There’s a particular phrase in medicine that sounds tidy, efficient, and responsible. It’s the kind of sentence you can say at the end of a long clinic day when you’ve reviewed the labs, scanned the imaging, and ruled out the disasters.
“Nothing’s wrong. All the tests are normal.”
For years, I heard versions of it. I said versions of it. And I watched what it did to people.
It doesn’t land as reassurance.
It lands as dismissal.
It lands as: you’re imagining it. You’re exaggerating. You’re difficult. You’re wasting time. It lands as the quiet accusation that if we can’t see it on an MRI, it doesn’t exist. And that belief has caused more harm than we like to admit, because it doesn’t just fail to help patients. It actively teaches them not to trust themselves.
My conversation with Dr. David Clarke shook that belief loose in a way I didn’t expect. Not by sentiment. Not by philosophy. By clarity.
He started by naming what so many clinicians are never taught to name: a whole category of symptoms that are generated by the brain, experienced in the body, and absolutely real. He calls them neuroplastic symptoms. Neuro, as in the nervous system and brain. Plastic, as in changeable. Not fake. Not imagined. Not “all in your head.” Changeable.
That one word matters. Because it points toward hope and away from the two dead ends patients get shoved into all the time: endless testing, or a shrug.
As he described it, a third of the patients he used to see as a gastroenterologist didn’t have organ disease or structural damage. They had neuroplastic conditions. Symptoms rooted in brain–body circuitry shaped by stress, trauma, personality traits forged in difficult environments, and the long tail of adversity that people carry without even realizing they’re carrying it. When those forces aren’t metabolized, the body speaks.
And then he told the story that changed his career: the elevator ride.
A 37-year-old woman. Two years of severe constipation, averaging one bowel movement a month. Four laxatives at double doses. Evaluations at multiple centers. Specialized motility testing. All normal. The system was ready to label her a medical mystery and send her away to “learn to live with it.”
And then, as they were wrapping up, she disclosed severe childhood abuse. In that era, this wasn’t even part of the medical conversation. It wasn’t asked about. It wasn’t linked to symptoms. It wasn’t in the textbooks the way lab values were. Clarke referred her to a physician-psychiatrist, assuming the best outcome would be coping.
Three months later, he ran into that psychiatrist in an elevator. Between the ground floor and the fifth, she told him she’d cured the patient with counseling alone.
No new medication.
No procedure.
No miracle test.
Just skilled work that took the brain’s role in bodily symptoms seriously.
That should be impossible if your mental model of illness is strictly “organ damage equals symptoms.”
But it isn’t impossible. It’s just a different category of problem.
This is where our profession has to face a hard truth: we’ve trained ourselves into a blind spot.
We are excellent at diseases you can point to. Tumors. Ulcers. Pneumonias. Heart attacks. Fractures. Things that show up in blood work, biopsies, CT scans, and scopes. We can be brilliant detectives in that world. There’s a satisfaction in it: find the abnormality, name it, treat it, watch improvement.
But the moment the investigation comes back “normal,” the culture quietly shifts. The patient starts to feel like they are the problem.
David Clarke put words to the ugliness of it. When organ and structure explanations fall away, the reflex becomes: this person is neurotic, weak, unable to handle life, nothing can be done. And he said what every patient living in that world needs to hear, and what every clinician needs to internalize:
Not a single one of those assumptions is necessarily true. In fact, for many patients, the opposite is true.
These aren’t fragile people. Many are mentally strong, highly functional, deeply responsible individuals who can survive enormous stress while still showing up for work, caring for kids, and smiling at dinner. That strength is often part of the trap: they’re so capable at holding it together that nobody suspects what their nervous system has been enduring for decades.
One of Clarke’s simplest examples was also one of the most damning. A man whose pain only appeared when he drove to work. He was fine on the drive home. Fine on weekends. No symptoms away from the office. That pattern is practically an alarm bell. Yet he’d been through the medical machinery without anyone making the connection or even asking the obvious question: what is happening at work?
Once it was uncovered and changes were made, the symptoms resolved.
The cruelty isn’t that clinicians miss rare zebras. It’s that we miss patterns that are hiding in plain sight because we weren’t trained to look for them.
And then there’s the second blind spot: mental health care often isn’t set up for this population either. Clarke described it as a mirror-image problem. Many therapists are trained for psychiatric diagnoses, not for the ways life history and chronic nervous system activation can manifest as vertigo, tinnitus, migraines, rashes, pseudo-seizures, fibromyalgia, chronic fatigue, back pain, and yes, a meaningful slice of long COVID presentations. Patients get bounced between specialties: “not my area,” “try psych,” “try physio,” “try another scan,” “try another pill.” They fall into the gap between silos.
That gap becomes their identity. The “mystery patient.” The “frequent flyer.” The “nothing we can do.” The patient who starts to doubt themselves, then gets angry, then gets ashamed, then gets labeled as difficult, then gets less help. It is a perfect way to manufacture chronic illness out of a treatable nervous system problem.
This is why Clarke’s work feels revolutionary. It isn’t just a new treatment. It’s a new stance.
It says: your symptoms are real, even if our current tools can’t localize them to a damaged organ.
It says: normal tests do not equal “nothing wrong.”
It says: the brain is not an afterthought in physical illness.
