Burnout and bias? Or medical gaslighting? [PODCAST]

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“Five years into my practice as an academic allergist/immunologist, my perceptions continue to evolve. Though once primarily informed by my mentors’ wisdom, I continue incorporating my experiences as both physician and autoimmune patient to guide my practice. Though we all know medicine isn’t like it used to be, nostalgia is bittersweet. In its wake, the real question remains: how are we going to respond to ongoing changes and fight for the health of our patients and our colleagues?

From the loss of autonomy with the advent of managed care and corporate takeovers, we find ourselves practicing under increased pressure from all sides. Less time and resources to help sicker patients. Answering not only to our patients’ needs but those of insurance companies and other interested parties whose motives are less than altruistic.”

Kara Wada is an allergist-immunologist.

She shares her story and discusses her KevinMD article, “Burnout and bias? Or medical gaslighting?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Kara Wada. She is an allergist/immunologist, and she wrote the KevinMD article “Burnout and bias? Or medical gaslighting?” Kara, welcome to the show.

Kara Wada: Thank you so much for having me on, Kevin. I really appreciate it.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Kara Wada: Absolutely. So I am a practicing pediatric and adult allergist/immunologist. I work at Ohio State Wexner Medical Center. I did my training in med-peds here and stayed on for fellowship. But life really took an interesting turn a couple years ago. Within about two weeks, I was diagnosed with Sjögren’s syndrome, and my daughter was diagnosed with egg allergy. And so we went from the seemingly healthy family to having some chronic medical issues. I think that really served as a turning point in our life as a family, and also in my journey as a physician, in really experiencing the medical system not only as a physician but also as a chronic illness patient.

Kevin Pho: All right, so let’s talk about that. In your article that you wrote, “Burnout and bias? Or medical gaslighting?”, now for those of you who get a chance to read that article, can you go more into your story about you and your daughter and how it changed you?

Kara Wada: What I think has been interesting is that we all turn to different support mechanisms as we are navigating crises in our lives. I think now more than ever we’ve realized that some of us turn to humor, and some of us turn to digging into the literature or to support groups. I think I’ve turned to all of them at some point or another. But I found a lot of really great support within the chronic illness community, and that has, I think, grown considerably over the pandemic, as everyone’s been locked down.

And I kept coming across this particular term called medical gaslighting. Over conversations with my husband, who happens to be a physician as well, we were discussing some of the feelings that come along with using that term. And really, I have some additional training in medical education, so I was looking at this as: How can we approach the physician-patient relationship to help these patients who are high health utilization patients, really looking for answers about their health. How can we help them navigate it? But also realizing that as physicians, we are in a different experience than when many of us started our careers. We have new pressures that we are working within, whether it’s time constraints or the numbers of patients we need to see.

We all know, with many episodes and articles that I’ve encountered, even on your blog, talking about burnout versus moral injury and how one of the first things we lose is our empathy for our patients. And so how can we reconcile all of these forces that seemingly are coming upon our physician-patient relationship, and really come back to why most of us all went into medicine, which was to help people?

Kevin Pho: So when you come across this term medical gaslighting in the chronic patient support forums, give us some context into when that term is normally used.

Kara Wada: So many patients will report, either in the clinic or on the social media forums, that they have these feelings where they have felt that their symptoms have not been taken seriously. They’ve either been completely brushed off or told that the symptoms maybe were in their head, those sorts of experiences. And it’s not uncommon, in particular in an academic allergy/immunology practice. I see some patients who’ve been to multiple different specialists, or I’m the third or fourth person they’ve seen for a particular problem, and they will many times get frustrated with not having answers. And so that’s where this terminology tends to come up.

Kevin Pho: From your standpoint as an allergy/immunology physician, when reading these forums and talking to some of these patients, how has that changed you as a physician?

Kara Wada: One of the things that’s changed considerably is trying to be the best listener I can be with the time constraints we do have. I may not always be able to explain a patient’s symptoms with the physiology, the anatomy, all that knowledge that I know. I may not be able to explain that or understand that fully, but I can still listen. I can tell them that I hear them, and I can validate that they’ve had that experience. And I sometimes will frankly tell them, “I don’t know why you’ve had that particular symptom. I don’t have the science to necessarily explain that, but I hear that you’re experiencing that, and let’s try to work together to find a solution to what’s impairing your quality of life.”

Kevin Pho: So I certainly agree with you that a lot of times, I do primary care internal medicine, and I see a lot of chronic illness as well, and sometimes we just simply don’t know. A lot of patients come to me after seeing four or five doctors, and I always say that if it was a clear answer, we would have told you already. So when you tell patients that you simply don’t know what’s going on, in general, what are some of their responses?

