Fat shaming

[rev ronin]

I'm a wee bit irritated tonight.

I spent about 20 minutes today sitting next to one of my eating disorders patients while she was having a panic attack, talking her through it, calming her as best I could.

This particular patient is on medicaid, from an historically oppressed/disempowered minority, and has a number of health challenges that takes more than two hands to count.  I'd given her a small list of things I wanted her to talk to her PCP about, because hey, I like to stay in my lane, and those were really general health issues, that I would have wanted a specialist to refer back to me if I was in the PCP role.  The PCP appointment happened yesterday, and nothing--literally nothing--got solved.  While this PCP may not have known that this patient had previously set a 'do not exceed' weight, above which she intended to end her own life, that PCP knew or should have known that this patient was actively under care of an eating disorders program.  So, the first thing the PCP does to my obviously large patient this visit is to weigh her, tell her the number, and chastise her for exceeding that 'do not exceed' weight--the one she'd previously purposed to kill herself if it was crossed.  I don't know what was actually said, because the substance of that visit has been filtered through my patient, with her own fears and biases, but it certainly wasn't helpful.  Thankfully, I work on a team with awesome therapists, a psychiatrist, and a dietician.  My only real job is to keep their electrolytes and QTc's in range, but because I was the one available in the moment, I'm the one who sat with her in her crisis. Honestly, I do NOT expect to use my Fire Chaplain skillset in a medical setting on a regular basis... yet there I was.

Can we please treat patients with weight problems at least as well as we treat patients struggling with addiction?  Because that's what it is.  No, instead, more often than not I hear of other medical providers treating patients with eating disorders as if it's a big moral problem or willpower failure.

I know none of you would ever do that, right?  Right?

[Guest Paula]

Right.  It's important to get the full history of the patient and to gain their trust so they CAN discuss what is really going on in their lives.  In today's healthcare we do not always get that history  adequately or at all.  Our smart phones do not have an app for that.

Rev, you did the right thing and had the right moment to counsel her.  You have probably made her want you to be her PCP.

[SedRate]

6 hours ago, rev ronin said:

 

Can we please treat patients with weight problems at least as well as we treat patients struggling with addiction?  Because that's what it is.  No, instead, more often than not I hear of other medical providers treating patients with eating disorders as if it's a big moral problem or willpower failure.

I know none of you would ever do that, right?  Right?

It proves difficult when said individual is also manipulative and/or malingering. They may try to pit providers against one another. I have had one patient in particular who would agree with our plan to lose weight before a revision knee replacement (referred from out of state), only to decline dietary consults and employ her family member to feed her addiction. Another would refuse to take his diabetic medication and show up to the ED with Glu >400-500+ with recurrent cellulitis and diabetic foot infections. He said the things we wanted to hear but would come back the next week with another infection. After our part was done, this went on for years with other body parts at several other hospitals. The gentleman was also seeing a chronic pain clinic. It makes you wonder if he enjoyed being in the hospital more than home and receiving IV pain meds after each of his dozens of surgeries. 

Although I have no real direct involvement with managing patients such as the one in your example as a practicing PA, only as a surgical consult, but from my training in inpatient psych where we treated concomitant borderline personality disorder often, it proves difficult to get through to these individuals and medication is often minimally effective. It requires a great team such as yours as well as an incredible amount of patience without stigma. This is hard to come by in the world nowadays, especially in the clinic where pressures are rising to meet metrics and quotas. Good on you for being there to help and offer compassion. 

[PickleRick]

Had a 350ish patient yesterday (minor care clinic) who tells me she stopped taking her metformin many months ago because she didn't like the way it made her feel.  I asked her if she liked how her feet feel, and went on to explain all of the long term possible negative outcomes of poorly controlled DM.  Encouraged to see her PCP.  The rest is up to her.  

[GetMeOuttaThisMess]

55 minutes ago, PickleRick said:

Had a 350ish patient yesterday (minor care clinic) who tells me she stopped taking her metformin many months ago because she didn't like the way it made her feel.  I asked her if she liked how her feet feel, and went on to explain all of the long term possible negative outcomes of poorly controlled DM.  Encouraged to see her PCP.  The rest is up to her.  

