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Join Maryna Mammoliti, a psychiatrist, as we explore the complex concept of “defensiveness” in the medical field and beyond. We’ll discuss why labeling reactions as “defensive” can carry negative connotations, the role of defensiveness as a natural survival mechanism, and how understanding it can lead to more compassionate and empathetic health care interactions.

Maryna Mammoliti is a psychiatrist.

She discusses the KevinMD article, “Is being defensive evolutionary healthy or modernly inconvenient?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Maryna Mammoliti. She’s a psychiatrist. She’s been on the show before. We’re going to talk about her KevinMD article, “Is being defensive evolutionary healthy or modernly inconvenient?” Maryna, welcome to the show.

Maryna Mammoliti: Thank you, thanks for having me again. I always look forward to coming back and chatting with you.

Kevin Pho: Perfect. So I see you in a car, and I understand you’re in a parking lot in a strip mall right now, so thank you so much for taking the time out to join us. So let’s jump straight into your article. People who want to go to your past episodes, go to KevinMD.com/podcast, can search up your name and hear your story. But today’s article, just tell us what it’s about.

Maryna Mammoliti: Well, I am a psychiatrist in Ontario in Canada, and I work with a lot of physicians as patients, but also I teach, I mentor, and I navigate the medical system. And we often encounter these labels of defensiveness. Somebody’s defensive, whether a medical student, a patient, or even ourselves. We get told you’re being defensive when you’re facing a situation.

And I really look at a very non-judgmental, curiosity-based understanding of the situation. Obviously you see my psychiatry training as a background. And reality is, being defensive is actually healthy. Being defensive is what kept us alive, it keeps humans alive. Being defensive is what defends our reality, our needs, our reputation, our ability to provide income, our ability to have employment. But really at the end of the day, defensive is, you’re defending the reality that you’re experiencing as a physician, as a student, as a patient sometimes. And defensive is often such a subjective label that we give to people when they’re not convenient to us, rather than trying to understand that no, it’s actually healthy to defend your needs.

Kevin Pho: So give us an example, in a medical context or in a medical school context, where a health professional may be perceived as defensive.

Maryna Mammoliti: Oh, I have a billion examples. I’ll try to give you, I always give things from my personal experience. So imagine if you are receiving an email, and as you know, a lot of the emails physicians receive are often very blaming. You didn’t do something, you forgot something, it’s your fault, right? It’s unfortunately, communication these days is blaming.

So let’s say you get an email saying, because you didn’t do something, the nurse has a complaint and there’s an issue. And automatically the physician will be defensive, because the physician logically will be defensive of, one, their experience of the interaction, what they did or they didn’t do. Two, they’re going to be defensive because now this might be a disciplinary issue, this might be going on the record, this might be patient harm, this might be a systemic issue that happened, right? And it might have been a miscommunication. And the thing is that the nurse might also have a very valid point in the interaction, and it’s just the opposites in how we physicians are faced with that, because we’re often faced with an issue in a very blaming way that triggers the defense mechanism, because it’s a threat.

If somebody emails me and says, hey, I just wanted to follow up and double check what happened, or can we talk about it, that triggers less defensive response, because it’s like, we want to talk about it. But as physicians we’re often faced, even if it’s a minor thing, with, you did something wrong. The starting point is the physician is wrong, the physician is bad, the physician is incompetent, the physician is in trouble. So if you start an email or any conversation from a point of, you were wrong, how can we not expect a physician to get defensive, especially if a physician holds a completely different recollection of what happened?

And remember, most of us physicians, we go into medicine because we actually care about our patients, we want to do good. We don’t go into medicine to lie and cause problems and do poor patient care, right? So when a physician that spent all these years of life training has a lot on the line, potentially tuition debt, this is your paycheck, this is your reputation, this is your ethical, moral want to take good care of patients, and then you get an email like that saying, well, this, this, and this. How can I not be defensive? How can I not be defensive about what happened? How can I not be defensive with what I think was the right way to do it? You see, it’s evolutionary protective for me to be defensive.

