194. Biases in Health Care and Medical Gaslighting: A Conversation with Andrea Nakayama
Bias and Gaslighting in Medicine
Systemic biases can have profound impacts on how we receive medical care and support.
Members of marginalized communities may be brushed off, misunderstood, misdiagnosed, and mistreated within the medical system, sometimes with catastrophic effects. And the toll of bias and medical gaslighting adds up and can impact the presentation and severity of disease symptoms.
Andrea Nakayama joins Erica for a discussion about bias, medical gaslighting, a systems approach to health, and how to advocate for yourself in medical settings.
Listen on your favorite podcast player or keep reading to learn:
The three tenets of functional medicine
How systemic and implicit biases show up in medical care
The sometimes subtle impacts of medical gaslighting
Three steps to advocate for yourself in medical settings
Reclaiming Ownership of Your Health
As the host of the 15-Minute Matrix Podcast and the founder of Functional Nutrition Alliance, Andrea Nakayama (she/her) is leading thousands of students and practitioners around the globe in a revolution to offer better solutions to the growing chronic illness epidemic. By highlighting the importance of systems biology, root cause methodology, and therapeutic partnerships, she helps historically underserved individuals reclaim ownership of their health.
Limits Others Place On Us
On the Pause on the Play® podcast, Andrea Nakayama (she/her) says that while her bio mentions her experience with her husband’s illness and death, and how those interactions with the medical establishment impacted her, she has also struggled with chronic illness herself.
She also recently sold her business, which brought her “head-to-head with some of the ceilings that exist and some of the ways in which female entrepreneurs can be gaslit.”
That experience, she says, woke her up to other ways “we experience the limitations that are given to us, even when we can tell ourselves that we’re not limiting our futures.”
Erica agrees that in many instances, based on our gender, sexual orientation, socioeconomic status, age, race, religion, etc, people will make assumptions about what you can and cannot do and what you should or shouldn’t have access to.
“It’s like, I already got my own shit I gotta work through. I don’t need you to create a whole ‘nother set that is part of this system that I gotta fight through as well.”
Andrea adds that when women “agitate positively” or otherwise act as disruptors to established systems, they get very different labels than men in the same position would.
“We gotta agitate. We gotta look at things from a different lens. We gotta flip everything upside down and say, wait, what are we getting wrong here? Because something clearly isn’t going right. That’s rebelling. That’s disruption. That’s agitation.”
Biases in Medical Care
Erica asks Andrea for her insight on defining two related terms, biases and medical gaslighting.
Andrea responds that in order to define terms, she needs to set the stage for her personal and professional lens.
Andrea is a functional nutritionist. Functional nutrition operates from a foundation of three primary tenets: the therapeutic partnership, looking for the roots, and a systems-based approach.
In practice, this means that she believes her patients are the experts about their own bodies and that they are equal partners in their care. When it comes to treatment, Andrea is always going to look for the root of the problems her patients present with.
“All our signs, symptoms, and diagnoses are branches…they’re not roots. When we ask why, we really get down into those roots.”
In the context of functional medicine, a systems approach is based on systems biology, “meaning we recognize…that the gut’s connected to the brain, and the hormones are connected to detoxification, which is connected to the gut and the immune system.”
She continues, “Those three tenets allow me to really honor the relationship with the patient and bring into the picture what I call functional empathy.”
Based on that foundation and background, Andrea views bias as existing in medicine both based on demographics that cause practitioners to make assumptions about the person they’re treating, but also bias toward the “diagnosis du jour.”
And “there are these biases that clinicians now see through that they place on the individual and see that individual through that lens.”
As an example, she recalls the way clinicians treated her husband when he was diagnosed with a brain tumor. “The bias was that he was his diagnosis. My late husband was my late husband, a father-to-be, a son, a brother, a husband, a musician, a software engineer. He wasn’t a glioblastoma multiforme.”
Symptom or Disease
Erica asks if the biases in the medical system are a symptom of a larger root problem or if they are the disease.
