Why it doesn’t matter. March 5, 2008Posted 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.