Tag: Medical Gaslighting

The DEI Crackdown in Academia Will Further Harm Patients and the Quality of Their Care: No “Could” About it!

There is no “could” about it; the current DEI crackdown in academia will yield negative outcomes for the workforce, but also worsen the quality of care rendered to patients, their families, and the communities we serve. 

A recent article published by MedPage Today and KFF Health News sent my brain into orbit. Entitled, Amid Falling Diversity at Med Schools, a Warning of DEI Crackdown’s Chilling Effect, the sub-title noted, “Education and health experts say this could ultimately harm patient care”. Use of “Could” in light of overwhelming evidence infuriates me. There is no “could” about it; the current DEI crackdown in academia will yield negative outcomes for the workforce, but also worsen the quality of care rendered to patients, their families, and the communities we serve.

The Value of Concordant Care

Concordant care involves aligning treatment with patient values and preferences. It is demonstrated in many ways, from open communication to having providers of the same race, ethnicity, sexual orientation, as well as gender identity, or gender expression. As a result, patients and their families feel psychological safety within a practice setting. Empathy is a vital competency for every healthcare professional that should be demonstrated toward every patient. But the ability to do so does not always assure concordant care. This is especially true when practitioners are employed by larger healthcare systems and organizations.

A patient’s need for health and behavioral health treatment brings them to practitioners for care. Yet, it is a patient’s trust in these practitioners that fosters their engagement in the care process. In addition, a patient’s comfort with providers of the same ethnicity, gender, race, or life experiences promotes their ability to feel safe, seen, heard, valued, and respected in the treatment space. In tandem, the practitioner’s knowledge of a patient’s culture, values, and beliefs inform their awareness of patient health literacy opportunities. This might translate to addressing spiritual and cultural differences in care, such as the need for prescription medications or treatments for chronic illness or even behavioral health. 

Discordant care contributes to medical gaslighting and invalidation. Dismissal of the patient and caregiver voice is the top patient safety issue for 2025, and a frightening fact. Increased numbers of Black primary care physicians are associated with longer life expectancy and lower mortality rates among Blacks. Similarly, when providers can identify with their patients, there are higher degrees of patient engagement, patient satisfaction, and treatment adherence for women, members of the LGBTQIA+ community, and other traditionally marginalized groups.

Healthcare utilization is higher and care costlier for these populations due to a trail of ignored complaints and symptoms and missed diagnoses. Their mortality rates are upwards of double that of numbers for less marginalized groups. These figures will only worsen as the patient voice is reduced, and particularly for traditionally marginalized populations and communities. My prior articles have detailed these abysmal numbers, with an upcoming article on this topic to be published in the May/June issue of Professional Case Management.

Systemic Bias

Countless thought leaders have emphasized the need for attention to treatment bias in healthcare. The Institute of Medicine’s seminal 2003 report, Unequal Treatment noted how African Americans and those in other minority groups receive fewer procedures and poorer-quality medical care than Whites. Stereotypes and stigma have impacted care across every cultural nuance encompassing ethnicity, gender, disability, race, and sexual identity to name just a few. These faulty beliefs have impacted every aspect of care from inaccurate treatment algorithms that fail to account for gender, race, and ethnicity to effective pain and other symptom management. Proper prescription medication dosing and other treatment is also at issue with condition not properly addressed. Patients are unnecessarily blamed for their symptom presentation rather than being fully assessed for individualized care.

The Mandate for Workforce Diversity and DEI Programs

A series of professional reports have identified opportunities to advance diversification of the healthcare workforce. The Council on Social Work Education revealed while 90% of social workers graduating with their MSW were women, opportunities for enhancing diversity continue to present. Only 22% of these same students were Black and 14% were Hispanic or Latino. The National Council of State Boards of Nursing revealed similar numbers with nurses from minority backgrounds representing under 20% of the RN workforce. Composition with respect to racial backgrounds is: 

  • 80.6% Caucasian
  • 6.7% African American 
  • 7.2% Asian
  • 5.6% Hispanic
  • 0.5% American Indian/Alaskan Native
  • 0.4 Native Hawaiian/Pacific Islander 
  • 2.1% two or more races; and 
  • 2.5% other

The Physician workforce also fails to reflect the inclusive nature of patient populations:

  • White: 56.5%
  • Asian: 18.8%
  • Hispanic or Latino: 6.3%
  • Black or African American: 5.2%
  • Multiracial (non-Hispanic): 1.3%
  • Other: 1.1%
  • American Indian or Alaska Native: 0.3%
  • Native Hawaiian or Other Pacific Islander: 0.1%
  • Unknown: 10.4% 

Gender composition notes a greater percentage of those identifying as male vs. female: 60.5% compared to 39.5%. 