Andrea responds that she believes that biases are a symptom “that has then been labeled, [and] become a disease in and of itself.”
Erica says that when she thinks about bias in the medical system, she thinks about Black birthing people (though most of the research on racial equity in birthing care refers specifically to women, we use birthing people as a more inclusive term) and the assumptions about “her pain level…how she heals, how she bleeds…her temperament.” To Erica, those assumptions feel like symptoms and the disease of how providers “think that Black people and their bodies and their processing of pain, healing, or lack thereof is not the same as white people.”
Andrea agrees and says that, “in part, it’s because of how we’ve pathologized pregnancy and we don’t bring in the adjunct care that actually works with the individual…[and] on top of that problem of there being the pathology of maternal care, we are then bringing biases to the table that…hinder us from being able to see the individual for who they are.”
Erica says that discussion of how bias in medical settings impacts different groups of people is not discussed widely enough, but she wonders if maybe it’s getting somewhat better.
Andrea says there is a “shift in attention, but I think it’s a drop in the bucket of what’s needed.”
One thing she’s been exploring and thinking about is how to bring attention to where it’s needed in different communities. “How do we bring the kind of care that we can to all individuals?”
In too many cases, she says that functional medicine has become “this realm of high-cost testing, concierge practices,” that are inaccessible to many.
“I don’t think it needs to be like that…Functional nutritional doesn’t mean we shop at Whole Foods, it means that we think differently about how we’re taking care and how we’re able to understand connections in our body and our life.”
A Broken System
Erica says that much of it comes down to “a broken system that has been operating exactly as it was designed to, and it was never really meant to keep us well. It was meant to be a money-making machine and there’s no money in being well based on the way that it has been set up.”
But she says there is potential in functional medicine to be “an antidote and a place to begin healing for those of us that feel like, all I know is the healthcare system as it is, and I don’t know what else there is.”
Andrea agrees and says that there are populations that just aren’t supported by the current system, and that there are a lot of intersections between underserved populations and rising rates of chronic illness. She says our medical system does acute care well, but for chronic conditions, “there’s a huge gap there, and we as patients have given ourselves over to a system that cannot hold our chronic health concerns.”
In a system that is designed to give a diagnosis and treat acute conditions, “how do we recognize that when we’re on this quest for a diagnosis, these diagnoses don’t lead to the answer…The label doesn’t lead you to the care that you’re going to need to get better. That is the place for functional thinking.”
Medical Gaslighting
Getting to a diagnosis, and from a diagnosis to effective treatment is where Erica says medical gaslighting often comes in. “You can’t get a diagnosis or any type of guidance around care if you are being guided or forcibly led to think or feel a specific way about it that really isn’t in your best interest.”
Andrea says at its core medical gaslighting is the result of poor physician-patient relationships. “It’s gonna be when you feel rebuffed or disrespected or treated like you’re not heard, and when you are denied care.” And those barriers to receiving care are higher for anyone from a marginalized group.
She says it can also be the subtle feelings you have leaving an appointment where you weren’t listened to, or you leave asking, “what the fuck just happened in that room?”
Erica gives two examples of medical gaslighting from her personal life and circle. She has a friend who misgenders themselves on purpose at doctor’s offices “to not have to have the conversations with the people that keep misgendering them, or ‘at least if I say this, I’ll get care.’”
In her personal history, Erica was brushed off and misdiagnosed before finally getting a Crohn's Disease diagnosis at 20, and then told by a white, male doctor that she needed to be on a medication she couldn’t afford and given no alternative options or treatments.
She was able to see another provider–a white, female gastroenterologist whom she still sees to this day–who ordered additional tests and told her she didn’t actually need to be on daily medication for her Crohn’s. She’s had flare ups and challenges, but did not need to be medicated the way the first doctor insisted she did.
