Bill Klaproth (Host): Welcome to the ASHRM Podcast, made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. I'm Bill Klaproth. And with me is Mary Steffany, an independent healthcare risk consultant, as we talk about an escalating patient safety issue, which is the dismissal of patient's, caregiver's, or family member's concerns by physicians. Mary, welcome.

Mary Steffany: Thanks, Bill. It's great to be with you.

Host: Well, we're happy to have you here. This is really an interesting topic. So, I don't think I've ever really done a topic like this before, so this is really going to be good. So, Mary, thank you for your time today. Let's start with this. So, we'll talk about caregivers dismissing families' concerns. How does the medical profession define medical gaslighting?

Mary Steffany: According to the American Journal of Medicine, medical gaslighting is an act that invalidates a patient's genuine clinical concern without proper medical evaluation. So essentially, a patient comes to see perhaps their primary care physician or maybe even a specialist. They have a complaint, and instead of the provider doing some baseline questions or perhaps even a cursory physical exam, they may just shake their head or look down their nose on their glasses and say, "Hmm, really? I don't know." And they may attribute it to something other than a medical etiology for the patient's complaint.

Host: So, they're not really listening to the patient at that point, or really trying to understand their concerns. They're kind of like, "Yeah, no, I don't think so," kind of like that, right?

Mary Steffany: That is exactly right. And it's very difficult to be a good listener. Now, I haven't taken a survey of medical schools, but having worked in healthcare a very long time, it is really a challenge to find a provider who is a good listener. They like to be in charge, and they haven't cultivated that skillset of listening and asking those, so to speak, newspaper questions, "Well, how did this happen?" or "When do you feel it most?" or "Is this the first time it's happening?" those sorts of things. Because they may lack that training, but they also may feel that pressure of, "I've got a waiting room full of patients. I cannot spend all this time investigating this patient's complaint."

Host: Yeah, that's a really, really good point. So, you mentioned maybe we're not training physicians to be good listeners, or just the realities of trying to get people in and out is very difficult. Are there other factors that contribute to medical, let's say, gaslighting?

Mary Steffany: Absolutely. Aside from the being rushed for time—which is probably universal in healthcare—a lot of times, providers, they're not intentional of this, but they're human beings and they have a bias. And there's bias towards people who are overweight, people who are older, people's sex—more bias towards women than men, Bill. I'm sorry to say—race or just they may be part of a community that the provider does not approve of, you know, lesbian, gay, transsexual, that sort of thing. And because of those biases, they may not have those critical thinking skills firing. So, they're just putting them in a category and you really can't be having what you're telling me you're having.

Host: Mary, that is really interesting when you talk about physicians that way. So, are there characteristics of a patient-physician encounter that suggests medical gaslighting is occurring or has occurred?

Mary Steffany: Absolutely. If you were to listen to or actually visualize a patient encounter monitor, you know, from the screen where they can see you, you could perhaps notice that the patient has perhaps poured their heart out or just said they're having some particular issue and the provider is just ignoring or refusing to acknowledge what they have been told. Or they may say, "Well, everybody has that ache and pain. After all, you're a certain age group or, you know, the type of work that you do, that should be expected." Or during this conversation, they may interrupt the patient or the family member or the caregiver, which is disrespectful at the very least, but also it's preventing the patient from sharing their full story and giving the provider the information that would help them figure out what a diagnosis may be or what tests might be necessary to render a diagnosis. And then, if we want to go to the darker side, sometimes providers will actually blame a patient for whatever their complaint is.

And lastly, and I have seen this way too many times, providers speaking in a condescending manner to patients. I've experienced it myself and I'm a registered nurse, and it takes a lot of courage, determination, and being an informed consumer to push back.

Host: That's a great point, what you said about physicians just discounting or blowing off what have to say. Sometimes you're talking about sensitive topics. People are afraid to bring things up to their doctor. So, you have the courage to bring it up and you're kind of brushed off, that really makes you feel small. That's terrible.

