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Otolaryngologist Alan P. Feren discusses his article “How system strain contributes to medical gaslighting in health care.” Alan explores why encounters that patients experience as dismissive or manipulative often stem from communication breakdowns driven by productivity pressures rather than clinician malice. He examines the cognitive reality of modern practice where heuristic shortcuts and a discomfort with uncertainty lead well-intentioned providers to offer premature reassurance that feels like invalidation. The conversation highlights critical inflection points like early interruptions and reliance on “normal” test results that erode trust and delay diagnosis. Alan argues that resolving this crisis requires moving beyond blame toward a partnership model where uncertainty is explicitly named and shared. Learn how shifting the focus from transactional care to collaborative sense-making can restore safety and humanity to the exam room.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Alan P. Feren, otolaryngologist and patient advocate. Today’s KevinMD article is “How to handle medical gaslighting.” Alan, welcome back to the show.

Alan P. Feren: Thanks, Kevin.

Kevin Pho: All right, so tell us what this latest article is about.

Alan P. Feren: When I started to get interested in gaslighting, I had no idea that I was going to end up writing a trilogy. At first, I read a couple of articles that were in mainstream newspapers. Gaslighting really is a very emotional topic. It has the tendency to place blame on physicians, and obviously as a physician, I take issue with anything that involves my profession.

So the first articles that I read explained what it was, and I decided that it was important to reframe it. The first article was really about what gaslighting was and how to recognize that if you have been gaslighted. As I finished that article, I realized that I needed to have an article that is more balanced from both the patient perspective and the physician’s perspective. That was the second article that I wrote, which explained why gaslighting occurs and reframed it really not as intent but as impact. I explained the reasons why it happens.

As we know, we have patients who are anxious and come into the office unprepared. They have a big story to tell and they are not organized in their storytelling. Physicians are on a treadmill. There is a great deal of pressure to have throughput. They are on that treadmill with administrative overload and heavy documentation requirements. This has all led to a collision of events that result in patients feeling dismissed and disregarded. Patients leave an office feeling worse than when they entered not because of the diagnosis but because they feel that they lost their voice. There was no agency.

So this third article that I have written and we are discussing today is: “OK, you have been gaslighted. Now what?” In the midst of all this, I recognized that a number of years ago I had a huge surgery on myself personally, and I had been gaslighted by my peer physician who was head of orthopedics at the time at the institution that I had trained at and worked. As I wrote this, some of it became autobiographical in a sense that the realization was there that I personally, as a physician, knowledgeable and organized, had been disregarded and it was hurtful.

Kevin Pho: So in your own personal story, what exactly happened to you and how did your peer gaslight you?

Alan P. Feren: It is somewhat of an interesting story. I had a very large spinal surgery and was placed into at that time a body cast. I continued to have a great deal of pain postoperatively. I have a very high pain threshold, which physicians will make and have some implicit bias about sometimes when patients come in and are complaining. But I continued to assert that something was wrong. It wasn’t until three months postoperatively that an X-ray showed that a pedicle screw had actually been severed. It fatigued and broke. The interior hardware that was applied to my spine had all kind of disaggregated and the spinal fusion was failing.

We had to wait another three months to see whether or not that was going to solidify and it didn’t. I was reoperated on again at six months and ended up spending a year in a body cast. The pain that I had explained being present was disregarded. I felt dismissed. It became a source of gaslighting basically.

Kevin Pho: Now before we talk about what patients should do if they find themselves in a position, just from your experience in this, what are some of the major reasons why physicians gaslight patients inadvertently or not?

Alan P. Feren: Yeah, I think the majority, and I am glad you said inadvertently or not, really is not about intent. It is really about impact. Physicians typically want to get on with a patient’s story. As I mentioned earlier, patients come in disorganized and haven’t prioritized their signs and symptoms. Physicians use heuristics to begin to identify, classify, and diagnose.

Early interruption is not uncommon and it prevents patients from really telling their story. I think that when a patient becomes interrupted very early, and some studies show between 11 and 18 seconds, that they need to take the time and say: “I will get back to that. But I want to finish this thought first.” So it is a way of respectfully telling your physician that you have a story to tell. They need to listen.

On the physician side, let someone spin out their story for the first minute, and then you can help guide them or co-create their story by helping to organize. One of the tricks that I have used as a patient starts wandering with their story is to help them organize. You can interrupt them and say: “Let me make sure that I have this correct.” You could repeat what that story is, and then you can also say: “Well, you have told me this already. Let me see if we can move further from this to help organize what your signs and symptoms may mean.”

Kevin Pho: So it sounds like from the patient perspective, there are things that they could do both before and after they are gaslit, and I want to talk about those individually. Okay. So how about those patients who felt that they have been gaslit? What are some specific techniques that they can do to make sure that they have been heard?

Alan P. Feren: First of all, what we are striving for in the end is understanding the communication breakdown and what happened. Patients need to feel that their voice has been heard. They need to know what has been ruled out and what has not been ruled out. This idea of uncertainty, which we as physicians are constantly working with, has to be explained.

So when you feel you have been gaslighted, when you return, talk to your physician and your clinician, whether it is a PA or your other types of health care professionals, and tell them: “Listen, I am not sure that I understood exactly what you had advised. Here are the issues that I understand I have said to you, but I need to have an explanation for what have you ruled out. What remains uncertain? What are the things that we can do moving forward, like tests and referrals, to help us exclude the things that I think that are necessary for my signs and symptoms?”

Kevin Pho: So typically, what are some spectrum of responses that you have heard, stories or case studies that you have heard after a patient has done that kind of circle back and ask for more clarification from the clinician? What are some typical reactions and perhaps some success stories or not that you have heard after a patient does that?