Andrea says that chronic conditions like Crohn’s are an example of a branch, not a root in functional medicine. “The roots of any chronic condition are the genes or the genetic predisposition, digestion, and inflammation. And when we actually address not just the roots, but the solid that those roots live in, we start to impact the severity and expression of the disease.”
She likens the medication Erica couldn’t afford and didn’t need to playing target practice, “we’re saying, what’s the terrain….When we address the terrain, we are addressing the symptoms and the disease.”
Andrea gives another example of a population that is frequently gaslit in medical settings. She says fat women are “told that their body is the fault…They may have done everything they could be doing or be recommended to do, and yet they’re still told that they’re at fault for whatever they’re experiencing and then dismissed. Their pain is written off.”
In her own experience, she was misdiagnosed with adrenal fatigue–a diagnosis du jour at the time–when she saw a naturopath while trying to figure out her thyroid issues.
“When I went back and said, this doesn’t feel right, I’m not feeling good, she said, this is what you’re gonna have to do to get better. That’s gaslighting, right?”
And she adds that structural racism is insidious in medical gaslighting.
“How do we stop and recognize when we walk out of an office that we were dismissed, that we weren’t heard, that something didn’t feel right, and find our next steps forward from there?”
Three Steps of Self-Advocacy
Erica says that one of the major challenges is that clinicians really are the best placed to make changes. “We can do all of the things as the patient, but it really is on the medical professional because they’re in a position to actually do the things.”
And if a provider won’t, then it raises additional questions and challenges about seeking out a different provider, if one is even available or accessible. “Being that we are very much at the mercy of the actual clinicians…how is that we can try our best to navigate that…what do we do with that when we’re like, this person is God-awful at what they do?”
Andrea says that being in that position of knowing you’re being treated poorly can exacerbate symptoms in and of itself because it’s putting your nervous system into a sympathetic (fight or flight) state.
She says she has three steps for self-advocacy. The first is to forgive yourself when you realize you’ve been gaslit in a medical setting.
“I think we often walk out of there and wonder and beat ourselves up…[But] every social insult is a physiological injury.”
And in terms of people living with autoimmune conditions, the body is already attacking itself. “So when we think about how we forgive ourselves and honor ourselves, that is the first step.”
Step number two is to examine your options, whether that’s finding a new doctor or practice or switching doctors within a practice, which she says a lot of people don’t realize they can do. “We have more agency with our healthcare than we think we do.”
She adds that you may have to examine and shift your expectations for our relationships with providers. She says it can be helpful to think in terms of agreements versus expectations when you’re defining what you want from a provider and the scope of your relationship with them.
Erica agrees that adjusting your expectations is a huge factor because “we are conditioned that doctors are there to help, and so there’s this expectation of you’re gonna have all the answers…and I don’t have to do this high level of personal advocacy and that’s not accurate.”
The third step is to take care. She says that could mean showing up to an appointment with a specific agenda or advocating for yourself by being upfront about your ability to process information when you’re anxious.
“When we’re tying these three steps together, and we forgive ourselves as an act of resistance, we have more time and energy to actually take care.”
Take Time to Pause
Andrea’s advice for recipients of medical bias and gaslighting, or caregivers who’ve received that, is to pause.
“When we’re forging ahead, in opposition, fighting, we’ve got the armor on, we have to protect ourselves from all of these inequities that are happening to us all the time. I think just taking that pause and honoring and recognizing, having the place to rest. To speak it out loud if you need to, to get the hug and cuddle from yourself or your people. That pause is what brings us into rest and digest, that parasympathetic state for our entire nervous system to reset and move forward…We’re always forging ahead, we’re always at battle, so I’m gonna say take time to pause.
Ready to dive deeper?
When we’re confronting biases and gaslighting, it can be easy to second-guess ourselves based on what we’ve been conditioned to think. That’s where having a space to navigate what’s happening, what you’re thinking, what you’re feeling, and having a soundboard can be immensely helpful.
The Pause on the Play® Community can be that place.
Learn more at https://pauseontheplay.com/community