And what we see is this conditioned way that we expect physicians to respond of, oh yes, I’m so sorry, it’s my fault. Or what we now teach is, you know, learning. But from a psychiatric perspective, what we actually want from a physician is a trauma response. It’s a fawn or a freeze response. Physicians freeze, they’re afraid, they’re terrified, oh my God, what does this mean, am I in trouble? Or they fawn. Fawn is when you collaborate out of fear to decrease the damage. And then when we get that response from a physician we say, oh yes, this physician learned.

But the reality is, that is what causes the physician to develop anxiety, to develop mental health issues, to be hypervigilant and afraid at their workplace, taking away emotional safety. And this is where I see the physicians struggle all the time, where a minor email can trigger such a big response, because they’ve had multiple repeated incidences where a minor issue has been used as a threat towards their position, their privileges, their ability to make income, their ability to provide patient care. So do you see how defensiveness is actually normal, but we want a trauma response, we want fawn or we want freeze, which we label then as cooperation, when that’s not going to be healthy for the physician?

In medical students it’s the same thing. If I’m coming to a medical student with my evaluation and I’m saying, you’re going to fail, I’m telling them that it’s a threat. I’m threatening your ability to move on in medical school, I’m threatening your potential career, your ability to do this. Why would the medical student not be defensive? Of course they’re going to be defending their experience. Of course they should be defending their experience and explaining their side of the story. And we see that as a problem, we think the medical student is uncooperative. But if my medical student just sits there and tells me, yes Dr. M, you’re right, you’re right, you’re right, to me that’s a problem, because to me that means they’re responding to me out of fear. They can’t talk to me, they can’t defend their position, and they can’t find the middle ground.

Doesn’t mean that we don’t hold people responsible for issues. We do. But it’s how we get to the point. The same with my children, right? Like, I have four kids. If I come in with my children and I say, you ate the cookies, right, they’re going to get defensive, they’re going to say no, it wasn’t me, it was another kid, whoever. Unless they’re terrified of me. If my kid is terrified that I’m going to hit them or yell at them or punish them, they’re going to fawn, they’re going to say, yes I did, because maybe I’ll just yell at them instead of hitting them. Or they’re going to freeze because they’re terrified that I’m going to hit them.

So do you see how what in medicine we want is actually not healthy for the individual physician? Because that’s like wanting children who are compliant. It’s not healthy. Compliant children are not healthy. That means they’re terrified. It means they’re terrified because you hit them, or they think you’re going to hit them. Being terrified and compliant is actually not good.

Kevin Pho: So let me address this from the two parties, from the physician standpoint and from the administrator standpoint. Now, for those administrators who may be listening to you, and in that scenario where they have to email a physician, how should they frame that so they don’t trigger such a response?

Maryna Mammoliti: That’s an awesome question. I wish everybody would listen. I’m going through that situation right now, working on email communication with a particular party as we speak.

But the point is that when we assume malice, when we assume intent, when we start from a blame point of view. And we have to understand that sometimes administrators do this because there’s the legal issues and malpractice issues, and really it’s a conflict of interest of who’s going to be responsible, the hospital or the physician, right? So you could see why somebody might start from a blaming perspective, because there’s the legal undertones.

However, in any communication it doesn’t hurt to start with, hey, we just had some concerns raised, could we talk? And potentially just leave it open with curiosity, and provide some details of when we can meet or any specific topic. Because one of the most threatening or scary emails is if somebody emails to say, hey, we have an issue, and you have no idea what the issue is. The issue might be somebody forgot to sign an order, or somebody forgot a minor thing, or there could be a big issue, right? So being clear about what the issue might be, being open about the communication, is also important.

See, the other threatening part about that communication might be is that we never know how far the issue could be taken. Because if you have a facility that doesn’t have clear consequences, then you the physician can sit there and catastrophize and say, am I going to get fired or am I just going to have a conversation? Am I going to be reported somewhere or am I just going to have a conversation? So I think part of what becomes threatening and triggers a defensiveness is lack of clarity, lack of clear disciplinary pathways, lack of clear timelines of things, right?

So again it’s the same thing as we do with children. With my children, there’s clear expectations, there’s clear consequences. We have to have consequences in life. I’m not saying you can’t be held responsible, but the consequences have to be clear, not punitive, not random. And so if somebody communicates and says, hey, we have an issue, this is the issue, can we meet, and this is the time, that’s less threatening. It’s still threatening because you don’t know what to do, but you have more time in your mind to prepare and what to do with it.

