Why So Many Doctors Doubt Patients With Long Covid | Psychology Today

[SNT Gatchaman]

Why So Many Doctors Doubt Patients With Long Covid

(Author is a psychiatrist with LC)

Key Points

• People with Long COVID experience stigma and dismissal from healthcare providers.
• Medical education potentiates stigma and mistreatment of individuals whose illness is not easily objectively identified.
• Trying to treat Long COVID with psychotherapy alone is like trying to meditate away diabetes without insulin.

In the meantime, developments in understanding Long COVID are occurring at a rapid pace and providers are often unaware of them.

Thus, a broken system promotes a rudimentary picture of psychogenic disease, with illness scripts based on oversimplified understanding, and applies them in circumstances that are fast-paced and siloed. It does not reward creativity or “out of the box” thinking, and encourages providers to stay in their lane by referring out conditions that do not fall under their purview. Until medicine takes a closer look at itself, stigma and alienation of patients will persist.

 

[Art Vandelay]

(I may be misunderstanding something due to cognitive dysfunction?)

I found this article fairly infuriating because the author still apparently believes that somatic symptom disorder and conversion disorder are valid illness categories rather than pseudoscientific nonsense.

The issue he's raising is that his colleagues are too quick to shove a patient, particularly one with LC, into the SSD box.

Apparently having LC yourself isn't enough to make you realise that Emperor Freud is wearing no clothes.

 

[Hutan]

Yeah, it annoyed me too.

It was Sigmund Freud and Joseph Breuer who first posed the notion that thoughts and feelings that are incompatible with someone’s psychological state could be pushed down into the unconscious, instead coming out in the form of physical symptoms, thereby acutely minimizing anxiety. This remains a majorly held belief in much of medicine, though emerging developmentsin neuroscience show that in many cases, processes are neither solely psychological nor biological, but rather both. Many still think in dichotomous way: A disease is either psychological or biological in origin and cannot be caused by both. In fact, this is sometimes true; for example, our current understanding of diabetes is that it is a disorder of insulin production or response to insulin, rather than, say, a psychological intolerance of glucose. However, things get a bit more complicated when you consider that meditation may aid in lowering blood sugar.

Also this bit where he's suggesting doctors are just "too logical", and that's why they automatically assume psychosomaticism when they see a young woman who seems anxious about her health.

Medical training teaches doctors to be quick on their feet, and recognize and treat illness by established methods; it leaves little room for creativity. This is exemplified by standardized exams, flowcharts, and protocols. In fact, medicine may attract individuals who are highly logical, detail-oriented, organized, and efficient, as these qualities lend themselves to the way that modern medicine is practiced. Unfortunately, this may result in physicians missing the forest for the trees.
As a result, patients who present with symptoms that cannot be explained by laboratory findings, particularly younger women, are already likely to raise suspicion for somatic symptom disorder or a psychogenic basis for their symptoms.

I think I may have thought a swear word or two when I read that. No, we don't need the doctors to be more creative to avoid being prejudiced, hopelessly ill-informed and swayed by psychobabble. We need them to think more logically, to think more critically, be curious and be a whole lot less biased. We need doctors to have better guidance for diagnosis, and be a lot more humble about applying truly evidence-based processes and being clear when they don't know something, rather than leaping to apply the most appealing prejudice.

 

[SNT Gatchaman]

His viewpoint is a product of his training - he is now much more informed than many in his profession by personal and more recent professional experience but Not Fully There Yet™. I found his previous letter in The Lancet pretty reasonable though.

While it is pay-walled, the author has a screenshot of the whole article pinned on Twitter, so I think it's OK to reproduce in part here (my emphasis).

---

Many people encountered previous providers who were unable to offer hope or who offered only false hope. They were told to wait it out, or were told that objectively nothing is wrong, after a few quick screening tests. Clearly, their functioning is radically disrupted; how can nothing be wrong? Some are referred with a suggestion that their symptoms are caused or worsened by psychology. They might have experienced palpitations that come with anxiety or fatigue that comes with depression, and can clearly describe that this is different. Yet skepticism abounds, and in a world in which evidence-based medicine is the gold standard, those with a disease that has yet to establish an evidence base are lost. Some are able to find a provider who will listen to them and express a willingness to restore quality to their life. Many cannot, and are tired of waiting.

At best, comorbid psychiatric symptoms might trigger a referral for psychological support; at worst, individuals with no psychiatric symptoms are told only a psychiatrist can help.

Then, they meet with me. While I can offer support or psychiatric treatment, I cannot offer much more. Who treats the crushing post-exertional symptoms, immune dysregulation, or vasculopathy? It sometimes feels as though I am trying to treat depression in a person whose oncologist can provide zero prognostic data and zero treatments.

My medical training taught me to recognise disease through illness scripts. It did not teach me how to treat those in whom the illness scripts are currently being written. Had I not been a patient with long COVID myself in 2020, who knows how long it would have taken me to learn the value of combining flexibility and creativity with empathy and curiosity.

