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Why it doesn’t matter. March 5, 2008

Posted by phledge in blood, fat, health, medical school, yellow bile.

Okay, so, rather than continue to go down a list straight out of Merck or Harrison’s (both excellent medicine reference texts), I’m going to comment on why I don’t give a shit whether allthediseases are caused by fat.

You can’t fix it.

If a patient walks into my office with a gazillion diseases all of which have been definitively demonstrated to be caused by, not just correlated with, adiposity*, there’s nothing I can do to eliminate the root cause.  Let me state that again, a little more clearly:  I cannot change the root cause.  Dieting does not work, weight is at least 70% concordant in monozygotic twins (second only to height in hereditability), and bariatric surgery kills people faster than teh fats.  Besides that, my goal as a physician is to aid my patients’ search for a quality of life consistent with their values.  I will not tell people that I won’t be their doctor if they don’t stop smoking/quit the booze/go to rehab already/lose a hundred pounds/choose any “your fault” disease.  You are a fucking grownup (and if you are not, then I hope my approach is to help you understand how to become one with minimal suffering) and it’s not my fucking place to tell you how to live.  I will do what needs to be done to keep you healthy in the body you’re in, whether it’s addicted, cancer-ridden, fat, or some sort of state that people generally assume are “not your fault.”  I do not see a difference.  I know that my attitude is extremely rare in medicine, where we just love to blame our patients for what’s happening to their bodies and refuse to help until the patient can demonstrate some sort of “improvement” in “modifiable risk behaviors.”  Fuck that.  Lemme tell ya story:

My dad is old.  Almost eighty.  He chose his parents well, as his siblings all have lived well past ninety and his mother died on her 99th birthday.  He started smoking non-filtered Camels when he was fifteen and drank at least one boilermaker a day from the time he was able to obtain alcohol.  As a child I remember my mom cutting the excess fat off of our barbequed steaks; my dad would eat those scraps.  He grew up on a farm in rural Oregon not too long after the Depression started and has no patience for people who throw away food.  He often ate bacon and eggs fried in butter for breakfast.  Until he retired at the age of 72, he stayed relatively fit (he’s always had a beer belly) and never had any health issues.  Never.  One of the pithy comments he would always make when I, in my pre-HAES days, admonished him to quit whatever it was I thought was killing him, was “I’m not gonna stop living so I can survive.”  As I’ve gotten older, more tolerant, hopefully wiser, I’ve learned to cherish that attitude and I have no doubt that it will inform the way I work with my patients.  I’d like to learn how to apply it to myself.

Suffice it to say, though, there are lots of things in today’s medicine that would contradict this attitude, and lots of people in it will not understand how I can be so laissez-faire about the health of my patients.  I tell you what:  I think it’s easier to run the code, follow the evidence-based medicine, rely on algorithms, do what the HMO tells you to do, pretend that every patient is the same. Way easier, in great part because it’s what’s socially sanctioned in a profession that relies too heavily on status quo and prestige.

I won’t, can’t be complicit.  That’s why I won’t prescribe a diet or a bariatric surgery, that’s why I won’t harp on my patients to quit whatever perceived harm they are inflicting on themselves—for fuck’s sake, do you know a smoker that doesn’t know it’s bad for them?—and that’s why I will be there to treat all the shit my patients are going through, regardless of their cause.  It is not anyone’s fault that they are sick.  Even those poor Munchausen patients who inject themselves with urine?  That’s sick of another kind, but still sick, and still not their fault.

Wish me luck.  It’s hard to do this kind of medicine and get out alive.

*I’ve decided that “adiposity” is a better word than “obese” or “overweight” to use with my faculty and classmates.  Because, really, teh death is about teh fatz, not teh sizes.


1. Patsy Nevins - March 5, 2008

I like your attitude, & your patients will be glad to have you as their doctor. Fat is NOT “our fault”, even though it really isn’t ‘bad’ for us & can even be beneficial, but you’re right…it doesn’t matter. You should, if you are a real doctor who means the Hippocratic Oath, do the best you can for everyone & remember to ‘first, do no harm’. I am glad that you understand that. I am also from a family of bacon eaters, steak eaters (including many who love the fat left on, though I personally cut mine off), drinkers, smokers, & a great percentage of fat people who have lived well into their 80’s, 90’s & one aunt who lived to be 101. I neither drink nor smoke & exercise, so I suppose that means that I should live to be 120; I doubt it, but I, like your father, chose my relatives well. I have three much older brothers, two of whom are fat & who swallow the hype & believe it is bad (though one is an alcoholic who eats a high fat diet & seldom sees a green veggies & frankly I don’t think he cares), but so far this ‘terrible’ fat is not killing them…& the fat ones are 72 & 69. Our fat mother inherited kidney disease from her thin father & grandfather, lost a kidney before she turned 45, but lived to be 85.

Sorry, fat haters, but I will not be tyrannized, shamed, or scared. I am fine as I am, we all are, & we all deserve to be given this kind of caring, respectful, size-blind medical care when we need it.

I hope that your dad lives another twenty years & that you inherited his longevity genes.

2. Amanda - March 5, 2008

I can has you for doctor? (We have a hard enough time getting *any* doctors up my way, much less those capable of thinking for themselves.)

I’ve really been enjoying your thoughts. Oh, and your dad’s perspective? Made of win.

