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Your blood pressure is fine. Your cholesterol looks great. So why do you still feel exhausted, wired, and unwell? Internal medicine and functional medicine physician Shiv K. Goel returns to explain what standard lab panels miss when chronic stress quietly reshapes the body. This episode is based on his article “Normal labs miss what most patients are living through,” published on KevinMD. You will hear how sustained stress ripples through your hormones, gut, and immune system, and why a patient can be genuinely sick while every routine result comes back normal. Shiv walks through the targeted tests he uses, from salivary cortisol to the Dutch test, and is candid that not all of it is covered by insurance or backed by the usual evidence. He also makes the case for listening longer and treating the root cause, with real ways to do it inside a packed schedule. You will come away with practical ways to hear more in a short visit and follow the clues standard labs leave behind.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Shiv K. Goel, internal medicine and functional medicine physician. Today’s KevinMD article is “Normal labs miss what most patients are living through.” Shiv, welcome back to the show.
Shiv K. Goel: Thank you for having me, Kevin.
Kevin Pho: All right. So why did you decide to write this particular article on KevinMD?
Shiv K. Goel: I think this is what I see every single day in my clinic. A lot of people are coming in, and they have been to multiple physicians. They have done everything right, as the evidence shows, and they still don’t feel that they are healthy. They still don’t feel that their life has what we would call vitality in it.
So, for example, there are patients who are having difficulty sleeping. They are living such a stressful life. They don’t know the real reasons, because their blood pressure is OK now. Their cholesterol looks fine on paper. And so when they go to their doctors, they always feel that something is missing in their life, but they don’t know whom to go to. That’s when I decided to look deeper into it, and that’s what this article is about.
Kevin Pho: OK. Now, for those patients where you order blood tests and everything is OK, blood pressure, cholesterol, and they are still clearly feeling unwell, just based on your experience and what you discuss in the exam room, what are some of the reasons that could be the case?
Shiv K. Goel: I think most of the time the reason is their lifestyle. The reason is the people around them, their relationships, their personal issues, their professional issues, their work issues. And it is something people don’t relate to their health. They just feel that these are separate things. The personal issues just keep happening in life. Work is work, and health is something they only think about when they get sick, and then they go to the doctor. So everything is so fractured and divided that nobody is able to see that everything is related, whether they have been having a stressful life, whether they are gaining weight, whether they are having issues at home or at work.
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Because if we have stress, our brain tries to compensate with what it can to prevent going into a crisis state, and that results in adrenal fatigue. I know that a lot of physicians do not agree with the concept of chronic adrenal fatigue, or adrenal failure, until somebody develops a different disease or is in the ICU in shock.
But I have seen this. And when they come to me, I see their patterns, what is going on in their life, how their situations and surroundings are. I do not usually ask them directly, but it is an indirect way of knowing how their environment is at home and at the workplace, and how well they are sleeping. What do they feel first thing in the morning when they get up? Do they feel very fresh, or do they just not want to get out of bed?
There are a few clues we can get, and we take it from there. And there is scientific evidence now that shows how stress itself, our gut-brain axis, our HPA axis, is linked to autoimmune issues and decreased immunity. It is linked to hormonal imbalance. In fact, to dysbiosis of the gut. It is one after another, even to the neurotransmitters, even to the neuroses. So many links are there. So it is all linked together. But if we don’t look deeper, we are never going to know.
Kevin Pho: Now, what are some of the ways that you can look deeper? Is it simply asking patients in the exam room? Do you order specific tests? Because in your article you use the term sustained threat physiology. What are some ways that you could determine whether some of this sustained stress is causing physiological damage?
Shiv K. Goel: One is that we can order a DUTCH test. I use it to see the salivary cortisol levels four times a day, to see what their level is and what the curve is. The people who have sustained sympathetic stimulation for a long period of time, you will see that they have a flat curve. And we can also do the organic acids test. We can also look at their sleep pattern and their heart rate variability. Nowadays everybody is wearing a watch. They have an iPhone, an Apple Watch, so they can see. It is easier to check that.
And I usually also check all their hormone levels, especially the salivary hormone levels, because their numbers vary throughout the day as well. And blood is not a very consistent way to check, because the hormones are carried in the blood, they don’t act in the blood, they act at the tissue level. So salivary hormones are very accurate, or you can do the urine one, and that gives me an overall idea. I can also check their neurotransmitters at the saliva level, to understand what is going on there, and then relate it to their symptoms, what they have been feeling, what situation they are in, and then you come to know. It is just mapping it out.
