When a crying patient brings me a complex constellation of symptoms that don't show up on an MRI, my first thought is always: why are you doing this to me?
Just last Tuesday, a woman sat in my mahogany-paneled office and informed me, with a distinct air of victimhood, that I was the eighth rheumatologist she had seen. She proceeded to tick off a litany of entirely unquantifiable complaints: widespread chronic pain, profound fatigue, and something she dramatically referred to as "brain fog." As she reached the climax of her medical mystery and began to weep right there on my examination table, I felt a familiar, terrifying sensation spreading across my forehead. I was sweating. Me. A physician who once confidently diagnosed a ruptured spleen from across a crowded charity gala.
I had run the standard panels before I even walked into the room. The complete blood count was pristine. The antinuclear antibody test was negative. The MRI of her brain was as unremarkable as a mid-tier Chardonnay. By all measurable, reimbursable metrics, this woman was a specimen of perfect health. Yet there she sat, insisting that she could barely get out of bed in the morning, stubbornly prioritizing her lived experience over my very expensive lab results.
It is difficult for the layperson to understand the immense emotional toll this takes on a medical professional. I did not spend four years at Harvard Medical School, three years in residency, and a prestigious fellowship at the Mayo Clinic to be confronted with a problem I cannot immediately vanquish with a highly profitable, FDA-approved biological agent. My training prepared me for glamorous, objective heroics—stenting blocked arteries, excising tumors, prescribing targeted monoclonal antibodies that obliterate inflammation like a tactical drone strike. It did not prepare me to sit in a room with a sad woman whose pain refuses to cooperate with my diagnostic imaging suite.
In the industry, we call this medicine's "magic-bullet problem." I have the bullets. I have so many beautiful, incredibly expensive bullets, developed by the finest minds at Merck and Pfizer, locked and loaded in my diagnostic chamber. But patients with fibromyalgia, long COVID, and poorly understood autoimmune conditions simply refuse to provide me with a clear, bioluminescent target. It is, quite frankly, poor sportsmanship.
You must understand that modern medicine is fundamentally a ballistic enterprise. We locate the rogue biomarker, we isolate the enzymatic pathway, and we fire a $4,000-a-month injectable directly into it. When a patient arrives with a systemic illness that lacks a definitive lab test, they are effectively asking me to put down my sniper rifle and engage in hand-to-hand combat, which is both exhausting and incredibly difficult to bill to Blue Cross Blue Shield.
I was discussing this very injustice over dry martinis with a colleague at the American College of Rheumatology convention in Geneva last week, and he perfectly encapsulated the crisis facing today's top-tier physicians.
These patients come to us expecting miracles, but what they fail to realize is that by presenting with unsolvable, multi-systemic chronic pain, they are actively sabotaging our sense of professional infallibility.
Dr. Vance is exactly right. We are not priests. We are highly compensated biological mechanics. When a patient cries in my office because their debilitating fatigue has ruined their life, what they are actually doing is forcing me to confront the glaring limitations of my own discipline, which ruins my entire afternoon. I am forced to utter the most humiliating phrase in the English language: "There is little we can do to help." Do you have any idea how it feels to say that while wearing a $3,000 Brioni suit?
It is time for patients to take a hard look in the mirror—assuming they aren't too fatigued to stand—and ask themselves if their relentless, invisible suffering is truly worth the emotional damage it inflicts on their doctors. Until you develop a disease I can easily verify with a blood draw and resolve with a 15-minute consultation, I am kindly asking you to keep your "brain fog" to yourself. We have real, curable diseases to treat.