As a quadruple board-certified physician and a patient with a complex autoimmune disease, I live on both sides of the examination table. My professional life is about finding answers; my personal life has been about the agony of waiting for them.

This dual perspective makes it impossible to ignore a systemic problem in modern medicine: A class of diagnoses that live in the shadows. Seronegative Sjögren’s, mast cell activation syndrome (MCAS), dysautonomia, chronic fatigue (ME/CFS), and small fiber neuropathy (SFN) are the ghosts in our machine. They cross every specialty, refuse to conform to our tidy flowcharts, and leave a trail of frustrated patients and deeply uncomfortable physicians in their wake.

They haunt our patients. Let’s be honest with ourselves—they haunt us, too.

The ghosts in every specialty

• For the rheumatologist, it’s seronegative Sjögren’s. The patient’s story screams autoimmunity—debilitating fatigue, sicca, systemic pain—but their labs are silent. With 30 to 40 percent of Sjögren’s patients being seronegative, we are left to weigh a clinical diagnosis against the “gold standard” of a lip biopsy, asking a patient to risk permanent numbness for a label we feel in our bones is correct.
• For the allergist, it’s the tightrope of MCAS. We’re caught between the rigid Consensus 1 criteria, which demand a fleeting tryptase spike that’s nearly impossible to capture, and the more clinical Consensus 2. We are terrified of both over-diagnosing a nebulous condition and under-diagnosing the patient whose life has shrunk to four foods and four walls.
• For the neurologist, it’s the conundrum of SFN and dysautonomia. We are masters of the reflex hammer, yet these conditions live in the invisible wires of the small fiber and autonomic nerves. We are forced to rely on a patient’s subjective story while the “objective” tests—a skin punch biopsy, a tilt table, a QSART—are difficult to get and not always definitive.
• For all of us, it’s the diagnostic orphan of ME/CFS. This is the condition that perhaps has no single specialty home, leaving it to the brave internist, neurologist, or rheumatologist willing to take it on. Its hallmark is post-exertional malaise (PEM)—a pathological inability to produce energy on demand, where a simple trip to the grocery store can cause a multi-day “crash” of profound flu-like symptoms and fatigue.

My tightrope walk: The fears we don’t say out loud

In the face of these ghosts, my role as a steady, all-knowing physician feels like a tightrope walk over a canyon of uncertainty. And as a patient, I know how far the fall is. These are the fears that wake me up in the middle of the night:

• I’m afraid of missing it. My training, my intuition, and the patient’s story all point to a “perfect storm” of illness. But without that positive antibody test—the so-called “proof”—I’m afraid of delaying a diagnosis that could prevent irreversible damage. I’m afraid of unintentionally gaslighting my own clinical judgment, let alone my patient.
• I’m afraid of the system failing my patient. I know what’s coming: The battle with insurance, the skepticism from colleagues, the endless hoops. It’s a core reason I built a direct care practice—to rebel against a system that requires a black-and-white data point for a gray-scale human. My fear is that despite my best efforts, the system will still slam the door on them.
• I’m afraid of causing “diagnostic fatigue.” The journey to an answer can be as traumatic as the illness itself. I’m afraid of ordering that next invasive test. Am I pushing my patient towards a procedure with real risks just to get a label that will satisfy a bureaucratic need for certainty? The burden of that proof feels incredibly heavy.
• And my biggest fear? I’m afraid of the patient giving up. That the person in front of me, exhausted and invalidated, will lose all hope.

The anatomy of our fear

This fear isn’t a personal failing; it’s forged by the systemic pressures we all face. Our clinical judgment feels flimsy because of:

• The fear of litigation: A “soft” diagnosis is a liability. A positive test is a shield.
• The tyranny of “test-based” medicine: The noble idea of “evidence-based” medicine has been bastardized. If a condition lacks a biomarker, we’re taught it’s less “real.”
• Pressure from gatekeepers: Insurance companies don’t do ambiguity.
• The silos of specialization: These are full-body conditions, and the patient gets bounced between us, with no one captaining the ship.

The ultimate question: Are we doing more harm?

Yes. Full stop.

When we raise the bar for diagnosis so high that only the most severe or luckiest patients can clear it, we engage in systemic medical gaslighting. We do harm by delaying treatment, inflicting diagnostic fatigue, and severing the sacred trust that is the foundation of our profession.

My job isn’t to be the expert with all the answers. It’s to sit in that uncomfortable, uncertain space with my patients. It’s to bridge our fears by saying, “I see the storm, even if the weather report says it’s sunny. Now, let’s build a better boat.”

It’s time for clinical courage. It’s time to treat the patient, not the proof.

Kara Wada is a quadruple board-certified pediatric and adult allergy and immunology, lifestyle, and functional medicine physician, a Sjögren’s disease specialist, and a Sjögren’s patient herself. She spent nine years on faculty at The Ohio State University Wexner Medical Center, where she served as associate program director of the allergy and immunology fellowship and led the Mast Cell Center of Excellence.

In 2025, she left academic medicine to build the kind of practice she could not find as a patient: the Immune Confident Institute, a national direct-care immunology practice licensed in 27 states. She treats the patients the health care system sends ping-ponging between specialists, people with complex, chronic, multisystem disease including mast cell activation syndrome (MCAS), dysautonomia, Sjögren’s disease, immune dysfunction, and the seronegative and “in-between” diagnoses that do not fit neatly into a single specialty.

Her premise is simple: These patients are not the problem. Fragmented care is. Medicine has become exceptionally good at looking through microscopes while losing sight of the telescope, the bigger picture of the person in front of us. Her work challenges a health care culture that demands compliance when it should assume competence, and aims to make strategic, compassionate immune-directed care the standard, and the exam room a place where patients are finally seen, heard, and believed.

Most of her reach is built outside the exam room. Her YouTube channel drew roughly two million views this past year, and more than 100,000 people follow her work across platforms, including a Sjögren’s community of about 6,600. She founded and hosts the Virtual Sjögren’s Summit, now in its sixth year and drawing some 4,300 registrants worldwide. She appears regularly on national television and in the health press, including Prevention, SELF, Good Housekeeping, WebMD, Medscape, and MedPage Today, and she writes for KevinMD on the diagnoses that live in the shadows and the medical gaslighting that surrounds them.

A TEDx speaker and sought-after keynote, Wada speaks to clinician and patient audiences about complex immune disease, the experience of being disbelieved, and what changes when the physician is also the patient. She is also an unlikely pageant titleholder, having served as Dr. Ohio America 2022 and Dr. Midwest America 2023, and has written about how pageantry sharpened skills medicine rewards but rarely teaches.

She earned her medical degree with honors from the University of Illinois College of Medicine at Peoria and completed internal medicine-pediatrics residency, allergy and immunology fellowship, and clinician educator fellowship at The Ohio State University and Nationwide Children’s Hospital. She lives in Columbus, Ohio, with her medical school sweetheart turned husband, Akira, and their three children.