The Myth of Medical Gaslighting: When Patient Perception and Physician Intention Collide

The practicing physician faces many challenges. Whereas some of these challenges have been around for years, physicians now face restrictions of time and accountability for productivity in ways that previous generations did not.¹ Besides the traditional time needed for examination and diagnosis, modern physicians must respond to communications with patients through portals and other electronic media and keep abreast of rapidly accumulating medical research, developments, and trends, while being mindful of limitations placed by insurance companies on office visit fees and costs of diagnostic testing. Ensuring profitability places additional constraints on physicians, especially hospitalists. Some of these demands place challenges on balancing patient care and treatment with the need to maintain a financially sustainable practice. 

Medical school does not train physicians to be timekeepers, but rather to be accountable to their patients, which has become increasingly difficult. Apportioning enough time for patients, some of whom present with difficult and not easily diagnosed disorders, requires a detailed history. Time restrictions may lead to a rushed assessment. Some individuals require more time to explain their concerns than the physician has available. The individual may attribute a rushed assessment to abruptness or disinterest by the physician, rather than the time limitations imposed by managed care. 

People also may come in with self-diagnoses, sometimes promulgated by popular consumer social media posts or videos, which cannot be summarily dismissed by the physician without risk that the individual feels unheard, diminished, or dismissed. This, along with the possibility of inadequate or frank misdiagnosis, has given rise to the term “medical gaslighting.” Ng et al² defined medical gaslighting as invalidating a patient’s genuine clinical concerns without proper medical evaluation because of the physician’s preconceived notions, implicit or explicit bias, medical paternalism, arrogance, or ignorance of a specific disease. The term “medical gaslighting” is a misnomer, however. The term “gaslighting,” derived from the play and 1944 movie Gaslight, involves a husband intentionally deceiving his wife for nefarious purposes.^1,2 Ignorance or insufficient evaluation may lead to misdiagnosis, but deception or malevolence is rarely contributory. Nevertheless, according to the nonprofit organization ECRI, patients may invoke medical gaslighting when they believe physicians have dismissed them, refused to discuss their symptoms or medication concerns, minimized their symptoms, ignored or interrupted them, or refused to order specific tests, or if they felt that they were being blamed, were being condescended to, or had their symptoms misattributed to personal attributes or other disorders (eg, obesity).³ The physician who behaves in this way is more likely to commit errors or miss a diagnosis. 

Medical errors are the third leading cause of death in the United States, and such errors contribute to loss of trust in the medical system.⁴ Physicians are no less fallible in their chosen profession of medicine than are experts in other disciplines. Difficult-to-diagnose cases are common in medicine. We therefore propose that a more apt adjective than “gaslighting” is “diagnostic misattribution”.

Diagnostic Misattribution

Diagnostic misattribution, which can be problematic for any individual, has additional impact among populations that have historically been marginalized, including women; individuals from underrepresented racial, ethnic, or socioeconomic groups; individuals with severe intellectual, mental, or psychiatric disorders; people with medical disabilities; people from the LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and other gender identities and sexual orientations) community; and older individuals.¹ There is ample evidence to support that people from these groups are more likely be taken less seriously; to have their symptoms overlooked, dismissed, or attributed to preconceived notions about characteristics of their group; and to receive inadequate care. As a result, due to implicit or explicit biases, physicians may fail to order appropriate diagnostic tests or to prescribe needed pharmaceutical or other treatments.

Previous Diagnosis or Self-Diagnosis

Another challenge for physicians is presented by individuals who have already been diagnosed by others or who are self-diagnosed. These individuals may request to be treated for these diagnoses before the physician has had the opportunity to begin the medical workup. Especially thorny is the situation when individuals have diagnosed themselves with a medical or psychologic disorder that has historically been overdiagnosed, is being widely reported in the media, or is not universally or historically accepted as an established medical diagnosis (eg, chronic fatigue syndrome, chronic Lyme disease, long COVID brain fog).^2,5 At times, these possibly questionable pre-office visit diagnoses have been made by nonmedical personnel, nonspecialist physicians or mental health professionals, or family or friends, or, most notably, by social media connections. The proclivity of some individuals to “doctor shop” until they find a physician who will endorse their self-diagnosis places a burden on clinicians who were trained in and rely on scientifically accepted conceptualization of disease.

