Friday afternoon: I am covering an acute care clinic for patients needing immediate attention without an appointment ... because they just got sick in the preceding few days and need to be seen quickly. Visits are rarely long nor require heavy medical thinking: colds, urinary tract infections, sprains, refills and so on.

The last patient of the day complains of fatigue. I feel an immediate sinking feeling as I review her chart. Really, how acute can fatigue be? Did you not sleep last night? Maybe the new baby kept you up or perhaps your loud neighbors did?
Nope, it is nothing like that. The patient has had fatigue for a decade or more and is tired of it on this particular Friday afternoon. She has complained to many physicians resulting in the usual workups for depression, anemia, low thyroid, hormones, sleep disorders, cancer, heart disease, lung problems, vitamin deficiency ... the list on the subject is two pages long in Harrison’s Textbook of Medicine.

As is often the situation, all tests have been normal or inconclusive.

Now what?

Taking a few mindful deep breaths, I enter the room. “Hello, Ms. Fatigue, how can I help you today?”

“Doctor, I am just so tired, all the time.”

After the standard line of medical questioning: “When did this start? What things were going on in your life when you started feeling this way? What makes it better or worse? What does this fatigue prevent you from doing at home or work? What tests have been done? Treatments tried? What do you think caused the problem? What do you think you need to do to get better?”

The usual 10 to 15 minute acute visit is suddenly an hourlong project. After a respectable amount of time, the head nurse politely pokes her head in asking if I need anything. Overtime wages for the staff if we stay too long are on her mind. I am thinking I need something else: a walk on the beach, time with my granddaughter who is coming over at 5:30 p.m. for her night over, maybe an adult beverage.

This is not an uncommon scenario, and believe me, it is as frustrating for the patient as it is for the physician.
How can we approach this common complaint of persistent and chronic fatigue rationally and effectively? After excluding the usual medical causes, I recommend a functional medicine approach. This examines the timeline of the patient’s symptoms, along with antecedents, triggers, mediators and perpetuating factors. Often the solution can be found in one or more functional domains such as gut assimilation, immune defense and repair, anatomical structural integrity, cellular and chemical communication, vascular and fluid circulation, metabolic biotransformation, detoxification and elimination, energy regulation and transfer. Mental, emotional, spiritual dimensions, sleep and relaxation, exercise and movement, nutrition and hydration, stress and resilience, relationships and social networks must be assessed as well.
So, if you are chronically tired, get a thorough medical evaluation and if nothing pans out, consider a more extensive, integrative and functional assessment. Next week, we will cover some possible remedies for chronic fatigue.

Dr. Victor S. Sierpina is the WD and Laura Nell Nicholson Family Professor of Integrative Medicine and Professor of Family Medicine at UTMB.