Turning Down the Flame on Medical Gaslighting

“Gaslighting” refers to a person of power psychologically manipulating another into questioning their own reality. The origins of the term date back to the 1944 film Gaslight, set in Victorian London, in which a husband leads his wife to the brink of insanity by insisting that she is imagining, among other events, the gas lamp flames wavering when he is out of the house. In actuality, the husband manipulates the flow of gas during his absences and intentionally deceives her. Use of the word “gaslighting” has recently become mainstream. The Merriam-Webster dictionary chose it as “word of the year” in 2022, citing the New York Times’ coverage of patients who used the expanded term, “medical gaslighting”, to describe feeling discounted or doubted by their physicians. The reality that patients feel psychologically manipulated by their physicians is deeply concerning and requires equally deep inquiry which, to date, has not been done.

According to the New York Times,¹ the term “medical gaslighting” gained traction on the social media platform Instagram; the hashtag has nearly 20,000 posts to-date. In the medical literature, the term “medical gaslighting” debuted in September of 2020 when JAMA² published a first-person account of a patient who believed she was gaslighted when her symptoms were repeatedly discounted; she was ultimately diagnosed with long COVID. In October of 2020, Hoffman et al.³ described the dismissal or downplaying of gynecological pain and symptoms in women as medical gaslighting. References to medical gaslighting in the media have eclipsed references to the topic in medical journals. In fact, a recent search for “medical gaslighting” in the National Institutes of Health’s PubMed database yields only 4 references regarding patients’ healthcare experience (in the medical literature, most articles about “gaslighting” refer to healthcare providers feeling manipulated by the healthcare system).

In this void, the popular press is shaping the definition of medical gaslighting, often through accounts of patients who felt dismissed by doctors and faulting physicians as the primary cause of negative healthcare outcomes. Reports frequently cite the context of structural racism, cultural and gender discrimination, and biases—real threats to health equity with a troubled history—as significant contributors to patients’ feeling written-off and manipulated. The New York Times⁴ attempted to explain the term in an article on July 29, 2022, entitled, “Feeling Dismissed? How to Spot ‘Medical Gaslighting’ and What to Do About It.” The article correctly acknowledged areas for improvement, such as the tendency of physicians to interrupt patients. However, it added a concerning new dimension to the term by asserting that a sign of gaslighting is when “your provider will not order key imaging or lab work to rule out or confirm a diagnosis.” Patients—particularly women and people of color—feeling that their concerns are minimized is a serious concern for the medical profession, but not ordering potentially unindicated tests in response to patient requests is another thing entirely.

Public awareness campaigns such as Choosing Wisely, a partnership between the American Board of Internal Medicine Foundation and specialty societies have developed clinical recommendations to discourage unnecessary care and instead promote value-based care. Although diagnostic diligence is critical, lab tests and imaging studies are not always the “key” to a diagnosis, and patients are not always aware of the right therapies. A common example is patients asking for antibiotics to treat a virus, and feeling unheard when requested drugs are not prescribed. The campaign promotes doctor-patient conversations about frequently-used tests that may “do more harm than good.”

It appears that a lack of such conversations, rather than a lack of testing, is creating gaslighting perceptions. Patients who feel heard, understood, and cared-for will not feel gaslighted; and with proper dialogue, it is more likely that physicians will order the right tests and therapies when they are indicated. Over 40 years of research have shown that using relationship-centered communication skills achieves this, and more^5,6. These skills are linked with improved health outcomes and better patient experience. Importantly, these skills can be incorporated into practice with modest effort. Key evidence-based skills include collaborative agenda-setting for the encounter, allowing patients to describe their symptoms without early interruption, eliciting the emotional context of that story, and responding with verbal empathy.

Many gaslighting anecdotes focus on physicians attributing patients’ symptoms solely to stress, poor nutrition, mental health, lack of exercise, or obesity. Since Dr. George Engel conceptualized the biopsychosocial model in 1977, an abundance of evidence has substantiated that biological disease is influenced by complex mind–body linkages as well as social determinants of health. For instance, we know that feelings of hope can improve cancer outcomes; cognitive behavioral therapy can reduce centralized pain; studies of drugs are confounded by placebo and nocebo effects; and adverse childhood experiences increase the probabilities of cardiac disease. Despite this, conversations about the psychological and social dimensions of health and illness leave some patients feeling accused of having an illness that is “all in their head”.

We must do a better job of exploring the biopsychosocial model with patients, and collaboratively untangling its relevance to the illness experience and clinical outcomes for each individual patient. Relationship-centered communication trainings that focus on the biopsychosocial model, such as those offered by the Academy of Communication in Healthcare, may improve physicians’ skill in discussing the mind–body connection. These trainings must be modified for the digital age to account for communication challenges caused by telemedicine visits, cumbersome electronic medical records, and a general reliance on technology for communication as opposed to face-to-face relationship-building.

Certainly, factors beyond physicians’ immediate control challenge relationship-centered communication. The proportion of physician time spent on direct patient care has been eroded by escalating administrative and insurance burdens, documentation requirements, and economic models that reward productivity over value. Time-constraints reduce physician and patient confidence in healthcare decision-making, quality, and safety. In a study of primary care medical teams, over two-thirds of respondents felt that time-pressures interfered with screening, diagnosis, or treatment opportunities. Additionally, patients receiving care from time-stressed practices were more likely to report lower levels of support.⁷ Such feelings of low support likely fuel gaslighting perceptions.

Determining which patient demographics, medical conditions, physician behaviors, and health system pressures are correlated with gaslighting complaints will enable the healthcare system to learn more about gender, class, race, disability, age, and time as factors in medical gaslighting and then create the appropriate solutions. Research using qualitative methods such as focus groups and interviews combined with quantitative methods such as patient surveys can help characterize differential experiences of gaslighting. In addition, data-mining, artificial intelligence, and deep learning algorithms can elucidate patterns and trends in medical gaslighting references in social media posts, although consideration must be given to the biases in such methods.

Gaslighting means deception. Ensuring that physicians have the time and skill to help each patient feel heard, understood, and cared-for will stop this cynical term from being further linked to the practice of medicine.

Declarations

Conflict of Interest

The authors have no relevant conflicts of interest to disclose.