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

Abstract

Background

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

Objective

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.

Design

Cross-sectional.

Setting/Participants

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).

Conclusions

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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Funding

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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