There is growing availability of health and behavioral health professionals who provide affirming, accepting, and inclusive care to all patients, yet access remains challenging. Outcare and FOLX health provide directories of LGBTQIA+ friendly providers. Data detailing workforce composition for this community remains limited, though one report notes barely 14% of all medical students identify within the community.

In direct response to the percentages above, professional schools advanced DEI programs. Academia has worked for the better part of the last decade to shift from a curriculum of racial bias and develop antiracist and anti-oppressive programming. New coursework was developed with expansion of learning experiences, practicums, residencies, and specialized learning forums. These approaches prepared clinicians to better understand the patients they treat. Deshazo et al. (2021) identify how “deeply rooted bias is within the infrastructure of American Medicine, based on skin color, religion, immigrant status, gender, and ethnicity are deeply rooted, and taught as scientific racism medical schools from their earliest points in history.” This new societal playbook is a return to those times where fear of segregation and rampant inequities in access to quality care are the norm, along with putting minorities and women “back in their place”.

The UC Davis School of Medicine initiated a “race-neutral, holistic admissions model”, which tripled enrollment of Black, Latino, and Native American students. Assorted other efforts increased funding and entry to healthcare career pathways for students unable to otherwise afford or access them. There are an endless list of merits for the communities served by these new clinicians, including growth of diverse workforce that matches the patients served. 

Communities Take Care of Their Own

I’ve long said that communities take care of their own and this reality can’t be overstated. Practitioners of color are more likely to build their careers in medically underserved areas, from rural communities to lower socioeconomic areas.  The 2024 report by AAMC is clear: a shortage of >40,00 primary care doctors is expected by 2036 unless dramatic changes occur.

One way to assure workforce intercultural effectiveness has been through CEU-requirements for licensure and renewal. Yet even these requirements are now at risk. The Texas Behavioral Health Executive Council voted for removal of language requiring cultural competence as a CEU-requirement for licensed mental health professions with other states working to advance similar actions. This move de-emphasizes cultural context as a critical element of providing and assuring ethical and responsible care and intervention to each person. These shifts will create gaps in the knowledge and skills needed for the workforce to effectively engage with and serve patients from diverse backgrounds, cultures, and genders. Respect for the unique experiences, beliefs, and values that distinguish populations and communities will surely be at risk.

Moving Forward

As my colleagues in this space know, strategic action remains a moving target. We stay informed, yet angry at the daily assault on inclusion. Yet, that anger drives my actions, which are absolute: 

  • I stay committed to the Quintuple Aim: providing patient- and family-inclusive care at the right time, right cost, rendered by those who embrace the work, and ensuring equity and accessibility for all. 
    • I continue to heed my professional ethical obligations to patients, their families, and colleagues. Every day, I define one tangible way to step up in this shifting space to advance diversity, equity, inclusion, accessibility, belonging, and social justice, and through my every action, whether by:
      • Use of my professional voice through teaching, training, or authorship.
      • Supporting the workforce through ethical challenges faced in their workspaces.
      • Mentoring newer practitioners on clear strategies for their own sustainability.
      • Advocacy through my assorted roles across the industry 

How will you step up and into this space today?

Medical Gaslighting and Employing Ethical Equity Advocacy

Medical Gaslighting intersects directly with health equity and is among the industry’s top priorities. What started with Lyme disease, chronic illness and chronic fatigue syndrome, now spans every disease state. There are massive fiscal, clinical, and human consequences from delayed and incorrect treatment.

Stop and consider if you, a family member, or someone you care about has experienced any of the following:

  • Had pain, or the severity of that pain, devalued by a provider?
  • Had a healthcare symptom, or severity of a symptom, dismissed by a provider?
  • Had a healthcare symptom, or severity of a symptom, attributed to “too much stress or balancing too many priorities”?
  • Had the presence, or severity of a behavioral health symptom (depression, anxiety, agitation, worry, insomnia), minimized by a provider?
  • Been told that you’re overthinking symptoms because of being “in the biz”?
  • Been interrupted by a provider while presenting symptoms
  • Had a diagnosis and/or treatment delayed or deferred?
  • Been told to stop self-diagnosing on the internet, OR
  • Left a provider feeling that you weren’t safe, seen, heard, or valued?

If you’ve acknowledged any experience on this list, then Medical Gaslighting (MG) has gained unwelcome entry into your world. What started with Lyme disease, chronic illness and chronic fatigue syndrome, now spans every disease state. However, it is also evident that MG intersects directly with health equity, and is among the industry’s top priorities.

