Racial bias can seep into U.S. patients’ medical notes

When health care providers enter notes into patients’ electronic health records, they are more likely to portray Black patients negatively compared with white patients, two recent studies have found. The unfavorable descriptions may perpetuate bias and stigma and influence the care patients receive.

“The first impression is the chart,” says Gracie Himmelstein, a physician training in internal medicine at the UCLA David Geffen School of Medicine. “That narrative is going to shape your views of the patient, even if you think you’re just looking for the clinical data.”

Himmelstein and colleagues analyzed more than 48,000 hospital admission notes from a Boston medical center. Stigmatizing language overall, and about diabetes and substance use disorder in particular, was more often used in the notes of Black patients compared with white patients, the team reported January 27 in JAMA Network Open.
Another study combed through more than 40,000 medical notes from a Chicago medical center. Black patients were more likely to be described as not complying with or resistant to treatment, among other unfavorable terms, a different research group reported in the February Health Affairs.

The two studies appear to be the first to quantify racial bias in the U.S. electronic health record. Bias can drive health disparities — differences in health tied to social, environmental or economic disadvantages — that occur between different racial and ethnic groups. For example, Black infants have a higher mortality rate than white infants due to health disparities (SN: 8/25/20).

The Health Affairs study’s team designed a computer program to look for phrases with negative connotations, including “not compliant,” “not adherent” and “refused,” in medical notes written from January 2019 to October 2020 for close to 18,500 patients. Overall, 8 percent of the patients had one or more negative terms in their electronic health records.

Black patients were 2.5 times more likely to have such words in their medical notes than white patients, the researchers found. This language “has a potential for targeted harm,” says coauthor Michael Sun, a medical student at the University of Chicago’s Pritzker School of Medicine.

Himmelstein and colleagues scrutinized the electronic health record for negative language like “nonadherent” and “unwilling” along with stigmatizing words — including the verb “abuse” — that label or place blame on the patient. The team studied medical notes that were written from January to December in 2018.

Overall, around 1,200, or 2.5 percent, of the admission notes contained unfavorable language. Notes about substance use disorder and diabetes had more of that language woven in, at 3.4 percent and 7 percent, respectively. In the full sample, Black patients were nearly 1.3 times more likely to have stigmatizing terms in their notes than white patients. That factor was about the same when the researchers focused on diabetes notes, while for records about substance use disorder, Black patients were 1.7 times more likely to have negative descriptions.

The new studies didn’t assess what impact the biased notes had on patients’ medical care. But other research has found that when short descriptions of a patient include stigmatizing language, the negative terms influenced physicians’ treatment decisions, making doctors less likely to offer sufficient pain medication.

Along with potentially leading to worse care, bias in medical notes may sour patients’ perception of their providers. Patients now have the right to read their electronic health records, as mandated in the 21st Century Cures Act. Notes that include stigmatizing or biased depictions can “potentially undermine trust,” says primary care doctor and health equity adviser Leonor Fernández of Beth Israel Deaconess Medical Center in Boston.

In a survey of nearly 23,000 patients, Fernández and colleagues found that 10.5 percent felt offended or judged, or both, after reading their own notes, the team reported in the Journal of General Internal Medicine in September 2021. (The survey didn’t ask about discrimination or racial bias specifically.) Many respondents also explained what prompted their feelings. One participant wrote, “Note said I wasn’t doing everything I could to lose weight which was untrue and very upsetting to see my Dr thought of me like that.”

Researchers have written about ways to remove stigma from descriptions of substance use disorder and obesity, among other conditions. This guidance encourages language that does not identify the patient by their illness and that focuses on the efforts a patient is making.

Rather than labeling a person a “diabetic,” for example, health care providers can write that a person “has diabetes,” researchers from a diabetes care task force recommend. And instead of describing a patient as “non-compliant” with their medication, the researchers suggest explaining why, as in, the patient takes insulin “50 percent of the time because of cost concerns.”

By noting the barriers to a patient’s ability to follow medical advice, says Himmelstein, a health care provider can “engage with that in a way that’s actually helpful in promoting health.” Instead of using terms like “non-compliant,” Sun hopes health care providers “think about what other context and what other story” can be told about the patient.

Accounting for the challenges a patient faces “actually makes you more effective” as a health care provider, says Fernández, and makes the patient less likely to feel blamed.

