Wednesday, February 20, 2013

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.


bobbie said...

Oh AMEN, Amen, amen!! How many times have I been in the same situation...

Me ~ "Ma'am ~ your husband (fresh out of the cath lab) has had a massive heart attack."

Mrs. Dumbunny ~ "Well of course he did; look at how fat he is! You HAVE to tell him to eat less. He'll listen to you! You go tell him right now!!!"

Then she waddles away...

Kristy said...

Great post, the family member sounds like horrible!

Lynda Halliger Otvos (Lynda M O) said...

Fatness seems to be a licence for some people to say things that are so totally inappropriate and out of line that I am appalled, astounded and embarrassed to be a human when i read about or hear these words and combinations of words. What gives individuals the right to say anything even remotely like what I hear ?~! Unbelievable.

jimbo26 said...

You can also be fat through genetics .

Anonymous said...

Superbly said as always. Are you available to run the NHS? And don't even get me started on the "obesity epidemic" phrase...


MommyFixIt said...

As a woman who was of average size until puberty hit, and thanks to PCOS and genetics is now big and round, I thank you. Until the PCOS blood sugar issues caught up to me this year, I was healthy as a horse, physically active and all my other health measures right in line. I just happen to be huge.

BTW, it took me five years and a lot of pushing to even GET the PCOS diagnosis, because I'm heavy. No joke - they told me to lose weight and it would go away. Um, facial hair knows if I'm heavy? Irregular periods? All the other stuff? Reeeeeeeeealy....

Wayne Conrad said...

This is among my favorites of your posts.

My sweetie recites this brief litany, a super-condensed version of your post: "You're fat, you're a woman, it's all in your head."

messymimi said...

A thousand times, yes! A very good friend of mine, with every symptom of lupus under the sun, can't get a doctor to take her seriously; they all just tell her if she would lose the weight, her symptoms would go away. My thinner friend with lupus was diagnosed within a few months. It's awful.

Wendy said...

In addition to genetics, there is also the issue of medications. I take one that affects my weight...not an excuse, by any means, but a reason to work harder. I have a friend with a similar issue, her medication makes her gain weight. Then her doctor turns around and tells her to lose weight. Huh? The fact that your patient ran a freaking half marathon and plays tennis and leads water aerobics tells me she's in pretty good health! My doctor, thankfully, regularly tells me that I should watch my weight BUT that my cholesterol and triglycerides and glucose are all very good. Keep working at it, she says. Stay active, she says. And that's the key there, don't focus on how you look, focus on how you feel.

Applause to you, Jo, and the other sensible people out there. Thank you! I'd have been tempted to tell concerned relative to go soak her head.

Janna said...

Thank you for writing this - I wish more people realized that fat is not a synonym for lazy (and all those other descriptors). I'm so tired of feeling like I'm "less than" because of my size.

Anonymous said...

Amen, sister---sing it! I, too, was a skinny kid who fat really fast due to undiagnosed hypothyroidism and PCOS. Yes, I take my Synthroid like a good girl, and YES, the ovaries (and their friend Uterus) don't live here anymore~~but the fat seems to like it here just FINE! Like others, my VS and labs rock...within my size 18/20 body.

When we had to change MD's due to a 700 mile move several years back, one of my questions when interviewing prospective docs was "Is every broken toe and GI virus I get going to be because of my weight?"

OTOH, I respect myself and others enough NOT to wear Daisy Dukes and a jog bra in public.....

Pattie, RN

Anonymous said...

Thank you, thank you, thank you!

You should give workshops about this!


Moose said...

Thank you for this. If only every other person in medicine could read this and take it to heart.

There isn't a fat person out there who hasn't experienced bigotry from medical professionals. I regularly read blog posts by people who work in emergency departments talking about how "fat people never take care of their health" and wind up in their ED. Few of them can accept the idea that fat people get so shamed by doctors (some of whom refuse to treat them until they lose weight or sit through shaming lectures) that they stop taking care of themselves medically, until they need an ambulance.

I've been reading and following medical research for almost 20 years now. I'm beyond "morbidly obese". I understand that obesity can aggravate some things and cause a few. And I understand the difference between correlation ("A is linked to B" or "A is seen more often in B type people") and causation ("We found something in B type people that causes the onset of A"). Obesity is correlated with diabetes, heart disease, high blood pressure, and more. Except the actual science says there's no cause there for any of them. (Obesity is a symptom of diabetes, not a cause; heart disease is independent of weight; high blood pressure has a variety of causes and weight can aggravate it *sometimes* but so can foods or lack of exercise, etc.)

Being thin is correlated with some things, too. For example, thin people are more likely to get colon cancer. Nobody says to colon cancer patients, "You know, you wouldn't have gotten this if you were only obese!"