Kevin Pho: And just to be clear, like you said, there are a lot of people who don’t order these tests, and to my knowledge, there is not a lot of evidence that supports the ordering of these tests. But from your experience, you can have some actionable treatment plans based on what you find from these endocrinology tests, right?
Shiv K. Goel: Yes. And I know that not all of my treatment plans are so-called evidence-based, because evidence is also based upon different demographics, and especially upon hormone levels. They vary significantly. Take testosterone. It runs from 280 to 900 or 1,000. That is the whole normal range. So what is your normal range? That depends upon your lifestyle, that depends upon your age. There are so many other factors that can contribute to that.
So when I see something abnormal in the test, I just don’t act on a number. It is not a number that somebody has. What is going on in the person? If the patient is a sick, sedentary person who doesn’t do anything, that person is going to have a flat cortisol curve. But if a person is feeling exhausted, who doesn’t want to get up in the morning, who feels like this is chronic fatigue, I feel like I can’t function, I’m feeling burned out, then you have a picture, and it is very clear that it is consistent. Then we check their DHEA level, their vitamin D level. So it is everything, it is a whole picture. It is not just one thing.
And when we start them on a protocol or a treatment, sometimes I give them a very small dose of a steroid if they are really fatigued and just cannot get through it. Like, I had a patient whose morning cortisol level was less than 2. Less than 2 was the morning cortisol level, and the evening cortisol level was 0.5. It was already crashing. But he doesn’t meet the criteria for Addison’s disease. That doesn’t mean the person is not sick. The person is severely sick. He has no drive left in his body. He feels like he has to drink five Red Bulls and coffee just to get out of bed.
So because he has been running like this for years and years, there is nothing left of it. So you have to give them the break. You have to counsel them regarding taking a break, meditation, mindfulness, breathing techniques to help increase the parasympathetic drive and decrease the sympathetic drive. And for that, we still have the evidence. We can show how that helps in decreasing your stress level, on adrenal gland health, and the overall impact on that.
Kevin Pho: Now, tell me what you would say to the critics, and I know functional medicine has a lot of critics, who say that ordering a lot of these tests, like you said, isn’t supported by the evidence, and a lot of the treatments, and the tests for that matter, they’re not covered by insurance, so there’s a lot of out-of-pocket costs for patients. So what do you say to these critics who just use that line of argument against these tests and functional medicine in general?
Shiv K. Goel: OK. So I would say, why do you keep testing your apolipoprotein B, apolipoprotein A, and everything, when you know that it is what it is? I don’t order tests just to show that I am collecting the numbers.
I order only those tests which make sense, such as if somebody is telling me that he doesn’t feel like he wants to get up from the bed. He doesn’t have good sleep. It has been years since he has slept well. So in order for me to confirm it, I order their salivary cortisol pattern, the DUTCH test.
That doesn’t mean I am not ordering all the other million tests for them, and that is for me to understand whether it is correlating, and 99 percent of the time they do correlate. So that means there is something behind it. I don’t order millions of tests. Yes, if somebody has an autoimmune issue. There is one female who has been diagnosed with so many different autoimmune issues by three different endocrinologists and rheumatologists, and all three of them have a different diagnosis.
So when she came to me, I found out that the year all of the autoimmune issues started, her mother passed away. Then a few months later, her brother passed away, and then she underwent a surgery. So she was going through extremely stressful situations, which lasted for a year, and about six months later she had her first flare of skin rashes, and they diagnosed her with autoimmune issues. And then she started having nerve pain, and then they said inflammatory neuropathy of unknown origin.
So what I mean to say is that everything is related. Like, I studied internal medicine. I was an anesthetist before that. So from anesthesiology to internal medicine to functional medicine, I know the science and I understand what evidence is. But evidence keeps changing. Evidence means that we only know this much right now. We don’t know. Tomorrow something comes up, and we go back and say, oh, we were not right, let’s have this one. So what is wrong in that? I don’t know yet, but there is something more than what we know. I think that is where we have to start, instead of saying that this is all it is.
Kevin Pho: Now, I am going to assume that in your practice you spend more than 15 to 20 minutes with your patients, so you are able to suss out a lot of the underlying reasons why patients are feeling the way they do. So what kind of advice do you have for busy primary care clinicians who see patients every 15 to 20 minutes? Tell us the type of questions we may need to be asking more often, and maybe some other tests that aren’t necessarily in our evidence-based panels that we may want to consider.
