You visited the physician and exited feeling worse

Patients dealing with elusive conditions, such as prolonged COVID or symptoms whose origins current medical evaluations struggle to identify, like irritable bowel syndrome, might feel overlooked when a clinician states they cannot determine the cause of the issue, or — more disheartening — when they insinuate that the issue might be entirely psychological. This phenomenon is often referred to as “medical gaslighting,” an issue that is far from novel but has been amplified by social media in recent times.

Alexandra Fuss, who leads behavioral medicine in inflammatory bowel disease at Mass General and serves as an instructor in psychology at Harvard Medical School, collaborated with colleagues from the University of Michigan and the Rome Foundation Research Institute in North Carolina to investigate this issue for an article published in the journal Translational Gastroenterology and Hepatology.

In this edited discussion, Fuss underscores the authors’ finding that most instances of medical gaslighting lack intent to mislead and should be termed “medical invalidation.” She also addresses how increasing patient loads and administrative pressures on physicians might exacerbate the issue.

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What drew your attention to the topic of “medical gaslighting”?

The term has gained significant traction on social media, and, as a mental health professional, I encounter it during sessions with clients.

Is there an element of medical arrogance at play when a provider cannot identify a solid reason for symptoms, leading them to assume there isn’t one?

That is indeed part of it, linking back to a mindset where “If it’s not showing up on a medical test, it’s likely psychological.” However, we must acknowledge that there is immense pressure on healthcare practitioners, especially M.D.s, to be knowledgeable, provide answers, and maintain expertise. It can be tough to say, “I don’t have the answer.” Yet, there is ample room for growth in stating, “I’m not certain, but I will collaborate with you, and we’ll work towards a solution together.”

You question the appropriateness of the term “gaslighting.” Can you elaborate on that?

There is considerable discourse in the literature regarding the significance of intent in gaslighting. Some scholars argue that intent must exist — aimed at forcing someone to doubt their own reality and rely on the viewpoint of the perpetrator — for it to qualify as gaslighting. Others contend that it’s not about intent, but rather the outcome, and any time there exists a power imbalance, the potential for gaslighting is present.

We maintain that intent is crucial for genuine gaslighting. Whether consciously or subconsciously, I seek for you to adopt my perspective and will challenge your experiences to destabilize your sense of balance.

Utilizing the term “gaslighting” when intent is lacking diminishes the chance for compassionate understanding of providers. The vast majority do not aim to harm anyone; they are striving to be effective healers and supporters. Nevertheless, there can be instances of “medically invalidating” conduct. While not intentional, it is still invalidating and harmful. Characterizing it as “invalidating” rather than “gaslighting” facilitates a conversation about “How can we mend these relationships? What measures can we take to avert this occurrence?”

Can you elaborate on how pressures on doctors may contribute to this issue?

Such pressures originate from hospital and organization-level leaders who establish the policies influencing the physicians within these structures. Physicians are perpetually urged to enhance productivity, see as many patients as possible, often within constrained timeframes. Moreover, studies indicate that doctors spend upwards of 50 percent of their day on documentation, typically extending work hours to complete everything. They must manage healthcare resources diligently, ensuring that patients do not undergo unnecessary and costly tests, and that resources reach the appropriate individuals. With pressures surrounding them, it’s unsurprising that burnout rates soar, impacting over half of practicing physicians. While it is certainly beneficial for providers to cultivate work/life balance skills, placing the full weight of blame on them neglects the effects of the system they operate within. Initiatives commencing at the higher levels can yield a more significant impact.

How does this stress influence interactions with patients?

This situation creates vulnerabilities where invalidation may occur. Suppose, for example, a doctor has an overwhelming patient list that day, with just 15 minutes allocated for a patient visit, but the patient spends most of that time discussing their concerns. This situation leaves little opportunity for the provider to inquire, “How are you managing this?” or to make those empathetic remarks that foster trust: “I trust you; let’s hear more about what’s happening.” Without the adequate time for the physician to elucidate, the patient finds themselves attempting to fill in the voids, which may lead to thoughts like, “Oh, my doctor is dismissing me” or “They brushed me off.” If some of that pressure could be alleviated, these scenarios may be circumvented.