How do you suggest that information about a patient’s nonadherence or anger, for example, be conveyed to the next clinician reader? What language do you recommend?

People always have reasons for their anger, mistrust of physicians or the medical establishment, or nonadherence. Sometimes, these reasons are not clear, sometimes you disagree with their reasons, but it is important to try to understand them and convey them in as neutral a way as possible. For example, “Mrs Smith has a complex family situation and finds it difficult to incorporate adhering to the treatment plan we put in place.”

What do you think contributes to the use of negative language toward patients?

I think that physicians’ stress and burnout are contributors. I also think it is natural and human to be frustrated, and that doesn’t necessarily come from a bad place. As physicians, we are invested in the wellbeing of our patients and we can feel frustrated when they are nonadherent to a helpful treatment regimen, for example. The problem is that sometimes we vent this frustration in the medical records.

How do you think physicians might address this?

I think the key is to see this type of writing as a wake-up call to remind ourselves that we are frustrated or burned out and take a second to think before writing.

Your analysis also included positive language. What types of positive language did you find?

We found that physicians’ positive language was more explicit than their negative language and included 6 categories: compliments, approval, self-disclosure, minimizing blame, personalization, and collaborative decision-making.

These positive sentiments also have the potential to influence the attitude of behavior of other clinicians who read those notes, and to contribute to improved clinician-patient interactions in the future.

What limitations did your analysis have?

My coauthors and I noted several limitations. One is that the data were collected from an ambulatory internal medicine setting at an urban academic center, and may not be generalizable to other specialties or settings. Moreover, we did not have data on the personal characteristics of the physician writers, such as age, gender, race/ethnicity, or training status (resident vs attending)—characteristics that may be important factors associated with how language is used. It would have been valuable to also know the racial/ethnic or gender concordance between the patient and the clinician.

It is also not known whether patients are able to detect the emotional and attitudinal tone of their clinicians, and their impact on the quality of subsequent care. Lastly, since we could not know the actual attitudes of the clinicians authoring the reports, or the attitudes and reactions of subsequent readers, we cannot verify all of our results and assumptions. We hope that this study will spur future research to investigate these questions.


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