neutral; p=0.001) when using the validated Positive Attitudes towards Sickle Cell Patients Scale (range, 7-35).

In summary, the results of the randomized controlled trial by Dr. Goddu and colleagues provides evidence that derogatory written words in the medical records likely result in less-than-optimal treatment of acute vaso-occlusive pain in adults with SCD. An equally important but nuanced message from the trial is the undue influence of medical attendings who elect not to correct the written and oral language stigmatizing children and adults with acute vaso-occlusive pain. Rarely in medicine do we have clear messages of teaching opportunities that make a true difference in how we manage acute vaso-occlusive pain, but we have one now. When stigmatizing language is used among our peers and trainees, we should correct the oral and written disapproving language. We should also reinforce the proper use of oral and written language when referring to individuals with not only SCD, but any disease, and highlight this strategy as a component of compassionate medical care. Studies like this highlight that being a good physician is not just about choosing the right medication, but also about selecting the right words.

1.
Alleyne J, Thomas VJ.
The management of sickle cell crisis pain as experienced by patients and their carers.
J Adv Nurs.
1994;19:725-732.
https://www.ncbi.nlm.nih.gov/pubmed/8021394
2.
Glassberg J, Tanabe P, Richardson L, et al.
Among emergency physicians, use of the term "sickler" is associated with negative attitudes toward people with sickle cell disease.
Am J Hematol.
2013;88:532-533.
https://www.ncbi.nlm.nih.gov/pubmed/23526459

Competing Interests

Dr. DeBaun indicated no relevant conflicts of interest.