Am I Gaslighting My Patients?

Medscape

3 days ago

Melissa Geraghty, PsyD, a clinical health psychologist at the US Department of Defense, developed unexplained episodes of lower body paralysis at the age of 34. 'I was told [by healthcare professionals] that it was 'just anxiety.' Throughout my life, I had been experiencing chronic pain and other odd symptoms but was told they were 'all in my head,'' she said in an interview with Medscape Medical News .
Melissa Geraghty, PsyD
Eventually, Geraghty was diagnosed with tethered cord syndrome, a rare neural tube defect requiring neurosurgery.
Geraghty was a victim of medical gaslighting — the dismissal or minimization of a patient's symptoms. The term derives from a 1938 play (later adapted into a movie called Gaslight ), in which a husband intentionally manipulates his wife into questioning her perceptions of reality. The term 'gaslighting' became so popular that in 2022, it was identified by Merriam-Webster as its 'word of the year.'
It has come to mean not only intentional manipulation of a person's perceptions but also dismissal of the person's legitimate concerns. In 2023, 'medical gaslighting' was trending on TikTok, garnering over 226 million views.
A new review focuses on harm caused by medical gaslighting, which the authors refer to as 'symptom invalidation.' Researchers examined 151 qualitative studies, encompassing 11,307 individuals and 11 conditions, including long COVID, fibromyalgia, endometriosis, Ehlers-Danlos syndrome, postural orthostatic tachycardia syndrome, and systemic lupus erythematosus.
The analysis identified broad classes of negative consequences: emotional states and beliefs (eg, self-doubt and shame), healthcare-specific responses (eg, loss of trust in clinicians), behavioral changes (eg, avoiding medical care), and diagnostic delays, leading to adverse outcomes.
Allyson Bontempo, PhD
'Patients described questioning reality and asking themselves self-doubting questions such as, 'Am I making this up? Is it all in my head?' This can lead to long-term trauma and self-doubt and can adversely affect medical care going forward,' lead author Allyson Bontempo, PhD, a postdoctoral fellow at Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, told Medscape Medical News .
Said Geraghty, 'This type of dismissal erodes trust and chips away at a person's sense of self.' It left Geraghty with 'medical trauma.'
Respondents 'reported downplaying symptoms to their providers so as not to look overdramatic,' Bontempo recounted. 'Many such patients avoid healthcare providers, even for unrelated conditions, because they feel hopeless and think that nothing will come of their visit.' In these scenarios, diagnosis and treatment are delayed.
Delays in diagnosis and treatment compromise the health of individual patients, and the negative sequelae of medical gaslighting go beyond its harmful psychological impact. It's a major public health issue, according to a report issued by the global healthcare safety nonprofit organization ECRI, topping the organization's 2025 list of the most significant threats to patient safety.
Why Do Physicians Gaslight Patients?
Devora Shapiro, PhD
'Physicians are under significant stress and strain, given continually increasing demands on their time and pressure from administrators to increase patient volume and decrease time spent in direct patient care,' Devora Shapiro, PhD, associate professor, Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio, told Medscape Medical News .
Physicians are also under tremendous pressure to justify their decisions (eg, ordering tests or performing treatments) to entities such as administrators and insurance companies. Alexandra Fuss, PhD, director of Behavioral Medicine in Inflammatory Bowel Disease at Massachusetts General Hospital, Boston, noted that 'with every medical decision, providers are authorizing the use of medical resources and must weigh the value of the service against the patients' needs, preferences, and circumstances.'
Alexandra Fuss, PhD
Physicians can find themselves needing to justify their medical decisions to patients 'who seem to think they know as much as their doctors or make specific requests for tests and treatments and have a customer-service mindset, where the provider is regarded as an employee who meets customer requests,' Fuss, an instructor at Harvard Medical School, Boston, told Medscape Medical News .
