How Much of Long COVID Is in the Mind?

What should doctors do when symptoms are real, but the science doesn’t have the answers...

When the term Long COVID emerged in 2020, it was not the product of careful scientific scrutiny, but of urgent patient activism on social media. The idea that COVID-19 could lead to prolonged symptoms after even a mild infection gained rapid popularity, long before medicine had a chance to investigate systematically.

The Neurologist Dr. Susan O’Sullivan detailed this journey in her book, ‘The Age of Diagnosis’, showing how the initial definitions of long COVID were alarmingly imprecise. It was defined simply as “not recovering several weeks or months after symptoms suggestive of COVID, whether one was tested or not.” What sort of definition is this?

It could never be taken as a serious disease definition. Instead, it produced a condition so nebulous, and a symptom list so large (fatigue, dizziness, brain fog, anxiety, depression) that almost anyone could meet the criteria at some point in their lives.

Rewriting The Biological Rules

Long COVID seemed to re-write everything we know about disease biology. It inverted long understood beliefs in medicine. With most infections, the general rules are simple: the sicker the patient in the acute stage, the greater the risk of long term lingering symptoms.

With long COVID, this pattern was reversed as those with milder acute illnesses were more likely to experience long COVID symptoms. Additionally those admitted to ICU with COVID, were more likely to be older, male and frequently diabetic. A clear contrast to the average patient experiencing long COVID that was more likely to be younger, female and non-diabetic.

This paradox gave many doctors a reason to stop and ponder: Yes, long COVID may represent the well documented ‘post-viral fatigue syndrome’. Some cases may even reflect the consequences of misdiagnosis during the pandemic, when patients struggled to access face-to-face care and serious conditions, like cancer, risked being wrongly attributed to long COVID.

But in light of its inversion of usual human biology, the most compelling explanation is that much of what we are seeing is psychosomatic in nature.

They Aren’t Malingering Guys!

A recent BMJ paper summarised the long COVID evidence and confirmed that anxiety, stress and depression are consistent predictors of Long COVID. Yet it would be a mistake to conflate this with malingering. Psychosomatic illnesses are not invented; they are very real. We can assure you that the fatigue, pain, and cognitive fog most patients report can be as disabling as the same symptoms in inflammatory bowel disease or osteoarthritis.

Are the mechanisms behind psychosomatic illnesses fully understood? No, it likely involves the complex interplay between expectation, belief and physiology (Academic doctors - relax, we know it’s called the nocebo effect). This complex interplay often means that as doctors, there’s not much we can entirely ‘do’. The ED SHO can’t quickly prescribe a medication to make the symptoms go away and as we know, doctors are very much interested in the ‘doing’ business.

The challenge, of course, is stigma. The term psychosomatic continues to be seen by many patients (and by some doctors), as code for “not real.” This stigma has created real issues in all directions.

For one, academics and doctors are hesitant to call something psychosomatic, even when the evidence is overwhelming. Meanwhile patients do all they can to cling on to diagnostic labels such as ‘long COVID’ that can explain away all their disparate symptoms and perhaps even offer them validation and an access to care.

Diagnoses Can’t Leave Science Behind

With long COVID, the narrative was captured early by social media and patient communities, rather than by the scientific community. This does not mean whatsoever that the symptoms experiences were not real and legitimate, but throwing those symptoms under the label of long COVID just obscured instead of establishing the underlying processes causing the symptoms.

Doctors should already be awake to this (especially our colleagues working front of house in hospitals or in GP practices). Patients are increasingly presenting with multiple, diffuse symptoms, that often lack a unifying explanation and are desperate for answers.

These psychosomatic illnesses are not imagined illnesses, but genuine disorders of the mind-body interaction. All we can do is await further science on the psychosomatic mechanisms and resist temptation of creating unhelpful labels.

The Four Horsemen of Ozempic: What We Currently Know About GLP-1 Side Effects

Each generation has its breakthrough medications, those scientific advances that define an era. GLP-1 receptor agonists, such as the famous Ozempic, are proving to be strong contenders. We should be championing their use, given the health and economic related burdens obesity has on society. Being cautious, however, does not mean undermining their use.

The On-Call community should be confident handling these medications and their side effects (even if most of the current information is derived from hypothesised risks and short-term data).

The ‘Four-Horsemen’ of Ozempic side effects are: nausea, vomiting, constipation and diarrhoea and affect up to 40% of patients, leading to one in 10 stopping treatment altogether. In fact, there is speculation that nausea is one of the main mechanisms of appetite suppression.

The rarer side effect of pancreatitis is fraught with speculation with not all studies finding this relational link with pancreatitis. A recent BMJ article suggested that non-arterial ischemic optic neuropathy is one of the most common emerging side effects reported in numerous observational studies. It seems that for both of these more serious side effects, further robust data is needed.

We are also finding that the rapid weight loss is part made up by a large loss of skeletal muscle mass, with one study indicating that up to 39% of the weight loss is from lean mass, raising questions of sarcopenia and frailty risk in later life. Maybe we should be recommending resistance training to this patient group in response to this?

Should You Protect Your Own Pocket Before Your Child’s?

Should your child’s first home come before your future care home? A closer look at the trade-offs

Many of our On-Call community balance their busy day jobs with the joys of parenting. It may not always be easy, but creating a secure future for their children is what keeps many parents going. Most parents are well aware that personal growth is sometimes achieved in an environment where children know the value of hard work.

‘Hand-out’ culture is rightly looked down upon as a practice that reinforces undesirable values in children. But investing for children and protecting their future is often more about buying them time and giving them the freedom to grow whether in their careers or as a person.

