Let me paint you a picture.

Third year of medical school. I am exhausted in a way that feels genuinely unreasonable. I am foggy, I am struggling, and I am surrounded by other exhausted, foggy, struggling medical students; so honestly, the bar for "something is wrong" is pretty hard to see.

My labs, at that point, were normal because they had not yet included the right labs. Which is a thing that happens more than medicine likes to admit.

The working theory was depression. And look: depression is real, depression causes fatigue, depression absolutely belongs on the differential. Also I probably did have depression, but because I was sick, not the other way around. Depression was not what was happening right then. What was happening was that my adrenal glands had essentially decided to go on strike, and nobody had sent them the memo that this was not acceptable timing.

I have Addison's Disease. My body does not make cortisol correctly. I am essentially a human phone running on a 1% battery that only charges via prescription hormones. People love to talk all day about Adrenal Fatigue, I have Adrenal Failure.

My family doctor caught it. Not a specialist. Not some elaborate diagnostic odyssey. One doctor who kept looking because the first answer didn't fit.

I think about that a lot. It’s changed the way I practice medicine.

Here is the thing about Addison's disease: it is managed, not cured. You find your baseline, you figure out your stress dosing, you learn your body's warning signs, and you build a life around the reality that your adrenal glands are basically unreliable coworkers who will occasionally just not show up.

For years, I did okay. Residency, somehow. The early years of practice. Even the pandemic, which, if you were a family medicine doctor during COVID, was not exactly a low-stress period. I was working overtime hours, night call, the whole thing. My body was keeping score, quietly, in the background.

And then COVID hit our house.

My husband got a bad case. Really bad; couldn't get out of bed for a month. And then he had long haul COVID fatigue for a year after that, the kind where you're technically "recovered" but you're exhausted in a way that doesn't make sense on paper. We eventually figured out he also had obstructive sleep apnea, which, I will tell you, is both very common and very easy to miss in someone you love. I had lived with him for six years before we put that piece together. Six years. I am a doctor. This is how subtle this stuff can be.

Getting him on a CPAP helped. But we were both running on fumes by that point.

And then I crashed.

Not dramatically. Not all at once. More like a slow puncture: the kind where you keep driving and keep driving and then one day you're just on the side of the road wondering when exactly that happened.

The exercise crashes started first. Then the anxiety-driven insomnia, which, if you have Addison's, is its own special problem, because sleep deprivation tanks your cortisol, and low cortisol tanks everything else. My blood pressure dropped. I was dizzy. I passed out a few times. I was aching in a way that is hard to describe to someone who hasn't felt it, the kind of tired pain that lives in your bones and doesn't move.

I could barely think straight. Something was very wrong, and I knew it, and I still kept going because that is just what you do.

Here is what was actually happening, for those keeping score:

My Addison's was flaring, pushed over the edge by pandemic work stress, sleep deprivation, and almost certainly COVID itself, even though I never tested positive. (My husband had it severely. There is no world in which I didn't have something.) On top of that, I had endometriosis that had been quietly progressing; stage 4, as it turned out, affecting my kidneys, causing pain that was disabling and a level of fatigue that stacked directly on top of everything else.

It wasn't one thing. It was never one thing. It was a pile of things that each made the others worse, and none of them were obvious in isolation, and the only way to see the whole picture was to actually look for the whole picture.

My endocrinologist eventually sat me down and said: stop, or I'm putting you in the hospital.

I stopped.

I ended up taking a long sabbatical that included multiple surgeries, a lot of sleep, and a whole lot of thinking time. Time I spent thinking about the system, it’s successes and failures, about access to care and advocacy for those who aren’t being helped. So I started building.

Last week I wrote about the 8 buckets of fatigue; my framework for thinking about what's actually driving someone's exhaustion. If you haven't read it, go read it. I'll wait.

(I won't wait, I'm a blog post, but you get the idea.)

The point of that framework is that fatigue almost never lives in one bucket. It lives in three, or five, or six, and they all interact with each other in ways that make each one harder to treat. That's not a reason to give up. It's a reason to actually look.

Here is what I have noticed, after all of this; as a patient, as a physician, as someone who has personally experienced the joy of being told her labs were fine when the right labs hadn't been checked yet:

Fatigue is one of the most common symptoms in medicine, and it gets handled terribly.

Not because doctors don't care. But because fatigue is complex, appointments are short, and somewhere along the way we decided that "your thyroid is normal, maybe try getting more sleep" was a complete sentence.

It is not a complete sentence.

Fatigue doesn't belong to any one specialist; which means it tends to get passed between them like a dish at a potluck that nobody will admit they brought. It doesn't fit in a 15-minute slot. It doesn't show up neatly on a standard panel. And the people who have it are often exhausted enough that advocating for themselves, repeatedly, across multiple appointments, is its own form of impossible.

I've been building something. For people who are tired of being told they're fine. Who have normal-ish labs and abnormal lives. Who have tried the sleep hygiene and the supplements and the "have you considered that you might be stressed?" conversation, and are still not okay.

It's almost ready. Details next week.

You've waited this long. What's one more week?