Table 1.

Text Employed in the Vignettes

Neutral language chart note	Stigmatizing language chart note
Section 1
Mr. R is a 28-year old man with sickle cell disease and chronic left hip osteomyelitis who comes to the ED with 10/10 pain in his arms and legs. He has about 8–10 pain crises per year, for which he typically requires opioid pain medication in the ED. At home, he takes 100 mg OxyContin BID and oxycodone 5 mg for breakthrough pain. Over the past few days, he has taken 2 tabs every 4–6 hours. About 3 months ago, he moved to a new apartment and now has to wheel himself in a manual wheelchair up 3 blocks from the bus stop. He spent yesterday afternoon with friends and wheeled himself around more than usual, which caused dehydration due to the heat. He believes that this, along with recent stress, precipitated his current crisis. The pain is aching in quality, severe (10/10), and not alleviated by his home pain medication regimen. On physical exam, he is in obvious distress. He has no fever and his pulse ox is 96% on RA. The rest of the physical exam is normal other than tenderness to palpation on the left hip.	Mr. R is a 28-year old sickle cell patient with chronic left hip osteomyelitis who comes to the ED stating he has 10/10 pain “all up in my arms and legs.” He is narcotic dependent and in our ED frequently. At home he reportedly takes 100 mg OxyContin BID and oxycodone 5 mg for breakthrough pain. Over the past few days, he says that he has taken 2 tabs every 4–6 hours. About 3 months ago, patient states that the housing authority moved him to a new neighborhood and he now has to wheel himself in a manual wheelchair up 3 blocks from the bus stop. Yesterday afternoon, he was hanging out with friends outside McDonald’s where he wheeled himself around more than usual and got dehydrated due to the heat. He believes that this, along with some “stressful situations,” has precipitated his current crisis. Pain is aching in quality, severe (10/10), and has not been helped by any of the narcotic medications he says he has already taken. On physical exam, he appears to be in distress. He has no fever and his pulse ox is 96% on RA. The rest of the physical exam is normal although he reports tenderness to palpation on the left hip.
Section 2
After 1 hour, the nurse documents:
Mr. R is sleeping but easily arousable and seems distressed. He is not tolerating the oxygen mask and still has 10/10 pain. His girlfriend is by his side but will need to go home soon.	Mr. R is sleeping but easily arousable and has been cussing at nurse. He refuses to wear his oxygen mask and is insisting that his pain is “still a 10.” His girlfriend is lying on the bed with shoes on and requests a bus token to go home.