People who believe that weight loss is as simple as "eat less and exercise more" are failing to understand the complex mechanisms of nutrition and metabolism. Most of them saw that working for them when they were 20 -- when the metabolism is still fairly fast due to the end of puberty. By the time you hit 30 your body is so much more complicated. Add to that the genetics of weight -- if at least one of your parents is fat, you may be, too.

Look at the work of Paul Ernsberger and Glenn Gaesser, two scientists who have proved over and over again that it's not about your weight, it's about your exercise level. No matter how much you weigh, those who exercise are the healthiest.

Kim said...

I've been reading your blog for years and I just had to de-lurk to comment on this post. I am a 6 foot tall, 365 pound woman. Minus the weird clot, I could be the patient in this story. I am also a doctor. I've been on both sides of this issue, and I could not agree with you more. I'm fat and I know I'm fat. If you saw me, you would know I'm fat too. The people who try to pretend it doesn't exist are generally well meaning, but I prefer to be honest. I am blessed at this point in my life not to have any major medical problems but have seen time and time again fat patients being written off because of their weight. I have had patients assume I am not a good physician because of my weight. People assume I don't exercise because of my weight. People assume I am not up to performing physical tasks or worse, that I am lazy and do not want to perform those tasks because of my weight.

Like I said, I'm honest. I don't object to the term as a descriptor ("I want to talk to that heavy-set doctor, I can't remember her name.") or to talking about my ability to do things ("how are you going to get behind the bed to intubate that patient? Do we need to move xyz equipment?") but I do object to the stereotype ("oh, man, I hate the fat, lazy ones"). All direct quotes I've heard in the last year. Just as you wouldn't make assumptions about people based on their race, gender, or sexual orientation, don't assume about fat people either. Ask us politely what we can and can't do, we'll tell you.

It's undeniable that many, many health problems are directly related to obesity and a sedentary lifestyle as well as a high fat diet. There is no reason not to be direct with your patients (or with your loved ones for that matter) about this issue. In fact, you are doing a disservice by not being direct. But as you said, not everything is due to excess weight, and it should never be a condition of a) loving someone or b) providing high quality medical care.

If you want to discuss this issue with your loved ones, make sure not to make it conditional. "I love you no matter what, but I'm concerned about you, how can I help?" is so much better than "You know, you really need to lose weight to be healthy" or worse "You would be so much more ______ if you would just lose weight." That implies that your loved one is somehow less because of their weight, and that isn't fair.

The same is true for health care professionals. "You have diabetes. Starting an exercise program and losing weight will help you to have better control over your diabetes. What are you doing now to try and control your weight? What can I do to help you?" is so much better than "You know, you're going to die if you don't lose weight." Never assume someone is leading an unhealthy lifestyle because they are fat. You can never know where someone is in their weight loss journey unless you ask. Your 300 pound patient might have weighed 400 pounds a year ago. You won't know until you ask.

I always enjoy your blog and just wanted to thank you for your insightful comments! I blog about my weight/life/marathon aspirations and have been contemplating a post on this issue. I will definitely link to this post when I do!

terri c said...

Huzzah!!! Three cheers!! Well said!!!!

Kim said...

I forgot to say, I think your response to Family Member was right on the money. Health care could use more people like you, Also, maybe Family Member should consider that pehaps when Patient is in the neuro ICU with a non-weight related problem and probably scared out her mind is not the best time to open a dialogue with her about her weight issues. OK I'm done now. Back to my own blog :)

Allison said...

I love your wandering uteri comment, having had to tell some younger docs that I'm more than the sum of my reproductive organs. Once you hit menopause, the opportunities for doctor education begin again. Don't get me started on what you hear once you're 60.

akvaughn said...

I so needed to read this. Thanks. Love your blog. First time visitor. Been a nurse for almost 30 years and seen lots of fat people and guilty as charged for the misjudgment. You have made me see the light.

Anonymous said...

Just want to add at least one skinny person's enthusiasm for your subject. I know I am just lucky that I am so small & can keep it that way doing stuff I like. One of my oldest friends is not so lucky (she's a doctor, too) and she has sometimes cut trips we've taken together short because of the comments she overhears. That's bad - but getting that stuff when you're in the hospital??? Wow.

As always, Head Nurse, I hope the world is listening to you!

Footie said...

Saw Mr B today, he's 45, runs marathons, and has folds of unsupported flesh that hang around his face and neck like a bloodhound. He looks miserable and is worried about high Cholesterol and statin abuse. Told him to avoid eggs, butter, cheese, and meat with fat. If I did that I'd die.
My cholesterol is superb, slim, and streamlined - totally unlike the rest of me unfortunately. I'm giving a prayer of thanksgiving to my parents and thinking about the scotch eggs I had for lunch. My partners mutter about the fat tax and suggest I might be giving our patients a bad example, but most of them take my extra pounds as a sign of kinship and humanity. Somewhere I read that a glass of wine a day is just as good as running a marathon. Sounds good to me.

