A particular patient archetype has emerged within the modern healthcare landscape. Such patients are historically prone to undergoing extensive and redundant laboratory testing, imaging, invasive procedures, and repeated specialist consultations, often without meaningful diagnostic or therapeutic yield. Their medical records are often populated with long lists of diagnoses and reported allergies that lack objective corroboration. Their hospitalizations are characteristically recurrent, their admissions are frequently prolonged, and their familiarity with medical terminology and hospital processes is high, leading them to be capable of articulating detailed expectations regarding tests, consultants, and treatments. Over time, this pattern of care produces not clarity or cure, but an over-medicalized patient whose personal identity has become inseparable from illness itself.
As physicians, we are trained to believe that knowledge and skill enable us to relieve suffering through diagnosis and intervention. But what happens when the source of our patients’ suffering remains elusive — when the suffering in front of our eyes is real and debilitating, yet we are left without answers for our patients? This uncertainty is frustrating to both the patient and physician. Patients continue to suffer without answers and fear of being dismissed while physicians contend with the limits of their advanced diagnostic modalities and the discomfort of inaction. Within this shared tension, ‘doing something’ can often feel preferable to ‘doing nothing,’ even when the likelihood of benefit is low. Consequently, the goals of care insidiously shift toward patient appeasement and clinician workflow expediency, transforming what should be a therapeutic evidence-based relationship into one that feels ever more transactional.
While these patient-clinician dynamics are increasingly recognizable to many physicians, the patient populations to which this matter pertains often have functional somatic syndromes (FSS). FSS refers to conditions marked by persistent, debilitating symptoms in the absence of clinically identifiable structural pathology. This category encompasses a range of conditions, IBS, functional neurologic disorder, fibromyalgia, chronic fatigue syndrome, and other functional chronic pain syndromes. The absence of empirical evidence supporting a specific diagnosis does not diminish the reality of these patients’ suffering nor its substantial impact on their quality of life. Contemporary evidence has firmly established that FSS represent genuine and disabling conditions, marking a decisive departure from earlier eras in which such symptoms were regularly dismissed as “hysterical” or purely psychogenic.
Current evidence on FSS supports approaches that actively engage patients in addressing psychological trauma and interpersonal dynamics over pharmacologic escalations and/or procedural interventions. A healthy physician-patient relationship can itself be therapeutic by regularly validating patient concerns, shaping symptom perception, and mitigating maladaptive illness behaviors. However, contemporary practice is increasingly forfeiting these treatment strategies for ones that favor medical intensification over conservative engagement. Patients with FSS are thus more likely to be exposed to adverse drug effects (i.e., polypharmacy), complications of unwarranted procedures, and the progressive entrenchment of disability through reinforcing patients’ maladaptive illness identification. Furthermore, observational data suggests that patients with FSS incur substantially higher rates of diagnostic testing, specialist referrals, and overall healthcare utilization and expenditures, reflecting a pattern of gratuitous over-medicalization rather than evidence-based care.
While the forces driving this trend in the management of FSS are unquestionably systemic, the responsibility to interrupt it rests with individual physicians who have the willingness to engage in difficult discussions and the courage to exercise therapeutic restraint when appropriate. Constrained by productivity metrics, documentation demands, and institutional pressures to maintain volume, the modern clinical encounter has become so time-compressed that meaningful, corrective dialogue is often displaced by expedient actions that offer short-lived reassurances without durable resolutions. It is far easier to order a scan than to explain why one is not needed. It is likewise far easier to prescribe a medication than to devote the time necessary to understand what is driving a patient’s distress. These tendencies rarely arise from apathy; they are adaptive responses to strain. But what is adaptive within a strained system is not necessarily therapeutic and may in fact be harmful, underscoring the importance of physicians being willing to engage in the sometimes uncomfortable conversations that responsible care demands.
In addition to systemic time constraints, physicians must also contend with a hyper-litigious practice landscape that subjects us to constant legal scrutiny. Fear of malpractice litigation has been consistently linked to defensive medical practices such as ordering unnecessary tests, referrals, and procedures. Surveys of U.S. physicians report that concerns about malpractice influence clinical decisions in ways that are predominantly intended to mitigate liability risk. These circumstances have conditioned the modern physician to equate restraint with vulnerability, making acquiescence to patient preference the perceived safer choice, even when it is not the wiser one. This defensive reflex is particularly consequential in the care of patients with FSS, where unnecessary testing, pharmacologic escalation, and procedural intervention rarely confer meaningful benefit and often deepen the cycle of illness. Thus, the defining question for physicians caring for patients with FSS is whether their decisions will be grounded in evidence-based clinical judgement — or governed by fear.
Medicine has never been a profession exempt from time pressures or risk, nor will it ever be. In caring for patients with FSS, failing to accept this reality shifts the balance of care toward over-medicalization. When physicians permit expediency and fear of liability to supplant evidence-based clinical judgment, action becomes reflexive rather than reasoned, and harm is often perpetuated under a veil of compassion. The responsibility to interrupt this pattern rests with physicians who are willing to engage patients in meaningful dialogue and who possess the courage to exercise restraint when confronted with imprudent requests for unwarranted interventions — because when it comes to FSS, the greater danger is often not doing too little, but doing too much.
