When his 6-year old son became very ill and was hospitalized, Dan Beckham observed how his own behaviour in the hospital began to dramatically change compared to his real life. Although he would readily send a restaurant meal back if it weren’t properly cooked, now when his son received poor care (e.g. a healthcare professional who did not wash his hands), Dan hesitated to be assertive “for fear of alienating the physicians and nurses whose goodwill he needed to maintain.” Here’s how he explained this:
“I felt dependent and powerless, as if my son was a hostage to the care he received and the system that delivered it. It was as though I was compelled to negotiate for his safe release from potential harm.”
Such a reaction is an example of what’s known as Hostage Bargaining Syndrome (HBS), as described in the medical journal Mayo Clinic Proceedings.(1)
The word “hostage” is deliberately provocative, according to the paper’s lead author Dr. Leonard Berry of Texas A&M University, who told the Institute for Healthcare Improvement:
“We recognize this is a startling term to use in a medical journal, but we felt we had to use it to bring attention to this issue and to describe it appropriately.
“Hostage Bargaining Syndrome, where patients feel intimidated by the doctor, is a very real phenomenon that many patients experience, particularly those with a serious disease or in a state of great vulnerability.”
“Hostage” is more commonly mentioned in the fields of criminology or behaviour science when describing illegal hostage-taking, and surprising to encounter in medical literature. Berry summarized the comparison like this:
“The behavior of adult kidnapped hostages has been categorized as cognitive (confusion and disorientation), emotional (fear and anxiety), and social (withdrawal and avoidance).
“I’ve seen that kind of behavior many, many times observing hundreds of doctor-patient interactions in the health care research I’ve done over the years.”
Berry and his co-authors explained that in HBS, patients and their family members can feel reluctant to assert their own important interests in the presence of those who are providing care. And the higher the stakes of a medical decision, the more entrenched the hierarchy-based roles of patient and physician can become, and the more dependent and powerless we patients can feel.
This makes perfect sense to me and to many other women living with a chronic illness like cardiovascular disease. I’ve been writing for years here on Heart Sisters about our puzzling reluctance to make a fuss about symptoms, or our fear of being labeled “difficult“, or our need to be considered a “good patient“, or our urge to apologize to docs and nurses for things that do not require apologies.
And a recent study published in the journal BMJ Quality and Safety revealed that 50-70 percent of family members with a loved one in the Intensive Care Unit (where the most fragile and vulnerable patients are admitted) “expressed hesitancy about voicing their concerns about common care situations with safety implications” – and, as one of the authors summarized: “True partnerships with patients and families may be limited if they don’t feel supported to voice their concerns.”(2)
A hospitalized patient or their family members, says Berry, may succumb to learned helplessness, making authentic shared decision-making almost impossible. This may include:
- understating a concern
- asking for less than what is needed
- remaining silent against one’s better judgment
Berry cites HBS examples like this one:
“One mother told [us] that when she noticed a subtle change in her child’s behavior during a hospital stay, she informed a nurse who promptly performed a routine set of tests that indicated no cause for concern. But the mother’s worry lingered, and she lay awake rehearsing what to say to the doctor in the morning. She feared being perceived as disrespectful of the medical team’s expertise, or as demanding and over-anxious.”
But he adds that this story could just as easily be that of a 70-year-old heart patient who’s unsure about the cardiologist’s surgery recommendation but hesitates to question it, or a 27-year-old woman with cancer who does not express her fear of treatment-related infertility to her oncologist.
Or even an experienced physician who becomes critically ill, like Dr. Rana Awdish, an Intensive Care doctor at the Henry Ford Hospital in Detroit, and also one of the publication’s co-authors. Her own patient story is a nightmare: she was hospitalized for months, and nearly died. She admits that she, too, felt like a hostage:
“I believed that I needed to make [my care providers] like me in order to receive their best care.”
Dr. Awdish did survive, and went on to describe her own Hostage Bargaining Syndrome experience in an essay published in The New England Journal of Medicine, and later wrote a book about it, too (In Shock – My Journey from Death to Recovery and the Redemptive Power of Hope.)
As she explained in an IHI interview:
“I realized that as a physician in my own institution I was, at least in theory, an empowered minority. I was someone who had a voice, some measure of authority and personal agency.