In the Health Affairs study, Sun and his colleagues observed an unexpected and encouraging change in the electronic health record over time. For notes written during the second half of the study, from March to October of 2020, it was no longer more likely that Black patients’ notes had negative terms compared with white patients. That time period coincided with the start of the COVID-19 pandemic and Black Lives Matter protests.

More work is needed to sort out what’s behind the drop, says Sun. He and his coauthors note that health care providers may have considered patients with COVID-19 less responsible for their illness, in contrast to other conditions. But perhaps it has something to do with how “impactful” that period was, Sun says, in raising awareness of racial health disparities. Perhaps the shift was “out of empathy.”

What we learned about COVID-19 safety from a NYC anime convention

As Kristin Meyer set up her merchandise booth at the Anime NYC convention last November, she was sure she’d be exposed to the coronavirus at some point during the three-day event. “Getting that many people together in one spot, the chance that absolutely no one had COVID was zero,” she says.

Meyer was one of hundreds of artists who paid for a space to sell their art in the convention’s Artist Alley. Many signed up, despite getting a cold or the flu, bronchitis or pneumonia at previous fan conventions. “I used to get everything,” says Daifei, another artist, who asked to be referred to by their online handle. “Just from being around people.”

Anime NYC, first held in 2017, has become a beloved meeting place for fans of Japanese cartoons known as anime and comics called manga. Fans wearing elaborate anime-inspired costumes enter contests and pose for group photos. Actors who voice popular characters speak on panels and meet attendees for autographs. Media companies offer exclusive previews of their upcoming releases.

In the Artist Alley, attendees buy anime-inspired prints, charms, buttons and other custom-made merchandise. At an event like Anime NYC, artists can make as much as $15,000 in a weekend, says Daniela Muino, an artist who traveled from Texas with her partner to the 2021 convention. “People physically seeing your art in front of them” is great for sales, Muino says.
The greatest draw of Anime NYC for many attendees is connecting with other fans. A hobby typically considered niche takes over one of the country’s largest convention centers — the Javits Center — and drives a three-day party in and around the venue. Even in the midst of a pandemic, the 2021 event drew a record 53,000 attendees from around the United States and 30 other countries.

People were clearly drawn to get together. “Self-isolating rules are vital [in a pandemic],” says Robin Wollast, a psychology researcher at Stanford University. But “they also undermine deep-rooted needs for social bonding.” In-person events can be crucial for mental health, he says, despite the health risks they pose.

Attendees aware of those risks were not surprised when news broke in early December that the convention may have been a superspreader event; one of the first U.S. cases of COVID-19 due to the highly contagious omicron variant had been traced back to Anime NYC. The shock came later, in February, when the U.S. Centers for Disease Control and Prevention reported that, in fact, omicron had not spread widely at the convention.

Anime NYC may offer some lessons for making large events safer now and in the post-pandemic future.

What went right?
Peter McGinn, who works in health insurance, felt confident flying to New York City from his Minneapolis home for the convention. The 31-year-old knew the virus spreads easily through the air. But he was fully vaccinated and boosted, as were many of his 30 or so friends coming in from more than 10 states. The group used Anime NYC as a long weekend party; they shared accommodations and socialized at the city’s restaurants, bars and karaoke venues.

“I felt pretty comfortable based off of everything I did to protect myself, and what the people I was with did to protect themselves and everybody around us,” says McGinn, referring to his friends’ vaccination status and their masking in the venue, except when eating or drinking.

Once back in Minneapolis, McGinn didn’t feel great, but he attributed his symptoms to “normal con fatigue.” Plenty of attendees of these and similar events expect to get sick. At the American Geophysical Union’s annual meeting, for example, attendees ruefully refer to “AGU flu,” which spreads among conference-goers every year.

When one of McGinn’s convention friends tested positive for COVID-19, McGinn took a PCR test, which came back positive. A week into his 10-day quarantine, the Minnesota Department of Health called to tell McGinn that he was the first known person in his state to be infected with the omicron variant. Once the health department learned he had been to the crowded convention in New York City, McGinn spent hours helping both Minnesota’s state agency and the CDC with contact tracing.
Once word got out that McGinn had omicron and that several of his convention-going friends had also tested positive, news reports suggested he may have been patient zero for a potential superspreader event at the anime convention.

This news was reminiscent of the February 2020 biotech conference in Boston that had become one of the first superspreader events in the United States. Infections at that conference may have been linked to more than 300,000 cases, researchers reported in Science in December 2020.

