“The good physician treats the disease; the great physician treats the patient who has the disease.” — William Osler (founder of modern clinical medicine)¹
Years ago, a patient walked into my office carrying a stack of medical records. Neurology had ruled out multiple sclerosis. Rheumatology had ruled out lupus. Cardiology had ruled out heart disease. Gastroenterology had ruled out inflammatory bowel disease. One by one, each specialist assured her the problem wasn’t in their field and suggested she see a psychiatrist.
By the time she reached me, she no longer heard, “We don’t know.”
She heard,
“It’s all in your head.”
She wasn’t relieved.
She was terrified.
“If all the tests are normal,” she asked, “why do I feel so awful?”
It’s one of the hardest questions in medicine because sometimes the most honest answer is simply,
“I believe you.”
“I don’t know...yet.”
Medicine is built on answers. We spend years learning diseases, medications, anatomy, laboratory tests, and imaging, yet some of the patients we remember most are the ones who leave without a diagnosis. Human beings don’t tolerate uncertainty very well. Patients want explanations. Doctors want explanations. Even insurance companies insist on explanations because the computer won’t accept “We’re not sure” as a diagnosis.
So when certainty disappears, medicine does what people have always done. It tells itself a story. Sometimes those stories become breakthroughs. Sometimes they become blindfolds. Instead of explaining the illness, we begin explaining the patient.
Anxious. Emotional. Dramatic. Attention-seeking. Hysterical.
As Atul Gawande (surgeon and author) writes, *”Medicine’s ground state is uncertainty. And wisdom—for both patients and doctors—is defined by how one copes with it.”²
History suggests we’ve never been especially comfortable with uncertainty.
• Before Helicobacter pylori, ulcers were largely blamed on stress.³
• Before EEGs, epilepsy was blamed on insanity—or demons.⁴
• Endometriosis still takes years, on average, to diagnose.⁵
Perhaps medicine’s greatest mistake isn’t that it sometimes fails to understand an illness. It’s that, every so often, it mistakes its uncertainty for the patient’s diagnosis.
The Graveyard of “It’s All in Your Head”
History has a remarkable way of humbling medicine. Again and again, illnesses once dismissed as psychological quietly migrate into neurology, immunology, infectious disease, or genetics. Not because the patients changed, but because science finally developed the tools to see what had been there all along.
Peptic ulcers may be the best-known example. For decades, physicians blamed stress, personality, and ambitious lifestyles until Barry Marshall (physician) and Robin Warren (pathologist) demonstrated that many ulcers were caused by Helicobacter pylori. The idea seemed so absurd that Marshall swallowed the bacteria himself to prove it. Twenty years later, he accepted the Nobel Prize.⁶
The story repeated itself. Multiple sclerosis was once dismissed by some physicians as “hysterical paralysis” before MRI scans revealed inflammatory lesions throughout the brain.⁷ Epilepsy spent centuries blamed on demons, insanity, or weak character before scientists learned to record the brain’s electrical activity.⁸ Parkinson’s disease, too, was once viewed through a psychological lens before its biological basis became clear.⁹
Today, the names are different, but the uncertainty feels familiar. Patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), fibromyalgia, hypermobile Ehlers-Danlos syndrome, postural orthostatic tachycardia syndrome (POTS), and long COVID often spend years collecting normal test results instead of answers.¹⁰ Some of these illnesses will undoubtedly be understood differently twenty years from now. History doesn’t tell us which ones.
It simply reminds us not to confuse the limits of today’s technology with the limits of today’s biology.
• Nobel Prize awarded for the discovery of Helicobacter pylori: 2005.¹¹
• Americans estimated to have ME/CFS: 1–3 million.¹²
• Nearly every generation has had diseases medicine first explained psychologically before understanding them biologically.
As Lewis Thomas (physician and essayist) wrote, *”The greatest obstacle to discovery is not ignorance—it is the illusion of knowledge.”*¹³. Medicine doesn’t become wiser because it stops making mistakes. It becomes wiser because it learns to recognize them.
Maybe the Body Never Read the Textbook
Medicine likes categories. Neurology studies the brain. Immunology studies the immune system. Rheumatology studies joints. Psychiatry studies thoughts, emotions, and behavior. The body has never been nearly so tidy.
Patients with ME/CFS, fibromyalgia, hypermobile Ehlers-Danlos syndrome, POTS, and long COVID often don’t fit comfortably into any one specialty. Their symptoms spill across organ systems, leaving each specialist with one piece of a much larger puzzle.¹⁴. Perhaps that’s because we’ve been asking the wrong question.
