Good news, bad news, and a favor to ask. March 6, 2008
Posted by phledge in fat, medical school.trackback
The good news: I’ve been asked to give a presentation on fat discrimination in health care to my fellow students and interested faculty.
The bad news: I have an hour.
The favor: would you please share with me what information you would most want future doctors to understand about the fat patient? Considering the time limit?
Edit to clarify: This presentation will take place whenever I want it to take place, but I have to talk for only one hour. If someone told me I had to present something on even the same day, I would tell them that I’m flattered that they think I am some sort of über-lecturer and all that, but no.
Four Humours 
Wow…I think the most important thing to understand is that fat people are PEOPLE *lol*. We are not ignorant children; we know we are fat. We are already afraid that doctors will see us only as fat and not as people, so when a doctor writes off our concerns as all being because of our weight…it just makes us never want to come back.
I would also share some stories from “First Do No Harm.” That is powerful stuff there.
Good luck!
We are not all lying about what we eat.
I would definitely bring up many of the issues raised on the First, Do No Harm site at http://www.fathealth.org. There are so many people who have serious illnesses or diseases who have been misdiagnosed or dismissed due to weight. It’s crucial that doctors give the same attention and consideration to a fat person with an illness as they would a thin person with the same illness.
I would also bring up the bedside manners of doctors, as this is an area that seems to be omitted entirely from most medical schools. If doctors do broach the subject of weight, they need to do so considerately and kindly. I would also recommend to doctors that they not encourage their patients to go on commercial diet plans that carry a 95 percent failure rate. If anything, they need to encourage those patients who express a need for help in learning nutrition to see a certified nutritionist.
Good luck!
How about, “We’re not all the same”? Look at people as individuals not numbers. ASK me about my habits instead of assuming, and assume I’m telling you the truth if the information I give you is consistent.
I totally agree with Rachel and would add that you should emphasize that fat people know they’re fat. Most of them have tried to lose weight before. Doctors should not treat fat people like they’re ignorant about their own bodies. (Or any people, for that matter, but that’s another talk!)
Congrats and good luck!
I agree with the above. Fat does not equal ignorance, or mental illness, or poor hygiene, etc. Fat people can (and do) care about their health as much as a thin person, and seek to “take care of themselves” as fervently.
(of course, this is another reason why a fat person may believe she is doomed to the prison of yo-yo dieting her whole life, given the current medically-accepted view that fat = unhealthy)
I’ll add to this that dieting doesn’t work for virtually everyone, hence fat patients may be frustrated and stressed out that their weight will be brought up in a deprecatory manner whenever they visit the doctor’s. Instead of a physician being combative, he/she could take this into account and be as gentle and understanding as possible, even if he/she does believe fat is unhealthy.
Good luck! Be sure to tell us about it. It’s very odd they gave you so little time to prepare, but I’m sure you’ll make the most of it! 🙂
In addition to all of the above, there are three things that come to my mind:
1.) A doctor should be aware that a fat person is more likely to have made traumatic experiences with health care professionals in the past than a thin person – so a fat person might not be as willing to trust a doctor as the average patient and/or might experience a doctor’s appointment as very stressful.
2.) A doctor should never ever compliment anybody on weight loss if he or she does not know how that weight loss was achieved. Sometimes even fat people need to be told that they are eating less than there body needs – or exercising more than is healthy for them.
3.) If you are a doctor and you still believe that fat people in general should try to lose weight despite the high failure rates of diets at least ask for the weight loss history of the respective person. It might not be a good idea to tell someone who has stressed their body with weight cycling for several decades to go on yet another diet – instead weight stabilization might be a better goal.
To what Rachel said about suggesting a nutritionist, I would also add asking first what kinds of foods the patient eats–and then believing them when they answer. We’re not all subsisting on McDonalds, as you well know. I went to see my first nutritionist at age 9 after having already been on a diet for two years. I’m pretty sure I wouldn’t get much out of the visit.
Good luck! What a great opportunity!
This goes with bedside manner, but doctors shouldn’t act shocked when a fat person doesn’t have high blood pressure, isn’t even close to becoming diabetic, and has good cholesterol numbers. I don’t know how many times I’ve been told by a doctor that my numbers are good and they don’t know why, since I’m “morbidly obese” and have been for at least 30 years.
My sister and a friend of mine both recently completed degrees in medical fields (one nurse, one pharmacist). I asked them that as a personal favor to me that they NEVER badger fat people about their weight – as sweetmachine said earlier, THEY KNOW. Making them (us) feel worse about ourselves is not going to change the current state of affairs – all it’s likely to do is make them dread going to see you again or avoid listening to you.
I want doctors to understand that fat people are like thin people are like tall people are like short people – they’re PEOPLE, not problems presenting themselves to be solved. Treat them as individuals just like you would anyone else and don’t assume that they can’t possibly be healthy just because of size – don’t make that judgement until you have their individual data.