As I talk to many physicians, whether it’s my patients, coaching, or you see in online groups, some of the biggest triggering situations is when somebody sets a meeting and says, hey, we’re meeting with HR. No idea what, how long, nothing. They have no time to prepare, they have no time to remember, they have no time to do anything, and they’re sitting there catastrophizing. Of course they’re going to be defensive, because in your mind you think the worst case outcome. And you have to, that’s evolutionary protective for you, because if you don’t, and that’s what you encounter. It’s like in war, you think about the worst threat. You don’t sit there and think, hey, it’s going to be OK. That’s not what kept humans alive. You prepared for the wars and then you managed the best, right?

And it’s the same with patients. I really get concerned when patients are compliant, because a patient should feel emotionally safe enough in a patient-doctor relationship to say, no, I’m not willing to talk about that information because it’s too painful, or this is too sensitive, or no, I don’t agree with this plan. It doesn’t mean that the physician has to change the plan, because our treatment plans are within our regulations and ethics and what we think is reasonable, but they do have to discuss it if they don’t agree with it. Because if they don’t agree with the treatment plan, they’re going to walk away, they’re going to be frustrated, they’re going to be resentful, they’re going to feel unheard. They might either go to another doctor, they might go write a negative review, they might go file a complaint instead of discussing it with you. They might also feel very helpless and retraumatized by the helplessness.

And so I also don’t want patients who are fawning in our appointments. I want patients who ask me questions, I want patients who challenge me about, why are we choosing this medication instead of this, or this is not going to work. Because it gives me opportunity to problem solve something that’s going to meet their needs. Because what I think might work might not actually work for the patient, because they might not have the insurance, they might not have the coverage, they might not want this side effect, or they might not understand the side effect, and I need to address that. Rather than people just taking whatever script I give them, not knowing that they don’t have insurance coverage because they were too afraid to tell me, this is too expensive, or I can’t do this, it’s not going to work.

Or in psychiatry a lot of patients are very hesitant to talk about sexual side effects or weight gain. Those are very legitimate fears, but they don’t bring it up because they don’t want to be seen as defensive or non-compliant. And of course they don’t take it, or they stop it the moment they develop side effects. And I’d rather know this at the beginning and not even try these medications.

Kevin Pho: Now what about from the clinician standpoint? So if they receive, or at the start of an interaction it’s perceived as threatening, I assume a lot of them don’t have the insight and they just react into defensiveness. So tell us some tips that you give to physicians who may receive that perceived threatening interaction. How should they respond in order to make that interaction more constructive?

Maryna Mammoliti: I guess it also depends. What we perceive as threatening also depends on our resources, abilities, our previous past trauma history, and our supports, right?

So I’m sitting right now in the parking lot, I’m parked. If I have a police officer pull over, I’m not going to perceive them as a threat, because I’m not breaking laws in my opinion. And if the police officer talks to me I can tell them, and if I get a ticket, I have resources to pay the ticket, I’m OK, that’s not going to be a problem for me. Versus if I was driving on the highway talking to you and the police officer pulled over and I know I’m doing something really wrong, and a huge ticket, it’s a huge problem. That’s much more threatening, and not having the resources, the money, it might have more consequences.

So I think in each different case we have to understand what is threatening to us depends on what we perceive the threat to be and the consequences, but also our resources. So if a physician is very dependent, trapped in a particular job financially, location, or because they have huge student debt, a lot of things might be very threatening to them. A simple email might be threatening to them, because they might be afraid that they’re going to lose their job or going to be reported. Versus a physician who might have a double income family, they have access to money, they have access to lawyers, this job doesn’t mean much to them, if it doesn’t work out they’re able to move away. To that person, they’re not going to take it or see it as threatening as the one who doesn’t have the resources.

So we always have to look at, when you get this email, the first thing I always suggest people, and the first thing I do, is what are my resources here, and what am I actually scared of? What is this email triggering? Am I scared that a patient might be harmed because this is misrepresented? Am I scared that it’s going to threaten my privileges? Am I scared that it’s going to threaten my reputation? Am I scared that this is happening and it’s denying my reality and what I recall is happening? So we really have to understand, what is my fear and what are my resources to manage this? Just like again, if somebody attacks you, you look at, what am I scared of, getting robbed or getting killed? What are my resources, can I call 911, do I have a way to keep myself safe? It’s the same thing, just a different context.

