In the world of medicine, we often encounter the term “defensive” used in various contexts – from patient interactions to professional evaluations. However, it’s crucial to reevaluate our understanding of this term and its implications on our practice and relationships.

Labeling a reaction as “defensive” carries a subjective judgment, often seen as problematic or negative. “Defensive” is often equated to a “bad” and “problematic” reaction or behavior. “Defensive” is a judgment, usually quite subjective with a lot of inherent bias towards the other party. “Defensive” is an adjective. “Defensive” is a sword that can fight back against any unwanted or inconvenient response to an action. “Defensive” is how people often describe an array of emotional and behavioral responses from others. “Defensive” is what we can label ourselves and others, such as our colleagues, students, or friends. “Defensive” is how one party feels about the other in any conflict, be it interpersonal, financial, legal, or medical.

Instead of quickly labeling a reaction as defensive, we should ask ourselves: Is being defensive inherently bad? Human interactions, at their core, involve the normal conflict of needs, and the behavior in response to that conflict is what usually causes modern problems, harm, or solutions (i.e., needs being met). Both parties involved inherently need to “defend” their needs to survive. Defensiveness is a natural human mechanism developed for survival. It’s a protective response honed over thousands of years, enabling humans to guard against threats and harm, such as other animals or other humans who posed a threat to their needs and existence. In the medical context, understanding defensiveness as a normal, evolutionary reaction is crucial.

Understanding “defensive” allows us to move away from judgmental, invalidating thinking that perpetuates conflict and weaponizes normal human reactions, perpetuating traumatic experiences in medicine for physicians, patients, and learners, hindering problem-solving. An alternative to a “defensive” human response is a trauma response, where facing a threatening event, we respond with a freeze or fawn (collaboration out of fear to reduce the damage). Many physicians and patients are forced by our system to respond with a fawn or freeze response not to be labeled as difficult or punished, perpetuating systemic trauma.

When considering defensiveness in medical settings, it’s important to recognize its role as a natural emotional and behavioral reaction. This understanding allows us to move away from judgment and towards growth and resolution. Recognizing the subjectivity of emotional responses is a part of emotional intelligence, crucial in handling conflicts and interactions in health care.

Understanding human behavior, we have to recognize that the subjectivity of emotional responses is a part of emotional intelligence, crucial in handling conflicts and interactions in health care. The same event triggers different thoughts, behaviors, and emotions for different people involved based on various roles, their underlying life experiences, vulnerabilities, and their current abilities to cope with real and perceived threats. Opposites are true at the same time – one’s interpretation of an event is valid to them based on their life experience, and ideally, we can understand each perspective and find a middle ground to problem-solve for a healthy interpersonal resolution rather than judging and blaming. Unfortunately, in medicine, especially with legal involvement, judgment and blame prevail, likely perpetuating physician trauma and distress as well as patient suffering.

The physician’s perspective: Facing complaints. Imagine a physician receiving a complaint from a nurse about a clinical interaction. During the meeting with the chair, the physician is labeled as “defensive.” However, this defensiveness is a natural protective mechanism. The physician may be defending against misinterpretations, systemic failures, or the fear of professional repercussions. Such defensiveness is not just a reaction; it’s a defense of their professional integrity and recollection of events and reality testing. It’s a response evolved over time to protect one’s livelihood and reputation in the face of potential threats.

The patient’s response: Guarding personal trauma. When gathering patient history, a patient might become “defensive.” This defensiveness is a protective shield for painful experiences that are mere words on paper to us but painful reality that can be misused. Defensiveness serves as a guard against reliving trauma or being judged. Recognizing this, physicians can approach such situations with greater empathy and understanding, facilitating better patient care.

The medical student’s reaction: Coping with pressure. A medical student appears defensive when receiving feedback. This defensiveness might stem from past negative experiences, such as abuse or unjust treatment in the medical education system, and serve as protection from further harm or unfair judgment. Understanding the context of this defensiveness can lead to more effective and compassionate mentorship.

Reframing “defensive” in medicine

In each of these scenarios, labeling a reaction as “defensive” without understanding its roots can lead to misinterpretation and conflict. Defensiveness is a complex emotional response, often rooted in legitimate concerns and fears. It’s a survival mechanism that has evolved to protect individuals from perceived threats.

As medical professionals, it’s essential to approach defensiveness not as a problem to be solved but as a signal to be understood. This shift in perspective can lead to more meaningful interactions, improved patient care, and a healthier educational environment. Embracing defensiveness as a natural and sometimes necessary response can transform our approach to care and communication, fostering a more compassionate and empathetic health care environment.

“Defensive” has been weaponized in medicine during administrative issues, or to punish, discredit, and intimidate physicians, perpetuating the unspoken trauma and anxiety we all carry from judgmental, punitive, and blaming interactions that interpersonal medical interactions are full of. As we enter 2024, if we are committed to physician wellness – we need to accept that “defensive” is what keeps humans alive and a normal (possibly inconvenient for the other parties) human response.

When people label me “defensive” – I accept it as a badge of reality of the situation – I am defending my professional opinion, recall of events, side of the story – I am doing what kept my ancestors alive instead of living in a convenient trauma response of freeze and fawn. If my patient is “defensive” – I either need to understand how I can support them or accept that they need to defend themselves. When my children get defensive – they need to defend their reality and needs. Accepting “defensive” is doing the opposite of perpetuating trauma responses of fawn and freeze when out of fear people appease us. Defensive is healthy but might not be convenient.

Maryna Mammoliti is a psychiatrist.