Testimonial Injustice: Linguistic Bias in the Medical Records of Black Patients and Women



Black Americans and women report feeling doubted or dismissed by health professionals.


To identify linguistic mechanisms by which physicians communicate disbelief of patients in medical records and then to explore racial and gender differences in the use of such language.




All notes for patients seen in an academic ambulatory internal medicine practice in 2017.

Main Measures

A content analysis of 600 clinic notes revealed three linguistic features suggesting disbelief: (1) quotes (e.g., had areactionto the medication); (2) specific “judgment words” that suggest doubt (e.g., “claims” or “insists”); and (3) evidentials, a sentence construction in which patients’ symptoms or experience is reported as hearsay. We used natural language processing to evaluate the prevalence of these features in the remaining notes and tested differences by race and gender, using mixed-effects regression to account for clustering of notes within patients and providers.

Key Results

Our sample included 9251 notes written by 165 physicians about 3374 unique patients. Most patients were identified as Black (74%) and female (58%). Notes written about Black patients had higher odds of containing at least one quote (OR 1.48, 95% CI 1.20–1.83) and at least one judgment word (OR 1.25, 95% CI 1.02–1.53), and used more evidentials (β 0.32, 95% CI 0.17–0.47), compared to notes of White patients. Notes about female vs. male patients did not differ in terms of judgment words or evidentials but had a higher odds of containing at least one quote (OR 1.22, 95% CI 1.05–1.44).


Black patients may be subject to systematic bias in physicians’ perceptions of their credibility, a form of testimonial injustice. This is another potential mechanism for racial disparities in healthcare quality that should be further investigated and addressed.

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  1. 1.

    Beach MC, Branyon E, Saha S. Diverse patient perspectives on respect in healthcare: A qualitative study. Patient Educ Couns. 2017;100(11):2076-2080. https://doi.org/10.1016/j.pec.2017.05.010

  2. 2.

    Schencker L. ‘Nine times out of 10, I was completely brushed off’: Black Chicagoans confront bias in health care, hope for change. Chicago Tribune. August 13, 2020. http://www.chicagotribune.com/news/breaking/ct-chicago-health-care-racism-george-floyd-implicit-bias%2D%2D20200813-nxrujltiyvg37pks2hyf6iwb7m-story.html?utm_medium=notification&utm_source=onesignal

  3. 3.

    Haywood C, Beach MC, Lanzkron S, et al. A systematic review of barriers and interventions to improve appropriate use of therapies for sickle cell disease. J Natl Med Assoc. 2009;101(10):1022-1033.

  4. 4.

    Macphee M. Hysterical women: Pain bias and epistemic injustice in medicine. Granite J Postgrad Interdiscip J. 2019;3(2):12-19.

  5. 5.

    Villarosa L. Why America’s Black mothers and babies are in a life-or-death crisis. The New York Times. April 11, 2018. https://www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html

  6. 6.

    Beeghly E, Madva A, eds. An Introduction to Implicit Bias: Knowledge, Justice, and the Social Mind. New York: Routledge; 2020.

  7. 7.

    Mossey JM. Defining racial and ethnic disparities in pain management. Clin Orthop Relat Res. 2011;469(7):1859-1870. https://doi.org/10.1007/s11999-011-1770-9

  8. 8.

    Santry HP, Wren SM. The role of unconscious bias in surgical safety and outcomes. Surg Clin North Am. 2012;92(1):137-151. https://doi.org/10.1016/j.suc.2011.11.006

  9. 9.

    Pennebaker JW, Mehl MR, Niederhoffer KG. Psychological aspects of natural language use: our words, our selves. Annu Rev Psychol. 2003;54:547-577. https://doi.org/10.1146/annurev.psych.54.101601.145041

  10. 10.

    Berry DS, Pennebaker JW, Mueller JS, Hiller WS. Linguistic bases of social perception. Pers Soc Psychol Bull. 1997;23(5):526-537. https://doi.org/10.1177/0146167297235008

    Article  Google Scholar 

  11. 11.

    Lindquist KA, MacCormack JK, Shablack H. The role of language in emotion: Predictions from psychological constructionism. Front Psychol. 2015;6. https://doi.org/10.3389/fpsyg.2015.00444

  12. 12.

    Beukeboom CJ, Burgers C. Linguistic bias. In: Oxford Research Encyclopedia of Communication. Oxford, UK: Oxford University Press; 2017. https://doi.org/10.1093/acrefore/9780190228613.013.439

  13. 13.

    Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010;21(3):202-207. https://doi.org/10.1016/j.drugpo.2009.10.010

    Article  PubMed  Google Scholar 

  14. 14.

    Kelly JF, Dow SJ, Westerhoff C. Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms. J Drug Issues. 2010;40(4):805-818. https://doi.org/10.1177/002204261004000403

  15. 15.

    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;33(5):685-691. https://doi.org/10.1007/s11606-017-4289-2

  16. 16.

    Sidnell J, Stivers T, eds. The Handbook of Conversation Analysis. Chichester, UK: Wiley-Blackwell; 2013.

  17. 17.

    Pomerantz AM. Giving a source or basis: The practice in conversation of telling ‘how I know.’ J Pragmat. 1984;8(5-6):607-625. https://doi.org/10.1016/0378-2166(84)90002-X

    Article  Google Scholar 

  18. 18.

    Pomerantz A. Constructing skepticism: Four devices used to engender the audience’s skepticism. Res Lang Soc Interact. 1988;22(1-4):293-313. https://doi.org/10.1080/08351818809389307

    Article  Google Scholar 

  19. 19.

    Chafe WL, Nichols J, eds. Evidentiality: The Linguistic Coding of Epistemology. New York: Ablex Pub. Corp; 1986.

  20. 20.

    Heritage J. The epistemic engine: Sequence organization and territories of knowledge. Res Lang Soc Interact. 2012;45(1):30-52. https://doi.org/10.1080/08351813.2012.646685

  21. 21.

    Drew P. Epistemics in social interaction. Discourse Stud. 2018;20(1):163-187. https://doi.org/10.1177/1461445617734347

    Article  Google Scholar 

  22. 22.

    Finnegan RH. Why Do We Quote? The Culture and History of Quotation. Cambridge, UK: Open Book Publishers; 2011.

  23. 23.

    JW Ball. Chapter 1: The history and interviewing process. In: Seidel’s Guide to Physical Examination. St. Louis, MO: Elsevier; 2015.

  24. 24.

    LS Bickley. Chapter 1: Overview: Physical examination and history taking. In: Bates’ Guide to Physical Examination and History Taking. Philadelphia, PA: Wolters Kluwer Health; 2013.

  25. 25.

    Chait J. Scared yet? The New Republic. December 30, 2008. https://newrepublic.com/article/64702/scared-yet

  26. 26.

    Honnibal M, Montani I. spacy 2: Natural language understanding with bloom embeddings. Convolutional Neural Netw Increm Parsing. 2017;(7.1).

  27. 27.

    Singh V. Replace or retrieve keywords in documents at scale. ArXiv171100046 Cs. Published online November 9, 2017. http://arxiv.org/abs/1711.00046

  28. 28.

    Fricker M. Epistemic Injustice: Power and the Ethics of Knowing. Oxford, UK: Oxford University Press; 2009.

  29. 29.

    Miller LR, Peck BM. A prospective examination of racial microaggressions in the medical encounter. J Racial Ethn Health Disparities. 2020;7(3):519-527. https://doi.org/10.1007/s40615-019-00680-y

  30. 30.

    Hall JM, Fields B. “It’s killing us!” Narratives of Black adults about microaggression experiences and related health stress. Glob Qual Nurs Res. 2015;2:2333393615591569. https://doi.org/10.1177/2333393615591569

  31. 31.

    Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. Third edition. Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins; 2008.

  32. 32.

    Blair IV, Steiner JF, Fairclough DL, et al. Clinicians’ implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Ann Fam Med. 2013;11(1):43-52. https://doi.org/10.1370/afm.1442

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This work was supported by a grant from the Robert Wood Johnson Foundation’s Building Trust and Mutual Respect to Improve Healthcare Program. Dr. Beach was also supported by the National Institute on Drug Abuse (K24 DA037804). Dr. Saha was supported by the Department of Veterans Affairs. Dr. Taylor was supported by the Robert Wood Johnson Harold Amos Medical Faculty Program.

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Correspondence to Somnath Saha MD, MPH.

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The Robert Wood Johnson Foundation had no role in the study’s design, conduct, or reporting. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Robert Wood Johnson Foundation, the Department of Veterans Affairs, or the United States government.

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Beach, M.C., Saha, S., Park, J. et al. Testimonial Injustice: Linguistic Bias in the Medical Records of Black Patients and Women. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-021-06682-z

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