Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, June 10, 2007

Time to Weigh In

This post appeared on KevinMD back on June 4th. Similar items have appeared elsewhere from time to time, with varying opinions. After much thought, I'm ready to weigh in, if you'll pardon the pun.

The issue is that of overweight doctors counseling overweight patients about diet, exercise and other lifestyle issues. The article quoted concludes that overweight and obese physicians are less effective than their slimmer counterparts in providing this kind of counseling and care to their patients.

I disagree.

The article discusses overweight physicians "feeling like hypocrites" advising their patients to exercise and lose weight. The feeling is that "heavy doctors who attempt to counsel their patients to lose weight may find their advice falling on deaf ears." In addition to everything else we are supposed to do and be for our patients, we are now also supposed to be role models.

Interestingly, three of the doctors interviewed for the article "found help at the Obesity Treatment Center, a for-profit operation (emphasis mine) run by internist John Hernried [another physician quoted in the article.]" The article continues:
The program, which in its most intensive phase costs as much as $700 per month, combines a very low-calorie diet and medical monitoring with intensive education around nutrition, exercise and awareness of behaviors that lead to weight gain.
The role model thing may be a valid argument, but this particular article now seems more than a little self-serving.

At any rate, I still disagree with the essence of the argument. At least as important as modeling behaviors for our patients is empathy with them. Frankly, I don't think an overweight patient is going to be particularly attentive to a skinny-minny little doc exhorting her to lose weight with platitudes like, "Just eat less and exercise more." Talk about falling on deaf ears! I can read that patient's mind: "What the hell does that little twerp know about how hard it is to lose weight!"

Disclosure: My BMI is in the range of "obese". My weight has yo-yo'd over the years, most recently ballooning upwards because of painful, treatment-resistant plantar fasciitis curtailing my exercise regime. Despite the article's claim that:
A study published in the journal Preventive Medicine in 2003 found that when doctors watch their own weight, they are more apt to counsel and encourage their patients to lose weight and improve their diets.
I regularly bring up the issue with my patients. I talk about diet and exercise all the time, however I am able to do so with true empathy. "Of course it's hard. Just look at me!" And then on to discussions of Weight Watchers, portion control, thirty minutes of walking daily and all the other lifestyle modifications that I once did and know I have to get back to.

I believe strongly that empathizing with patients counts for a helluva lot more than plain "role-modeling." Having "been there" -- whether it's trying to lose weight, undergoing a procedure (I've had both upper endoscopy and colonoscopy) or suffering the loss of a family member -- and therefore being able to offer genuine empathy is tremendously valuable, and patients appreciate it. In fact, in many cases it's the essence of credibility. I know for a fact my practice of pediatrics underwent a tectonic shift once I had kids. I'm not saying that one can't be a good pediatrician if one isn't a parent; but there's no denying it's a definite boost for credibility.

I know I need to lose weight. I've done it before and I know I can do it again. But I know that shame and fear and humiliation do not work as motivators for me. Just the opposite; depression about inability to lose weight leads to emotional eating. In fact, I'm only able to lose weight once I accept myself at the current weight. (Murphy's Law of Shopping, too: once I buy all new clothes in the bigger size, that's when the diet finally starts working.) So what I offer my patients is loving support: "How can I help?" I've done all the diets; I know all the tricks. Let me help you brainstorm.

But if your BMI is under 21, don't come trying to talk to me about weight loss!


At Sun Jun 10, 10:58:00 PM, Blogger Judy said...

I have one exercise recommendation -- swim. Much easier on the plantar fascitis than walking. I also like recumbent bicycles (easier on arthritic knees), but I'll be much happier when the lap pool at my gym is finished.

At Sun Jun 10, 11:45:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

I think I would be a more effective motivator to my patients if I could accomplish what it is I want them to do. Then every visit with me they could see that what they want to achieve is possible. Because if I can do it, anyone can.

Getting from thinking this to doing this is the problem....

That said, I have succesfully motivated a number of patients to lose weight, despite my own shortcomings. Because in the end, it is about them, not me. They know that, and so do I.

