Intended for healthcare professionals

Letters Chronic fatigue syndrome and long covid

Long covid: reshaping conversations about medically unexplained symptoms

BMJ 2021; 374 doi: (Published 28 July 2021) Cite this as: BMJ 2021;374:n1859
  1. Sean L Davidson, psychiatry registrar1,
  2. David B Menkes, academic psychiatrist2
  1. 1University of Auckland, Waikato Hospital, Hamilton, New Zealand
  2. 2Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
  1. sean.davidso{at}

Newman’s article, a linked patient commentary, and the tranche of rapid responses show how “long covid” has reignited debate about the causes and management of chronic fatigue syndrome.1 Rather than moving beyond the controversy, most of the ensuing arguments have fallen back into familiar grooves deepened by confirmation bias and dualistic thinking.123 On a more positive note, the intense media attention on and public interest in long covid present a golden opportunity to reshape and extend discussions about medically unexplained symptoms.

Patients presenting with symptoms in the presence of normal diagnostic tests account for 26-35% of consultations in primary care.4 The banner of medically unexplained symptoms encompasses heterogeneous issues—simple transient problems, recognised symptom complexes such as chronic fatigue syndrome, and emerging phenomena like long covid. All present challenges to the doctor-patient relationship, confer risks of overdiagnosis and overtreatment, and can provoke frustration and anxiety in junior and experienced clinicians alike.25

These common clinical scenarios emphasise the pressing need for a framework to aid communication with patients who are frustrated by the mismatch of disabling symptoms and normal investigations. The contrasting societal and medical narratives that Newman outlines regarding chronic fatigue exemplify the challenges that doctors and patients face together in coming to a shared understanding of diagnosis and management options.12 These consultations often carry the weight of decades of power imbalance, psychological stigma, and bitter dualistic debate, leaving both doctor and patient dissatisfied.13

In contrast to most medical specialties, neurologists have made remarkable progress in establishing a patient led terminology and common framework to positively identify and manage functional disorders.6 Other disciplines should strive to match this example but recognise that complex and undifferentiated presentations will doubtless persist and require skill and judgment to investigate appropriately and to constructively manage uncertainty. Crucially, this approach must leave room for an evolving evidence base because “unexplained” does not mean “unexplainable.” Long covid provides an opportunity for the medical profession to move beyond stale controversies and to reconsider how we discuss symptoms lacking clear cause with patients, students, and colleagues.


  • Competing interests: None declared.

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