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Fat shaming by medical providers

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Just to play devil's advocate here a bit. I, at one time, was that patient that was 'fat shamed'. Early teens-early 20s. Active, played sports. Weighed 120-130#. Considered obese BMI because of my height. Though, because of my build, I'm quite muscular. I remember hearing all the time that I was fat. Needed to lose weight. That I was unhealthy. Needless to say, I started dieting and being more unhealthy trying to get that number down. Looking back, I was probably a little overweight. But, given my activity level an build, I was fairly healthy. And honestly, hearing how obese and unhealthy I was at that age, led me into years of even worse and unhealthy behavior. There's a right and wrong way to approach weight and it's relation to health. And not all health issues are weight related.
The news article may have been going a little far with its generalizations, but, I do feel many providers just want to sit and blame everything on weight

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We used to have an issue with people using/abusing the BMI in and of itself for determining "fatness"...BMI  is supposed to tell us to look a little closer at things.  The fine print says body composition is supposed to be taken into consideration, but, like many people, few read the fine print.  I'd seen people with 1% body fat put on career probation in the military because they were "overweight" because of the their BMI, yet if they did a caliper or dunk test, they strangely passed -  they were simply lean and mean, but big.  Note I didn't say they were fit - a lot of those behemoths couldn't run to the washroom without getting out of breath...they just weren't "fat" or "obese".

SK

 

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I firmly believe we all want good health for our patients.

We have been micromanaged by the insurance companies and now the government with their metrics and measures of how "successful" we are. Instead of holding patients responsible for personal health and achievement, we are the scapegoat who doesn't get paid.

Just had this discussion with my new chief of staff at VA. 

I can document till my fingers fall off that John Doe has been counseled to stop smoking and his direct and frequent retort is "I will stop smoking when they nail my coffin shut". If some insurance company wants to pay me less for that - then our world has achieved a new low.

I am fluffy - not something I am terribly proud of and I feel like the "do as I say, not as I do" kind of thing. However, my fluff makes me approachable to the patient - I fight the same battle. Never smoked a cigarette a day in my life but never walked past a cookie. 

If I can relate to my patient - I have done something right - I can tell them about high blood pressure, diabetes, stroke, arthritis, back pain, etc etc etc and tell them how it affects me and what gems my grandma gave me genetically. 

I tell my patients I cannot go home with them or to the grocery store - I can give them advice and it is important. It is not as tangible as the mechanic telling you your brakes are shot and then you go get in an accident because your brakes went out. It might take years to see the consequences but I have the information, education, data and some solutions.

Those solutions are not always a pill and shouldn't be. 

I am not rude to most patients - I choose the sharpness of the blade based on my relationship with the patient, the current situation and how things have worked for that person in the past.

An extremely unbelievable female doc that I had to work with would shame EVERYONE - told smokers that they had polluted our exam room and now it couldn't be used for a couple of hours due to stench and she would go home and smell it on herself and have to dry clean her clothes. Told obese patients that they were too fat for the exam table and "don't break my equipment". She shamed everyone - tattoos, hair styles, colors, clothing choices - all in the name of "I am a doctor and know best".  Truly an awful and ineffective provider who did nothing to help her patients.

The article is one sided and totally politically correct instead of addressing the growing obesity problem and HOW we can approach it effectively. 

I don't blow sunshine and rainbows but I sure don't go in swinging either. 

Do right by the patient, do no harm and be helpful.

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I have been a lurker on this forum for some time and have really enjoyed reading posts made by you all but I found this one quite dissapointing. This post seems to reflect exactly the attitudes that caused the article to be written in the first place. How do you get this:

"So...I'm going to get sued when I recommend weight loss for someone who is 400 pounds, can't fit in the MRI machine, and has 10+ pitting edema, but I don't recommend weight loss for someone with a BMI of 26 who exercises daily?"

from this:

“Recommending different treatments for patients with the same condition based on their weight is unethical and a form of malpractice,” Chrisler said. “Research has shown that doctors repeatedly advise weight loss for fat patients while recommending CAT scans, blood work or physical therapy for other, average weight patients.”???

This is a textbook example of fallacy of ridicule. The point the article was trying to make, since it apparently sailed right over your head, is that its easy to blame all of a patient's problems on their weight and neglect other possible causes. You'd never jump to conclusions like that, right OP?

I would also like to point out that fat doesn't necessarily = stupid, and that when you think of your patients as "fat slobs" it's quite likely that while they might not know your exact phrasing they probably do pick up on the contempt you feel for them, and this may very well cause them to avoid seeing you, delaying their treatment. I would posit that "do no harm" also applies to emotional/psychological harm, and while it is absolutely necessary to tell your patients the truth, fat is indeed fat, doing this with the same common courtesy and respect you would offer anyone else while you're doing it would probably go a long way toward making you a provider who could actually benefit your fat patient rather than just making them feel bad. I thought that was the point.

 

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I try to be honest with all my patients. that includes the following:

telling type 2 diabetics that weight loss may decrease their need for insulin and decrease their risk of developing comorbidities such as kidney failure, retinopathy, etc

telling 350 lb pts with chronic knee pain that wt loss may decrease their pain and prevent the need for a knee replacement

telling patients who smoke that it increases their risk for heart disease, stroke, etc

telling meth and heroin addicts that IVDU increase their risk for dying of many types of disorders

telling folks who drink gallons of soda a day that they are at a higher risk for developing kidney stones, etc

we shouldn't treat obese patients(or smokers, or diabetics, or drug addicts) differently, but we should tell them the truth, even if they don't want to hear it.

 

 

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There is an art to telling patients frankly that their lifestyle is directly harming their health. It can and should be done without shame--but this requires a respectful discussion. I like to ask directly: how do you think your weight impacts your knee pain?
I have had blank stares from a few folks who honestly never put 2+2 together, but most people tell me they know it's not good. What you don't do is what I used to say in my younger and less tactful days (INTJ me, sorry lol): "The human body was not designed to carry the weight of three people on one set of knees". I used that line a few times...ouch. True but yikes.


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On 8/20/2017 at 7:02 AM, primadonna22274 said:

There is an art to telling patients frankly that their lifestyle is directly harming their health. It can and should be done without shame--but this requires a respectful discussion.

I routinely use pretty direct but disarming language:

"I'd rather see you keep your money in your own pocket instead of giving it to Big Tobacco"

"You let me know when you'd like pharmaceutical help quitting smoking"

... and the like.  I emphasize that life is full of tradeoffs, that our natural desire for high glycemic-load foods is adaptive when they're scarce, but maladaptive when "convenience store".  An earnest desire to help your patient, and an absolute lack of disdain or disgust for your patients are essential.  I am so glad I didn't get into practice until my early 40's, because I would not have been able to do it right earlier in my adulthood.

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