Definitions and Distinctions

Gaslighting involves psychological manipulation through inappropriate use of power and has long been associated with bullying. Consider the boss who invalidates an employee’s thoughts, feelings, or emotions by making that person question what was said, thought, or if any of the events that were experienced really happened. Logical rationale is questioned, as well as the individual’s mental sanity. MG is an extension of this behavior and counter to patient-inclusive and proactive care.

MG is not simply a difference of opinion or negative interaction with a practitioner. It involves physician (or practitioner) ignorance and a blatant misuse of power to disregard, dismissal, degrade, and devalue the patient, their family, or other decision-makers. These actions may occur verbally or non-verbally, as in the curt reply to a question posed, eye-rolling or grimacing. Patients may face chronic interruptions by the provider and not be permitted to present their symptoms fully. Worries about increased shortness of breath, chest pain, decreased endurance, or brain fog become trivialized and chalked up to stress. Concerns about decreased mobility or functionality are automatically associated with menopause or “normal” aging.

There may be documentation entered in a person’s electronic health record noting biased perspectives of a patient’s “chronic” or “repeated” visits to the provider, or even “drug-seeking” behaviors. Perhaps a patient’s unanswered questions about their health status prompt frustration and, thus, a more assertive presentation. The provider views this behavior as aggressive and documents it as such. Patients are made to feel powerless and guilty for their self-advocacy, and blamed for being engaged and motivated participants in their healthcare process. These dynamics can easily trigger a patient’s trauma experiences, and from any point in their lives.

Ethics, Evidence, and Equity Impact

MG involves the privilege of biomedical expertise over lived experience. The physician is often viewed as a revered spokesperson for the institution of medicine; this perspective provides them with an endowed power to pronounce which symptoms are real and which are not. The result is a refusal to listen to patients and appropriately diagnose their illness, with increased morbidity and mortality rates. There are massive fiscal, clinical, and human consequences from grossly delayed, poor, and incorrect treatment.

MG is counter to the ethical principles shared by all health professionals: autonomy, beneficence, fidelity, justice, and nonmaleficence. The evidence demonstrates the concerning escalation of MG’s ethical equity impact across populations, and specific to patient physical and psychological harm:

  • 94% of patients note at least one experience of MG in their interactions with providers, with roughly 10% on multiple occasions
  • Women and Persons of Color have the highest rates of maternal mortality with dismissal of symptoms or voiced concerns, and delay in treatment; this is often associated with systemic racism and bias by providers.
    • Black women die at a rate of 41.7%, American Indian and Alaska Native women at a rate of 28.3%, and White women at a rate of 13.4%.
  • 66% of women are told (by providers) that their physical symptoms (e.g., headaches, shortness of breath, severe pain, excessive bleeding) were stress-related, or due to obesity
  • Women are 4X more likely than men to have their physical symptoms attributed anxiety, depression, or stress.
  • Diagnoses of cancer, heart disease, and other chronic illnesses in Women are often delayed by a minimum of 4 years compared to men.

Marginalized and minoritized populations experience a far higher incidence and prevalence of MG compared to other populations. Recent research validates how >50% of healthcare workers identified providers as more accepting of White patients who advocate for themselves than Persons of Color. Even when communicating the same messaging and in the same way (e.g., in-person), Whites are viewed as assertive while Persons of Color are more often assessed to be aggressive, and an immediate safety threat.

Data across these populations would fill several articles, but chew on these outcomes for now:

The LGBTQIA+ Community:

  • 50% are more likely to have experienced MG vs. cisgender, heterosexual people.
  • 40% had at least one negative experience or form of mistreatment from a health care provider in the past year

Individuals seeking Reproductive Health:

  • 72% experienced MG by providers
  • 57% were told their infertility was due to stress or anxiety
  • 54% were told that gaining or losing weight would improve their fertility outcomes
  • 37% of Women of Color were denied care for symptoms associated with cancers, blood clots, and other acute health issues.

Older Adults

  • 45% felt their symptoms were dismissed or devalued by providers
  • 54% were Women of Color

Ableism

There is a large data gap involving Ableism and MG. Ableism is the marginalization of disabled people according to their disability status. Individuals with visible and invisible disabilities are among the largest marginalized groups in the US. They face gross health inequities with poor outcomes and were officially designated by the National Institute on Minority Health and Health Disparities (NIMHD) as a health disparity population. Considerable literature speaks to the mandate for practitioner training, as well as ongoing care gaps, stigma, and discrimination faced by individuals. Yet, despite these realities and almost 25 years since passage of the 1990 Americans with Disabilities Act, systemic barriers to healthcare access are the norm versus the exception. While volumes of anecdotal data demonstrate the severity of these issues, frequent invalidation by practitioners remains a mandated area of focus for the research.

