Medical haste, COVID-19, and the mythology of “Medically Unexplained Symptoms”

Here is an extract from a lecture I gave last year for my colleagues at the Psychiatric Association of Turkey. It concerns the issue of so-called “Medically Unexplained Symptoms”:

I attempt to show how the primacy effect — a reliance on first impressions — serves to distort medical reasoning. For example, our first impressions of COVID-19 was of an illness characterised by high temperatures and lots of coughing (hence all those forehead thermometers and hand-washing). These impressions have remained influential, even though we now know that the fever/coughing stereotype is largely misleading: fatigue and headache are by far the most common symptoms of the illness, and most people who get Covid do not develop any fever or persistent cough at all. Something similar could be said about Long Covid too. The power of our collective first impressions — that people recover from Covid after a few weeks — is probably why governments around the world have been slow to acknowledge the scale of the Long Covid crisis.

The primacy effect hampers doctors as well as governments. As part of my lecture, I discussed this recent study of General Practitioners and the speed with which they form diagnoses. The study found that GPs tend to draw their conclusions rather quickly, especially when they believe a patient is not really physically ill but has illusory, psychosomatic, or hysterical symptoms.

Shockingly, the study found the following:

  • It took GPs a median of just 12 seconds to decide that a patient’s symptoms were psychosomatic.
  • In 50% of consultations, GPs had decided that symptoms were psychosomatic before the patients had even started talking.
  • For those GPs who allowed patients to speak before attempting to diagnose them, the median time taken to declare their symptoms illusory was still just 132 seconds. In other words, they gave patients the physical “all-clear” in under three minutes.

The killer here is that a determination of so-called “Medically Unexplained Symptoms”, or MUS, is supposed to be a diagnosis of exclusion. Technically all other possible diagnoses need to be ruled out first. The symptoms can only be deemed “unexplained” if all other explanations are found wanting.

Doctors who diagnose a patient with MUS should form this view only after many hours of consideration. That is the logic of the deliberation required. It should take a very long time.

But it seems as though (some) doctors decide these things using processes other than logic.

* * *

I was reminded of this problem when I read the news from the Irish High Court yesterday. The Court has awarded a 20-year-old man compensation of €6 million because of a catastrophic misdiagnosis he received when he was just 14.

His symptoms — fatigue, brain fog, and numbness — will be familiar to many of us in these Covid times. The young boy’s doctors quickly declared these ailments to be “psychological”, and prescribed a regimen of mental health treatment and physiotherapy. But they were wrong. The boy in fact had a brain tumour, which, because of the physicians’ attachment to theories of psychological magic, went undetected — and thus untreated — for five months.

All this will sound eerily familiar to patients with complex illnesses such as ME/CFS, many of whom have been fobbed off by their doctors for years. More recently, patients suffering from Long Covid have joined the masses experiencing similar medical pushback.

It would be nice if the doctors concerned could perhaps try to be a little less hasty, and a bit more humble. “Medically Unexplained” does not mean “Medically Unexplainable”. Just because you don’t know what’s wrong with a patient doesn’t mean that nothing is wrong with them.

Not knowing something is perfectly fine.

Pretending to know, on the other hand, should be seen for what it is — medical negligence.