Despite my own challenge of holding on to hope at times, I know there are researchers who are uncovering pathophysiology and investigating treatments. I know that one day this will lead to improved quality of life for my patients.

Until then, many will continue to suffer. Some told me they were hesitant to come to psychiatric treatment for fear their non-psychiatric symptoms will no longer be taken seriously. Indeed, this fear of dismissal is based on prior experiences they have had with other providers who have been quick to shoo them off, mistaking their anxiety and urgency for recovery as causative rather than a correlation, and tightly wrapping it up in a psychogenic bow. It is deeply unfortunate that these experiences undoubtedly prevent many from receiving the care they may need. When we get caught up in academic debates on Cartesian dualism and somatic symptoms, we run the risk of allowing our patients to get caught in the crossfire.

Our best way of treating patients starts with aligning with them. We must be sure not to assume that we know; humility and self-skepticism go a long way. For now, all we may have is hope, but "where there is hope, there is life".

 

[Art Vandelay]

His viewpoint is a product of his training - he is now much more informed than many in his profession by personal and more recent professional experience but Not Fully There Yet™. I found his previous letter in The Lancet pretty reasonable though.

Thanks for posting this @SNT Gatchaman. It's a very good letter.

 

[boolybooly]

Skillfully written but very detached and retains the potential for deep disingenuity.

It is about empathising with patients to gain their trust but not necessarily believing them. The author accepts medical knowledge is incomplete but still adheres to the hocus pocus of the unconscious and somatisation which imho, from an empirical neurological perspective, is shamanic gobbeldy gook.

In the nervous system, where a decision inhibits an impulse it does not build up a back pressure and ramify like pressurised pipework or some abstract demonic entity with a life of its own, it terminates. The Central Pattern Generators involved may still generate impulses and decisions may be reevaluated but there is no basis for assuming somatisation will result. The human brain evolved as a decision making organ, it stands to reason it wont make itself dysfunctional by doing what it evolved to do in the way it evolved to do it unless there is something physically wrong with the biology of the nervous system. Somatisation is based on an incorrect model invented by a tobacco marketer reinforced by generations of placebo effect outcomes.

This writing reminds me of Garner before he went LP balmy and completely discredited himself with everybody... not to mention Lewis Carroll’s Walrus.

There is a lot at stake for the "professionals" involved and those who rely on them, like the insurance companies.

They want to maintain a facade of unimpeachability. The likelihood is that if the revelations of personal experience from one of their own prove at all significant to the wider world in a way which undermines the gobbeldy gook of somatisation and the cheap insurance settlements it permits, moves will be made to draw them back into the fold, or ruin them.

 

[CRG]

"Yochai Re’em, M.D., is a psychiatrist and psychotherapist in New York City, and a Clinical Assistant Professor of Psychiatry at Weill Cornell Medicine. He completed his psychiatry training at NewYork-Presbyterian Hospital/Weill Cornell Medicine and earned his medical degree at NYU. Re’em has a special interest in Long Covid; he has treated individuals with Long Covid-associated psychiatric and psychological challenges, he has written on the topic in STAT News, the Wall Street Journal, and Lancet Psychiatry, and he has contributed to research efforts with the Patient-Led Research Collaborative. He maintains a private practice in New York where he treats individuals with a spectrum of psychiatric and psychological concerns."

My bold - looks like 'psychotherapist' is doing a lot of the heavy lifting in his LC writing.

 

[Hutan]

Yes, it is a good letter. And even while being annoyed, I could see from the article posted in the first post that this psychiatrist has moved a long way from where his training placed him to start with.

My medical training taught me to recognise disease through illness scripts. It did not teach me how to treat those in whom the illness scripts are currently being written. Had I not been a patient with long COVID myself in 2020, who knows how long it would have taken me to learn the value of combining flexibility and creativity with empathy and curiosity.

I still feel uneasy though. I would have thought that many, maybe even most, of the people psychiatrists see are those for whom either useful illness scripts or truly effective treatment approaches are 'currently being written'. And so, if this man's natural humility and training didn't prepare him for that, it's a big problem.

And do we really want psychiatrists who are creative in the way they approach diagnosis? To me, that opens the door for "diseases" and diagnoses that really are just expressions of cultural bias. Creativity is a long way down the list of skills I want to see in a psychiatrist or a doctor.

Creativity: the use of imagination or original ideas to create something; inventiveness.

Creativity in a scientist, sure. And if a clinician is also a scientist, developing and testing ideas in a rigorous way, a way where they are very transparent with patients that they don't know but are trying something, fine, creativity can push things forward. But doctors doing everyday medical care under normal conditions? They are skilled technicians. I might be wrong about this, but I think they should be following best practice and solid evidence when they treat patients outside of trials, rather than boldly believing they know best and using patients as guinea-pigs. It's quality management - the best way to do things is researched and documented with the evidence used clearly stated, and everyone follows that except in exceptional circumstances. If there are problems or someone has a good idea, things are researched to find an improvement, and the procedure is updated. That works fine when the staff don't believe that standard operating procedures are for other people.