Alan P. Feren: When a physician sees that the patient really is seeking partnership and communication, they are going to be receptive. Of course, with the burden of documentation, the administrative issues, and the treadmill time constraints, these are all things that I think are stressing the system and stressing our physicians in trying to treat their patients the way they would like to. This is the moral injury that I referenced in a prior article that physicians really want to do what is best for their patients. Because they are not able to, they leave dissatisfied, burned out, and things of this nature.

Kevin Pho: You mentioned earlier that there are things that patients could do before, because one of the root causes you mentioned for gaslighting is sometimes a lack of organization that a patient comes to their clinician with. So what are some things that patients could do before the visit to help prevent being gaslit during the visit?

Alan P. Feren: Preparation, I believe, is key. So for those of us who have anxiety going in to see our doctor, be prepared. Write down what the one, two, or three main things are that are bothering you that you are seeing your physician for. Realize that you have a 15-minute time limit typically, and five minutes of that time is going to be used with computer documentation.

Write down the aspects of when this started, what makes it better, and what makes it go away. Are there things that you have changed in your life that perhaps are related to these signs and symptoms? What have you done to try to alleviate these things yourself? What are the medications that you are taking? Have you changed any medications? Have you changed the schedule of medications?

All of these things help you become organized and prepared. A prepared patient is what physicians really want. If you come in and say: “These are the top two things that are bothering me today. This is when it started. These are the things that make it worse. These are the things that I have tried. I have made no changes in my medications, no changes in my activity levels.” Then the physician has a good picture of what your signs and symptoms are and can begin to apply the heuristics that are typically done by physicians to come to a diagnosis. A prepared patient is going to end up with a better clinical outcome and is going to be safer by being able to tell his or her story accurately and completely.

Kevin Pho: And as a primary care physician, I definitely concur with what you say. I am one of those physicians who have to see patients every 15 minutes. If a patient comes to me with a printout or a list of specific questions that they want me to answer during that visit, it becomes a much more productive visit. I have even had patients come with AI printouts of their symptoms from ChatGPT or Gemini where they would just throw in everything that they were concerned about. Then the AI large language model would prioritize that with specific questions that they could bring in to see their physician. Is there a role for these consumer AI models to help patients organize their thoughts and organize their medical history before coming in to see their clinician?

Alan P. Feren: I think they can be helpful, but they also kind of supercharge the visit in the sense that there is a lot of disinformation and misinformation that is promulgated by these large language models. So I think it is difficult for a patient to sort what is true and what is not true. I think as a physician, it is important to guide them and explain based upon your own personal knowledge and experience why something perhaps is not a consideration.

Again, I think actively letting patients know what has been ruled in and what has been ruled out is very important for patients to hear. Reassurance is important. One of the points that I like to make when I speak to audiences is that reassurance given too early is not very helpful. If you come in and all the blood tests apparently are normal and the diagnostic imaging is normal, and you tell them everything looks fine, the patient goes away not happy because they don’t know exactly what “feeling fine” is. Does that mean the doctor really has dismissed me because nothing is wrong, but yet I still have these symptoms? So what is the explanation?

Reassurance without explanation I think is a very important thing for physicians to realize and patients to understand and to be able to ask: “OK, these tests are normal. What do we do next?” And confirm, based upon what you said, nothing serious is there, but what else can be considered? If you are not comfortable in having that conversation, there is a letter format that I have included in that article that is a sample of what you can send to your doctor.

Using the sandwich technique that I like, you can say: “Thank you for your care to date. I understand that we have spoken about thus and such and that you feel that such and such is my problem. I would like to understand what other considerations we might discuss and what is our path forward. I appreciate your response. Again, thank you for your care.” I think that a respectful recognition of the doctor trying to do his or her best is very important. Patients who are not comfortable having that conversation can send this in advance either using the portal or just sending it via snail mail or email.

Kevin Pho: As a physician, what would you do in that situation? Because there are a lot of symptoms where sometimes physicians don’t know what could be causing it, and there would be a slew of normal lab results of X-rays and most of the major things would already have been ruled out. Yet the patient still has these symptoms. So tell me how you would validate these symptoms and concerns even with all your testing being negative and not having a clear answer from your perspective as to what is causing that patient’s symptoms.

Alan P. Feren: Given that we work in uncertainty often as physicians, it is important to recognize that uncertainty and acknowledge that you have that uncertainty and these are the reasons why. So you are not telling a patient that you are not experiencing what they have experienced, but you are telling a patient that you don’t have an explanation currently. There are ways to do this in which a patient will be accepting and understanding that there is not always an immediate answer for their problems. But you have to let patients know that you will continue to work with them to try to identify what the symptoms are. Do not fail to acknowledge that the symptoms are real. When patients leave the office or leave the exam room and feel that they have been dismissed, this really is a communication breakdown and has significant impact on the patient.

Kevin Pho: We are talking to Alan P. Feren, otolaryngologist and patient advocate. Today’s KevinMD article is “How to handle medical gaslighting.” Alan, as always, let’s end with take-home messages that you want to leave with the KevinMD audience.

Alan P. Feren: On the patient side, it is important that your agency and your voice be heard. When you don’t understand something, ask and ask until you understand. On the clinician side, listen for the first minute. Don’t interrupt. But when you do, do it respectfully and say: “Let me get this right. This is what I have heard.” From there you can help guide the conversation. You are co-creating together that history with the patient so that you can confirm a diagnosis and also firm up a partnership. I think partnership is really what I have been pushing for and advocating for years. Without that partnership, I think care breaks down. When patients feel that their voice is heard and physicians feel that patients are prepared and working with them, they are going to get the best result in clinical outcome.

Kevin Pho: Alan, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Alan P. Feren: Thank you.