Additionally, physicians are more vulnerable to engaging in dismissive behaviors when there are medically unexplained symptoms, maybe because complex stories or nonspecific symptoms 'don't fit neatly into the categories required by many health systems and insurance companies,' Bontempo explained.
'Lack of comprehensive objective testing or results that may not match expectations also contribute,' noted Anna Hayburn, PsyD, clinical health psychologist, Neuromuscular Center, and assistant professor of psychiatry, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland. 'Ambiguous symptoms are often attributed to psychiatric or psychosocial factors, even when those aren't the primary driver of the symptoms.'
Anna Hayburn, PsyD
Most of Hayburn's patients have complex neurologic conditions and 'have experienced some form of medical gaslighting and/or other forms of medical trauma throughout their healthcare journey. Providers often lack understanding of the symptoms or approach them with preconceived notions.' It can take years to receive a diagnosis and appropriate care. 'Patients are often burned out by the time that happens,' she told Medscape Medical News .
The Role of Implicit Bias
Fuss encourages medical providers to 'be mindful that we all have heuristics and biases that influence our behaviors and decision-making.'
Zed Zha, MD, a family physician and dermatologist who practices at the Yakima Valley Farm Workers Clinic, Toppenish, Washington, told Medscape Medical News that her practice consists primarily of underserved populations — mostly immigrants. 'It's known that people of color, immigrants, members of the LGBTQ population, people with obesity or disabilities, and women more frequently have their symptoms dismissed, compared to White cisgender males, and I've seen this in my patients.'
Zed Zha, MD
For example, Zha treats patients with hidradenitis suppurativa (HS), a chronic inflammatory skin disorder characterized by painful lesions affecting intertriginous areas. HS disproportionately affects women and people of color and is typically associated with a 10-year delay between symptom onset and diagnosis. 'The diagnostic difficulty is compounded by the fact that this is a population more frequently dismissed and not taken seriously,' Zha said.
Zha recalls a patient who had HS symptoms for more than 20 years without accurate diagnosis. 'The first thing she said was, 'I know I'm having these problems because I'm fat.' This is what she had been told by previous providers, and she accepted this flipped version of reality that was a totally untrue theory.'
Another bias comes from the old adage, drummed into the heads of physicians from the first day of medical school: 'When you hear hoofbeats, think horses, not zebras.' This encourages physicians not to attribute a patient's symptoms to some rare disease but to look at more common conditions — an approach that can lead to dismissal or misattribution of symptoms in the quest to find a 'common' explanation, such as anxiety.
'A deeper question is what constitutes a 'rare' disease,' commented Zha . 'Are certain diseases actually rare, do they just more frequently affect women, people of color, transgender patients, or patients from other cultures?'
Even common conditions are often missed in marginalized populations because of implicit bias. 'When we think about heart attack symptoms, we think about a hunched-over man with crushing chest pain, holding the left side of his chest or left arm. But that type of presentation isn't common in women. Women experience 'atypical' symptoms. By definition, if we're defining symptoms as 'atypical,' we're implying they're rare. But how can the presentation of a common medical emergency be defined as 'rare' if it affects women who comprise 50% of the population?'
Misdiagnosis of myocardial infarction in women is more common than that in their male counterparts because 'atypical' symptoms are misattributed to anxiety and because of a stereotype that women are less affected by cardiovascular disease than men. Another myth is that Black people feel less pain, Zha noted. This misperception has contributed to undertreatment of pain in Black vs White patients. And women, more often seen as exaggerating pain, are less likely to receive pain medication than men presenting with the same complaints — a phenomenon Zha described as 'medical misogyny.'
Zha asks herself throughout the day, 'How would I approach this patient's care if the patient were an able-bodied, thin-bodied cisgender straight White male without an accent?' She acknowledged that this self-investigation requires 'courage,' adding, 'every day, I'm still working on it.'
Tips for Physicians
The experts offered tips to help physicians avoid medical gaslighting.
Don't be afraid to admit you don't know the answer.
