Not Everyone Fits in a Box

Early in my career I made the decision to come to the United States to learn how to save people who were dying.

After I finished medical school in Mumbai, I worked a job in an intensive care unit, watching patients enter and often not come out. Each bad outcome seemed to have a common link, a lack of resources. In a developing country in the early 1990s, we couldn't order a test on a whim. We had to think hard about how to spend every rupee of diagnostic capacity. I assumed that if I could get to a place where ventilators, dialysis machines, balloon pumps, and the subspecialists were all sitting there waiting, we would simply save more people.

Determined to train myself in these protocols, I moved to the United States to start my residency program.. I packed my schedule with as many ICU rotations as I could get, and soon realized facts that would upend my careful plans of becoming an intensive care physician.

The patients who arrived at an American ICU in poor condition were still dying at roughly the same rate. Every resource was available. Every expert was a page away. While these methods may have bought a patient some time, it didn't change the math nearly as much as I had expected. What predicted survival was not the technology in the room, but the state the patient was in when they came through the door — and, I noticed again and again, their will to fight.

That was the moment I stopped trying to become the hero who rescues you at the end and started trying to become the person who prevents you from getting there.

The box problem

American medicine is extraordinary at what it was designed to do. It reduces the body to systems, systems to organs, organs to cells, cells to molecules — and then it intervenes at the molecular level with remarkable precision. That reductionism is not a flaw, it's the engine that produced the biologics that keep my rheumatology patients walking.

But it’s not a perfect system, and unfortunately, if you've been sick for a long time without answers, you already know exactly what flaws our medical system has.

The American Medical system works by classification. You arrive with symptoms. Those symptoms get sorted toward a diagnostic category. The category determines the specialist. The specialist determines the treatment pathway. It's efficient, and for most people, most of the time, it works.

The trouble starts if you don't fit in a box.

A patient comes in with fatigue, joint pain, brain fog, and digestive trouble. Rheumatology finds nothing that meets diagnostic classification criteria. Gastroenterology finds a functional disorder and no structural disease. Neurology finds nothing on imaging. Each specialist, working correctly within their domain, returns with a negative. The patient leaves with four "normal" workups and the same symptoms they walked in with — plus the corrosive suspicion that people think they're just imagining it.

No doctor did anything wrong. The architecture of the system was wrong. When every door is a category, the patient who spans across these categories falls between them.

The advocacy tax

The current workaround relies on the patient to do the integration themselves. Carry their records from office to office. Notice that the rheumatologist and the gastroenterologist have never spoken. Discover on their own that the fatigue got worse after the mononucleosis. And build the theory of their own case.

I've watched patients do this, and some of them do it brilliantly. But asking a sick person to be their own diagnostician has two problems.

The first is knowledge. Pattern recognition across specialties is what a decade plus of training buys you, and it isn't available at any price on the internet.

The second problem is harder, and it's the one people underestimate. When you are personally suffering from an illness, it is extremely difficult to be objective about it. Fear distorts. Hope distorts. The desperate wish for a particular answer distorts. This isn't a character failing — it's what pain does to reasoning, and it happens to physicians when they get sick too. Objectivity about your own body is close to a physiological impossibility.

That's the entire argument for professional expertise, and it's the argument for having someone in your corner whose judgment isn't compromised by being the one in the chair.

What root-cause actually means

The phrase gets used loosely, so let me be concrete about what it means in our practice. It is not an alternative to conventional diagnostics. It's when conventional diagnostics are used more thoroughly, sequenced differently, and interpreted with a wider set of questions.

It starts with a history that takes real time. Most of the diagnostic signal in complex illness is in the timeline, and the timeline takes longer than fifteen minutes to elicit. When did this actually start? What happened in the six months before? Was there an infection, a pregnancy, a surgery, a bereavement, a move? Chronic illness usually has an inflection point, and patients rarely volunteer it because nobody has ever asked them to think in those terms.

It looks at domains conventional workups skip. Gut function and the microbiome. Immune system aging and senescence. Autonomic nervous system regulation. Nutrient status. Metabolic and hormonal function. Prior viral exposures and how well the immune system is containing them. Connective tissue and joint hypermobility. Mast cell activity. These are not fringe concerns — each has a well established literature — but no single specialty owns them, so in practice, nobody checks.

It uses the best available laboratory and radiological testing, not less of it. I want to be unambiguous here, because "root cause" is sometimes code for replacing tests with intuition. That is not what we do. We use the full modern diagnostic arsenal. We just don't stop when the first four panels come back “within range”, because within normal limits does not equate to optimal

It expects more than one answer. This is the part that most changes outcomes. In complicated cases there is rarely a single culprit. There is a stack — a viral trigger the immune system never fully cleared, a gut ecology that shifted, a connective tissue predisposition, an autonomic system stuck in the wrong gear. Each one is a modest contributor. Together they're disabling. Treat one and you get a partial response that fades. Treat the stack and people get their lives back.

It treats lifestyle as a mechanism, not as advice. When I ask about sleep, stress, food, and movement, I'm not filling out a wellness checkbox. Those inputs act on the same inflammatory and autonomic pathways the drugs act on. Ignoring them means leaving a high efficacy and low risk intervention out of the toolkit.

Why I got here from rheumatology

Autoimmune disease is the ideal training ground for this way of thinking, because it refuses to fit into a single box.

Your lupus is not the same illness as the lupus of the person sitting next to you in the waiting room. Same name, same antibodies, entirely different disease. One person's kidneys, another's skin, another's brain. Same drug, opposite results. After enough years of this you stop believing that the diagnosis is the most important unit of information and begin to understand that, what’s most important is understanding who the person is and how the disease is expressing in that particular individual's body.

Once you see that clearly in autoimmunity, you can't unsee it anywhere else.

The honest limits

I want to be careful not to oversell, because this field attracts overselling.

Root-cause evaluation does not find an answer for everyone. Some illness is genuinely idiopathic with our current tools. Some findings are interesting but not actionable. A more thorough workup produces more incidental results, and part of the skill is knowing which ones to leave alone.

It also isn't a rejection of pharmaceuticals. I prescribe them constantly, including the ones with real side effects, because sometimes that is the correct answer and delaying their use causes real harm. The goal was never to avoid medication. The goal is to need less of it, for less time, because we addressed what was driving the process and not just dealt with the disease in its current state.

And it takes time. Real evaluation is not a single visit. If someone promises you a root cause in ninety minutes, be skeptical.

What I want for my patients

I trained to keep people alive in intensive care units, and I'm glad I did — it means I'm not frightened of a genuinely sick patient. But that training taught me something it wasn't geared to teach me: by the time you get to that room, most of the important decisions have already been made, years earlier, by processes nobody was watching.

So the mission became the opposite of what I set out to do. Not to be brilliant at the end, but to be transformative at the beginning.

That's what it means when we say we look for the root cause. Not a slogan. A commitment to keep asking until the picture actually explains the person in front of us.

Disclaimer: This article is for educational purposes and is not medical advice. It does not establish a physician-patient relationship. Individual results vary, and no diagnostic approach guarantees an answer or an outcome. Please discuss your own care with your physician.