At Mon Jun 11, 01:02:00 AM, Blogger Dreaming again said...

The doctor's I listen to the most ... the ones who me obviously struggle.

That does not mean that they are obviously overweight ...but I've had one female doctor who I'm not too sure isn't a half step from an eating disorder herself ..and is obsessive about her size and weight and has dieted to the extreme even taking phen fen when she was a resident (although on the quite skinny side) ...but ..for her, it is a constant thought in her mind ... and I don't think it's a "ooh, look at me, I'm so thin, I'm going to pretend I know what you're thinking"

I guess, I just know the talk too well. I know real disordered talking from placating talk. If she's not there, she's on the boarderline. So, when she empathizes with me, I do know she understand what it feels like emotionally, even if she's never really physically been where I am.
(I worry about her)

The overweight men docs ... yea, especially 2 imparticular "Look at me, I understand!"
That, went a long way to telling me ... I'm working too ...

and when I get some success ... my doc asks ME what I'm doing!! When he finds something he tells me ...and it's not a here ... you have to try this's let me share. It's a give and take ...and it is a definite show of support.

At Mon Jun 11, 07:55:00 AM, Blogger Bookhorde said...

But I know that shame and fear and humiliation do not work as motivators for me.
I agree with that. Celebrating good choices works/worked for me in weight loss.

At Mon Jun 11, 03:47:00 PM, Blogger MedStudentGod (MSG) said...

Perhaps. I think that a physician who is *actually trying to lose weight* is more likely to be understanding of and understood by patients. I also agree that someone who's always had a high metabolism and drinks several sodas a day is less likely to get the message through. But the really overweight docs, the obese ones who are clearly out there it will be harder for someone to take their advice without thinking them a hypocrite. Personal experience and observation all tend to agree with this sentiment.

At Mon Jun 11, 03:55:00 PM, Blogger Sara said...

Amen. Of course it's better coming from someone who's been there.

At Mon Jun 11, 04:28:00 PM, Blogger Dk's Wife said...

Interesting, and I have oftened wondered how overweight doctors handle discussing diet/exercise with their overweight patients.

At Mon Jun 11, 06:26:00 PM, Anonymous Anonymous said...

Weight happens to be one of the few things that are clearly visible.

I wonder how many physicians lecture their patients about curbing their alcohol consumption... yet drink far too much themselves? Or lecture about safer sex but are boffing one of the nurses? Or lecture about stress management but can't manage their own stress?

My point being that it's easy to get fixated on what we perceive as hypocrisy about weight... but overlook the other stuff because it just isn't as visible. And isn't that equally hypocritical?

I don't think someone else necessarily has to walk in my shoes to really understand my problems and challenges. But I do appreciate physicians who are ready to acknowledge they aren't perfect either. It makes them a little more human and makes me feel safer about being honest.

There is enough of a power imbalance in the doctor-patient relationship without having the doc be (ostensibly) perfect as well. I would not be comfortable sharing some kinds of information with a perfect doc.

My doc is slender, good for him, but I happen to know he was sued a couple of years ago, so I know he's had his share of heartache. It gives him just a little more credibility, you know?

At Mon Jun 11, 07:27:00 PM, Blogger Bardiac said...

The weight thing is SO hard. I don't even know how to ask for help, because the answer's easy, right? eat less, exercise more. But it's really so darn hard. And I don't want to get sent to be lectured at (strike that) "educated" about losing weight. And going to a group to talk about weight would make me nuts.

At Mon Jun 11, 08:58:00 PM, Blogger Bo... said...

I'll never forget an ER experience I had in which a lanky old cowboy with lung disease came in with lung problems.

The very overweight ER doc (who happened to be a VERY unpopular guy with the staff because of arrogance and poor treatment of nurses), made a flip, rude statement to the patient right off the bat, stating sanctimoniously: "Well, I see you still haven't given up the cigarettes--so there's your problem."

Without batting an eye, the old cowboy simply replied: "And I see you're still fat."

Half the ER staff had to leave the area to laugh in private.....

At Mon Jun 11, 09:00:00 PM, Blogger Dr. J. said...