Kara Wada: I’ve gotten good feedback, especially when I’ve just blatantly said, “I hear you, and I’m sorry for your experience,” especially if it’s been a negative experience. That seems to really help, I think, engender some of that therapeutic trust with the patient. I think also offering to partner with them, that I may not have the answers, but I am going to do my best within my purview and my area of expertise, or by working with those colleagues that I work with or can turn to. I think one of the great things about increased communication and social media and everything is having more communication with our colleagues who may have some real specialized expertise in certain areas, and helping make those connections has been really helpful too.

Kevin Pho: So in your article, you talk about some other ways that we could rebuild a therapeutic trust with our patients. What are some other ways we can do that?

Kara Wada: I think being up front with patients about what your limitations are. I think there are many times patients don’t necessarily understand that we are juggling several, sometimes a couple dozen, patients a day, depending on the practice, and that you may not get to telephone encounters immediately, or what the turnaround time is that you should expect for lab results, those sorts of things. Putting that up front in one way, shape, or form, I think, can be really helpful for patients. What is an appropriate use of the patient portal messages? This is something I am still working on. This is a great opportunity to have more connection with your physician and your care team, but at the same rate, there are only so many of us, and we are also working on balancing as well. I think it restores some humanity to us as physicians as well, that we’re not perfect and that we have our own limitations.

I think the other thing that’s really important is being willing to rethink. I think that’s incredibly difficult when we’re under time constraints or we are dealing with burnout or moral injury, whatever we want to label it as. But trying to come to a complex or difficult situation that a patient is dealing with, and come at it with curiosity, and trying to put ourselves back in the shoes of when we were maybe a first- or second-year medical student and every case was a really interesting case. It’s not necessarily easy, and it’s not feasible for every patient, but in those situations where you keep coming against the wall, I think that can be helpful.

And I think the other thing that has kept me humble, in particular within the field of allergy/immunology, is realizing we as human beings are still evolving. We’re still discovering. We know a whole lot, and we know a whole lot more about our anatomy, our physiology, how and why things go wrong in our bodies, but we as a species are still evolving. And we have conditions, especially within the field of allergy, that we’ve only known about for maybe 25 years. For instance, eosinophilic esophagitis is one that comes to mind. If you ask GI physicians or allergists who are at the latter parts of their careers, this is a pretty new entity. There were maybe a few cases here or there, the canaries in the coal mine, and now we’re seeing a large number of patients with these conditions. And so I think having some sense of being humble, that some of these patients may turn out to have a new condition that we don’t fully understand, and to brush them off or rebuff them, we can maybe try to approach that with a little more empathy and understanding.

Kevin Pho: We’re talking to Kara Wada. She is an allergist/immunologist, and she wrote the KevinMD article “Burnout and bias? Or medical gaslighting?” Kara, as you go through your journey as a patient, and also the journey of your daughter as she’s a patient, what’s something that you’ve learned over the last little while that you didn’t know before going through that journey?

Kara Wada: I think one is trying to be patient with my colleagues. I also really realized the need to advocate for yourself. I had a pretty significant flare-up, 18 months, two years, actually two years ago, where I had some pretty significant liver injury and really had to advocate and push to pursue that workup. And I think instilling that in patients, that sometimes you do have to be the squeaky wheel to make sure you’re getting timely and adequate care.

And then the other thing that I think has been really humbling is navigating the insurance network, and co-pays, and in-network, out-of-network. That is a whole new education. I give our patients who navigate that well so much credit, because honestly, I think one could require a degree sometimes to navigate how best to go through the system that is medicine and not end up bankrupt or in some pretty significant financial troubles. And so I think that is also something else that’s been really humbling on this journey.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Kara Wada: I just encourage my fellow clinicians to actively listen, to be up front about limitations, and to really be willing to rethink a situation, even if it takes that extra five minutes. That can really mean a considerable amount to someone who is struggling with symptoms that are impacting their quality of life day after day, and enough to bring them to your office to see you. And they wouldn’t be there, in most cases, in almost all cases, they wouldn’t be there if it wasn’t impacting them. And so I think stepping into those shoes for a moment, and also being willing to allow them to step into your shoes for a moment too, to show that you are human, and that’s where sharing those boundaries or limitations can be really helpful in navigating that physician-patient relationship.

Kevin Pho: Kara, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Kara Wada: Thanks so much, Kevin. I appreciate it.

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