If doctors understood this one point alone it would make all the difference in the world.
The most important thing for me would be for doctors to know that assumptions don’t help either of us. I’ll fire any doctor who doesn’t ask me about my habits BEFORE telling me to change them. It takes ten minutes to talk to a new patient about their lifestyle; granted, you can save eight of those minutes by just telling them to exercise more and knock off the donuts, but you’re likely not doing them any good and you’re certainly not increasing your knowledge about the patient.
God, this is going to be long.
1. We already know we’re fat. Some of us have accepted that, some of us are ashamed of it, but we still know it.
1a. We already know that fat is considered unhealthy.
1b. We don’t need a lecture that we ought to lose weight. The message is already everywhere. We’ve already heard “eat less and exercise more” a thousand times this week.
2. There is a massive societal stigma against the fat, so even mentioning weight as an issue can cause emotional and physical distress. Especially with women, and even with those who don’t appear fat.
2a. Many fat people have issues with being weighed, especially in a public area of the clinic. If you absolutely must weigh a patient, such as for calculating medication dose or checking pregnancy progress (there are few other situations where it’s necessary), have your scales in a private area and record the weight silently and without comment. If the patient wants to know, they’ll ask. Tell them without added judgement.
3. Do not assume anything about a patient’s lifestyle. And especially do not assume they must be lying or exaggerating when they’re giving you information. Don’t assume they must be stupid or ignorant if they’ve “let themselves go” and so on.
3a. Do not blame their health condition on being fat. Treat them as you would any slim patient and investigate all causes of health concerns through the normal channels. Even where being very heavy may exacerbate a condition, such as arthritis in the knee, treat fat people the same as the slim – eg, cortisone + physiotherapy + gentle strengthening exercises.
3b. Don’t act surprised or offended when a fat person’s blood pressure is normal and their blood panels return normal results.
3c. USE THE CORRECT SIZE EQUIPMENT. A too-small blood pressure cuff will give inflated readings. Even the standard extra-large one may be too small. Check the manufacturer’s specs and actually measure the patient’s upper arm. (And many fat people are anxious about being at the doctor’s, so may present with “white coat hypertension”.) If you’re concerned about blood pressure, home measurement or 24-hour ambulatory may be a better way to see what’s going on.
Have sturdy examination tables (many are quite narrow and alarmingly flimsy) with a step.
Have a range of exam gown sizes – they come in sizes up to 10XL.
Have chairs without arms in your waiting room.
If you get some new equipment or are ordering supplies, think about whether it will be suitable for very fat people.
And above all, never ever complain or be judgemental about having to use larger equipment, or draw unnecessary attention to it. (Having the nurse yell out “Get the really huge cuff for this one!” is not helpful, to say the least.)
4. If a doc is concerned about a patient’s nutrition, ask them neutrally, like “Tell me about what you eat”, “Do you have any concerns about that” – and remember that most doctors simply do not have the nutritional education to properly educate on this subject. Offer to refer to a dietician (a HAES-friendly one of course) if there seem to be problems that need help. Don’t make a big thing of it – something like “I think checking you’re getting all your vitamins could help you feel better”, etc. Don’t even go into “good” and “bad” food territory.
5. If a doc is concerned that the patient isn’t moving enough, again ask them neutrally, eg, “Tell me about the kinds of physical activity you do” – and remember that looking after kids, housework, manual labour, and non-gym exercise count as activity. Remind that physical activity has health benefits even if you don’t lose any weight, such as better sleep, improved mental health, improved metabolic fitness, etc, and that anything is better than nothing, such as a 10 minute walk around the block. But most importantly, remember that fat people face discrimination and harassment when they dare exercise in public, so of course they might be disinclined to do so. It’s also hard to find good exercise clothing, especially if you’re over a size 18 or so. Some kinds of exercise may be physically uncomfortable for the very fat. And if they’re really not interested in exercising (plenty of thin people sure aren’t), don’t push the issue.
6. Fat people have eating disorders too, and not just binge eating or compulsive overeating. There are fat people with all the expected symptoms of anorexia nervosa except being thin. There are fat people with bulimia. And most GPs and PCPs etc again do not have the training to treat this and may not even recognise the symptoms. And those with binge eating or compulsive overeating do not need a weight loss diet or just “willpower”. They need competent mental health care from a specialist.
6a. Most fat people are not bingers or overeaters. They’ve been told they are for eating normally, though. And it’s perfectly normal to eat a large amount once in a while.
7. Eating a balanced diet and getting regular exercise does not make most people lose large amounts of weight. They may lose a tiny amount if they’ve been sedentary and had an unbalanced diet, or they may not lose any weight at all. And that’s OK: the health benefits of this are beyond weight loss.