Physicians may have their own biases and may dismiss such diagnoses out-of-hand, which may leave individuals feeling dismissed. Patients deserve a forum to discuss their concerns without feeling harshly judged and rushed. Of course, patients are often rushed because physicians are rushed⁶; however, if patients believe that they are being listened to and that their concerns are being addressed, they will be less likely to feel disrespected by their physicians. Numerous studies indicate that patients are more inclined to pursue legal action against their physicians when they perceive a lack of respect, poor treatment, or insufficient communication regarding their medical care.⁷

Medically Unexplained Disorders

Complicating diagnosis and care is the prevalence of medically unexplained disorders (ie, persistent physical symptoms).^6,8 Frequent users of health care services are disproportionately represented by individuals who fit the criteria for somatization disorder which contributes to the high cost of medical care. In addition, physicians may occasionally see patients who are frankly malingering, although in the general hospital setting this is rare (~.15%) as opposed to patients seen in neuropsychologists’ offices for forensic purposes.⁹

Medicine is introduced to trainees as being a collaborative process, but physicians need to believe that patients respect their training and humanistic concerns; when this appreciation is not apparent, miscommunication between the patient and physician may ensue. Except in the most extreme circumstances, initiating a "reset" in which a clinician restarts the patient encounter may do much to undo an initially tense situation. Extending the length of the physician encounter also may be warranted. Physicians must be mindful of the overlapping and sometimes competing movements of patient-centered care, a collaborative effort between patient and physician (to replace medical paternalism), and health care consumerism, with direct outreach to patients (including frequent rating questionnaires), because each may affect the physician’s or health care institution’s income.^10,11

Specific Populations and Relevant Considerations

People With Neurologic Disorders

The overlap in clinical manifestations and paraclinical findings between multiple sclerosis (MS) and other neurologic and non-neurologic disorders can lead to misdiagnosis.^12,13 The International Advisory Committee on Clinical Trials in Multiple Sclerosis has recommended diagnostic approaches to improve the accurate diagnosis of MS.¹² However, because these criteria were drawn from mostly White, European, and North American cohorts, there is a risk that people from underrepresented racial and ethnic backgrounds remain at risk for misdiagnosis.¹³ Alternatively, individuals may be misdiagnosed with MS and later found to have migraine, psychogenic disorders, or vascular disease.¹⁴ However, apprehension of causing distress or fear of litigation may lead clinicians to withhold communication of this misdiagnosis. Consensus-based guidelines were issued in response to these concerns.¹⁴ These include scheduling an appointment with the patient in a timely fashion once the misdiagnosis has been discovered, delivering the information in an unhurried fashion, being completely transparent with the patient, being apologetic, helping to manage the emotions of the patient, discussing treatment options, and informing the patient that additional testing may be necessary for clarification of the correct diagnosis.

Women

Chronic pelvic pain—that which lasts in the pelvic region for >6 months—may have different symptomatology from woman to woman, both in terms of severity of pain and specificity.¹⁵ Chronic pelvic pain may interfere with normal activities, such as work, exercise, or sexual activity. Symptomatology besides genital pain is nonspecific and can include painful defecation, heavy menstrual bleeding, bloating, and fatigue.^15,16 Etiology may be varied and comorbid with other conditions (eg, irritable bowel syndrome). 

Misdiagnosis and delayed diagnosis are common among women with chronic pelvic pain.¹⁵ A diagnosis of endometriosis—a possible cause of pelvic inflammatory disease—may require visits to 7 different physicians and 7 to 10 years of searching for treatment before a final diagnosis is made.¹⁶ As a result of the disorder and prolonged time to diagnosis and treatment, women with these symptoms often experience depression, anxiety, and stigma. A similar pattern has been reported for a pathologically distinct gynecologic disorder (i.e., adenomyosis).¹⁷ In the past, endometriosis and other gynecologic disorders came to be associated with the now-discarded diagnosis of “hysteria”, an ancient designation long ascribed to a psychologic disorder of women that was first codified by Hippocrates: in Greek, “hysterikos” means “wandering uterus.”¹⁸

Women who undergo pelvic or vaginal mesh insertion for repair of pelvic organ prolapse or for urinary incontinence, or subsequent removal of the mesh, may experience considerable physical pain and emotional sequelae.¹⁹ Surveys of a cohort of these women in the United Kingdom and Australia revealed great dissatisfaction with their treatment, with descriptors including “broken body,” “broken mind,” and “broken life,” and reports of distrust of doctors and the medical industry. These patients complained of denial of their mesh-related problems, which was described as gaslighting.

Dissatisfaction with the British medical community concerning pain with insertion of intrauterine devices was shared among women on social media.²⁰ These tweets, reported in BMJ Sexual & Reproductive Health, included complaints of missing or misleading information about pain, dismissal of pain, and invalidation of experiences.

