Against "Medical Gaslighting"

First, I am sick of the word "gaslighting." In the play and movie of that name, a wicked husband launched a concerted plan to convince his wife that she was insane. One used to see the word occasionally, used in exactly that sense: a plan to undermine somebody's grasp of reality. Now it just means "lying" or "being intentionally confusing," and another once interesting word drowns in the mass of trivial speech.

Second, it has become an article of faith in some quarters that doctors ignore women. There are bunches of studies that show this, several of which are cited in the recent NY Times piece, "Woman are Calling Out Medical Gaslighting." This piece does not mention that there are also bunches of studies that show the opposite, but they do exist. Pain is a big topic in all of this, but neither this article nor any other I have seen on this theme mentions that1) it is really difficult to measure pain, since the response varies so much from person to person, and 2) it is medical folk wisdom that men understate their pain for reasons of machismo, which is why doctors take men's complaints more seriously. Every doctor has a story about a man who had a knife blade in his abdomen or a broken leg but put off going to the doctor for months because the pain "wasn't that bad."

The target of the anger involved has also shifted. When there weren't many female doctors, people blamed the sexism of doctors. Now that there are plenty of female doctors, and this has had no effect on the torrent of women complaining that they are ignored, we blame the medical system: the way trials are set up, the way doctors are trained, the categories of insurance companies. Activists used to complain that many medical trials involved only men, which was true, because researchers were terrified of damaging the fetus of a woman who didn't know she was pregnant, and because hormonal cycles were a complicating factor. This led the US Congress, back in 1993, to pass a law requiring that most government-funded studies include women. So now they do, and this has had no effect at all on the number of women who think they have been ignored and misdiagnosed.

And maybe there is something to all of this. Doctors ignore and misdiagnose people all the time, and in fact regularly kill people with their mistakes. Because doctors' time is so expensive, the length of visits and consults keeps shrinking, meaning that many subtle problems will not be caught. But if you are measuring the effectiveness of our health care system in terms of outcomes, which I would say is the best way, it works great for women. In the US, women live six years longer than men and have lower death rates from almost every disease that both sexes can get.

What bothers me is that you are not allowed to say, you, know, the world is full of hypochondriacs, many of whom are women. In fact all the doctors I know will say that they waste huge amounts of time dealing with hypochondriacs, and that most of the ones they see are women. Plus, and this is important, all the patients who appear in these stories are pushing for more: more drugs, more surgery, more interventions of every sort. It goes unmentioned that maybe doctors should have a role in resisting this pressure, both because of cost and because unneeded medical interventions kill hundreds of people every year. A typical story goes like this:

Jenneh Rishe could easily run six miles in under 45 minutes — until suddenly she couldn’t. In the spring of 2019, Mrs. Rishe, now 35, began finding her daily jogs a struggle.

Years earlier, she had been diagnosed with two congenital heart conditions that, she said, doctors told her would not affect her daily functioning. Yet she was getting worse: Intense chest pains woke her up at night, and she started using a wheelchair after passing out too many times.

Mrs. Rishe, who lives in Los Angeles, found a highly recommended cardiologist in the Midwest and flew there to see him. He immediately dismissed her symptoms, she said. “People who have these heart conditions aren’t this sick,” she remembers him saying. He prescribed a new heart medication, told her to exercise and sent her home.

Unsatisfied with her care, Mrs. Rishe saw yet another doctor, who ordered extensive tests that found her arteries were spasming from a lack of oxygen. “I was basically having mini-heart attacks, whenever I was having chest pain,” she said. Two months later, she had open-heart surgery to correct the problem, which she later learned may have saved her life.

Is that true? How would we know? Hundreds of thousands of Americans believed that heart bypass surgery saved their lives, until we got good studies showing that it has no effect. The truth is that heart bypass surgery probably killed several times as many people as it "saved." As one among tens of thousands of victims of overtreatment – I lost most of the hearing in my left ear because of unnecessary surgery I had as a child, besides the trauma involved in all those hospital visits and never being able to swim – I bristle whenever anyone suggests that our hospitals aren't cutting people open enough.

And just because Jenneh Rishe felt better after her surgery doesn't mean it helped her; the relationship between any medical intervention and improving health is complicated and uncertain, and this applies to surgery as well. Thousands of people think they were helped by surgical procedures that can be shown, statistically, to do the average patient no good.

There is also the problem, which I have written about several times, that people are insulted when a doctor suggests that their pain may be psychosomatic. But psychosomatic pain is very much a real thing, and there is no reason why anyone should be insulted by that diagnosis any more than one of "fibromyalgia." People feel dismissed, but that is the fault of their own prejudice, not anything to do with the medical system. All doctors understand this, and many studies have confirmed it; people who are depressed or upset about their lives or going through divorce or have lost their jobs often suffer from pain that has no obvious physical cause. Sometimes that pain is debiliating. What do people like Jenneh Rishe think doctors should do? Lie?

What happens in our medical system is this: tens of thousands of patients flow into clinics every day, complaining of their suffering. Some of them have problems that are easy to recognize and treat. But a very large number have problems that are complex and subtle. For a lucky few, a doctor recognizes this right away, most likely because he or she has recently seen another case just like it. But for most it means a dreary round of specialist visits and lab tests and people who sigh and scratch their heads, and frankly the people who do end up getting treated are mostly the ones who push hardest for somebody to do something. And even those, once they get treated, may never be cured; I know people who have been through this for years about their chronic pain, never finding a cause, never getting any help but steroids and painkillers that have side effects nearly as bad as their conditions.

We expect too much from medicine. If you think that our medical system should be able to cure everything that ails you and give you a life free of suffering, sorry, it doesn't work like that. If you think your doctor should have more time to listen to your complaints and think hard about all the strange conditions you might have, well, maybe. But how are you going to pay for that? And this is one thing about medicine that is not better in other parts of the world, at least the ones I know about; costs are kept down in Europe partly by limiting the interactions people have with doctors.

If you think that every woman whose complaints have been dismissed by a doctor as psychosomatic is a truth-telling victim of a sexist system, then you are in the grip of ideology. Somebody has been gaslighting you, and it isn't doctors.