In January, McGinn said he hoped the investigation into Anime NYC would push back against the perception that this convention had been a superspreader. “It’s overwhelmingly likely that where I caught COVID was outside of the event at dinner or karaoke,” he says. While at the convention center, he and his friends constantly wore masks.

McGinn felt vindicated when the results of the investigation were published as a pair of reports in the Feb. 18 Morbidity and Mortality Weekly Report. One study focused on McGinn and his friend group, and the other presented a big-picture view of COVID-19 at the convention. The researchers searched state and local health databases for test results from about 34,500 out of the 53,000 convention attendees whose contact information was available from the event organizers. They identified 119 cases among 4,560 people who got tested. Of those 119 cases, 16 were in McGinn’s friend group — and the only cases confirmed as omicron were among those 16.

The CDC characterizes a superspreader event as one infectious person giving the corona­virus to many others at a rate higher than average transmission. This didn’t occur at Anime NYC, the investigation found, because the rate of positive tests among convention attendees was close to the overall rate in New York City two weeks after the convention: about 3 percent.

“It’s nice to confirm that the event wasn’t a spreader event,” McGinn said after receiving news of the reports. “It makes me more comfortable in the future going to these types of events as long as mask and vax requirements are in place.”
Layers of protection
The CDC reports attribute this convention’s success to layers of safety measures put in place, including masks, vaccine checks and good ventilation.

“Everyone was always wearing their masks … when speaking to me or walking past my table,” Meyer says. She notes, however, that some costumed attendees took their masks off for photo shoots. And the Artist Alley was also located near the food court, where attendees took off their masks to eat.

Muino was impressed by the safety behaviors she saw at the convention in comparison with her home state of Texas. Still, the spacing of tables in Artist Alley “felt way too close together” for social distancing, she recalls. During busy periods, the area became incredibly crowded.

“There’s only so much control you can exert over a population that large,” Muino says. “People are going to take their masks off for pictures. They’re going to take them off to talk to friends.”
Attendees needed to show proof that they’d received at least one vaccine dose, following the city’s regulations at the time. Among 3,845 attendees whose test results and vaccination status were both available from local health departments, 3.4 percent were partially vaccinated, 84.5 percent were fully vaccinated and 12.1 percent had received a booster dose. Studies have shown that partial vaccination offers significantly less protection against COVID-19 than full vaccination.

However, Anime NYC organizers had too few staff checking proof of vaccination outside the venue, leading to long lines and crowding outside. Some attendees waited outside up to four hours on the first day of the convention.

The Javits Center itself took COVID-19 seriously, partly due to its roles during the pandemic as a field hospital and then a mass vaccination site. Newly installed hospital-grade air filters throughout the building may have helped prevent transmission.

“All the employees at the Javits Center had to go through training,” says Gavin Macgregor-Skinner, senior director of the Global Biorisk Advisory Council, part of the worldwide cleaning industry association that certifies organizations, including the Javits Center, on preparedness for biological threats. This training included cleaning protocols and how to manage traffic through the building.

This venue also worked with event organizers, including the company that runs Anime NYC, to ensure they followed safety protocols. The Javits Center’s attitude was, “if you come into our house, you follow our rules,” Macgregor-Skinner says.
The CDC investigation results do not mention, however, that Anime NYC was also very lucky with its timing. When this event took place, omicron hadn’t yet gotten a foothold in Manhattan. The city’s first wastewater samples containing omicron were collected on November 21, the final day of the event.

If the same event had happened two weeks later — when omicron was raging through the city — organizers would have needed more safety measures, such as a stricter vaccination requirement and rapid testing, to achieve the same low transmission, says Ayman El-Mohandes, an epidemiologist and dean of the school of public health at the City University of New York.

Heroes wear face masks
A successful COVID-19–safe event requires layers of protections that align with the community that the event is serving, says Mark Billik, founder of BeCore, a marketing agency that pivoted to organizing COVID-19–safe events during the pandemic. Billik recommends that his clients tailor their COVID-19 protocols for their events and he offered suggestions for future fan conventions (see Page 25).

Advance communication may be particularly successful when it’s tailored to a community and drives “enthusiasm about creating a safe environment,” El-Mohandes says. For instance, the next Anime NYC could provide masks with the faces of famous anime characters or post signs that show these characters encouraging distancing and frequent handwashing.