Kevin Pho: So how about in the exam room? Because I think this dynamic sometimes plays out in the exam room between physicians and patients. What are some things physicians can do so they don’t come off as threatening whenever they talk to patients, and maybe not elicit that defensive response from patients? What are some things that doctors can do in the exam room?

Maryna Mammoliti: Well, again, I think we have to understand that the defensive response is always a mix between the one person and the other person. When patients get defensive, it’s usually because, one, there’s trauma history, they’ve been dismissed, traumatized, or they have personal trauma.

So for example, if I’m getting a history from a patient and they don’t want to talk about something, there might be trauma because it’s just too hard to relive, to discuss what happened. Or there might be trauma that that information was used against them, or dismissed, or they were judged for that information. So again, if somebody gets defensive and I’m doing a history, I might say, it sounds like it’s a sensitive topic for you, I’m not sure why, you could let me know or not. Or I explain to them why I need that piece of information. And I’ll say, I need that trauma history to understand what you’ve been through so I could help you, but you don’t have to give me details. And when I explain that, they might be willing to explain to me why I need to know that, and especially like sexual history, sexual trauma, or all sorts of trauma, right?

So we need to know that. The other reason people might be defensive as patients is because they come into our office expecting a particular treatment, but, one, we might not have the training, we might not be able to do it, there’s no insurance coverage, or it’s actually not safe. And so they might feel defensive out of helplessness. And again we have to understand that’s about them, because you’re setting a boundary. You’re setting a boundary saying, I can’t offer that treatment, I’m sorry. I could see you read about it, I could see you think it’s reasonable, your cousin thinks it’s reasonable, I can’t do it, for whatever reasons.

And so we have to understand that defensiveness is a signal. Is it a signal about the past? Is it a signal about what people want and you can’t deliver? And the main thing is to actually acknowledge it, because you see, we feel all of this, and if you don’t acknowledge it, we act out of it, right? So we need to acknowledge it.

And again, in medicine, commonly people say you’re defensive, and I’ll hear this very commonly, and I say, yes I am, you’re right, I am defensive, because I’m defending either my expertise in this case, or I’m defending my ability to do X, Y, and Zed. I am going to be defensive and I’m going to own that. Or I’m defending meeting some sort of a need that I need, potentially financial, like compensation. Here in Ontario, when physicians bargain for money from the government, I will be defensive, because I’m defending the ability to sustain our practices, right?

And so we need to bring it into the conversation and not see it as something bad. Because often in medicine, when we see defensive, it’s equated as bad physician, not open to feedback, bad medical student, bad patient. When it’s like, no, they’re doing what’s right for them evolutionary. Let’s understand what are they defending against. And when you’re dealing with administrators, the reality is, Kevin, administrators are not safe, because when there are issues, we’ve all been in a situation where we’ve been manipulated. So a lot of physicians come into any of these situations with distrust because they’ve been hurt at some point in the past, and we have to validate that that’s a valid evolutionary response. We can’t punish people for that.

Kevin Pho: We’re talking to Maryna Mammoliti. She’s a psychiatrist. Today’s KevinMD article is titled “Is being defensive evolutionary healthy or modernly inconvenient?” Maryna, let’s end off with some of your take-home messages that you’d like to leave with the KevinMD audience.

Maryna Mammoliti: The take-home message is, defensive is a valid experience. Let’s use it as a signal and understand what it means, what it means to you, what it means to others. We have to bring it in the room in healthy, emotionally safe environments, whether it’s at work, patient-doctor relationship, or learner relationship. And in medicine, discussing our emotions is part of that, that’s called emotional intelligence.

And so defensiveness is an emotion, it’s subjective, it’s valid. Literally that’s what kept humans alive, so we can’t start deciding that this is a bad thing that kept us alive for thousands of years. Let’s understand it. It might be inconvenient, it might take time, it might take emotional intelligence, but it kept us alive. It’s not a problem, it’s a skill.

Kevin Pho: Maryna, thank you so much for sharing your time and insight, and thanks again for coming back on the show.