Shiv K. Goel: Yeah. So I understand that 15 to 20 minutes is not enough time, but I think a lot of primary care physicians have been seeing the same patients over a long period of time. It is not that it has to happen in the first visit. They can create, like I have created, a protocol, a map, in which the patient fills in all the information before they even come in. What does their sleep pattern look like? How do they feel in the morning? So when you have all of these things in your hand beforehand, you know what is going on with that patient.
If I have all the right data in front of me and the patient is being honest, 80 percent of the time my diagnosis and my input don’t change. Then it is all about confirming with the patient, and sometimes patients say something on the second, third, fourth, or sixth visit that makes me go back. But a lot of the time that doesn’t happen. So that is the one thing.
Second thing, we are in a time of AI. So by using integrations of AI, they can synthesize the data without giving the patient’s name or the information, and you can create a lot of things beforehand.
The other thing is, I think it is a time when people who really want to dig deep into their health, there is direct primary care. You can offer them the other models. So you also shouldn’t have to suffer just because you’re spending too much time, so you can have extra revenue too. You can start a membership for the patients who want to dig deep into their root cause analysis, or to find out why they are having these issues.
Because insurance companies are not there to keep them healthy. They are there when they become diseased, so that we can write a prescription for them, and I understand their perspective as well. But I think this is somewhere medicine should be heading towards. Not just putting a prescription or a Band-Aid on somebody and doing the same thing again and again. Because finally we feel burned out. We feel like we are not doing what we were supposed to do. It is both professional and personal.
Kevin Pho: Now, one of the reasons sometimes why we are cautioned about ordering too many tests is that it could uncover symptoms that may necessitate more testing for symptoms that are eventually pretty benign. Now, do you ever encounter that whenever you order these cortisol levels or these other tests with the patients, and that necessitates a treadmill of more tests for things that are eventually benign?
Shiv K. Goel: No. So first of all, I only order a test which I think is going to benefit or add to the diagnosis. If it is not going to add to what I am thinking, I do not have to order it.
There are certain kinds of patients, and it is a two-way street. I have seen there are patients who just want a million-dollar workup to be done. They have the money, and if I don’t do it, they go to some other person. So I just send them to a lab. They can get the whole panel done, all the allergy testing, all the genetic testing. They just want to make sure that they are never going to have a cancer or whatever. But personally, I only order the test if somebody is telling me that this is the symptom they are having.
A lot of times it happens to me that I discover something, sometimes, not a lot of the time, which the patient was not telling me. So in fact, it gave me a tool in my hand, for the patients to let them know you have to be honest with me. If your test is showing your testosterone level is 1,000 and you are 50 years old, and you are saying that you never took any testosterone in your life, and your LH, FSH is low, that tells me you are not telling me the truth. And if you don’t tell me the truth, I can’t help you.
If their PSA is going up high and high, I do not order PSA on anybody over the age of 65, 70. I don’t have to, because what are you going to do if the PSA is high at that age? So those are the things I always keep in mind. I do not have to order the test just because I have to prove myself, that I am a functional medicine physician, so just order all that kind of unnecessary testing. No, you do not. You only order tests to correlate what the patient is saying and what the science says. They actually go line by line.
I am not disregarding the evidence-based, and I am not disregarding the functional-based either. I am trying to build a structure which helps people from their root cause. Give them the insight into the structure. Why is it happening in their life, what they can do, and how can we help them.
Kevin Pho: We’re talking to Shiv K. Goel, internal medicine and functional medicine physician. Today’s KevinMD article is “Normal labs miss what most patients are living through.” Shiv, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.
Shiv K. Goel: I would say to every physician out there, first, listen to your patients. If your time doesn’t allow it, then come up with alternate practices such as direct primary care or membership options. But there are a lot of people who can afford it, and they need help. A lot of patients who can’t afford it, I still help them. I still go above and beyond to assure them that this is what it is. Because ultimately, healing is their job. We can only show them the light. We cannot take them on the path.
So, spend some time. If you can’t, create a structure. Now we are in the age of AI. Create intake forms which comprise everything, and get it through a structure so that you don’t have to spend much time, and you will be able to provide better care to your patients.
And I think I also keep learning every single day, and that is the good thing for me, that it keeps me on my toes, it keeps life interesting, that every patient comes up with something which I never thought of before. And I think that is what we are here for, to be the healer, not just to be the physician or provider or whatever. That’s it.
Kevin Pho: Thank you so much again for sharing your perspective and insight. Thanks again for coming back on the show.
Shiv K. Goel: Thank you, Kevin. Thank you for having me again. Thank you.
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