Medical Gaslighting: A Problem With a Solution

No, it is not in your head.

Reviewed by Lybi Ma

Part II of II

Some physician practices offload additional tasks to (less well-trained) physician extenders, medical assistants, administrative assistants, or even AI assistants.^{5 6 7} However, none have the physician's experience, training, or ultimate medical authority. People trust their physicians more than any other physician extender; if the physician can't or won't take the time to explain these issues to the patient, their buy-in is highly likely to suffer. Non-compliance with medical therapy is a major part of the high cost of medicine.^{8 910} This is undermined by brief visits with the person ultimately responsible for implementing these strategies or being given only superficial or vague explanations by someone other than the physician.

It doesn't matter whether it is a VA hospital, a major academic center, a small private hospital, or a for-profit hospital: all of them are run by administrators who are driving their physicians to see more patients in the amount of time that they have for their allotted clinic or office hour. That often results in physicians telling patients, “We can only go over one of your problems today, which one is it going to be?” Or just trying to get through the day, a physician may take a mental shortcut, look at a report generated by a clinician not experienced in a particular area, and say, “The report looks normal, there's nothing wrong with you, move on,” and hope that their medical authority will dispel what they believe to be a “functional” complaint, i.e. one that does not have a radiologic correlate or does not have an underlying etiology that can be treated, that is, what that doctor believes is just a psychological or invented symptom, and just telling them that it's not real will hopefully make it go away.¹¹

Many of my patients had been told for a decade or more that there was nothing wrong with them; we identified by digging deeper into their symptoms, looking for the correlation between symptoms and physiology, and identifying common pathways that can be a source of treatment. If clinicians are incentivized not to do that, then that step will likely be overlooked. Some may say that medical malpractice concerns drive physicians to take more time than their administrator might want, to avoid being sued for medical malpractice. However, most clinicians don't believe that they are “mal-practicing.” Therefore, as a day-by-day measure, that usually isn't enough to make somebody tell three people in the waiting area that they'll have to wait a little bit longer, and that this patient requires a 30-minute visit instead of a 10-minute visit.^{12 13 14}

Most surgeons are incentivized by what is known as an “RVU-based model.” Surgical procedures or sub-procedures are typically assigned (by Medicare) a “resource-based value unit” (or RVU, also sometimes known as mRVU for Medicare RVU) that is meant to express the relative complexity of that procedure. For example, one procedure might have five RVUs assigned to it, or another operation might involve five different procedural codes, each of which has somewhere between two and 30 RVUs associated with it.¹⁵

Surgeon’s salaries, for example, are typically based upon the expectation that they will perform enough surgical procedures to generate a certain number of RVUs per year, incentivized further on a bonus plan based upon exceeding that number of RVUs and by how much they exceed that number. Surgeons are primarily incentivized (in most medical academic and private practices) based on the volume of procedures they perform, not the quality of outcomes.

Managing these complications takes time, office time, and often more time, but not always at the same level of reimbursement as the primary case. “Oh, there's nothing wrong.” “This is a normal outcome after this surgery.” Or, “I don't see anything wrong.” Essentially, “It's all in your head.”

This is where the physician transfers the blame for the patient's symptoms onto the patient, instead of a potentially identifiable and treatable cause, to avoid adding workload or potentially even adding reputational damage to their practice by suggesting something wasn't as it was supposed to be. Part of this is also not taking the time to manage the patient's expectations in the first place, which was likely due to the overworked clinic schedule.

After all, if you were told that you would be left with some degree of permanent pain, that there was a risk that the procedure would need to be repeated and that the bigger the operation, the more chance of one or more of those complications happening, perhaps the patient would have pushed back and asked for a smaller operation to begin with.

Insurance companies are slow to change and update what they authorize treatments for. Care denied (especially when claiming to be looking out for the patient's best interest) usually results in the patient remaining untreated for their condition, which helps no one. Whether it’s cancer diagnostics or therapies that can return a patient to a better quality of life, it’s a cost insurance companies pay in several layers of “red tape” to delay and deny care to millions of customers. Insurance companies have reported billions in quarterly profit, but patients are being gaslit, by insurance companies they pay premiums to.

Patients are being medically gaslit because physicians are being incentivized to move them through the system quickly, but not effectively. They're essentially being shuffled like cards to make them feel like they're getting better care than they are. In the end, they are being undertreated, and in many cases, mistreated, ignored, or worse, being pushed past their ability to manage their frustrations, disabilities, or diseases.

And the cure? Just listen, and try to help them. Even if it takes longer than the schedule says they have. Perhaps a treatment is more complicated or involves a hybrid of two treatments instead of just one simple one. And most patients don’t mind the doctor being late to their appointment if you explain that you were taking the time the patient needed before them. They want the same thing from you, if they don’t accommodate you, they may not be a good fit for your practice.