Chronic Pain Patients Have Highest Rates of Stigmatizing Language in Medical Records

By Crystal Lindell

Chronic pain patients are the most likely group to find discriminating and judgmental language in their medical records, according to a new study published in JAMA.

The researchers also found that having a low income increased the likelihood of patients finding stigmatizing language in their records. Being older decreased the chances of finding it.

The research is based on a survey of 500 people from a nationally weighted sample of U.S. adults. The study was made possible by passage of the 21st Century Cures Act in 2021, which began a new era of transparency in healthcare by giving patients immediate access to their clinical notes in electronic health records.. 

About 1 in 6 patients (17.1%) reported discriminating or judgmental language (DJL) in their medical records or health care encounters. Such stigmatizing language was defined as any terminology that "conveys disbelief, disapproval, or implicit judgment about a patient’s character, behavior, or social identity.”

Researchers anticipated that medical providers would be more careful about their choice of words, knowing patients might see them. But five years after passage of the Cures Act, there was “little if any improvement” in stigmatizing language.  

“Our findings are consistent with a broader literature on stigma and health communication, demonstrating that DJL can undermine trust, reduce patient engagement, and negatively influence patient perceptions of health outcomes,” wrote lead author Natasha Steele, MD, Stanford University School of Medicine. 

Steele and her colleagues found that patients with chronic pain were 3.25 times more likely to find stigmatizing language in their medical notes, compared to people who did not have chronic pain. It was the highest rate of any group in the study.

Low-income patients were 2.64 times more likely to find discriminating and judgmental language, compared to other income groups.

Interestingly, older people were slightly less likely to find stigmatizing language compared to other age groups. For each additional year of age, the odds of finding it dropped by about 2%.

Beyond that, the researchers did not find links between gender, race, ethnicity, or educational level and the likelihood of patients finding stigmatizing language.

Not surprisingly, finding negative language in their medical records made patients less likely to trust that their medical providers were doing a good job of documenting their health issues. 

About 85 percent of patients said they were less likely to see that clinician again and 75% worried it would influence their treatment. A similar percentage thought it would lead to worse health outcomes, including the possibility of medication or diagnostic errors. 

The stigmatizing language was also associated with nearly 6-fold higher odds of diminished trust in clinicians to write accurate and respectful notes.

The researchers said that while health record transparency is a good thing, clinicians need to change their note-take practices in response.

“Our study demonstrates the need for clear standards promoting respectful communication in both medical documentation and clinical interactions. Clinical training programs should emphasize person-centered language, particularly since written notes are increasingly visible to patients, with special attention to populations that may be subject to bias based on social identity,” they said.

Acetaminophen May Slow Language Development

By Pat Anson, Editor

Another study has linked acetaminophen to learning difficulties in young children born to mothers who used the over-the-counter pain reliever during pregnancy.

Researchers at the Icahn School of Medicine in New York City say toddlers exposed to acetaminophen in the womb had a slower rate of language development at 30 months. The findings are consistent with other studies reporting higher rates of autism, attention deficit disorder (ADHD) and behavioral problems in children born to mothers who used acetaminophen while pregnant.  

Acetaminophen (paracetamol) is one of the most widely used pain relievers in the world. It is the active ingredient in Tylenol, Excedrin, and hundreds of other pain medications. Researchers say over half the pregnant women in the United States and European Union use the drug.

“Given the prevalence of prenatal acetaminophen use and the importance of language development, our findings, if replicated, suggest that pregnant women should limit their use of this analgesic during pregnancy,” said senior author Shanna Swan, PhD, Professor of Environmental and Public Health at the Icahn School of Medicine at Mount Sinai.

“It’s important for us to look at language development because it has shown to be predictive of other neurodevelopmental problems in children.”

The study involved 754 women who enrolled in the Swedish Environmental Longitudinal, Mother and Child, Asthma and Allergy study (SELMA) during weeks 8-13 of their pregnancy. Researchers asked the women to report the number of acetaminophen tablets they took between conception and enrollment, and tested the acetaminophen concentration in their urine.

A delay in a child's language development, defined as the use of fewer than 50 words at 30 months of age, was measured by a nurse and a follow-up questionnaire filled out by the mothers.

Girls born to mothers with high exposure -- those who took acetaminophen more than six times in early pregnancy -- were nearly six times more likely to have language delay than girls born to mothers who did not take acetaminophen.

While the number of acetaminophen tablets and concentration in urine were associated with a significant increase in language delay in girls, there was only a slight increase in boys.  The findings suggest that acetaminophen use in pregnancy results in the loss of the well-recognized female advantage in language development in early childhood.

The study is published online in the journal European Psychiatry. Researchers will follow-up with the children and re-examine their language development at age seven.

A 2016 study of over 2,600 Spanish women linked acetaminophen to autism and attention deficit problems in their children. Studies in Denmark and New Zealand have also linked acetaminophen to a higher risk of ADHD.

Over 50 million people in the U.S. use acetaminophen each week to treat pain and fever. The pain reliever has long been associated with liver injury and allergic reactions such as skin rash. In the U.S. over 50,000 emergency room visits each year are caused by acetaminophen, including 25,000 hospitalizations and 450 deaths.