Opinion: How bad is healthy supposed to feel?

The 43-year-old woman sitting across from me in my exam room is exasperated. “I just don’t feel like I have the energy or stamina I used to,” she tells me. “I could run 5 miles a day no problem when I was 23.”

Today we are reviewing her labs, all of which are normal. She has been my patient for several years and recently lost 50 pounds. In many ways, she feels better. Despite all that, despite a normal exam, vital signs, and labs, she just doesn’t have the energy she used to. Something must be wrong.

She then proceeds to tell me how stressed she is, a single mom of three working two full-time jobs. She doesn’t feel like she has any time at all and admits she doesn’t exercise anymore. She isn’t sure how she can fit anything beyond the most basic life tasks into her day. Sometimes she struggles even to do that.

As she is talking to me, I hear her answer her own question.

She has two full time jobs and three kids. She isn’t exercising anymore and feels overwhelmed.

I wait for her to connect the dots.

She doesn’t.

So I do for her.

We talk about exercise and stamina, how it is something that needs to be continually maintained and consistently trained. We talk about how hard it is to raise three children alone, how she isn’t getting good sleep, isn’t eating the best. And then we talk about how 23 is not 43. By the time we are finished, she’s starting to connect the dots, too.

I am a family nurse practitioner who works in both primary care and emergency medicine, and I now have this conversation with patients on a regular basis. A pattern is emerging. The patients differ and the minutia of their symptoms may change, but the underlying is the same. They are asking more than, “Is something wrong with me?” They are asking: “Am I normal?”

Not too long ago, life was understood to be functioning and carrying on despite unavoidable discomforts. Moderate fatigue, mild anxiety, grief, and poor sleep were considered symptoms of a busy life — not always comfortable, but usually not dangerous, either.

Patients are now arriving to see me not because they can’t function, but because they think they aren’t feeling the way a healthy person should.

I am not advocating that we should dismiss patients or their symptoms. We investigate them for a reason. Fatigue can indicate sleep apnea, anemia, maybe a thyroid disorder, or even cancer. Just because a symptom is vague does not rule out something more concerning. Lives have been saved because these have been investigated.

The problem is, medicine is so good at finding answers it is being asked questions it was never designed to address. It can certainly investigate whether that fatigue could be caused by anemia, sleep apnea, or malignancy, but medicine isn’t really able to answer the question of how tired you’re supposed to feel from the wear and tear ordinary living brings.

In the 19th century, a similar problem was discussed. In 1869, neurologist George Beard gave a name to what he believed was one of the defining illnesses of their modern times: neurasthenia, or nervous exhaustion. Symptoms included fatigue, headaches, poor sleep and concentration, and a vague inability to keep up with the increasing pace of demands of the age.

The diagnosis exploded in popularity and was widely blamed on railroads, radios, telegraphs, newspapers, and the industrialization of the times. The very things that were supposed to be making life easier were overwhelming the human nervous system, patients and doctors alike believed. Neurasthenia seemed to give a label for the anxieties of the era, with some Americans worrying that speed, technology, and industry itself might be making them sick. The diagnosis gave a vocabulary and a tangibility to their fears.

While that diagnosis eventually disappeared — I have certainly never diagnosed anyone with it — the symptoms and the concerns didn’t. It now goes by new names: chronic fatigue syndrome, autonomic dysfunction, somatic disorder, to name a few. If neurasthenia gave label and tangibility to the anxieties of the past, I suspect these diagnoses may sometimes do a similar task today.

Let me be clear: Medicine does have a regrettable history of dismissing symptoms, particularly in women. Patients with genuine illnesses have been told their symptoms were anxiety, or maybe they were just on their periods. Sometimes it can take years before they were taken seriously enough to be further investigated and finally diagnosed, and they can often still remain poorly understood. It is almost never helpful to tell a patient to “buck up,” and just because medicine hasn’t been able to find a good reason for it yet doesn’t mean they aren’t suffering.

But while that history should be acknowledged, we shouldn’t conflate illness and the hardships that come with living. We need to be able to separate those with a true chronic disease from patients who are convinced they have one just because they are struggling. Taking patients seriously doesn’t mean every symptom must be labeled any more than reassuring someone they’re healthy means dismissing what they may feel.

My patient isn’t just comparing herself to other single mothers working two jobs and struggling with the day-to-day activities of life. She’s comparing herself to the social media wellness influencer who is up before dawn to use her red light mask, stand on her vibration plate, drink her green smoothie, and run her 5 miles all with a smile on her face and seemingly with energy to spare for the rest of the day. She certainly seems to still have energy to post her perfectly curated dinner on Instagram at the end of the day. 

My point is, the comparison is no longer with your peers — it’s an algorithm. And against an algorithm that curates optimization and a veil of perfection, everyone seems sick. Why we can’t do that? Where is our energy for the 5-mile run and nourishing dinner? Something has to be wrong, and we call and make an appointment with our doctors.

The woman in my exam room is asking if this is what 43 is supposed to feel like. In her situation, I think: Yes, that is what it feels like when you’re working two jobs, taking care of three kids, and can’t seem to get on top of your to-do list. This isn’t an abnormality in search of a diagnosis. It’s life.  

Kirsten Balin is a family nurse practitioner who works in both primary care in her own medical practice and in emergency medicine in her hometown of Klamath Falls in rural southern Oregon. She writes about medicine, health, and modern culture on her Substack, Differential Notes.