Mary Steffany: Exactly right. And it's hard enough sometimes, first of all, to get the appointment. You finally get there. Maybe you've been waiting 15 minutes, a half an hour, or 45 minutes. You go into the room, you're half dressed, they close the door, you're sitting around waiting. Maybe your phone is running low, so you can't play any games or you can't text anybody, you know, low on battery. And you're anxious. And then, the knock on the door and they come in. And now, because of electronic records, they may be carrying a tablet or a laptop with them and they're busy bringing up your record and they're not making eye contact with you. They are just bringing up the information and they kind of want to go through their checklist as opposed to saying, "Hello, Mary. How are you? What's going on? What brings you here today?" to set a platform for a conversation.

Host: Absolutely. And that little conversation and listening can make a huge difference. So if someone feels like a physician isn't paying attention to them, dismissing their concerns, what steps can a patient, a caregiver, or family member take to address, as we're calling it, medical gaslighting?

Mary Steffany: Well, it's a very good idea to actually bring with you a list and as detailed as you can make it without it being an epistle, if you will, of what your complaints are, if they're associated with anything, like, say a particular time of day or perhaps maybe after a particular encounter with maybe a coworker or a family member. And if you can be as descriptive as possible because this is information that will help the provider, and also have some questions. And if you can, it's great to bring a friend or family member who could be as scribe. Because many times when you get into a conversation with a physician, you may start hearing things if they are responding to your questions or explaining things that upset you. And it's very hard to be the patient and your own advocate and taking down notes that will make sense to you when you leave the appointment. And then, you start reflecting on what your situation is, what's been recommended, what the possibilities could be. So, you know, essentially, bring your information, have some questions. And if you can, bring a friend or family member who could be your scribe, your personal secretary, if you will.

Host: Those are great tips. Bring a list, be descriptive, have questions. Bring a friend or family member if you can. If you have that list in front of you, it's harder for that doctor to potentially blow you off if you say, "Okay, what's the answer to this, Doc? What do you think about this, Doc?" Right? Okay. what about this one? I want the answer to this one." It kind of puts them in the position to have to answer all of the questions and concerns right to you. So, what can an organization do then to minimize patient encounters that may lead to the symptoms of invalidation or medical gaslighting?

Mary Steffany: This is definitely a challenge, but it is one that can be met. Improving the scheduling of patients to just allow more time. Oftentimes—I'm not going to speak for every organization. Oftentimes new patient every 15 minutes. Now, somebody may be returning for just a quick followup, and 15 minutes is plenty of time.

But for a new patient to get their history, to ask them questions, to examine them, you can't do it in 15 minutes, even if you're the smartest, sharpest provider in the world with great diagnostic abilities. So, having those short intervals kind of sets you up for this problem to foment.

Now, on the provider side, it would be terrific if doctors are trained in becoming better listeners. And that is just the word, listening. Taking the time to let the patient describe what it is that brings them into the office. And then, also educating the providers that, yes, you are a physician, you've been trained, you have diagnostic capabilities, but you don't know everything. And there are certain conditions where the symptoms are very vague, and patients are presenting with that. So, don't jump to a conclusion that you know what the diagnosis is without doing the proper questioning, the proper assessment, the proper diagnostic testing. And again, along with the training of physicians, address the issue of bias, because everybody has them—every single person. And people go, "No, no, no. I don't have them." Yes, you do. And you may not be aware that you have them.

And the other thing is, I think it's great if schools, in training their doctors, if they could have the role playing. Because when you're in the other position, you think a little bit differently. If you are the patient now and, "Oh, they're treating me like this. They're blowing me off," they're not going to answer that question, they immediately jump to that diagnostic conclusion, "Hmm, not good."

Host: Absolutely not good. And while you're talking about this, Mary, I'm thinking to myself, this gaslighting certainly then leads to poorer outcomes then, which is not good. So, can you share, examples of poor or compromised clinical outcomes because a patient, caregiver, or family member's concerns were dismissed? I imagine people are not receiving the right care because the doctors are, as we're saying, this term, gaslighting them.

Mary Steffany: There was a case of a woman who presented with complaints of gluten intolerance. The provider scolded her and suggested to her that she was really imagining and exaggerating her symptoms. And that she probably was just depressed and anxious. Now, this woman was ultimately diagnosed with celiac disease, but only after she underwent surgery to remove her gallbladder, which turned out to be an unnecessary procedure. Now, that's devastating. First of all, to have a procedure that you don't need, whether or not you have insurance coverage, it doesn't matter. You didn't need it. And you had an invasive procedure. And then, you have to deal with the fact that time passed and you weren't properly diagnosed. So, it's trauma on many, many levels.

