Hospitalists and social workers with Duke’s COMET (Caring for Patients with Opioid Misuse through Evidence-Based Treatment) consulting service teamed on a recent interdisciplinary study that encompasses social work and inpatient medicine to understand providers' use of stigmatizing and affirming language in the electronic health records of patients with opioid use disorder (OUD) hospitalized at Duke.
Where most research is physician-led, COMET team social workers stepped up to create an unusual study structure that added an essential communications element to the team’s effort to understand the ways in which stigma may impact patients.
“Our social workers are true advocates for our patients,” said Dr. Dana Clifton, assistant professor of pediatrics and general internal medicine, who co-leads the COMET team with colleague, Dr. Noel Ivey, associate professor in General Internal Medicine. “They’re at the bedside and get to know them really well as part of our team. The study was a unique way for them to advocate for our patients differently, in an academic way, and to highlight some of the things that we still need to work on for this population.”
System-Generated Stigmas
With the prevalence of stigmatization surrounding patients with substance use disorders, the team’s findings were not surprising but they were also encouraging, they said, with recommendations, tips and tools for easy, immediate changes that all clinicians can make in their language use to reduce stigma.
The COMET study concluded that stigmatizing language was present in both provider and system-generated language, and was nine times more frequent than affirming language in the medical records of hospitalized patients with OUD. Further, while provider education may reduce stigmatizing language, institutional level changes to the EHR and International Classification of Disease codes are necessary to decrease stigmatizing language within medical records.
The study included patients with a first-time referral to the Duke University Hospital OUD consult service who met diagnostic criteria with a hospital stay of 28 days or more from July 2019 to February 2022. Reviewers independently evaluated each admission and discharge note for stigmatizing or affirming language and met weekly to validate coding reliability.
Forty-eight patients (96 notes) met the inclusion criteria with 434 occurrences of stigmatizing language identified and 47 occurrences of affirming language. One-third of stigmatizing language appeared in system-generated fields such as drop-down categories and diagnosis codes with the rest authored by providers.
Social workers Shavone Hamilton, PhD, LCSW, Melissa Walker, MSW, LCSW, Alan Ellis, PhD, MSW, and Rachel Hirshman MSW, LCSW-A, led the effort.
The study was motivated by the team’s desire to understand the language providers use when documenting their encounters with patients with OUD, Dr. Hamilton said. With the passage of the 21st Century Cures Act, patients have full access to their medical records online, which makes the team’s work timely.
“What the study represents is an opportunity for providers to learn to improve and use clinical language differently,” she said.
“We hoped this knowledge would inform ways we can reduce the amount of stigma our patients encounter when interacting with health care systems,” Hirshman added.
The COMET team, launched as a quality improvement initiative in July 2019 to improve the quality of care for hospitalized patients with opioid use disorder and withdrawal at Duke University Hospital, today consists of 16 hospitalists and two social workers.
Patient-Centered Language
“We need to be cognizant that our records and our documentation are visible to our patients,” Dr. Ivey said. “They can see what we write about them, and this impacts how they will engage with us as providers, as social workers, going forward.”
“And then it has a ripple effect,” Dr. Clifton said. “So then, nurses read your chart notes physical therapists, case managers, and all of that gets perpetuated. Some terms are hard to undo once they're in the chart. The study represents an opportunity to think about patients differently, which impacts the way other people view patients, which in turn impacts patient care.
“The ultimate goal is to care for these patients in a patient-centered, high-quality way and that's hard to do when they're being stigmatized,” she said. “We encounter a lot of barriers to care that negatively impacts our patients because of stigma so this is one way to help combat that. Obviously, there are a lot of cultural changes also needed, but can we make small steps towards improving patient care by reducing stigma in ways that we can actively change.”
For example, Dr. Clifton pointed out someone with acute opioid withdrawal may have the term “agitation” in their chart, which can be interpreted as they are behaviorally challenging or difficult. But agitation is a part of the acute opioid withdrawal spectrum — a medical diagnosis — and opioid withdrawal which should be aggressively managed with medication. Conversely, she added, it is important to see patients as people and not just a medical diagnosis.
“We can continue to build Duke as a as a welcoming environment for patients with substance use disorders,” said Dr. Ivey. “If we use the right language, they will feel more comfortable in sharing their experiences, and maybe being more open to talking about medications for opioid use disorder which are life-saving treatments. Having the background and the fundamentals to use the right language, will then open Duke up to be the most welcoming community for patients with substance use disorders.”