You are telling stories, sir.  There are no such patients in your clinic that would do such a thing.

[SedRate]

59 minutes ago, PickleRick said:

Had a 350ish patient yesterday (minor care clinic) who tells me she stopped taking her metformin many months ago because she didn't like the way it made her feel.  I asked her if she liked how her feet feel, and went on to explain all of the long term possible negative outcomes of poorly controlled DM.  Encouraged to see her PCP.  The rest is up to her.  

It is incredibly mind-boggling regarding the misconception around the diabetes disease process and management. I do hope PCPs explain the ultimate benefit of exercise in reducing blood sugar level and a healthful diet as a first line of defense in preventing excess intake of sugar in the first place. And more importantly, that insulin helps to store the glucose thereby reducing the blood-glucose level, not get rid of glucose altogether, which contributes to weight gain and fat storage. Not only that, but that diabetes ultimately causes irreversible damage at the microscopic level. Microvascular disease is something I've found that patients don't typically understand. They know high blood sugar = bad, but when I explain the process of long-term microvascular damage, especially to their kidneys and distal extremities, I am typically on the receiving end of a deer-in-headlights look.

PCPs have the most difficult job in trying to get through to these patients, especially after a disease process has already set in and preventive medicine is no longer possible. I try to do my part as a subsurgical specialist who still cares dearly about overall health maintenance and education -- that's the beauty of being a generalist-trained PA, no matter what specialty is pursued. It helps me see the bigger picture in medicine.

[thinkertdm]

To be clear, the PCP that rev was counting on ignored the list, focused on the obvious- weight- and targeted that.  And not in a good way either, leaving the patient humiliated.

One might say, "well, that's what the patient said".  True.  I counter- if that's what the patient took away, then the provider didn't do his job.  Doesn't matter how gently he (or she) put it, the patient took the wrong message away, and it is the providers job to make sure- to set the stage, to ensure the audience is prepared to listen, to sell the plan.  You have to be the salesperson of the year, Shakespeare of the exam room.  You have to inspire them. 

I went to a practioner (of the nursing persuasion) who berated me on my variable blood sugars.  She was in charge, came in, made sure I knew I was wrong, and left me feeling useless. So  f@#$ them.  I see my job as a pcp to ensure the patient has the tools to do it.  To do that, you need to leave your biases at the door.  And trust me, we all have them.  Diabetics in particular get no pity from me.  What they do get is understanding.  I know where they are coming from.  I know it aint easy.  They don't have my sympathy, they have my empathy. 

As rev said, the sometimes the problem isn't the weight.  It isn't the uncontrolled blood sugars.  It isn't the noncompliance.  Ever wonder why people need six antihypertensives?  Maybe they aren't taking them?  So instead of adding more medicine, instead of blaming them, find the actual problem.  Do they not understand the disease?  Are they scared of the pills?  Are they scared of their own mortality?

Oh, and for the love of...everything, don't scare the patient without giving them hope.  Its what revolutions are made of.

[NYCPAC]

Might get flack for this but wish more PCPs would consider looking through this curriculum. It does not “promote” obesity. But rather encourages providers to help their patients identify barriers to optimizing their health. Health should not exclusively be defined as physical fitness and a number on that antiquated BMI scale, there are SO many layers to wellbeing and general health.

https://www.sizediversityandhealth.org/content.asp?id=19


Sent from my iPhone using Tapatalk

[Mayamom]

15 hours ago, rev ronin said:

My only real job is to keep their electrolytes and QTc's in range

Wow that's a very difficult thing to monitor.  Can change in an instant.  I found eating disordered patients (restrictive type mostly) to be 

very difficult to take care of.  They are lucky to have you. 

[rev ronin]

3 hours ago, Mayamom said:

Wow that's a very difficult thing to monitor.  Can change in an instant.  I found eating disordered patients (restrictive type mostly) to be 

very difficult to take care of.  They are lucky to have you. 

Thankfully, I'm doing this outpatient, so if they needed to be checked more often than weekly, they go to a higher level of care.  I don't think I've actually seen a BMI lower than 18; there are FAR more intense/seriously physically ill ED patients around than mine.