Long COVID

  • 79% report negative interactions with providers
  • 34% had symptoms dismissed
  • 39% identified delays in treatment
    • 75% identified as Female
    • 22% identified as Male
    • 3% as other

Employing Ethical Equity Advocacy

Four critical steps will enhance effective management of MG by case managers and other health professionals.

First, Heed Established the Resources of Guidance: These evidence-based and industry-vetted resources guide how professionals step into their work. These resources span professional regulations and practice acts across all disciplines, organizational accreditations (e.g., CMS, NCQA, URAC, NQF, Joint Commission) and codes of ethics and professional conduct for individual certifications and credentials, as well as standards of practice for professional associations. My colleagues in case management should be particularly familiar with their professional codes of conduct (2023) through CCMC, CDMS, and CRCC and CMSA‘s Standards of Practice for Case Management (2022). All:

  • Prioritize cultural humility and awareness
  • Mandate a whole person assessment
  • Promote health equity through every effort
  • Heed integrity, worth of the person, and objectivity in all relationships
  • Leverage ethical principles of autonomy, fidelity, beneficence, justice, and nonmalfeasance through every professional intervention and interaction.

Second, Promote Psychological Safety Using Trauma-Informed Care and Other Anti-Oppressive Practices: Implement use of Trauma-informed Care to set a space where patients, their families, and staff feel respected by, comfortable with, and confident of the care they receive, and by every member of the workforce. Every professional interaction should assure:

  • Physical, psychological, and emotional safety
  • Trust
  • Choice
  • Collaboration
  • Empowerment

This action involves more than simply offering annual and mandatory employee continuing education on the topic, or other related content on microaggressions or implicit biases. Instead, professionals should always ask:

  • Does the person fully understand your role?
  • What are their provider preferences or choices?
  • What name or pronouns they wish you to use?
  • What types of accommodations might they need with respect to physical, cognitive, intellectual, or other disabilities?
  • How will health literacy be assessed and addressed?
  • Will information be provided in the patient’s primary language, whether written or electronic?
  • Who does the patient want with them during the interview, assessment, examination, or test (if anyone)?
  • Do they know how to use, update, or troubleshoot their digital device, specific EHR platforms, or apps?
  • How do they understand their diagnosis?

Third, Employ Advocacy at the Macro, Meso, Micro Levels Practice: This domain spans policy, community/organizational, and population-based practices, such as:

  • Advance professional state-specific CEU requirements for licensure renewal encompassing Anti-oppressive practices, trauma-informed care, intercultural effectiveness, bias management, microaggressions and other related themes.
  • Advance and enforce Federal requirements by HHS, the Office for Civil Rights (OCR) and EEOC including the 2024 HHS Rights of Conscience Bill , EEOC Workplace Guidance to Prevent Harassment, and the HHS Health Equity Action Plan.
  • Case managers can also refer to the work of CMSA’s DEIB Committee for guidance inclusive of the association’s Position Statement (2024) and upcoming resources to guide case management practice. These items will encompass a dedicated standard of practice, position paper, member library, and other deliverables.

Within organizations:

  • Provide easy ways for patients and staff to anonymously report situations involving racism or discrimination 
  • Examine policies to make sure they result in equitable outcomes
  • Require coursework on bias and discrimination at professional schools, and 
  • Ongoing performance metrics that address continuing education
  • Ensure policies and procedures through Human Resources that enforce anti-discrimination practices, and are addressed through employee performance appraisals. Incentives and disincentives for heeding (or not heeding) these policies should also be consistently enforced.
  • Have patient voices reflected through involvement on boards and organizational committees and with the ability to vote on decisions.

Fourth and most importantly, Model and Mentor: Maneuvering MG is not a “one and done” activity, especially amid the changing face of patient and workforce demographics. Nobody is an expert in this space. Any ethical, caring, quality-driven professional should be committed to eliminating MG. We must recognize the uniqueness of each patient experience, and:

  • Be a steward of inclusive, empathic care and lead by example
  • Be humble and accept the need for lifelong learning
  • Strive to engage and establish rapport that fosters partnership with patients and their families
  • Talk to, and with patients and their families, rather than at them
  • Use shared-decision making for every dialogue with patients and their families
  • Inform patients of your process the start of each interaction; this will promote your valuing of their voice
  • Hire diverse staff to ensure patient populations are reflected

I know there are other strategies to stop MG and welcome those through your comments. Experience my CMSA Annual Conference presentation on MG through the digital content. Register for CMSA of Houston’s Annual Conference on 9/14 where I’ll be presenting on Medical Gaslighting’s Universal Truth and moderating a panel discussion on this topic of critical workforce importance.