Erasing inequality: Examining discrepancies between electronic health records and patient narratives to uncover perceived stigma and dismissal in clinical encounters

Abstract

Current policy efforts to reduce health disparities focus on integrating patients' social determinants of health (SDHs) into their electronic health records (EHRs), with the goal of addressing both clinical and social risks through the health system. Yet clinicians' documentation of and engagement with patients' social characteristics may, in certain circumstances, actually contribute to health disparities. This paper compares accounts of clinical encounters from in-depth interviews with forty-six non-college-educated women against their EHR's codes and free-text notes, which document the clinician's perspective of the encounter. We identify how documentation of clinical encounters may exacerbate the very health disparities that health systems seek to intervene upon by 1) translating social suffering stemming from structural inequality into stigmatized risk factors, and 2) suppressing conflicts over diagnosis and treatment, sometimes by framing observations of women's social identities as evidence of their unreliability as patients. We demonstrate how perceived negative interactions lead some women to resist the health system, either by self-treating in ways that could adversely affect their health or by attempting to challenge the authority of clinicians, which is not documented as resistance in their medical charts.