It should be no surprise, therefore, that nearly nine in every ten parents have some form of savings put aside for their children, often by setting aside money in a separate account in the child’s name. The question we want to ask is whether this is an optimal way to give your children a leg up in life?

Considerations Considerations…

The first thing you need to ask yourself is if these accounts are ISA or Non-ISA accounts. If your money is being held inside a standard current account and not inside an ISA tax-wrapper then you are missing out on the most tax-efficient way of saving. A Junior ISA (JISA) is an account that can’t be withdrawn from until the holder turns 18, with all profits tax-free.

The annual allowance on the account is £9,000 and is in addition to the parent's own £20,000 per year ISA allowance. You can choose to hold your JISA money in either cash or invest in the stock market on behalf of your child using a junior stocks and shares ISA.

For some of our On-Call parents, the uncomfortable part is that once a child turns 18, the junior ISA is legally theirs to do what they want with, which includes going on an all inclusive tour of the Greek islands. Not a bad holiday if you ask us, but not exactly what many parents have in mind when they consider putting aside money for their child’s future.

If the JISA makes you uncomfortable for this reason, you could always hold money inside a cash ISA or stocks and shares ISA that is in your own name and transfer this money to your children when you are ready.

Your Pocket First?

We should have a great deal of respect for these types of parents. In today’s difficult economic climate, the idea of sacrificing their current purchasing power to give their child a leg up in life is admirable, but is this the best financial decision doctors should be making?

Doctors occupy a unique position when it comes to retirement planning, benefiting from a generous defined-benefit pension scheme that provides a guaranteed, inflation-matched income in retirement. This offers a strong foundation, but depending on the lifestyle you wish to maintain, additional costs such as long-term care or unexpected family expenses can still place pressure on finances.

The average cost of a UK residential care home is £1,160 a week. That totals £60,320 a year, and this amount continues to grow with inflation. Sacrificing your standard of living or relying on your family to help pay can have long-term consequences.

Will your children be grateful that you helped them towards their first home forty years ago? Of course, but they would arguably have been more grateful if you had used that money to establish a sense of financial security for your own future.

These conversations become even more complex when we consider the impact of cultural values and emotions. However, when stripped back to harsh economics, but there is undoubtedly an argument to be made that if they can’t do both, parents should prioritise avoiding being a future financial liability over providing major financial help to their children.

For example, if someone had kept the £10,000 they gifted to a child and instead invested it for 40 years at an average 8% annual return (a rate consistent with global historical trends), that money would now be worth approximately £240,000. What initially seems like a relatively small sum could have made the difference between a comfortable retirement and one burdened with complexity and financial difficulty for both parents and children.

No parent knows how their future will unfold, but if you are not preparing adequately for your own future, should you be saving for someone else’s?

“Which ring of Dante’s Inferno are we placing people who hand over a PR exam to the night doctor?”

“Where does everyone keep their on-call bleep? Are you a back trouser pocket person, front scrub pocket, belt buckle, neckline or some other ingenious form of holder. Personally, I am a believer the wretched thing should be no where near your ears, so waist line is the area for me”

“If I see a doctor waiting to be seen in the waiting room, I will nearly always see them a bit earlier. Is that unethical? I could sit here and come up with some post-hoc response that suggests the reason I feel this way is because if they are seen earlier they could go back to work earlier etc etc but no, for me this is more about an emotional feeling I am overcome with that tells me I should look after my own. A feeling of kinship and collective responsibility. Does that mean i’d fail an SJT?”

“I remember being taught that if I had access to an investigation readily and easily (like routine bloods), then I should be able to justify why I chose not to do it”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

Mr Neil Hopper, a consultant vascular surgeon, is a case study in how greed can overcome us. He recently appeared before Cornwall Magistrates’ Court accused of fraud by false representation. After undergoing a bilateral leg amputation in 2019, he attempted to claim over £460,000 from insurers, falsely stating his lower-limb injuries were caused by sepsis, when in fact they were self-inflicted by deliberately freezing his own legs. His account was so convincing at the time that he was even awarded a Brave Briton award in 2020.

The team at the BMJ did a good job illuminating some key figures earlier this month. In 2023, 28,956 doctors took up a General Medical Council license. More than 2/3 of these doctors trained outside the UK. 11% of these doctors trained in the European Union (EU) and 57% trained outside the EU. Read more to see how the governments immigration reforms may impact the NHS workforce.

A recent indicative ballot conducted by the BMA revealed that 67% of consultants and 82% of SAS doctors would support industrial action unless meaningful pay improvements are made.

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The BEST Investment Doctors Can Make

Doctors, to those who’ve made it to the end of this week’s article, we want to ask you to pause for just a moment. Remember that once you have health, you have everything and once you don’t, nothing else matters.

When we’re young, we think we are indestructible. We overcommit, take on extra shifts, and spend our waking hours chasing career goals, like the discussion section of that research paper you’ve been working on for the past two months.

The fragility of our health evades us, until the day it doesn’t. Life-altering scenarios are scary and stressful on their own, but they can happen to anyone and are only made worse by worries of not being able to pay the bills.

After five years’ service, NHS sick pay entitles you to six months full pay followed by six months on half pay. Many of our readers won’t have any form of insurance or income protection and it’s not surprising why.

Insurance policies are a minefield and come with so many get-out clauses that leaves doctors scared they are paying for things that don’t actually cover them. Luckily many brokers today can offer fee-free advice and advise you on the best insurers that will cover you on a rainy day.

We’re not here to alarm our colleagues at On-Call, only to remind you that, of all the investments you can make, the most important is in yourself and your health.