Why Don’t Doctors Want to Hear About Psychosomatic Problems?

In a busy medical practice the gift of time is horribly expensive

Posted Dec 05, 2015

It happens all the time: symptoms without lesions. You feel awful, have pains here and there, but physicians can’t find anything organically wrong with you.

Even worse, your internist or family doc, for lack of anything better, refers you to a psychiatrist. Psychiatrists hate these patients. You turn up in their office with a complaint of chronic chest pain, no organic findings.

“What am I supposed to do about this?” will be the psychiatrist’s unspoken but heartfelt response. You apparently don’t have any other psychiatric illness, no depression, no psychosis, anxious yes but not disabled. The consultation will be a waste of her time, and a waste of yours.

This subject of symptoms-without-lesions has recently come back on the medical radar, after decades of not being discussed. Medical schools are increasingly offering programs in “communication,” in the hopes that physicians who communicate better will be able to deal better with patients like this. But medical students normally hate all this “communication” stuff and see it as a complete distraction from the business of organicity, which is what they’re in medical school to learn about.

The realization is dawning that “functional” patients are costing the system an enormous amount of money. In a general medical practice, up to half of all patients may have nothing organically wrong with them. Yet they are the objects of cover-your-ass half million dollar investigations. And then the patients move on and the investigation begins all over again. Nothing is ever found, but it runs up enormous insurance bills.

So, yeah, functional is back on the radar.

It is not that doctors are unfamiliar with symptoms without lesions, which are as old as medicine itself. Over the years, different specialties have developed different terms for describing them.

In Ear-Nose-and-Throat medicine, dizziness is a huge problem. Those patients who don’t have an organic explanation of their unsteadiness are called “avestibular,” meaning there’s nothing wrong with the vestibular system in the ear that controls balance.

In psychiatry, women with unexplained somatic symptoms were, until 1980, described as “hysterical,” later “psychosomatic,” and got rid of as quickly as possible. Hysteria as a diagnosis was abolished in psychiatry with DSM-3 in 1980.  And one rarely hears psychiatrists today using the “h” word. (This is partly a result of the declining influence of Freud’s psychoanalysis, where “hysteria” was a favorite diagnosis.)

Neurologists for decades have called these patients “functional,” originally meaning a disturbance of function but quickly reaching code-word status for non-organic.

“Non-organicity” has become a recent across-the-board favorite. The meaning is clear.

So what is the problem?  That brutish, unfeeling doctors are unwilling to deal with patients who cannot be pigeonholed in neat categories of organic diagnosis? No, not at all. Medicine has been familiar with this issue for two centuries.

It’s not that physicians are uncomfortable around non-organicity. Their desire to turf these patients to another colleague is born of another cause entirely: The only thing that works in dealing with non-organic patients is the gift of time.

You’ve got to give them the gift of consultation time. Nothing else works. No meds, no physio, nada. You’ve got spend time with them, and let them tell their stories and have the feeling that a sympathetic medical ear is attending to their woes, and, guess what?  They slowly get better. (For more on this see my book From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era, New York, Free Press, 1992)

Who knew? Medical insiders have long known this, and ever since the “Patient as a Person” movement in the 1920s, this has been bruited around the seminar rooms.

But think of the implications for a busy medical practice of giving each non-organic patient 45 minutes of your time on a regular basis. This would work for the patient, but your income would collapse. This simply economic reality is what prevents many physicians from undertaking the main known effective treatment of the functional patient: the gift of time is horribly expensive for the system because if you don’t give it, the patients doctor-shop; and it is ruinously costly for individual doctors – insightful and understanding though they may be – because insight here can lead to economic catastrophe.

This is probably the biggest systemic problem in medicine right now. The discipline’s collective embarrassment, not communication issues, is what prevents its discussion.