“Yet, as a patient, I didn’t feel at all empowered to be vocal about my needs or fears. I thought about how voiceless you become in many ways just through illness. And, perhaps more importantly, I realized that, if I felt that way, then the experience was far more common than I had understood it to be.
“Once I framed it that way for myself, I felt a responsibility to admit the ways in which my own system had in many ways failed me because if it was failing me, then it was bound to be failing others. What about people who don’t have the medical vocabulary or the foundation of knowledge about what is going on in their body? What about those who don’t know the people in the room or the roles they are meant to play?
“We have an obligation to fix this for the people who can’t tell us we need to fix it.”
But what is the fix when frightened, confused and vulnerable patients feel and behave like hostages?
Dr. Berry and his team have a number of recommendations for healthcare professionals:
“To subvert HBS and prevent learned helplessness, clinicians must be sensitive to the power imbalance built into in the clinician-patient relationship.
“To build trust, doctors should demonstrate compassion, maintain patient privacy, have good communication skills and show interest in the patient as a person. Body language and physical stance, such as sitting rather than standing in front of a patient, signal that the doctor values what the patient says.
“They should then actively facilitate shared decision-making by earning patients’ trust. Clinicians must sincerely convey to patients and their families that it’s safe to communicate their concerns and priorities, ask questions, and contribute knowledge about themselves to help make the best possible clinical decisions about their care.
“The vast majority of doctors don’t want their patients to feel like hostages, and are not to blame here. But they have to acknowledge it, and actively work against it, to stop it in its tracks.”
The physician-turned-patient Dr. Rana Awdish agrees, reminding us that in telling her own story, she is not in any way attributing blame or finger -pointing. Echoing the same concerns I raised in a 2014 British Medical Journal (BMJ) essay about doctors who become patients, she added:
“It was an exercise in describing our (medical) culture. This is who we are. This is who I was. I just hadn’t seen it from the patient’s point of view.
“Until you do that, you can’t really appreciate how even the smallest things matter – the things we say casually, the things we don’t think are overheard, the casual way we frame illness for people – all of it matters. It’s even embedded in the metaphors of illness we use – illness as a battle, a war.
“There’s so much that’s unconscious and part of the culture that I think we need to bring to the surface so we can say, ‘This is who we are. Now, is this who we WANT to be?’ Because right now, in this moment, it’s who we are.”
Berry and his colleagues also stress that their message is not a broadside criticism of clinicians. He believes that HBS is mostly a function of a confluence of several factors:
- the knowledge disparity between clinicians and patients
- the fact that we, as a society, tend to put doctors on a pedestal
- the fear patients often have of offending care providers and getting less care or less attention as a result.
This is especially important to patients who are seriously ill, or are in a state of great vulnerability and dependence. This confluence of factors, warns Dr. Berry, is what leads to HBS.
(1) L. Berry, T. Danaher, D. Beckham, R. Awdish, K. Mate, “When Patients and Their Families Feel Like Hostages to Health Care“, Mayo Clinic Proceedings, September 2017;92(9):1373-1381 Mayo Foundation for Medical Education and Research.
(2) S. Speaking Up about Care Concerns in the ICU: Patient and Family Experiences, Attitudes and Perceived Brriers“,
NOTE FROM CAROLYN: I wrote much more about before, during and after hospitalization in my book “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press, 2017). And you can save 20% off the list price by mentioning the code HTWN when ordering directly from Johns Hopkins!
Q: Can you identify with this concept of Hostage Bargaining Syndrome?
- When you fear being labelled a “difficult” patient (an important study of patients, described as “wealthy, highly educated people generally thought to be in a position of considerable social privilege and therefore more likely than others to be able to assert themselves” – yet who still claim to defer to their physicians)
- News flash: care improves when doctors consider the whole person
- Why physicians must stop saying “We Are All Patients” (my BMJ essay)
- Do you want the truth, or do you want “Fine, thank you”?
- “How To Be A ‘Good’ Patient”
- The heart patient’s chronic lament: “Excuse Me. I’m Sorry. I Don’t Mean to Be a Bother…”
- When your doctor mislabels you as an “Anxious Female”
- How Minimally Disruptive Medicine is happily disrupting health care