Human, too.

By Allie Howard

Hi. My name is Allie. I am currently a Dietetic Intern at Saint Louis University and I wanted to take a moment to tell you a bit about an experience I had this year that helped shape my view of patient-centered care. I am going to warn you that I had trouble articulating my thoughts into anything that made any sort of sense - I still wish it was possible to just plug my brain into my computer so it could spit out exactly what I was thinking in perfectly flowing sentences. (Refer to picture showing the inside of my scattered brain and the idea process for this blog)

I want to talk about an experience I had with a patient that made me think deeper into the implicit biases we form in health care based on the Electronic Medical Record (EMR). For background purposes, most charting in hospitals and doctors offices have switched from paper to electronic in the past several years. This allows providers to receive real-time results from other medical offices with the click of a button. It safely stores all patient information, lab results, medical history, medications, office visit summaries, etc. in one central location that can be accessed at any computer on the medical campus. There are far more pros than cons to this new electronic system, however, there are still some major downfalls, specifically how easy it is to form implicit biases of patients based on their EMR alone before even meeting them.

Any professional who visits the patient has access to their EMR and the documentation on that patient. Stigmatizing language used in medical charts can foster implicit bias among medical professionals. For example, “drug abuser” vs. “substance use disorder” can prompt different impressions about the patient. One study published in 2018 explored the spreading of bias between clinicians through language documentation in the medical record. The study found significant results that physicians exposed to medical charts with stigmatizing language had more negative attitudes toward their patients and treated less aggressively than physicians that reviewed medical charts with neutral language. With that in mind, I will tell you about my patient interaction. Read on, humans….

The back story.

During the first rotation of my dietetic internship, I was looking into a patient’s chart that I would go see later that day. Just from reading this, I formed an idea of what this patient would be like. Here is what I remember reading:

Patient is 22 year-old male admitted for diabetic ketoacidosis. Multiple previous admissions this year. Blood sugars running 600 and above. Hemoglobin A1c > 16.0%. Non-compliant with medication.

Just from reading this, I was able to give my preceptor a summary of what I already knew about this patient right before going in to see him: “He is a non-compliant, 22 year-old guy with a HbA1c >16.0%.” This one sentence painted the entire picture of this HUMAN on the other side of the door. Now, reading between the lines of this one sentence, I was essentially telling her that I didn’t expect much of this interaction. There was no way I was going to make a change when he had been here before and the same things happened over and over. My biases clouded my ability go in with a blank canvas and get to know this patient human-to-human.

So...did you go in?

Glad you asked! Yes, I did. I walked into a room with a young, thin male about my age laying in a hospital bed with his mother next to him. As soon as I saw him, I wanted to know his story and the humanness behind what the chart had told me. This patient was diagnosed with type 1 diabetes at age 18; and for those 18 years he was a healthy, carefree, active young man living without everyday fear for his health. He had been taking his insulin for a while, but the family had recently lost their insurance and could no longer afford it. He worked full-time at the YMCA and played pick-up basketball with his buddies everyday after his shift. Playing sports was what he looked forward to and kept him smiling, and this disease was not going to stop him from doing what he loved. There were other children in the house that the mother had to feed and this needed to be the priority over medications. I asked about his diet and he gave me examples of foods they might have some weeks, but not others. He liked chugging a large, 32oz cup of milk before work in the morning when they had it. Sometimes he brought a frozen meal to work, but often, he just got chips and gatorade from the vending machine for lunch. After playing basketball with his buddies, he went home and straight to bed without eating dinner because he was too tired.

The idea I formed of this patient from his medical chart versus the person I had a real, honest conversation with was like night and day. As we talked, I found myself relating to him and feeling so compassionate toward him and his family. I thought about this patient the entire week following...wondering if the social worker found them access to affordable insulin, if he was able to get back home and play ball with his friends, and how his mom was doing juggling this among her other kids. I will never forget this patient and the lesson that he taught me. He shaped the way I view charts and interact with patients in such a powerful way. After all, they are human, too.

Ok, so how do we get rid of our biases?

Well you see, the thing is...it’s not that simple. Cognitive bias is not something we can just get rid of, but we can become more aware of the biases each of us hold and alter our response to the bias. Awareness of the biases we hold, although hard to admit, is the first step in changing our reactions. Anchoring bias is one type bias often seen in medical professionals. I have read of multiple cases where doctors focus on one detail in a patient’s chart and don’t pay as much attention to everything else - thus, anchored to one piece of information. Let me give a scenario to help explain:

A patient comes into the emergency room after a drug overdose. After the patient is admitted, the nurse follows up and reads his chart. Although the nurse read the entire chart, she was so anchored to “drug overdose” that she failed to ask further questions about the bruises over his body - she just assumed he was in a fight the night of the overdose. She talked to this patient several times and she eventually picked up the hints that he was being physically abused. Finally, she consulted social work and a case manager on behalf of the patient.

Initially, the nurse was ignorant to the possibility that the bruises were from something more serious than a bar fight. Luckily, she caught the hints and was able to find help for the patient. Had she never known of the abuse, she may have sent the patient home to the same situation from which he came. This is just one example of how anchoring bias can have a severe impact on we interact with and treat patients.

Medical professionals have the ability to influence one another with the language used in the EMR. More attention should be paid to the verbiage used as to not increase the incidence of implicit bias in healthcare. Every individual has biases and recognizing them is the first step to changing our reactions.

Reference:

Goddu, A. P., O’Conor, A. J., Lanzkron, S., et al. (2018). Do words matter? Stigmatizing language and the transmission of bias in the medical record. Journal of General Internal Medicine, 33(5), 685-691.