The implication here is that MUS do not result from disease, and therefore their explanation must be psychosocial—an implication consistent, O’Leary notes, with the classification of MUS as “psychiatric” in the Oxford Textbook of Medicine.“In medicine, the leap between ‘doctor doesn’t know’ and ‘problem is in the mind’ is instant,” O’Leary told me. “They are the same thing.”“Every virus has a post-viral syndrome. In a global pandemic we’re going to have a certain number of patients present with a post-viral syndrome, and shame on us for not being ready.”
Tracing the history of terms like “medically unexplained symptoms,” O’Leary showed how they have been deliberately chosen to mislead patients about the nature of their diagnosis as it is understood by the physician. These terms—call them ambidextrous—are used to soothe patients. They don’t sound like a diagnosis of psychogenic illness. But at the same time, they communicate exactly that diagnosis to other medical professionals.Consider this passage from “To Tell or Not to Tell: The Problem of MUS,” written by the British psychiatrist Simon Wessely (who consulted on the PACE trial):“ ‘So it is all in my mind, is it doctor?’ says the patient threateningly. The correct answer from our truth telling neurologist would of course be ‘yes’, followed by a plaintive ‘but psychiatric disorders really are genuine illnesses’, but by that time… the patient may well have left in disgust … There are insuperable objections to the neurologist ‘telling it as he sees it’.”Another popular ambidextrous term is “functional,” which appears most often in neurology (“functional neurological disorder”) and gastroenterology (“functional bowel disorder”). The term is only applied to symptoms that have no clear biological origin, and was originally coined by neurologists and psychiatrists as a replacement for “conversion disorder,” itself a euphemism for what used to be known as hysteria.“In medicine, the leap between ‘doctor doesn’t know’ and ‘problem is in the mind’ is instant,” O’Leary told me. “They are the same thing.”
“She presented with a verbal flood of symptoms, and they weren’t very structured either, jumping from one thing to another and shifting from one physical symptom to the next.”
“The pattern wasn’t that logical and so on. I can understand you getting out of breath at the top of the stairs, but of course if you also get short of breath regularly when at rest, that’s a weird pattern.”
Especially influential was a previous diagnosis of MUS or psychogenic symptoms, which means that once one doctor says it’s anxiety, even if they are wrong, others are more likely to do the same, a phenomenon known as “anchoring bias.” O’Leary points out the anchor is much heavier when the misdiagnosis is psychogenic, leading to “diagnostic delays at least 2.5 times as long, and up to 7 times as long, as those caused by mistaken medical diagnosis.”“I think he is a real MUS patient because he never has a concrete story. Of course that’s not very nice of me and I realise that.”
The authors of the Dutch study conclude that “non-analytical reasoning was a central component in [the GPs] thought process.”Doctors themselves admit as much. Dr. Ethan Weiss, a cardiologist at UCSF, was frank with me in his evaluation of the situation.“These people don’t get better,” he said. “We all want to feel good at our jobs, and it is very frustrating not to be able to make progress. And these people are often very frustrated, they’ve been dismissed by multiple previous doctors, and so there’s a level of contentiousness when they walk in the door.”Most crucial is the question of limited time, which came up in every one of my conversations. “If you are being rushed to see someone with a complex issue in 20 minutes, establishing a good relationship, doing an exam, a history—it’s laughable,” said Dr. Kate Chebly, chief resident in internal medicine and primary care at NYU’s School of Medicine. “PCPs [primary care physicians] would agree with that, patients would agree with that.”Symptoms that fit a logical pattern are quickly dealt with. So are patients whose condition clearly fits a medical specialty. ME/CFS, rare diseases, long COVID do not fit a pattern or specialty. With 30 patients in the waiting room, a difficult person in the exam room, and billing policies that incentivize quick decisions, MUS provides an easy out.“That is simply the medical history you have. I’ve seen her a few times and the first time, well, you get a shock because she really comes across as very neurotic and crazy.”
“A part of it is practical,” O’Leary said. “They’d be fighting all day with patients so now they say mind-body is a continuum. It’s just bullshit, using pseudo-philosophy to avoid a fight.”“It’s an understatement to say that a lot of physicians have God complexes.”