Let's talk about how not to be an asshole to your patients.

Or, for that matter, to your family members when they're in the hospital.

(Inspired by this post at XOJane, and by my own experience over the weekend.)

I had a patient this past weekend who was, by any definition, a Big Girl. Several inches over six feet, broad and strong in proportion to her height, and well over 300 pounds. She'd had a crazy-ass, rare clot in a weird place that had landed her with us. She also had a relative who, while well-meaning, was a royal pain in the patookus in regards to her weight. The relative, incidentally, was also tall, but very, very slender. And had an obsession: her relative's--my patient's--weight.

So I'm in the room, talking to the patient about her Cray-Cray Clot, and the relative starts in about the patient's weight. "You need to tell her she's fat," the woman says, "and that she needs to lose weight."

This is true. She is fat. She's way the hell over what any rational person would consider a healthy weight.

Nonetheless, she had recently finished a half-marathon. She played tennis twice or three times a week, and led a water-aerobics class a couple times a week. Her mobility was not impaired. Her lipids and blood pressure were normal. Medically speaking, she had no problems at all save an extra hundred pounds.

So I turned to the patient. "Do you own a mirror?" I asked. "Yes" was the reply. "Do you know that you're fat?" I asked. "Yes, of course" said the patient. "Are you aware of research that finds that extra weight can lead to health problems?" "Yes."

"There. Done" I told her relative.

Which brings me to my first rule of dealing with fat people: Do not treat them as though they don't know they're fat. 

As a fat person myself, I am constantly reminded that I'm fat. I can't buy clothes from straight-size stores, I am always the largest person in any group picture, and there are some things I find uncomfortable to do because of my weight, like going down stairs. (Going up stairs is easier on the knees, and my aerobic capacity means I'm often outdistancing my skinny colleagues. Still. . .)

If you're fat, you know it. Please give us fat folk the benefit of the assumption that we have brains.

Then the relative asked me straight out if the Cray-Cray Clot was due to the patient's weight.

It wasn't, and I told her so. It was due to the fact that the patient has a rare clotting disorder that hardly ever shows up in women.

In asking that question, Relative had fallen into the same trap that all the doctors who'd seen Patient had fallen into for months. Despite an unyielding headache and neurological changes, the docs who'd seen her hadn't looked at her brain; instead, they'd blamed her weight for her symptoms. Doing so had led to a three-month delay in diagnosis, incalculable damage to her brain and spine, and a lot of pain.

This is Rule Two: Not everything that is wrong is due to excess weight. Do not be blind to the fact that there might actually be a problem that can't be expressed in BMI.

Back in the day, doctors blamed wandering uteri for everydamnthing that went wrong with their female patients. This is exactly the same thing: blaming the most obvious factor for all the trouble ever. Fat equals wandering uterus in today's medicine. Do not blame fat: look for an underlying cause. Examine your patient's general health and activity level. Dig deeper.

Eventually, Family Member took me aside and asked me to have a serious talk with the patient about her weight. If she would just eat less, Family Member said, all her problems would be solved.

I leave it as an exercise for the reader to determine whether or not this is true. (Hint: it's not.)

By the time you get to be fifty, or a hundred, or five hundred pounds overweight, there are other things going on besides overeating. It's not a failure of willpower or a lack of knowledge and understanding. Thirty years ago, we had that attitude about drug abuse: if the person would Just Say No, things would be unicorns and rainbows and the world a better place.

Really severe obesity is a product of a multitude of factors, most of which have nothing to do with food per se. Therefore, my addressing one facet of the problem by saying "Hey, I just met you, and this is crazy, but you eat like a fucking pig, so cut back, maybe" is not going to help. At best, it's telling somebody something they already know. At worst, and most commonly, it demonstrates a lack of respect for whatever deeper issues that person's dealing or not-dealing with.

Morbid obesity is like heroin addiction: it starts from a place deep in somebody's psyche and has to be addressed holistically.

So here's Rule Three: Fat is not about food. Fat is about something else. Don't insult your patient, or your loved one, by assuming that it's just about the calories.

"If you want to help," I told Family Member, "you could reassure Patient that you love her no matter what her size is, and that you'll be there for her if she needs you. Right now, you're telling her that your love and acceptance is conditional on her being thinner. That's a losing game."

Finally, and without illustrative examples, here is Rule Four:

Fat is a descriptor, just as "strong" or "red-haired" or "really good at eye makeup" is. "Fat" does not mean "lazy" or "slovenly" or "smelly" or "bad."

Fat is just another adjective. Avoid making value judgements about somebody just because they're bigger than you, or--equally important--hating yourself because you're not at an ideal weight.

If I had my way, everybody would feel comfortable being who they are. Nobody would feel bad about how they look or however it is that they don't conform to whichever ideal is in fashion. People would eat greens and trot around enthusiastically and take their baby aspirin daily and be cheerful about their futures.

That's not likely to happen soon, so in the meantime I'll deal with the fracas surrounding fatness.