I find it endlessly fascinating that doctors continue to find fault with themselves for the competent decisions of their patients.
If a patient needs to loose weight, I tell them that in my opinion they need to loose weight. In the ensuing conversation I assess their readiness to make changes. If they are ready, I pounce and help them, if they are not I use techniques to confront any ambivalence and try to move them towards change. When they leave the office, I chart it and let it go.
I offer assessment and treatment, and the patient decides what they want to do. The decision is theirs as long as they are competent, whether it is rational or not, and regardless of what their own personal payoff is. My job is not to hold my self up as a beacon of all that is light and good (or light and healthy as the case may be), and I'd suggest any doctor who does subscribe to that notion is treading on dangerous ground.

At Mon Jun 11, 10:20:00 PM, Blogger Rebecca said...

The most useful piece of information that I learned in school is that fear is the least effective motivator.

I don't need my provider to lose weight or be perfect in their personal life. I need them to listen to me and help me do what I need to do. My boss once explained to me, in a very clear way, why an effective marriage counselor does not need to be married (he is a former counselor). It's the same thing. If someone is heavy, they can use the empathy better than someone who never struggled. Someone who has never struggled, may be such an effective counselor that it is irrelevant. It comes down to the individual provider.

At Tue Jun 12, 01:22:00 AM, Anonymous Anonymous said...

I'm a morbidly obese family doctor. I weighed 100lbs. at age 10 and just kept gaining-- college, med school, residency, my first job where I was sleep-deprived more nights than not. The further along in my training I got, the more I thought I should just be able to lose weight on my own and was too embarassed to ask for help from other doctors. I also read every study ever done on obesity and all of them showed that morbidly obese people can't lose weight and, even if they do, they all gain it back. That made me figure, why try. Medications weren't shown to help long-term, and then there was the fen-phen fiasco that came to a head while I was a resident. Gastric bypass? No way--the horror stories I've seen. I'd rather be fat than have my life ruined like a couple of my patients--dying early would be better than what these people have gone through.

Last year, I actually started to consider it. I became so fatigued, sore, and miserable, I knew I had to do SOMETHING. Some hormone issues led to my doc recommending I see an endocrinologist. An endo fellow friend recommended one who also specializes in obesity, and I jumped at the chance to see him.

He told me I wasn't a bad person or a failure for being obese and that he planned to treat it like any other disease. He looked for organic disease making it harder for me to lose weight. Found some (hypothyroid, Vit. D deficiency worsening insulin resistance) and ruled out others (pituitary tumor, Cushing's). Treating the first two made me feel a million times better so I had the energy to exercise. I started Meridia the first visit (he takes it and showed me how much he's lost). I've lost over 85 lbs. and today, actually, dropped under 300 lbs. for the first time, probably, since medical school. I know it's going to be a daily struggle forever, but boy does it help to have someone to help.

I would not have trusted a skinny doctor. I probably wouldn't have taken a Meridia script from him or her. This clinic generally works on a team approach so you see other providers in the clinic, but the other main doc is skinny (there's a certificate in the lobby he got running an Ironman triathalon for god's sake). I heard a talk he gave--seems nice enought. I don't want to see this person--I'm completely intimidated--so I just keep requesting the endo, and they let me see him, thank god.

I totally agree with the dinosaur that having been through an illness, procedure, etc. makes a doctor better able to care for patients with the same problem. (To the endoscopy and colonoscopy list which were no big deal due to VERSEd, I'll add brain MRI--I'm not generally claustrophobic but would NEVER do that again without Valium.)

I know people don't WANT to be fat (or smoke or drink too much). I don't just tell them quit smoking or die. I comment how hard it is to quit smoking or lose weight, especially without help. Then I discuss some of the things that can help. I figure they might not take the help the first (or tenth) time, but if they know I'm there to help and not judge them and have struggled with similar issues myself, maybe they'll accept the help eventually--it takes us all time to work through our issues, doctors, too.

At Tue Jun 12, 10:30:00 AM, Blogger Dk's Wife said...