7a. Losing weight is not a cure for depression, a stressful life situation, marital or family problems, discrimination, bullying, social isolation and so on. Strengthening self esteem and body image in a weight-neutral way through various forms of therapy can be. Many people are convinced that weight loss will solve all their problems, you don’t need to encourage that.
7b. Losing enough weight to make a ‘clinically obese’ person ‘normal’ weight is not possible long term for pretty much everyone. A few people may be able to keep off small amounts like 15lbs, but they’re not usually that fat to start out with.
7c. Hence, and I repeat, don’t prescribe weight loss.
Summary: Fat people are just like everyone else, treat them with the respect and care they deserve. Treat the patient, not the fat.
Maybe include some quotes from the stories at fathealth.org to illustrate fat bias in medical care?
I won’t take up more commentspace by 3000 references, but the HAES page at Wikipedia links to lots of the important stuff including clinical references:
http://en.wikipedia.org/wiki/Health_at_Every_Size
And this isn’t exactly fat-accepting but it’s pretty good, explaining why weight stigma is a bad idea and how well-meaning doctors can create health issues by focusing on weight:
http://her.oxfordjournals.org/cgi/content/full/20/2/259
And this is a site written by a doctor and two nurses specifically for health professionals:
http://www.jonrobison.net/FDNH/INDEX.HTM
I would say that for some overweight patients (namely me) weight is an extremely sensitive subject. And frankly, if it can be left out of the conversation altogether, that is the best option. My Gyno is the sweetest lady in the world and I know she didn’t mean to upset me, but she brought it up in our last appointment and I started crying in her office. Really, it would just be better if it didn’t come up since all of my other vitals are fine.
What should future doctors most understand about the fat patient? That they are a human being, and thus just as deserving of proper medical care as any other human being.
This also means that there is no such thing as “the fat patient”. Being human beings, fat patients are all different. Some will have perfect BP, cholesterol, you name it. Some will have numbers that make you wonder how they’re still in front of you. Some will be rich, some will be skipping some meals because they can’t really afford a doctor visit but are too sick not to. Some will smell bad, some will shower three times a day. Some will listen if you tell them to stop smoking, some will smoke an extra cigarette as soon as they leave the office just out of spite.
The only thing you can say for certain about “the fat patient” is the same thing you can say about “the patient” in general: they are there to try to figure out the best way to allow their bodies to be healthy while maintaining the best quality of life possible. That means sometimes they will refuse a particular treatment option because they aren’t willing to risk the side effects. So future doctors need to know how to talk to their fat patients – and all of their patients – about the real risks and benefits of any course of treatment, and they need to be willing to accept that some patients aren’t going to “comply” with treatment. It is a patient’s right to choose whether or not to follow a proposed course of treatment. Patients are adults who can make their own decisions, and it is a doctor’s responsibility to propose alternate treatment options (if available) if a patient refuses one for whatever reason.
Of course you know all of those things, but I think they’re worth emphasizing. That said, for fat patients in particular, I would think that it’s important to mention the failure rate of any attempt to lose and keep off weight over a long period of time. Would a responsible doctor propose any other treatment plan that, 95% of the time, is ineffective and possibly harmful 5 years down the road? Not to mention that (as far as I know) there’s no evidence showing that losing weight (as opposed to being at a lower weight to start with) is correlated with a reduction in risk for any disease. So I would say that a huge point to emphasize the HAES aspect. If a doctor tells me to lose weight, I won’t want to go back to them. If they tell me to be more active without mentioning my weight at all (or bonus, without weighing me!), I won’t like it, but I might be willing to talk to them about what sort of exercise I could do that would be best. That’s the doctor that I’ll go back to, and that I’ll tell everyone I know about. It won’t be because they ignored my weight, it will be because they a) did not propose a treatment that won’t work, and b) spoke to me as a person and an adult who is capable of making her own decisions.
Sorry for the rant! Like I said, you know all these things. But I think that doctors could go a long way towards eliminating fat prejudice in medicine by simply treating fat patients and ALL patients as equals, not as incompetents.
Physicians should initially approach a patient as essentially size-less. In other words, how would you approach a diagnosis and treatment options if you had no idea how much they weighed? Only once you have answered that question for yourself should you factor in weight (or, likely more relevant, weight changes) as a possible symptom/side effect/issue (eg, PCOS causes weight gain).
Case in point: My husband has bad knees, due in large part to a career that involved willingly jumping out of perfectly good airplanes. My husband also weighs about 350lbs. For the last several years, his current doctor’s total recommended course of treatment begins and ends with “Lose weight. Lots of weight. Diets, pills, surgery. Anything and everything.” Now not only is long-term weight loss a pipe dream, but even if he loses 100lbs or more? He will STILL have bad knees! At no point, to my knowledge, has she ever discussed the underlying factors or any other treatment options beyond “get un-fat”. Physical therapy? Cortisone shots? Orthopedic consultation? Anything??? Nope. Just get un-fat.
