Words are important in medical records.Recent reminders of this truth come from health affairs and JAMA Network This raises potential concerns about racial and ethnic bias in physician files.

According to the study and subsequent media coverage, the overuse of negative terms such as “non-compliant” to describe black and brown patients may affect future caregivers’ perceptions of patients. Furthermore, with patients now having virtually online access to their doctor’s notes, reading clearly derogatory descriptions of themselves would certainly reduce trust.

While bias due to language in medical records is an obvious potential problem, it may be time for a broader review of the way clinicians describe patients in medical records.

The reason for the visit is often referred to as a “complaint”, eg “patient complains of fever”. When a medical student overhears a patient’s medical history on a ward round, it’s not uncommon for the patient to exclaim, “I’m not complaining, I’m just telling you what’s wrong with me.” With the rest of the world Unlike in the exam room, complaints are expected and welcome.

We also talk about “failed” treatments for patients, as in “patients who failed to receive doctor’s care and now see a doctor”. Except for the reality that if a patient does not get significant pain relief from prescribed physical therapy, it is the therapy that is failing the patient, not the other way around.

We often use the term “denial” if a patient reports that they are not a substance user, such as “patient denies using drugs or alcohol.” There is an undercurrent of disbelief in the use of “denial” in most parts of the world, as if clinicians were saying “maybe so, maybe not”. Even if the doctor does not intend to appear suspicious, the patient or other clinician who reads the record may believe it. In the case of substance use or abuse, depending on the situation, the patient may not tell the truth. We also use “denial” to report the absence of various symptoms, such as “patient denies coughing”. If they cough, who knows better than the sick? A physical exam doesn’t need to be described as a cross-check in the medical record, does it?

When a patient cannot or does not want to follow a doctor’s advice, the patient may be called “non-compliant.” We might as well call them “disobedient”. The term smells of condescension and promotes childishness of the patient, which is inappropriate. Its use negates the idea of ??shared decision-making between doctors and patients, where decisions about testing and treatment are made together — and fully informed. Ironically, shared decision-making resulted in patients being more likely to “comply” with the plan.

The use of OpenNotes has increased over the past few years, patients can access physician notes from their medical records online, and is now integrated with the 21st Century Cures Act. Initially, such visits worried physicians, worried—eventually unnecessary—that these online records would lead to a flurry of (non-billing) calls to the office where patients would ask about slightly abnormal lab values ??or the meaning of medical terms . This fear doesn’t seem to materialize in any significant way, in part because patients are not yet fully aware that the notes are being shared.

We have all learned to use specific languages ??as part of our medical training. Maybe it’s time to refresh the language.