For generations, medicine has tried to decide whether an illness is physical or psychological. Increasingly, modern biology suggests the answer is often both. The brain, immune system, endocrine system, and autonomic nervous system are in constant conversation. Chronic stress changes immunity. Inflammation affects mood. Infection alters cognition. Childhood trauma leaves measurable biological fingerprints decades later.¹⁵⁻¹⁸ The deeper scientists look, the harder it becomes to draw a bright line between mind and body.
This doesn’t mean every mysterious illness has a hidden biological cause waiting to be discovered, nor that every psychiatric illness will someday be diagnosed with a blood test. It simply means the body functions as one interconnected system, while medicine has traditionally studied it one organ at a time.
• Stress changes biology, and biology changes how we experience stress.¹⁹
• The brain is not separate from the body. It is part of the body.
• The line between “mental” and “physical” grows blurrier every year.
As Siddhartha Mukherjee (physician and author) writes, *”The boundaries that separate disciplines are often artificial.”*²⁰. Perhaps medicine’s next great breakthrough won’t come from discovering another disease. Perhaps it will come from discovering that many of the boundaries between diseases never existed at all.
The Most Honest Diagnosis
Every generation of physicians wonders how the generation before could have been so wrong. How could they blame ulcers on stress, epilepsy on demons, or women with chronic pain on “hysteria”? A century from now, physicians will almost certainly ask the same question about us.
Somewhere today, patients are living with illnesses medicine doesn’t yet understand. Some will eventually be explained by genes, infections, immune dysfunction, environmental exposures, or mechanisms nobody has yet imagined. Others may prove more complicated than any single diagnosis can capture.
The patients won’t change. Our understanding will.
That’s why the most dangerous words in medicine aren’t always, “It’s all in your head.” Sometimes it’s the certainty behind them. History reminds us that today’s unexplained illness may become tomorrow’s textbook chapter.
• Every generation overestimates what it knows.²¹
• Every generation underestimates what remains to be discovered.
As Voltaire (writer and philosopher) observed, *”Doubt is not a pleasant condition, but certainty is absurd.”*²². Perhaps the best physicians aren’t the ones who always have the answers. They’re the ones willing to say, “I believe you.” I don’t know.” “Let’s keep looking.”
Notes & Sources
¹ Osler W. Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Philadelphia: P. Blakiston’s Son & Co.; 1904.
² Gawande A. Complications: A Surgeon’s Notes on an Imperfect Science. New York: Metropolitan Books; 2002.
³ Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. The Lancet. 1984;323(8390):1311-1315.
⁴ Devinsky O. Epilepsy throughout history. Epilepsy & Behavior. 2003;4(6):680-689.
⁵ Zondervan KT, Becker CM, Missmer SA. Endometriosis. New England Journal of Medicine. 2020;382:1244-1256.
⁶ Marshall BJ. Nobel Lecture: Helicobacter pylori and peptic ulcer disease. Nobel Foundation; 2005.
⁷ Compston A, Coles A. Multiple sclerosis. The Lancet. 2008;372:1502-1517.
⁸ Devinsky O. Epilepsy throughout history. Epilepsy & Behavior. 2003;4(6):680-689.
⁹ National Institute of Neurological Disorders and Stroke. Parkinson’s Disease Information Page.
¹⁰ Institute of Medicine. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: National Academies Press; 2015.
¹¹ Nobel Foundation. Nobel Prize in Physiology or Medicine 2005.
¹² Centers for Disease Control and Prevention. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS).
¹³ Thomas L. The Medusa and the Snail. New York: Viking Press; 1979.
¹⁴ Davis HE, McCorkell L, Vogel JM, Topol EJ. Long COVID: major findings, mechanisms and recommendations. Nature Reviews Microbiology. 2023.
¹⁵ Slavich GM, Irwin MR. From stress to inflammation and major depressive disorder. Psychological Bulletin. 2014;140(3):774-815.
¹⁶ Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine. 1998;14(4):245-258.
¹⁷ McEwen BS. Protective and damaging effects of stress mediators. New England Journal of Medicine. 1998;338:171-179.
¹⁸ Dantzer R, O’Connor JC, Freund GG, Johnson RW, Kelley KW. From inflammation to sickness and depression. Nature Reviews Neuroscience. 2008;9:46-56.
¹⁹ Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed. New York: Henry Holt; 2004.
²⁰ Mukherjee S. The Song of the Cell. New York: Scribner; 2022.
²¹ Kuhn TS. The Structure of Scientific Revolutions. 4th ed. Chicago: University of Chicago Press; 2012.
²² Voltaire. The Philosophical Dictionary. 1764.
Additional Sources
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: APA Publishing; 2022.
Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127(23):2336-2342.
Comments
Nothing yet. Say the first thing.
Sign in to join the conversation.