I want to grab her and shake her and say “What would you do for him if he were 225lbs? Really?? THEN WHY AREN’T YOU DOING IT NOW???”
Of course, I also want to grab *him* and shake *him* for not asking her the same thing.
First off, great blog! I’m finding it very interesting.
What do doctors need to know about “the fat patient?” First thing that comes to mind, Have a sense of perspective. Do a little mental triage. So the man coming in weighs 400 lbs. Is he really going to have a heart attack in the next 15 minutes? Or is he there for his toe fungus? If it’s the latter, don’t get hysterical and harp on the former unless there really is an immediate, serious issue (like you’ve checked his BP and it’s life-threateningly high, or maybe the toe fungus is a sign of undiagnosed, untreated diabetes.) Crying wolf all the time just gets you ignored. And the older a patient gets, the more he or she may treat weight hysteria as simply crying wolf, especially if they’ve been fat most of their lives and relatively healthy.
I would tell doctors, realize that nagging, shame, and blame do no good. All they do is make patients avoid you – and in avoiding you, they forgo necessary and important care.
I’d like to see an emphasis on weight changes, rather than the weight itself. I think that either a sudden weight gain or loss would be cause for concern.
If your weight is stable for years at 100 or 200 or 400 or whatever lbs, without other health problems, why disrupt a working system?
Thinking about the great doctors I’ve had, I think they’ve understood that what we’re doing together, doctor & patient, is a kind of relationship.
There are expectations on both sides, and responsibilities on both sides. But if it’s going to work, I’m going to need to be able to come back. It doesn’t mean that there is zero margin for error on either side, but generally, thinking, how do I need to act so, long-term, this person will continue to seek care for issues.
The amazing doctor I found a few years after I was diagnosed with diabetes worked with me for a while, monitored my A1C, and when it was clear to her that I needed medication, she was so gentle. She knew me well enough to say, “I know you don’t like to take medication, but it’s time to do this.” I thought, “I don’t mind taking medication” but she was right, I didn’t want to take medication for diabetes. She knew I was trying to exercise, and that I was under stress, and that while lifestyle changes would be great, she didn’t say, “why don’t you try to lose weight first” because she knew my history very well.
I miss her very much. My current doctor is also sensitive and focuses on the doctor-patient relationship. He appears to have a holistic view of me. He’s flexible and understanding, and treats me with respect.
None of this should be surprising, but considering some of my awful past experiences, I am a little shell-shocked. Had I not had great medical care from these two physicians, I might have gone for many years with diabetes in poor control. As it is, I was diagnosed nearly 15 years ago and I don’t have any complications yet.
Also, consider that the underlying “problem” or “condition” they are seeing (in the case of diabetes, PCOS, and others) may be what is causing both the weight itself, and the other symptoms. So, someone with a family history of diabetes and a crappy early life and a stressful job, exhibits diabetes, is it the weight? Or those things causing both what the physician sees as a high weight, AND diabetes.
Compare how these two things sound:
“Your blood sugar is in the range that is considered diabetes. Would you like to talk about some changes to how you eat and how much physical activity you are getting that might bring your blood sugar down to a more safe level?”
“You have diabetes. You need to lose weight. Here are your options for losing weight…”
Which one would be more likely to help a patient come back on a long-term basis to control diabetes? Which one might actually produce long-term changes that can help control diabetes? Which one recognizes the patient’s role and responsibility in her health care?
Okay, stepping off of the soapbox now…
Thanks for asking. You rule!!!
Oh, and I wanted to add… thank you so much for being willing to take on this presentation on top of what I know must be an already overwhelming course/study load. If you help even one other person think about these things, it would be a huge improvement. Their future patients thank you. 🙂
I know it’s been said before, but I want to emphasize the “We already know we’re fat” bit. Many of us struggle to make our peace with that and it doesn’t help to have an “authority figure” like a doctor telling us, once again, that we are seen as societally unacceptable because of our size.
The other thing? If we come in with some complaint – ESPECIALLY a complaint that cannot even tangentially be linked to our weight – do NOT give us the weight loss lecture.
I stopped going to the local G.P. I had been using because I went in for the flu shot and she started telling me, “You know, if you want to lose weight, I can prescribe something.”
No – I am here because I want NOT TO GET THE FLU. They are two totally different things.
The other thing? For a lot of us, it takes a lot of guts to go in and see the doctor just because of past histories like that. Especially for a new doctor – you never know if they’re going to be cool or if they’re going to start preaching WLS at you even though you’ve not mentioned any problems related to your weight.