People From Underrepresented Racial or Ethnic Groups

Racial disparities in health care, which have an unfortunate established history in the United States and elsewhere, have resulted in unfavorable outcomes in Black relative to White populations. Implicit bias is thought to contribute to a 3-fold greater pregnancy-related mortality rate in Black vs White women.²¹ The US Centers for Disease Control and Prevention explicitly characterized racism as a serious public health threat and associated racial biases with negative outcomes for cardiac testing and treatment, pain management, cancer screening, and pediatric care.²² Implicit biases can affect outcomes of traumatic brain injury; in one study, Black caregivers were viewed as being more problematic, troublemaking, and difficult compared with their White counterparts.²³

The infamous Tuskegee syphilis experiments have long been cited as exacerbating the distrust of Black Americans for the US health care system²⁴; however, the history of mistreatment of Black Americans extends back to the period of enslavement, including reports of gynecologic and other surgical experimention.²⁵

To this day, access to health care is lower for Black than for White individuals, and Black people with specific disorders, such as HIV infection, report feeling stigmatized and discriminated.²⁶ The initial reluctance of some Black individuals to receive the COVID-19 vaccine was attributed to the US history of systemic racism.²⁷ This distrust of the health care system is not unique to Black Americans, but among other groups, distrust may be more closely aligned with a lack of health care literacy, which can be changed if patients develop confidence in their providers’ skills and knowledge.²⁸

Hispanic individuals, similar to Black individuals, experience barriers to health care.²⁹ Compared with White individuals, Hispanic individuals are less likely to be seen in a physician’s office, outpatient clinic, or emergency department. Disparities in health care seen in Hispanic individuals is especially pronounced in older populations.³⁰ Older Hispanic individuals report greater problems with health care access as well as depression and disability. Self-identified Black, Native American, Hispanic, and multiracial respondents were more likely to report perceived discrimination than were their counterparts who self-identified as White.³¹ Consequences are profound, with postponement of medical tests and treatment, underutilization of health services, decreased satisfaction with care, higher levels of mistrust of health care practitioners, and decreased adherence to physician recommendations leading to a greater likelihood of severe medical conditions and poor outcomes.

People With Comorbid Psychiatric Diagnoses

Stigma concerning numerous health conditions, particularly severe mental illness and drug addiction, is cross-cultural, and health care providers are not immune to bias.³² This bias can undermine diagnosis, treatment, and successful health outcomes. At times, symptomatology is vague, or so common as to not be pathognomonic to any specific disorder, and may be summarily dismissed as secondary to depression, anxiety, or stress.

People with personality disorders, especially borderline personality disorder, present challenges to the practitioner both in terms of time and patience.³³ These individuals often appear strained, may not articulate their needs adequately, and may have unrealistic expectations regarding treatment (e.g., available time resources). They are twice as likely as people from the general population to experience somatic disorders and tend to be sensitive to criticism and rejection and to be mistrustful. They are prone to abrupt changes in mood and behavior and may have poor stress tolerance and poor adherence to treatment guidelines. Individuals most likely to engage in “gaslighting” themselves are those with borderline, paranoid, narcissistic, or other personality disorders³⁴; what is not known is how often individuals with personality disorders level such charges against physicians who treat them. 

People With Certainty of Self-Diagnosis

The current public landscape, including the Internet and social media, abounds with misinformation, as well as individuals fomenting distrust in science and medicine. Although individuals’ assertions of diagnosis may present a challenge, patience on the part of the physician can produce favorable outcomes.³⁵ As long as individuals feel respected to assume responsibility for their own health, searching the Internet and discussing information found with their physicians can be positive. The most important variable is the belief that decision-making is a consequence of a collaborative relationship between the patient and their physicians rather than a challenge to the authority of health care professionals.

Recommendations 

Jean-Pierre⁴ has endorsed federal legislation to encourage clearer apology laws and the expanded use of communication and resolution programs for medical errors. The Joint Commission has issued an advisory which provides recommendations for improving physician communication skills.³⁶ Openness to frank communication with patients, especially those regarded as challenging, will be beneficial in minimizing errors and improving trust among patients, which can lead to mutually more satisfying and less stressful interactions. Such communication does not exclude discussing the role of emotions as a source of symptomatology.³⁷

Invoking the contribution of psychological factors in the formation, experience, exacerbation, or interpretation of symptoms expands the discussion between patients and physicians and intrduces the possibility of augmenting medical treatment with psychotherapy. This is especially true for gastrointestinal disorders that may be explained as disorders of the gut-brain axis; it is important for a multidisciplinary approach that provides  patients with an expanded health care team that may include psychologists, dietitians, physical therapists, and other specialists.⁵ Rather than leaving patients to feel abandoned by their physicians, such an approach can be empowering for patients, making them active partners, rather than passive recipients, of health care. 

Neurologists can benefit from a similar consideration with a multidisciplinary approach for the treatment of psychogenic nonepileptic seizures.³⁸ Psychotherapy, especially cognitive–behavioral therapy, and psychopharmacologic treatment has a distinct place in the management of comorbid anxiety and depression, which frequently contribute to nonepileptic seizures.