And it says: neuroplastic circuits can change, which means people can get better.
If you’ve lived through years of normal scans and normal labs while your life shrinks, that’s not a small message. That’s oxygen.
And for clinicians, it’s a call-out we need to take seriously. Because the archaic belief “if it’s not on imaging, it’s not real” isn’t just outdated — it’s iatrogenic. It harms patients.
It also harms us.
There’s a quiet burnout that comes from repeatedly meeting suffering and having nothing to offer beyond ruling out disaster. Clarke mentioned a physician who told him these ideas “put the joy back into her work,” because suddenly the large percentage of primary care visits that fall into this neuroplastic category weren’t hopeless anymore. They were treatable.
That matches what I see: when doctors feel useless, they become defensive. When they become defensive, they dismiss. When they dismiss, patients suffer more. It’s a vicious cycle. The solution isn’t to shame clinicians. It’s to update the model.
So what does this look like in real life, for patients and for the people who love them?
Here are the practical takeaways I want my listeners and the general public to sit with.
1) Normal tests are information, not a verdict
A normal MRI or normal blood work does not mean “nothing is wrong.” It means something specific: we have not found structural damage or organ disease with the tools we used. That’s actually valuable. It can reduce fear. But it shouldn’t end the conversation.
If anything, normal tests should open a different door: what is driving the nervous system?
2) Patterns matter more than intensity
One of Clarke’s strongest points was chronological linking: when do symptoms flare, and what is happening in life at those times?
If symptoms reliably worsen around specific people, places, obligations, or internal states, that is not random. It is data. It is your nervous system telling the truth in code.
Keep a simple log for two weeks:
- When symptoms rise (time and situation)
- What was happening emotionally or relationally
- What you were anticipating
- What you were avoiding
You’re not trying to “prove it’s stress.” You’re trying to learn the pattern.
3) This isn’t about blaming patients or psychologizing everything
Clarke was clear: just because someone has neuroplastic symptoms does not mean they can’t also have “regular” medical problems. Good care is both/and, not either/or. Rule out what needs ruling out. But don’t stop there.
The message to patients should never be: “It’s your fault.”
The message is: “Your nervous system is involved, and that means you have a path forward.”
4) Fear keeps symptoms loud
Medical uncertainty creates fear. Fear amplifies symptoms. The person becomes hypervigilant to every sensation, not because they’re weak, but because the brain is trying to protect them.
A crucial early step is simply reassurance with credibility: tests are normal, there’s no evidence of a dangerous progressive disease, and there are evidence-based treatments for neuroplastic symptoms. Lowering fear isn’t hand-waving — it changes physiology.
5) Many “helpers” are starved of joy
This part of the conversation was quietly profound. Clarke described patients who care for everyone else but can’t put themselves on the list. They’re competent, dependable, productive, and depleted. The body eventually forces a stop.
His “prescription” wasn’t fluffy. It was targeted: carve out regular time for joy with no purpose other than joy. Not productivity disguised as self-care. Not errands. Not “I’ll relax by catching up on emails.” Actual play.
He called it “the moral equivalent of finger paints for a four-year-old.” No outcome. No score. No optimization.
If that sounds ridiculous, that may be exactly the point. Many adults never learned how to play, or were taught it was selfish. The nervous system pays the bill for that.
6) Be cautious with elimination spirals
People with stress-sensitive GI symptoms often start eliminating foods because symptoms flare after eating and it feels logical. Clarke has seen people shrink their diet down to almost nothing, which adds more stress and social isolation, which worsens symptoms.
A better approach is to stabilize the nervous system and then reintroduce foods gradually, rather than letting fear dictate a life of restriction.
7) Find clinicians who can hold both realities
If you’re a patient: you need someone who can rule out dangerous disease and still take you seriously when tests are normal.
If you’re a clinician: you need to become that person.
That means changing the language. “We didn’t find evidence of organ damage, which is good news. Your symptoms are real, and there are brain–body mechanisms that can produce them. Let’s look at patterns, stress physiology, and treatment options.”
That single shift; from dismissal to roadmap, can be life-changing.
8) The system needs to teach this, not treat it as fringe
Clarke referenced randomized trials and neuroimaging evidence showing brain pathway changes and meaningful symptom improvement with neuroplastic recovery therapies, including dramatic improvements in chronic back pain in controlled settings. Regardless of the exact study you hang your hat on, the broader point is unavoidable: the evidence base is here, and it’s growing. Medical schools should be teaching this as a core competency, not as a curiosity.
Because right now, patients are falling into a blind spot that is massive. Clarke estimated at least a quarter of the adult population suffers from these kinds of conditions. If that’s even close to true, this isn’t niche medicine. This is everyday medicine.
What I walked away with most powerfully is this: “We can’t find anything” is not a conclusion. It’s a fork in the road.
Down one path is the old world: dismissal, stigma, endless referrals, and patients slowly losing their trust in their own bodies.
Down the other path is what David Clarke is building: a model that treats unexplained symptoms as meaningful, reversible, and deserving of serious clinical skill.
We owe it to patients to take that second path.
And we owe it to ourselves, because medicine isn’t supposed to be a place where suffering gets reduced to what an MRI can capture. The scan is a tool. It’s not the definition of reality.