Just wanted to add something else: My husband smokes, and our doctor (an angel, I swear I love this lady) has been "coaching" my husband on cutting back on his smoking. He respects her and has total faith in what she does; hence, he has cut back quite a bit. As she continues to work with him, I hope that it will eventually lead to him quitting altogether. That is a joint effort by both parties.

Point being is that matters so much how a doctor approaches a patient. My husband would think and has thought I was just nagging, but she has worked wonders with him on this subject.

Okay, I am done now!

At Wed Jun 13, 01:03:00 AM, Blogger ERnursey said...

The sad thing is there is such pressure to be thin that I have actually had post-bariatric surgery patients tell me they purposely gained weight so they would qualify for the surgery.

At Thu Jun 14, 06:57:00 PM, Blogger Evil HR Lady said...

Weight loss is hard for anyone, even doctors. I would probably be more inclined to listen to a doctor who wasn't a twig.

At Fri Jun 15, 03:13:00 AM, Anonymous Anonymous said...

I don't think the common sense advice of "eat less, exercise more" is affected by the girth of the person offering it.
It's way too common, and way too full of sense.

At Fri Jun 15, 02:57:00 PM, Blogger Liana said...

Well, I guess I'm a "skinny minnie" physician. I've always suspected what you've said in this post: that patients won't listen to me when I talk to them about weight loss because I've never had to deal with that issue personally.

I've also never had asthma, COPD, heart disease, diabetes, HTN, depression or most of the other conditions I treat on a daily basis.

It's a no-brainer that the whole issue of obesity is laden with cultural values. I know that I can't possibly know what it's like to be overweight and struggling to lose weight. I can't empathize. But I can sympathize, and say that I realize how difficult the process is and offer my support and evidence-based advice.

I hope somehow that comes through when I talk to my patients.

At Sat Jun 16, 07:56:00 AM, Blogger Midwife with a Knife said...

I'm also a doc who's BMI puts me in the obese range. As a patient, I've always felt more comfortable with docs who've also been a bit overweight talking about weight loss. This is because the skinny np who once lectured me about my weight (I was an ob resident at the time) just seemed to have no clue.

When talking to my patients about weight, I always say, "Look, I've been there, it's really hard. But it's important to try. And if you keep trying to exercise and eat right, even if you never get down to your goal weight, you will have some success, and you will feel better and you may live longer. Just keep trying. Every day is a new day, and if you have a bad day, just try again the next day. A bad day is just a bad day. It doesn't make you a failure."

At Sun Jun 17, 01:11:00 AM, Blogger Bardiac said...

MWAK, I really like the point that you make about the bad day not making someone a failure. That seems likely to be helpful.

At Wed Jun 20, 07:22:00 AM, Anonymous Anonymous said...

hi. nytimes sunday magazine had a great article a few months ago on various adenoviruses that may be implicated in obesity. i'm fat. i'm 5'8" and weighed 127 when i got pregnant at age 34. now at age 54, i weigh 240, so, i've really seen both sides of the fence. in particular, i just dropped off the radar in terms of admiration from the opposite sex, and it's not my age, it's my weight, because third world types with different body ideals occasionally hit on me now. i looked at the band but i'm too afraid of side fx from anesthesia (i had a bad experience with fentanyl once and saw a relative also have a bad experience with it.) i'm just resigned to being fat. i can't run any more (and i too got plantar fasciitis from running) but i can still do yoga, lift weights and walk and swim, altho i hate the chlorine. however, i don't do all of the above the way i should, because, well, because i hate it. i'm so envious of those people who love to play tennis, or to run, or to bike, and who just can't let a day go by without getting their fix. for me, exercise is such a chore (except for going on vacation, when i can walk around a new city for ten hours a day with pleasure) but there are times i get up the courage to take a class five or six times a week. i have the luxury of not having to work, but if you're actively practicing medicine, i don't know how you find the time to do that. anonymous overweight family doc, my heart goes out to you. i do small things to work exercise into my life. i have big exercise balls to use as chairs (they're actually very comfortable, especially if u spend a lot of time in front of the computer) and they help get rid of backaches. i also have a bosu half-sphere so that when i'm standing around reading the paper i can at least stand on that and get some core exercise.


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