(114) Stigmatizing Language in the Medical Record After Addiction Consult Service Implementation

Background & Introduction: Stigmatizing language by healthcare providers, and the associated negative patient outcomes related to these terms, persist throughout the Electronic Medical Record (EMR)1; however, to our knowledge, there are no published studies that investigate the use of stigmatizing terms related to substance use disorder (SUD) in patients admitted to a general medical hospital. It is well-established that healthcare professionals generally hold negative attitudes toward patients with addictive disorders and hospital medicine providers have found caring for admitted patients with SUDs less satisfying than caring for patients with other health conditions2. It has been suggested that the incorporation of an Addiction Consult Service (ACS) into a general medical setting has been associated with improved attitudes of healthcare providers toward patients with SUDs3 including health professional trainees4. We sought to investigate whether the implementation of an ACS at a large urban hospital would impact the incidence of stigmatizing addiction language in the EMR. We hypothesized that in the 5 years following the implementation of our ACS there would be an overall reduction of stigmatizing language use in hospitalized patients' medical charts across all provider types and training levels.

Methods: Our study took place at a large, urban academic medical center in the Midwest. A retrospective analysis of inpatient medical records 5 years prior to and 5 years following implementation of our hospital’s ACS, called the Addiction Psychiatry Consultation-Liaison service. Data was pulled from admitted patient hospital records only. Records were analyzed for inclusion of stigmatizing language related to substance use using predetermined string terms. These string terms included “substance abuse”, “alcohol abuse”, “tobacco abuse”, and “other drug abuse”. Stigmatizing language across these categories was further aggregated to determine the total incidence of stigmatizing terms used.

We gathered and compared data across multiple professions including, but not limited to, physicians, fellows, residents, advanced practice providers, pharmacists, allied health professionals, and medical students. The goal of our study was to evaluate changes in the use of stigmatizing terms among attending physicians, residents and fellows, and medical students, due to the APCL service participating most closely with these groups.

Analysis was conducted using descriptive statistics to investigate the total number of SL terms used overall, as well as the analyze the percent of notes containing SL before and after APCL service implementation.

Results: The absolute use of terms matching our string term library that appeared in individual notes increased from 272,102 to 297,667 across all providers combined when comparing notes before and after our ACS was created, respectively. Specifically, the use of stigmatizing terms in residents and fellows notes was increased from 76,871 to 83,771. Decreases in total use of stigmatizing terms was only seen in Medical Students (7,371 to 6,557) and Attending Physicians (135,553 to 119,619); although physicians wrote less notes in general after the cutoff date.

The percentage of total notes that contained stigmatizing language between all providers decreased from 7.7% to 7.43%, a 3.44% decrease. Further analysis showed that the relative change in the percent of notes that contained stigmatizing language decreased in residents/fellows and medical students but increased in attending physicians. Residents/Fellows had a 14.6% decrease in use of SL per note, while medical students had a 27.4% decrease in use of SL. Attending physicians had a 9.07% increase in use in SL.

Conclusion & Discussion: Our hypothesis that total use of stigmatizing language related to substance use would decrease after our ACS launched was incorrect. We conjecture that problematic substance use was previously going unaddressed and that after ACS implementation providers were likely to become more cognizant that SUD interventions for hospitalized patients were available, resulting in increased documentation of these concerns. The potential increase in detection and subsequent treatment of hospitalized patients would be a positive finding but requires further investigation.

Across provider training levels, a decrease in stigmatizing language in medical student notes is a positive finding potentially influenced by our ACS, as student inclusion and education on our ACS has already been shown to improve attitudes and decrease stigma towards those with SUDs (Lew, 2024). The decrease in percentage of notes using SL in both medical students and residents/fellows was also encouraging.

Our findings support the inclusion of medical students, residents, and fellows on ACS teams for clinical training in addition to SUD stigma education in the didactic curriculum. Further investigations are currently in progress comparing all different provider types and analyzing the differences between specific term use. We encourage other institutions to investigate SL related to SUD in their own EMR.

References: 1. 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;33:685–691.

2. Weinstein ZM, Wakeman SE, Nolan S. Inpatient addiction consult service: expertise for hospitalized patients with complex addiction problems. Med Clin. 2018;102(4):587–601

3. Wakeman SE, Kanter GP, Donelan K. Institutional Substance Use Disorder Intervention Improves General Internist Preparedness, Attitudes, and Clinical Practice. J Addict Med. 2017 Jul/Aug;11(4):308-314.

4. Lew BJ, Balasanova AA. Medical Student Attitudes Toward Patients With Substance Use Disorder After Experiential Learning on an Addiction Psychiatry Consultation-Liaison Service: A Pilot Study. Subst Use Addctn J. 2024 Apr;45(2):292-298.

5. 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;21:202–7.