Gaslighting is Dismissiveness

The term gaslighting originates from a 1938 play called "Gas Light," first produced in London by Patrick Hamilton. The play was later turned into two psychological thriller films, the first in 1940 and the second in 1944. We are more familiar with the second version starring Ingrid Bergman as Paula and Charles Boyer as her husband. Ingrid Bergman won her first Oscar for her role as Paula, the wife whose new husband was trying to drive her insane so he could take over her sizable fortune.

The 1944 movie “Gaslight” revolves around the play’s central theme of a husband who slowly manipulates his wife into believing she is losing her mind by simply altering the gas lamps in their home and denying her observations. At the time of the movie's setting, gas lights were more common than electric lights. The husband turns on all the gas lights in the house at one time, which causes them to dim. When Paula notes that the lights are dim, the husband says that it is just her impression. There is really nothing wrong with the gas lights.

Paula's husband created a number of incidents to cause Paula to think she was loosing her mind. He knocked on walls and moved or hid items around the house. Paula was a grieving and rich widow this new husband had quickly married after discovering she was wealthy. The story ends tragically. Paula is committed to a mental institution so that her inheritance can be stolen by her conniving husband.

While today, this story of Paula may seem unreal, in the mid 1980s a patient told me how worried her mother had been that her father was going to put her in a mental institution. They had nine children for whom the mother was the main parent. My patient tole me her mother was very concerned that she wasn't going to be able to be the wife her father had wanted and he would put her in a mental institution.

A recent article by Kris Gates on medical gaslighting indicates that dismissiveness is ranked #1 in a list of the top 10 patient concerns. She defines medical gaslighting:

"Medical gaslighting broadly means patients feeling their symptoms are being ignored or dismissed thus they experience "medical gaslighting" or "feeling manipulated into doubting their perceptions, experiences, or understanding of events.”

She indicates in her article that the #1 concern of patients is dismissiveness, as reported by the Healthcare Quality and Safety group and its Institute for Safe Medication Practices affiliate. Dismissiveness is the number one cause of derailing good medical care which in turn causes a significant risk to the patient, a poor patient outcome, and lawsuits.

National Public Radio (NPR) has provided stories of many cases of dismissiveness leading to poor pregnancy outcomes. The story of Lauren is particularly alarming. According to the NPR ProPublica article, American women are three times more likely than Canadian women to die in childbirth (defined by the CDC as the start of pregnancy to one year after delivery) and six times more likely than Scandinavians. In every other wealthy country, and many less affluent ones, maternal mortality rates have been falling. Our country is the exception. In the U.S., the maternal mortality rate is increasing.

Over my four decades as an obstetrician, I delivered over 6000 babies. I had no maternal mortality in the moms I’ve delivered. I prevented most of the bad trouble and dealt effectively with what I couldn’t prevent. None of my patients had eclampsia. (seizures from preeclampsia) None had a liver capsule rupture or kidney failure or any other serious or permanent injury. Yes, I had some really sick patients. I’ll never forget the postpartum patient with a very bad kidney infection and a high fever. I spent the entire night in the hospital checking her every 15 minutes, and she recovered completely. She is not the only one I spent the whole night watching. I did not dismiss any patient’s care.

In the ProPublica story of Lauren, another postpartum patient delivered by the same doctor died. Tara Hanson, a 29-year-old special education teacher, died from necrotizing fasciitis. She delivered a nine-pound boy, had a “tear” near her vagina, and had a lot of pain. Tara was sent home anyway. She returned to hospital with necrotizing fasciitis and died. The dangerous dismissiveness here is much simpler. She should have been examined and should not have been sent home.

In almost any illness or disease there is a time when the condition is easily and effectively treatable. Good healthcare means finding that time window and using it wisely and effectively. When a healthcare provider ignores our complaints, unfortunate results, including death, become unavoidable.

In yet another case of dismissiveness, Kira Johnson, a “Black woman” bled to death 8 hours after her planned repeat C-section in April of 2016. Charles Johnson, Kira’s husband is suing Cedars-Sinai Medical Center for death due to discrimination and massive internal bleeding according to the autopsy. There are two issues here. The first is wrongful death. The second is discrimination. The judge has rightfully decided to separate those two issues. While this case should be a slam-dunk for wrongful death, it’s a little harder to prove discrimination which just serves to muddy the waters. Wrongful death cases should not be attenuated by the discrimination charges whether they are true or not. Discrimination charges are hard to prove and would probably be better off resolved at a different time. The waters are further muddied by the description of the 17-minute surgery being described as “reckless.” A good surgeon can do a repeat cesarean section in 20 minutes. The operative word here is “good.” As I’ve said many times before, the surgery is not complete until the bleeding has stopped.

In the end, dismissiveness killed Kira Johnson. While bleeding is a known complication at surgery and is forgivable, it is not forgivable or pardonable to delay by eight hours the second and potentially corrective life-saving surgery. The fault probably lands on several providers including doctors, nurses. and the systems departments. The CT scan, which was probably ordered around 6:00 pm., was never done. If it had been done, it would’ve shown massive amounts of blood in the abdomen and probably would have gotten the attention of the nurses and the doctors.

The huge problem of taking a vascularly-compromised person to the operating room is that they tend to compensate up to a certain point, but the anesthesia interferes with the compensation and causes a significant unmanageable vascular collapse, most often culminating in death by heart attack. That risk needs to be firmly understood before returning a patient to the operating room. A blood transfusion or a fluid volume replacement before return to the operating room probably would’ve been very helpful in this case. Again, the problem here, as it was for Lauren, is deadly dismissiveness. The providers had had eight hours to avoid this problem.

I have written several times about moms who present to labor and delivery with concerns about not feeling enough fetal movement. One of these moms presented four times to labor and delivery and was told she simply didn’t know how to monitor her baby. On the final visit, she was told that her baby was not living and that she should have come in sooner. This is a very good example of dismissiveness and gaslighting, ending in deadly dismissiveness.

In summary, let’s return to the medical gaslighting article by Kris Gates, who gives this example:

“You make a doctor appointment, report your symptoms, and your doctor dismisses them. You feel your provider is not hearing what you are saying. And you start to doubt yourself – maybe it’s me.”

That’s the point of dismissiveness—deflection. Change the topic and make it about your sanity. Then your provider doesn’t need to address the reasons for your visit.

What can you do about gaslighting or dismissiveness? That depends a lot on what your problem is and what you’re trying to get done. For example, if you feel that your baby isn’t moving enough and you go to labor and delivery, the nurses will probably put you on the continuous external fetal and maternal monitor. Since you probably don’t have or won’t have a lot of experience reading a fetal heart rate monitor or uterine contraction monitor, you will most likely have no choice except to believe what they tell you. But remember, the point of gaslighting or dismissiveness is to make you doubt or negate your own perception of reality.

Since ignoring, dismissing, or gaslighting your concerns about adequate fetal movement can result in deadly consequences, you need to be able to think in terms of what to do next or what are your alternatives. I would recommend that the first thing you do is to call your health care provider and get an appointment. Most doctors will have external fetal and maternal monitoring devices in their offices.

You should be able to get in to see your doctor in less than 24 hours. If you can’t get an appointment to see your doctor within 24 hours, I suggest you try an alternative doctor in an alternative healthcare system. All of the doctors in the same clinic will probably hold similar views on a given subject. My best advice is to talk to your neighbors, friends, or relatives about alternatives. You might also try another emergency room or another labor and delivery in a different hospital. Don't get discouraged and stop trying to find a doctor or hospital that will take your concerns seriously when you believe your concerns are real and need to be addressed.