Myrisha Lewis

Professor Alice Abrokwa’s article, Too Stubborn to Care for: The Impacts of Discrimination on Patient Noncompliance, focuses on a rarely acknowledged source of bias in the healthcare system: medical records. Although this bias may not be easily visible to the public, medical records can significantly impact the medical care that individuals receive, as well as eligibility for government benefits and the size of medical malpractice awards. 

Professor Abrokwa begins her article by concisely telling the history of Elijah McClain’s interactions with law enforcement and emergency medical personnel, where he was labeled a “non-compliant person” during the interactions that eventually led to his death. As part of this story, she provides a quote from the City of Aurora’s investigative reportand recommendations in the aftermath of Elijah McLain’s death: “[I]mplicit biases can lead medical professionals to perceive Black patients as noncompliant and more resistant to pain, which can impact decisions regarding care to the detriment of Black Patients.” From there, she briefly outlines other instances where the labeling of patients in healthcare settings as “noncompliant” had significant detrimental impacts on their healthcare.

Part I of the article, “Situating the Analysis of (Non) Compliance,” provides practical and scholarly background on the meaning of the word “compliance,” particularly as it relates to Black people and other people of color in the United States. Professor Abrokwa explains that she extends the analysis of other scholars to “argue that norms about race, gender, and (dis) ability operate together to mark the difference between a ‘compliant’ and ‘noncompliant’ patient.” (citation omitted). In doing so, she shows that many individuals, regardless of race, do not “comply” with medical treatment. For example, many patients do not book “follow-up appointment[s] as soon as suggested or perfectly adher[e] to a recommended diet.” Yet, for patients of color, non-compliance can have more significant detrimental health outcomes as outlined in Part IV of the article.

Part II of the article, “Understanding the Stereotypes Underlying Noncompliance Biases and Providers’ Perceptions,” draws from Professor Kimberlé Crenshaw’s intersectionality framework in particular. In Part II.A, Professor Abrokwa “identifies the three stereotypes about Black people in the United States” that she argues are “most at work in driving perceptions of Black patients as noncompliant.” Professor Abrokwa then provides context evincing these stereotypes using media stories, scholarly literature, and historical accounts. In Part II.B, Professor Abrokwa cites to numerous studies demonstrating how racial stereotypes translate into the use of certain terms in patient notes. Moreover, Professor Abrokwa shows how just the use of a biased term in a patient’s medical records will then be transmitted to subsequent health care providers who, even though they may not be biased in the same way as the preceding medical provider, can still perpetuate that bias.

Part III, “Understanding Patients’ Reasons for Noncompliance,” explains why noncompliance is often justifiable and potentially evidence of healthcare providers’ failures, or systemic failures, not patients’ failures. Part III.A notes that patients may wish to undertake another course of action for family reasons or personal politics. Part III.B reminds the reader that in the U.S. health care system, patients may be noncompliant because following their provider’s recommendations is cost prohibitive. Part III.C. explains how provider communication failures can lead to noncompliance, whether the communication failure is about what prescribed medications a patient should undertake or patient education more broadly. Part III.D shows how “[a] patient’s perception that their provider is biased against them can…impact adherence to that provider’s recommendations” including through “reduced use of medical services.” Part III.E, “Medical Mistrust” discusses the many reasons why individuals might be suspicious of the healthcare setting, referencing notable instances of racial discrimination in the health care setting such as the federal government’s mistreatment of Black men in Tuskegee, Alabama. Moreover, Professor Abrokwa cites to Professor Nancy Krieger’s 2022 stunning reminder “…that everyone who is age 57 and older in this country was born when Jim Crow was legal.”

In Part IV, Professor Abrokwa explains how noncompliant patients can lose disability benefits, suffer reputational damage in benefits cases, and suffer potential reductions of damage awards in tort cases. In the next part, she provides solutions to minimize these harms. Part V.A. provides practical solutions that can reduce labels of “noncompliance” and render medical care more accessible in the United States, such as structural changes, hiring more providers of color, and hiring more providers with proficiency in multiple languages. She also acknowledges the limitations of these solutions, even referencing a study that found primary care providers would need “26.7 hours per day to see an average number of patients” in compliance with national guidelines. Part V.B focuses on the role of legal advocacy, including a description of one study, which found that “[m]ore than 1 in 5 patients perceived mistakes in their notes, judging more than 40% of them as serious.” In light of the role of medical records in litigation and benefits determinations, it is important that healthcare providers provide accurate notes. Lawyers can aid patients in requesting amendments to their health care records as that “process… can be time-consuming, resource-intensive, and emotionally taxing for patients to do on their own.” Moreover, Professor Abrokwa encourages attorneys to file complaints or pursue private litigation as appropriate and additionally advocates for attorneys, administrative law judges, and other judges to “carefully consider” why a patient might be noncompliant, in light of the reasons provided in Part III. She also encourages the Social Security Administration to issue guidelines that are less punitive of noncompliance.

The article brings attention to a significant but overlooked issue. Many individuals do not pay attention to their medical records after a provider visit, especially the section of their health record containing the summary of their visit with their providers’ notes. For those who do examine their own health records they may not realize that these provider notes exist not only for patient history but also as tools for physicians who have been counseled to write those notes in a way that minimizes the likelihood of lawsuits against them or more successful litigation outcomes as physicians. Yet, for patients, their providers’ notes, which are difficult to change, can be biased and harmful. Moreover, beyond legal outcomes, as Professor Abrokwa noted at the outset of her article, “[n]ot everyone survives being seen as non-compliant.”