Using anime characters to promote safe behaviors is an example of classical conditioning, says Wollast, the Stanford psychology researcher. In classical conditioning, people learn to associate a particular stimulus (like wearing a face mask) with an unrelated stimulus (a favorite character) to drive a particular behavior. “My heroes are wearing face masks so I should wear one too,” Wollast says.
Safety beyond COVID-19
Along with avoiding COVID-19, Anime NYC attendees who spoke to Science News noted that they also avoided other respiratory illnesses. “Less people have been sick that I’ve heard of this year, than any other convention that I’ve ever been to,” Daifei says.

Maybe a cold or flu doesn’t have to be a necessary evil of attending conventions or similar events.

COVID-19 safety measures probably contributed to an unusually low number of flu cases in the 2020–21 season, according to the CDC. Leaders in the events industry are considering safety measures that build on lessons from COVID-19 — such as new technologies to improve ventilation and cleaning protocols — to reduce future outbreaks of flu and other infectious diseases, according to the Global Biorisk Advisory Council.

Some Anime NYC attendees hope to see continued handwashing, mask use and policies that encourage people to stay home when not feeling well, long after this pandemic recedes. All these practices are “very applicable to non-COVID respiratory infections,” El-Mohandes says. Such safety practices may also make large events more inclusive for immunocompromised people, many of whom already had to avoid crowds for their potential to spread infection before the pandemic.

“I feel like this is something that we can actually keep doing,” says Nicole Tan, an artist who shared a booth with Daifei at Anime NYC. The pandemic inspired a widespread realization that “we could have prevented a lot of illness if we just put our minds to it.”

A hole in a Triceratops named Big John probably came from combat

A gaping hole in the bony frill of a Triceratops dubbed “Big John” may be a battle scar from one of his peers.

The frill that haloes the head of Triceratops is an iconic part of its look. Equally iconic, at least to paleontologists, are the holes that mar the headgear. For over a century, researchers have debated various explanations for the holes, called fenestrae — from battle scars to natural aging processes. Now, a microscopic analysis of Big John’s partially healed lesion suggests that it could be a traumatic injury from a fight with another Triceratops, researchers report April 7 in Scientific Reports.

In summer 2021, Flavio Bacchia, director of Zoic LLC in Trieste, Italy, was reconstructing the skeleton of Big John, the largest known Triceratops to date, when he noticed a keyhole-shaped fenestra on the right side of its frill. Bacchia then reached out to Ruggero D’Anastasio, a paleopathologist at the “G. D’Annunzio” University of Chieti-Pescara in Italy who studies injuries and diseases in ancient human and other animal remains.

“When I saw, for the first time, the opening, I realized that there was something strange,” D’Anastasio says. In particular, the irregular margins of the hole were odd. He had never seen anything like it.
To analyze the fossilized tissues around the fenestra, he obtained a piece of bone about the size of a 9-volt battery, cut from the bottom of the keyhole. The rest of Big John sold at an auction for $7.7 million — the most expensive non–Tyrannosaurus rex dinosaur fossil ever.

Looking at the bone under a scanning electron microscope, D’Anastasio and his team found evidence consistent with the formation processes of new bone that are usually observed in mammals. New bone growth is typically supported by blood vessels, and in the bone near the border of the hole, the tissue was porous and strewn with vascular canals. Farther from the fenestra, the bone showed little evidence of the vessels.

The team found that the irregularity of the hole margins that D’Anastasio had observed was also present at the microscopic level. The border was dappled with microscopic dimples called Howship lacunae, where, in one of the first steps of bone healing, bone cells eroded the existing bone to be replaced with healthy bone. The researchers also observed primary osteons, formations that occur during new bone growth.

In addition, a chemical analysis revealed high levels of sulfur, indicative of proteins involved in new bone formation. In mature bones, sulfur is present in only low quantities.
Taken all together, it was clear that this particular fenestra was a partially healed wound. “The presence of healing bone is typical of the response to a traumatic event,” D’Anastasio says.

Scientists can only hypothesize what happened so long ago. But the location and shape of the wound suggest that Big John’s frill was impaled from behind by a Triceratops rival, adding evidence to the idea that Triceratops fought with one another (SN: 1/27/09). It was probably an initial puncture that was pulled downward to create the keyhole shape, the researchers say.

“Pathology is a great tool to understand the behavior of dinosaurs,” says Filippo Bertozzo, a dinosaur paleontologist at the Royal Belgian Institute of Natural Sciences in Brussels who was not involved in the study. Dinosaur behavior has long been in the realm of speculation, he says, but analyses like these can provide a glimpse into the lifestyle of these animals.

