Medical Gaslighting: A Systemic Problem

Why the medical system is broken.

Reviewed by Lybi Ma

Part I of II

Gaslighting is the process by which one (or more) people are bullying somebody into questioning or believing something about themselves that is not true, often involving devaluing their opinions, validity, or sense of self¹. Medical gaslighting is when the perpetrator is one or more members of the medical community and is usually involved in the process of undermining the patient's credibility, symptoms, or even their sense that they have a right to healthcare or certain treatments.²

This can take many forms. However, this entity has been described in the medical literature and the lay press over the last several years. As a result of patients being medically gaslit, they endure increased symptoms, untreated medical conditions, and frequently suffer lost economic value due to the inability to work or have an impaired quality of life as a result of not getting the treatment that they were seeking. This does not necessarily require that a particular treatment be sought: for many patients who are told there is “nothing wrong” with them, they don't know what their problem is, they don't know what treatment they need, and their medical practitioners are brushing them off.

How does this happen in a society that has increasing access to technology and diagnostic testing and one that should value empathy? The answer to this question requires a deeper look into the incentives that exist in our current medical system to understand that the root of this problem lies in the changing social and financial incentives to provide medical care.

Susie (not her real name) had been very active as a child and teenager; as an adult, she participated in weightlifting, rowing, and many other activities. She was often dizzy as she stood up, but was told this was normal. After random dizziness during a workout, she began to have an unstable gait and imbalance. She also had brain fog and felt pressure changes in her head as well as neck, back of skull, and ear pain. Her symptoms continued to get worse as she met with multiple specialists. None had any suggestions for treatments, and several had suggested there was nothing to treat.

Patients who unfortunately have slightly more complicated problems than the average primary doctor, orthopedic surgeon, or physical therapist may be aware of or have the time to evaluate fully are more likely to be gaslit. Why is that? Rationing healthcare resources have been discussed in the media and academic literature for more than 50 years³ due to a combination of scarcity, rising costs, and increasing consolidation of medical practices, either under hospital chains (for-profit as well as not-for-profit), private equity-owned medical practices, and even physician-owned medical practices. The number of physicians in solo or small group private practices has decreased over the last 30 to 40 years. While 80 percent of solo practitioners are self-owned practices, only 35 percent of practices more than 5 MDs are self-owned.⁴

The medical community has also been squeezed financially by progressive decreases in the amount of money insurance companies and government agencies like Medicare (the single largest government-sponsored insurance entity). Most insurance companies usually use Medicare reimbursement rates as a benchmark to pay physicians. Therefore, when Medicare fees go down, so do insurance company fees. In addition, the relative percentage of that benchmark that insurance companies pay (for example, 300 percent of Medicare) has also been decreasing over the last few years. Some insurance plans pay even less than Medicare rates, and this is accentuated even more by the “copay” phenomenon (whereby the insurance companies feel that the patient needs to have some “skin in the game”) and only pays typically 50 to 80 percent of that “allowable” physician payment, reducing even further the payment to physician and making physicians get that difference from the patient.

Imagine only getting half of this lower fee, and you can see that physician practices might be anxious about their financial viability when faced with Medicare-based reimbursements. Many have sold their practices (after becoming not financially viable as independent entities) to a larger entity or hospital that subsidizes the practice in exchange for those patients being admitted to the hospital, which then makes more money on the admission than the physician who treats them, and using some of that money to help offset the lower physician collections and the physicians' salaries.

The way most practices (in all environments) manage this issue is to ”make it up in volume.” That is to say, see even more patients to increase their revenue. But the problem with that strategy is that the only way somebody can do that, absent making them work more days of the week or more hours in the day, is to reduce the amount of time with each patient. At a time when our understanding of the complexity of medical conditions, physiology, and the breadth of conditions that we can treat, we need to be spending more time with each patient rather than less.

However, the common complaint I hear from physicians is feeling excess pressure to see more patients in less time. This push for more “efficiency”—treating more patients in a given hour of the day—has to come at the expense of quality.

How can you possibly review all of the relevant findings of a patient's medical condition, when we might be discussing a patient with diabetes, which causes high blood pressure, coronary artery disease, liver disease, as well as possible cerebrovascular disease and other conditions (and that's just one unifying diagnosis)? Add cancer and other medical and orthopedic conditions and the complexity of each visit goes up significantly because many of these conditions cross-interact with each other. Add mental health issues, which can range from management of anxiety and depression to questions about various people in your life who may be having a detrimental impact, whether it be bullying or “safe space” violations. There's very little time in a compressed physician visit to query, manage, and perform the critical explanation of these medical impacts and the proposed treatments and their strategies.

Part I of II