[ventana]

many different topics coming up in this thread

 

A few that I think warrent specific mention

 

1) Just because some suit (or the EMR) thinks we need to get full vitals on every patient that does not mean we do.....   we decide what care is given.  I have a patient with an eating disorder in the nursing home, weights are a HUGE trigger and they were trying to do weekly.  (weights pretty stable).  they were truly taken back when I said "stop weighing her"  Took a fair amount of explaining.

Another on in the office who fights anorexia and bulimia (and unfortunately is also uncontrolled bipolar and possible borderline) and the MA got in a yelling match with her (really the patients fault) but had to explain to the MA not to push.

2) Staff splitting - I hate to say it but listening to the patient is a sure way to think you coworkers are idiots.  Patients staff split, and sometimes have very devious intentions.  Maybe not with your patient, but it does have more times then not

3) the biggest issue is the meltdown of PCP fields.  It is sorry to see and I just hope and pray the insurance industry maybe recognizes the value of PCP and bring up our reimbursements with out adding in yet more hoops to jump through.

 

These three issues...... ugh

[PickleRick]

23 hours ago, GetMeOuttaThisMess said:

You are telling stories, sir.  There are no such patients in your clinic that would do such a thing.

I'd bet a dollar to chicken fried rice that if you knew my clinic, and my previous colleague that left me high and dry during flu season, you would think differently. ;)

[rev ronin]

14 hours ago, ventana said:

2) Staff splitting - I hate to say it but listening to the patient is a sure way to think you coworkers are idiots.  Patients staff split, and sometimes have very devious intentions.  Maybe not with your patient, but it does have more times then not

Yup, which is why I tried to be very specific that this was per the patient's report.  I agree that vigilance is always a good idea, but on a 'devious' to 'powerless' scale, this patient exudes the latter.  With a background in security, I'm also always doing a risk assessment on everyone lying to me: my patients, my staff, other providers... and I still can't figure an angle why this lady would be faking any part of this report.

[SedRate]

On 12/6/2019 at 7:12 PM, rev ronin said:

Yup, which is why I tried to be very specific that this was per the patient's report.  I agree that vigilance is always a good idea, but on a 'devious' to 'powerless' scale, this patient exudes the latter.  With a background in security, I'm also always doing a risk assessment on everyone lying to me: my patients, my staff, other providers... and I still can't figure an angle why this lady would be faking any part of this report.

She may not be lying or faking, but her memory recall may have been skewed by her emotions. 

I think we all know how common it is for us as providers to say one thing and patients to hear another, whether by their lack of attention, refusal to accept what we're saying, or by emotional blocking. When you introduce something emotionally charged, you can almost guarantee clear-thinking (and subsequent memory recall of said emotionally charged event and dialogue) is thrown out the window, especially with psych patients. 

I'm not here to defend this PCP or vilify this patient. But I try to give people -- patients and other providers alike -- the benefit of doubt. 

Have you called said PCP to discuss?

[rev ronin]

5 hours ago, Sed said:

Have you called said PCP to discuss?

To be honest, I hadn't even considered trying.  PCPs who see medicaid having time to talk to a specialist PA?  Why would I even waste my time... or theirs? Would one phone call make a difference to a provider so overwhelmed trying to care for an entire panel of such patients?  I suspect I'd be dismissed as unrealistic in the best case.

[SedRate]

16 hours ago, rev ronin said:

To be honest, I hadn't even considered trying.  PCPs who see medicaid having time to talk to a specialist PA?  Why would I even waste my time... or theirs? Would one phone call make a difference to a provider so overwhelmed trying to care for an entire panel of such patients?  I suspect I'd be dismissed as unrealistic in the best case.

I hear ya. Maybe calling them won't change anything, but it obviously affected you enough to write a post on here in the middle of the night. Maybe contacting them will help put your own concerns to rest as well as possibly expanding your medical community outreach and deepen your relationships with colleagues in the community.

Disclaimer: I, too, try to stay in my lane, but I also communicate with providers whenever possible. I let others know to always reach out to me if there's something to discuss, especially if it's affecting our patient's medical care.