“I just don’t feel well,” she says. “I’m tired all the time.”
The patient is sitting across from you in clinic. She struggles to describe exactly what is wrong. There is no specific pain. No new shortness of breath. No fever. Nothing that immediately points you toward a diagnosis. It is a vague and broad symptom, almost an enigma.
You turn toward the computer screen. The laboratory results are reassuring. Most of the numbers are in the green. The few highlighted in red are abnormal, but stable for this patient. You scroll through the results again, looking for something you might have missed.
Nothing. You turn back to her. “But your labs look good.”
How many times have we, as clinicians, found ourselves in some version of this conversation? And how many times has a patient heard those words while thinking, “Then why do I feel so bad?” There is a space between the numbers and the person. It reflects the expectation that the clinician can answer every physical discomfort in the human body and the hope that stable labs will be a reflection of an individual’s well-being.
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Modern medicine has accomplished extraordinary things. Diseases that once rapidly shortened lives can now be treated for years. Cancer therapies have become increasingly targeted. Dialysis replaces a vital function of failing kidneys. Transplantation gives patients another chance at life. Medications control diseases that only years ago carried devastating consequences.
In many cases, we cure disease. In others, we transform an acute or terminal illness into a chronic one. And yet, there is a space our laboratory values and imaging studies do not always capture. I have come to think of this space as “the intersected gray.” It is not a clear black and white of disease versus health. It is the intersection where, by objective measures, medicine has succeeded, but the person sitting in front of us still does not feel well.
- The cancer is in remission.
- The dialysis numbers are acceptable.
- The hemoglobin is stable.
- The scan looks better.
- The life-threatening problem has been addressed.
And still the patient says, “Doctor, I’m tired,” which is usually immediately followed by, “Is there a vitamin I can take that will make me stronger?” “I just want to feel like myself again.”
When medicine cannot find the bull’s-eye
There is, of course, a long list of reasons someone may feel unwell despite reassuring laboratory results. Medications can contribute. So can nutrition, sleep, deconditioning, chronic disease, pain, anxiety, depression, financial strain, caregiving responsibilities, loneliness, and the accumulated stress of living with illness.
- Sometimes there is one identifiable culprit.
- Often there are several.
- And sometimes, despite our best efforts, we simply cannot find the bull’s-eye.
That can be frustrating for both the patient and the physician. We are trained to identify problems and intervene. A potassium of 2.8 gives us something to correct. A hemoglobin of 6 gives us a pathway. A new infiltrate on a chest X-ray gives us something to investigate.
“I don’t feel well” is much harder. When the workup is unrevealing, there can be a temptation, usually unintended, to use reassuring test results as the conclusion of the conversation. “Everything looks good.” But perhaps the laboratory results should not end the conversation. Perhaps they should change it.
Acknowledgment is also an intervention
There is an important difference between saying, “Your labs look good, so you should feel fine,” and saying, “Your labs are reassuring, but I hear that you still don’t feel well.” The first statement inadvertently asks the patient to reconcile their experience with our data. The second statement allows both things to be true. And you can feel terrible. The two are not mutually exclusive.
We accept the reverse without hesitation. Patients can have remarkably abnormal laboratory results and tell us they feel perfectly fine. We do not dismiss the laboratory abnormality because the patient lacks symptoms. Why, then, should we dismiss the symptom simply because the laboratory values are reassuring?
This does not mean ordering endless tests in pursuit of an answer that may not exist. Nor does compassionate care require that we have a treatment for every complaint. Sometimes the intervention is acknowledging the limits of what we know.
- “I believe you.”
- “I see that you are struggling.”
- “I don’t have a single number that explains why you feel this way, but that doesn’t mean what you’re experiencing isn’t real.”
Those words will not cure fatigue. They will not reverse chronic illness. They may not fill the gap between what modern medicine can measure and what a patient actually experiences. But they can prevent another kind of suffering: the feeling of not being heard.
Living in the intersected gray
Medicine will always celebrate its measurable successes: remission, survival, improved ejection fractions, lower creatinine levels, controlled blood pressure, negative scans. And we should. These are real and meaningful achievements.
But alongside these victories, we must also learn to sit more comfortably in the intersected gray, the place where medical success and human suffering coexist. Our role and responsibility in that space may look different.
We continue to investigate when appropriate. We treat what is treatable. We address reversible contributors. We address medications, nutrition, sleep, mental health, functional status, and the other contributors we can identify.
But when we reach the limits of what our tests can explain, we are not required to abandon the patient at that boundary. We can remain present. We can acknowledge uncertainty without retreating from it. We can name the gap between what we can measure and what the patient experiences. And perhaps, most importantly, we can resist the urge to let “normal labs” become the final word.
Instead, we might say: “Your labs look good. And I hear you; you still don’t feel well. Let’s stay with that together.” Sometimes, that is where care truly begins.
Stella Awua-Larbi is a nephrologist with more than 15 years of experience in private practice at Kidney Care Center in the Chicagoland area, where she also holds a hospital affiliation with Silver Cross Hospital in New Lenox, Illinois. She earned her undergraduate degree from the University of Wisconsin-Madison and her medical degree from the Medical College of Wisconsin, completing her internal medicine residency at Loyola University Medical Center and her fellowship at Northwestern Feinberg School of Medicine.
A 2023 recipient of the Physician Leadership Excellence Award, Awua-Larbi is known for her ability to listen deeply and connect with patients as they navigate the complexities of their illness. She is passionate about mentoring the next generation of physicians.
Her debut book, The Other Side of the Bed: A Physician’s Journey Into the Human Side of Medicine, explores humanizing patients beyond the chart. Part reflective narrative, it advocates for patient-centered care while reminding health care workers of the sacred, rewarding nature of walking alongside patients at life’s crossroads. She shares her writing on Facebook, Instagram, LinkedIn, and TikTok.