He adds that this particular wound is “not a Rosetta stone,” because it’s unlikely that all fenestrae are battle injuries. “Fenestration is still a big mystery.”

What’s also a mystery, D’Anastasio says, is why the bone remodeling seen in this Triceratops sample was more similar to healing observed in mammals than in other dinosaurs. And Big John himself might hold more secrets.

“We published an aspect, a paleopathological case,” D’Anastasio says. “The complete skeleton of Big John must be studied.”

The W boson might be extra hefty. If so, it could hint at new physics

There’s something amiss with a mass.

A new measurement of the mass of an elementary particle, the W boson, has defied expectations. The result hints at a possible flaw in physicists’ otherwise stalwart theory of the fundamental bits and bobs of our world, known as the standard model.

That theory predicts a W boson with a mass of about 80,357 million electron volts, or MeV. But the new measured mass is larger, at 80,433.5 MeV, physicists with the Collider Detector at Fermilab, or CDF, collaboration report in the April 8 Science.

The finding could hint at new particles or other mysteries of physics yet to be discovered. “If confirmed, this would clearly mean very interesting new physics that we can explore,” says theoretical physicist Sven Heinemeyer of the Institute for Theoretical Physics in Madrid.

Still, several earlier, less precise measurements found W boson masses more closely aligned with the standard model, including one from the ATLAS experiment at the Large Hadron Collider at CERN near Geneva. So physicists are awaiting further confirmation before declaring their prized theory incorrect.
“CDF’s new result seems barely compatible with the previous ones, including its own previous result, which prompts questions,” says ATLAS physicist Maarten Boonekamp of the Institute of Research into the Fundamental Laws of the Universe at Université Paris-Saclay.

Discovered in 1983, the W boson plays an important role in the standard model (SN: 2/5/83). The particle comes in two varieties, with either positive or negative electric charge. Together with their uncharged partner, the Z boson, the particles carry the weak nuclear force, which is responsible for certain types of radioactive decay and plays an important role in the nuclear reactions that power the sun.

Using data that CDF collected from 2002 to 2011, the team looked for W bosons produced in collisions of protons and their antimatter counterparts, antiprotons, in the now-shuttered Tevatron particle collider at Fermilab in Batavia, Ill. (SN: 9/9/11). The analysis was designed so that researchers couldn’t tell what the end result was until they were done.

The moment of the unveiling was striking, says experimental particle physicist Ashutosh Kotwal of Duke University. “When the answer popped up … we were awestruck about what we might have just learned.”

With a precision of 0.01 percent, the new W boson mass measurement is about twice as precise as the previous record. “This is a very special measurement; this is a true legacy,” says experimental particle physicist Rafael Coelho Lopes de Sá of the University of Massachusetts Amherst, who worked on measuring the W boson mass for another Tevatron experiment. “The level of dedication and care and detail … is amazing.”

The new measurement disagrees with the standard model expectation by 7 sigma, a measure of the statistical significance of a result. That’s well above the 5 sigma that physicists usually require to claim a discovery.

Still, “before getting too excited,” says ATLAS physicist Guillaume Unal of CERN, “I would like to see an independent measurement that confirms the CDF measurement.” In addition to the ATLAS measurement, described in 2018 in the European Physical Journal C, another measurement of the W boson’s mass from the CERN experiment LHCb was also in line with the standard model prediction, researchers reported in the January Journal of High Energy Physics.

“The W boson mass is notoriously difficult to measure,” says LHCb physicist Mika Vesterinen of the University of Warwick in Coventry, England. That explains why it took CDF so long to wrap up this analysis, published more than 10 years after the experiment ended.

Hopefully, scientists won’t have to wait that long for another measurement. The ATLAS and LHCb collaborations are already working on improved W boson mass analyses. CMS, another experiment at CERN, could also size up the particle.

If the new measurement holds up, it’s not yet clear what secrets of physics might be at play. New particles — such as those predicted by the theory of supersymmetry, which posits that each known particle has a heavier partner — could help shift the W boson mass upward (SN: 9/6/16). Intriguingly, Heinemeyer points out, those same particles might also help explain another recent physics mystery — the magnetic gyrations of muons reported by the Muon g−2 experiment (SN: 4/7/21).

Whatever physicists uncover, they’ll gain a new grasp on the particulars of this crucial particle, says theoretical physicist Nathaniel Craig of the University of California, Santa Barbara. “At the end of the day, the added energy and attention devoted to the W mass measurement … will be an immensely positive thing.”