Another example is a woman who had an elective hernia procedure. Postoperatively, her complaints were not addressed. She developed an infection, she became septic, and she died. Now, that is the absolute worst outcome. Another example is a patient who was on blood thinners. She complained of having the worst headache of her life. That's such a classic complaint. You know when somebody says, "worst headache of my life," that's like a 10-alarm fire and complaints were not addressed. And she had an aneurysm and because of the aneurysm bleeding in the brain, blood going where it should not go, she had permanent neurological injuries.

I'm going to give just two more examples. A patient had severe back pain, numbness, and bladder incontinence, so she did not have an MRI in a timely fashion. And as a result, she developed a very serious syndrome, cauda equina syndrome, and resulted in severe neurological injuries. I worked at an orthopedic specialty hospital for 10 years, and I will tell you when we suspected cauda equina syndrome, all hands on deck, you have to intervene in a really timely fashion to not have a bad outcome.

And the last example I'm going to give is there's a very well-known tennis player, Serena Williams. Before she was ever pregnant, she had a history of pulmonary embolism. After the birth of her second child, she was feeling short of breath. She complained about it to the nurses who did an ultrasound of her leg, which was negative. So, there was no deep vein thrombosis in the leg, but that's because the clots went to her lungs. And she had to insist on having an MRI, which did in fact document she had blood clots in the lung and she had such a difficult time during the management of that coughing and a lot of discomfort that she coughed so hard that her wound dehisced, the wound opened up and she needed more surgery because of that. So, that child birth experience, which should be joyful and happy, turned out to be really very problematic for her. And she's a person that people would recognize. But oftentimes, women and women of color have to advocate more strongly for themselves to get care for their complaints.

Host: Yeah, it sounds like, Mary, you really need to advocate on your own behalf, and a lot of people probably are afraid of confrontation or we've been ingrained in our heads. Doctor always knows best. I'm not disparaging doctors, they're wonderful of what they do and all of that. But if there's something you're concerned about, and like you said, if you are feeling that your concerns are being dismissed or blown off, you have to stand up for yourself, right?

Mary Steffany: Absolutely. And depending upon the situation, for example, In a hospital, oftentimes there's a patient advocate, so you could reach out to them and explain what your concern is and why. There's also those wonderful Press Ganey patient surveys. But I think the limitation with them is the questions are so geared to how the system is doing and the way they ask the questions, I think, sometimes patients really can't express why they were dissatisfied during a patient encounter. Thoughtfully express it so that things could be done to correct what the problem was.

And it's difficult for people because my mom always used to say to me, "But you're a nurse, you can do that." I said, "Mom, you're a consumer. You need to know who you're going to and why." And you need to be prepared because that will help the provider help you to help yourself. We each have our responsibilities and you can't put it all on the provider and the provider can't put it all back on you. It's got to be collaborative

Host: Great point. And if you come with that list, like you say and have specific questions, it probably does make it easier for the provider to go, "Okay, let me ask," "Okay, here's what's happening here," "Okay, this is your concern for this. Here's what I'm seeing, or hearing or feeling." So, it just makes sense, the tips that you gave us, Mary. This has really been interesting topic, Mary. Thank you so much for your time today. Before we wrap up, any additional thoughts you want to share with us?

Mary Steffany: Well, I would just like to say that, on a point that you made, while it might be scary to be your own advocate, it's really important to know that that is your responsibility. Educate yourself. Do some reading on what your symptomatologies, what your complaints are, how you're feeling. Have that ready when you go to the doctor, have your questions.

Also ask, if the questions can't be answered, "Can I get back in touch with you after this visit?" And to really solidify having a good encounter, bring somebody with you who can help take down some notes. Have you understand what it looks like you're dealing with and be able to move forward and address it.

Host: This has been a great topic, Mary. Thank you so much for your time. We really appreciate it.

Mary Steffany: Thank you. I appreciate the opportunity to chat about this important concern.

Host: And you bet. Once again, that is Mary Steffany. Learn more and to get other great education from ASHRM—make sure you are a member, very easy to join—just go to ashrm.org/joinashrm. And the ASHRM podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance, safe and trusted healthcare through enterprise risk management. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. Thanks for listening.