Political correctness of medical documentation

While discussing a complex patient with one of my esteemed colleagues, he expressed his opinion that it was inappropriate to include terms describing the patient’s race/ethnicity or country of origin in the medical documents. He regarded it as antiquated and reflective of having practiced in the South. On the contrary, although I had practiced in Kentucky and the very far south—Miami, Florida—the template I had used for writing a history and physical examination was learned in Philadelphia, Pennsylvania, the same city to which I had relocated.

 

The history and physical examination started with the following description:“This 36-year-old, right-handed, African American man presents to office…” Commencing the report with this descriptive detail provides a mental image of the patient to the reader. The argument my colleague proffered was that race, ethnicity, and country of origin are essentially of no value. Any person could have any illness. He made note of a fact that I had appreciated in the short time that I have been at the new institution, namely, that few physicians or trainees included such elements in their histories...

 

 The more I reflected on the issue the more I considered these descriptions not only appropriate but, at times, critically important. There are 3 reasons to consider this to be the case: (1) certain illnesses are far more common in some races, ethnicities, or regions of the world; (2) depending on their genetics, some people may respond to medications differently; and (3) rich descriptions of the patient incorporating elements that may not be essential for diagnosis or management help the physician to recall the patient...

 

In my multiple sclerosis clinic, neurosarcoidosis is high on the list of differential diagnoses in the African American patient presenting with suspected multiple sclerosis...

 

Progressive weakness in a child of Japanese ancestry might suggest Fukuyama muscular dystrophy, a condition seen virtually exclusively in Japanese individuals and that is among the most common causes of childhood muscular dystrophy in that population...

 

Another example is drug-resistant epilepsy that has been described in Han Chinese individuals due to an overexpression of efflux drug transporters.

 

Lastly, the richness of the description of the patient humanizes the patient and, by association, improves the physician’s ability to recall other details of the patient’s medical history and examination. I have also described elements of the history that do not necessarily help in diagnosing or treating the patient but assist in the social context...

 

Alternatively, I may comment on a tasteful or unusual tattoo or piercing, the quality of dentition, and the nature of how a patient dresses, among other characteristics. I see nothing wrong in these descriptive elements of the history and physical examination; however, I am open to suggestion and would like to hear how others perceive this issue.

 

See:  Berger JR. Political Correctness of Medical Documentation. JAMA Neurol. 2015
Jun 1;72(6):624-625.