3. anniemcphee - March 5, 2008

I wish you more than luck – I will pray for you. I wish there were a hundred thousand more in medical school right now who would think the same way. I think my doctor comes close – he never bugs me about my weight for any reason, and he treats my brother-in-law and many other active alcoholics…they can actually tell him about their drinking and he just…treats them. Hard to describe or explain – though he DID tell my BIL to please stop drinking gin in particular, as he believes it is especially toxic. He switched to vodka at that point and it ceased to be an issue.

4. anniemcphee - March 5, 2008

And…now that you’ve got me thinking, I’m picturing how overrun you’re going to be by patients…many unable to pay. Yikes. You’re going to need a ranch like in Patch Adams or something!

5. vesta44 - March 5, 2008

I second Annie’s wish, that there were a hundred thousand more like you in med school now, and that all doctors had your attitude. I truly believe that if doctors had your attitude about patients and treating them, people would be a lot happier, and probably a bit healthier.

6. phledge - March 5, 2008

Thanks, everyone, for your kind words and thoughts. I also think that doctors would be happier if they stopped judging and blaming, and stopped feeling like failures when patients don’t take their advice, and stopped thinking that they themselves need to be perfect when they walk into that exam room.

7. anniemcphee - March 5, 2008

This is why my doctor needs to be on some list of fat-etc. friendly docs – I’m telling you, he just doesn’t make demands on his patients like that. He’s like some Christian Patch Adams or something. He only made my BIL go into the hospital because his BP went deathly low and he was severely emaciated – he didn’t even demand he stop drinking. He knows, after these years, that that isn’t going to happen and he treats him for what he has at that time. In hospital, they gave him librium, fluids, food, normalized his BP, and afterwards he was told he could go ahead and continue taking his Xanax (Doc told him to try to substitute Xanax for some of the times he wants to drink – upped his dosage even) and his Toprol, but to make SURE he eats (funny, isn’t it, how EATING helps so many people so much with so many problems?) He *encouraged* him to join AA, but AA is not for this man, and I don’t blame him on that score. It’s NOT for everyone. What BIL did was cut out “the hard stuff” and start sticking to wine and beers, and embark on a bit of moderation. The Doc is fine with that – sure he’d probably love the guy to quit outright and become superman overnight…but he treats people where they ARE.

Phledge? I can haz u as my Dr. or az my eventual Dr. when mine retires? (Totally copying another poster, but seriously. We need more of those.)

Ok this is ridiculous, I’ve fallen in love with this blog like overnight. Because there’s no ranting in med school lol. I’ll forever think of you as Patch. 🙂

8. anniemcphee - March 5, 2008

Um…I should probably add that this Dr. also helps people who come to “dry out” (is that detox I guess?) and he goes far more by experience than training. If you want to stop a behavior, he will support you 100% and give you any tough love you ask for, but he doesn’t force. Nor, my God, would he stop treating you. That would be unconscionable.

9. twilightriver - March 6, 2008

I am the caregiver for my developmentally disabled brother. As part of my job, I am attending a class which covers the fundamental laws surrounding my job.

It was very interesting to read this after a day of discussing respect for the client and the client’s rights to individuality and choice. One of the questions that came up was, “What if the client wants to do something that isn’t good for the client, such as smoking or eating foods that may not be healthy?”

The answer was that we could not interfere with any personal choice that we have the freedom to make. Nobody has the right to stop us from eating bacon and eggs for breakfast even if we have high cholesterol, so we cannot exert that kind of control over our clients.

If a client wants to run around in public naked, that would be breaking a law, so we do have a responsibility to help the client understand appropriate behavior. However, if my brother wants to run around in his superhero costume in public, I can’t stop him. He has the freedom to make that choice no matter how much it bugs me.

10. beckduer - March 6, 2008

Phledge, you’re my hero.

I love, love, love this post.

Oh, and when you’re ready to begin practicing (why DO they call it “practicing” anyway?) Please let us all know where. There will be a sharp influx of new residents to that area, but since we all have different strengths and professional abilities, it will be GOOD for the local economy. I demand that it be so!

11. Becca - March 6, 2008

Add another “will you be my doctor” to the list!

12. phledge - March 6, 2008

Aw, shucks. Thanks for the woot, guys. What I hope will happen is that people who don’t know about FA will either accidentally become my patients or hear about me from someone who does know about FA, and they hopefully will see that medicine doesn’t have to be paternal, patronizing, cruel, and degrading. 🙂

13. SingOut - March 7, 2008

I don’t suppose you’re practicing in the Twin Cities? My doctor is an ass.

14. phledge - March 7, 2008

Singout, thanks for asking. I’m actually only a lowly second-year student so I have miles and miles to go before I will actually be able to hang a shingle. Have you looked at the Fat Friendly Health Professionals list? They might have someone you could work with, or they also have tips on how to get the health care you need from less-than-cooperative physicians. Good luck!

15. littlem - March 7, 2008

You are made of specificity and win.

Re: requests for doctorhood/patient waiting list *shouts with glee*

I told you so! I told you so!

*points to her reservation of place in patient line 2 months ago*


16. phledge - March 8, 2008

Lady, you are too much. Something funny: I just realized that your screen name was “little m,” not “little em.” So forgive me for calling you “Em” as if I knew what the hell I was talking about. 😉

17. ladoctorita - August 14, 2008

amazing post. i think i may tattoo it on my forehead . . . or just print it out. 🙂

also, just so you know, i plan to eventually open a feminist, fat-accepting primary care clinic where payment will be accepted in the form of tasty baked goods. you should open one too, and we can make a whole network! 🙂

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