The Nerdy Nurse said...

How horrible!
I feel so bad for your poor patient having such an atrocious family member.

When people are overweight they are treated poorly and discriminated against in many arenas. Healthcare is the same.

She was obviously active and there were other underlying issues causing her weight, but at the time that really wasn't what needed to be addressed.
Someone needs to backhand the patient's family member or shake her really hard a few times. Knock some sense into them!

Anonymous said...

You really touched the point. Love you.
I am a nurse as well

Bryan said...

If age is a factor why you have problem with metabolism, then take some help from herbal that boost metabolism. Eat right and regularly. As much as possible, eat vegetables and fruits. Exercise everyday, You have to discipline your self. Do it every day. Jog. Don't waste your time in the gym alone. Jog. Set a standard . I've been fat before, and it is not easy. Needs a lot of will to do it. If you really want to. I feel better everyday doing the active lifestyle.

Davis Mards said...

That's outrageous to judge a patients by looking at the physical outlook. He/She could have health problem that lead to mass buildup or the inability to convert fats.

Ryott said...

Haha, this was such a great post and very accurate! I'm a student and plan to make your blog a regular read.

Sharona Zee said...

Amen! Fat is the last group in america (ok, and smokers) that it is socially acceptable to openly discriminate against.

SillyProfessor said...

Fabulous post. You hit the nail on the head. Funny, one day I was too fat. Then I was crazy. Then I was too thin. Your blog makes an excellent point. So eloquent...

SillyProfessor said...

Fabulous post. You hit the nail on the head. Funny, one day I was too fat. Then I was crazy. Then I was too thin. Your blog makes an excellent point. So eloquent...

Steven Saus said...

I work in a hospital. I had reason to call nurses to see if a patient's weight was over a certain limit (350#) to determine which set of equipment to use.

Nurses would routinely - emphatically - guess that a patient who weighed 200#-250# was over the 350# limit.

As someone who is close enough to that limit to see it around the bend, I felt crushed each and every time a nurse overestimated a patient's weight by a hundred pounds or more.

Anonymous said...

THANK you for this.

I am the spouse of a heavy guy. He is, as one observer remarked, 2 years and 107 pounds into his fitness journey. He exercises 3 times a week with a trainer, does 10000 steps (not a typo) on the treadmill every day in addition to that and he is maybe halfway there. We are not certain. He doesn't remember his weight when he was healthy and I did not, as he once observed, marry him for his svelte pool boy physique.

Standing next to him, it astonishes me the godawful, unhelpful, sabotaging, intensely selfish and self-focused things that theoretically well-meaning relatives will say to him. Because he isn't instaskinny, he is evidently unaware that he should eat well - or is being careless with his health or lyign about his efforts or is miserably unhappy (because fat == depressed, obviously). I want, desperately, to capture these folks on video and encourage them to watch themselves and hear the words escaping their lips. It would be Not Okay of me, but I'd be lying to say I hadn't contemplated it.

One positive note: he went in this weekend for flu symptoms. Now, he is a big guy - but they pulled his records, glanced at the steadily decreasing weight numbers and improving BP (now in the pleasantly healthy range) and his lovely sugar numbers and started diagnosing for 'you appear to have lots of flu symptoms'. They didn't mention weight. They jumped to no conclusions about a connection there, glanced at the data, and went after the real issue.

(Course, he got tamiflu, and because I was too bloody stupid to go in, I got DayQuil. My own damn fault.)

Thank you. nice to read a perspective like this.

Tez said...

What a pertinent topic and so well written about. I was diagnosed as "morbidly obese"25 years ago. My weight has been the same in all those years but I still get these kind of comments from people in the medical professions. I'm thinking of putting a sign around my neck saying, "Yes, I know I'm fat. Get over it."

Thank you for writing this, you're my hero.

Debbie said...

I came here from Five Star Friday, and I LOVE this post -- I've never had any sort of clot, but Family Member sounds like My Mom. Every single problem in my entire life is caused by The Fat, and I should skip lunch and go hungry even if it makes me want to punch people.

Rose said... many times have I been in a similar situation..usually in a child pt vs parent scenario... your description of the situation kills me :)

LifePainter said...

What a wonderful post. Thank you for your attitudes, and for sharing them.

Alice Cox said...

Well Said. I have been told that I eat right, which I try to do, and I still have weight problems. With the ever increasing time sitting in traffic, sitting at work, taking care of family, it is often difficult to take care of one's self. And as you said, "It's not always about the calories."