'Most patients aren't expecting perfection,' Geraghty said. 'They're looking for someone to walk alongside them. Saying, 'I may not know yet, but I'm committed to figuring it out with you' is far more supportive than minimizing symptoms or blaming the patient.'
You don't have to do everything the patient wants.
Patients, often armed with articles from the internet, may ask for a medication, procedure, or test that's not warranted for their condition or symptoms. If this happens, 'take a moment to explain why that's the case, which can reduce the patient's feeling of being dismissed,' Hayburn advised.
Some patients have developed their own hypotheses about what's causing their symptoms, which may not be 'based in empirical evidence,' Fuss added. 'The willingness to listen to their perspective regarding causation is important for establishing trust.' But this doesn't mean physicians are 'required to defer to patients' perceptions about the etiology of their symptoms.'
Be careful about 'diagnostic overshadowing.'
'Be mindful not to over-engage in diagnostic overshadowing,' Fuss warned — a process by which healthcare professionals wrongly attribute a person's physical symptoms to other causes, such as disability or mental illness.
She encouraged physicians to engage in 'thoughtful communication' when discussing potential psychological interventions. For example, patients with irritable bowel syndrome 'often describe unhelpful messages they've heard in the past, such as 'it's all in your head' or 'it's just stress.' So it's important to communicate the role of the gut-brain axis and discuss how psychological support is a valid treatment option recommended as part of comprehensive healthcare, as psychological factors can influence physical symptoms. Providers should emphasize that they'll continue to work on addressing [physical] symptoms as well.'
Empathetic demeanor and validation build trust.
Demeanor is an important component of helping people feel valued and taken seriously. Fuss advises clinicians to build trust by 'bolstering perceptions of competence and warmth.' Competence includes intelligence, skill, and assertiveness, while warmth includes qualities such as empathy, kindness, and honesty. Demonstrating both qualities also builds trust.
An empathetic demeanor also includes validating the patient's statements, which 'doesn't take a lot of time but just takes intention,' according to Geraghty, whose private practice includes a specialty in medical gaslighting. 'You can say something like, 'I believe you' or 'that sounds really difficult,' which only takes a few seconds. That kind of acknowledgment can completely change the tone of the appointment.'
Allow patients to ask questions.
'Asking if the patient has any questions means patients are more likely to feel heard and listened to,' said Fuss. Despite the compressed nature of medical appointments, time can be reserved for questions at the end of the visit. If patients require additional time for the discussion, a follow-up appointment can be scheduled.
Validation isn't the same as reassurance.
Bontempo recommends that physicians 'do not reassure patients that their symptoms are 'normal,' especially if they've been living with them for a long time and have distress about them. Patients know when something is wrong with them, especially the longer they live with their symptoms.'
Research suggests that reassurance isn't helpful to patients with high distress about their symptoms and may be perceived as dismissive. So instead of reassurance, Bontempo recommends validation. 'Many patients who struggle to receive a diagnosis actually have reported wanting to have their symptoms validated independent of whether a diagnosis can be identified. At the very least, this validation reassures patients that they are not crazy and offsets the self-doubt that ensues from being undiagnosed, which is only exacerbated when physicians normalize their symptoms.'
A Call for Action
Although the term 'medical gaslighting' has 'exploded,' it has garnered relatively little formal research, Zha pointed out. Furthermore, 'some are even arguing that we need to abandon the term because it's cynical and not good for our business.' But that itself is a form of gaslighting — acting as though a real problem doesn't exist. 'The popularity of the term is a message to us. Rather than putting our energies into eliminating this term, let's put our energies into providing patient care that is affirming and takes symptoms seriously.'
Geraghty emphasized that her statements reflect her own views and not those of the US Department of Defense, and Zha emphasized that her statements reflect her own views and not those of the Yakima Valley Farm Workers Clinic. Hayburn, Fuss, Geraghty, Zha, and Shapiro reported having no relevant financial relationships.