Nobody likes to feel powerless

“Because I want to help people.”

When you’re going through medical school interviews, you can expect to answer many variations on the theme of “Why do you want to be a doctor?”  (I know I’ve written about this before, but whatever I said and whenever I said it are lost in the misty ethers of the Internet.)  And there are all manner of things one could say that would make an acceptable answer.  An affinity for life sciences, for example.  (“Money,” though perhaps admirably honest, is  nonetheless a response best avoided.)  However you mix it up, though, you’re going to need to work “I want to help people” in there pretty quick.

And it had better be true.  If you don’t derive a good measure of professional satisfaction from knowing you’ve been of service to people who needed you, the money won’t be worth it and the frustrations and annoyances of medical practice will weigh you down.  Leaving an encounter with the certainty that you did right by your patient must be a meaningful reward, and one that motivates you to get up in the morning the next day.

We like to help.  We’re trained to fix things.  We like it when people get better.  (A patient population comprising mostly healthy people was one of the signal reasons I chose pediatrics.)  We do not like to be confronted with our own collective inefficaciousness.  (See also: death and dying.)

One of the things modern medicine is not particularly efficacious at fixing is obesity.  Losing weight sustainably is incredibly difficult, and (short of bariatric surgery) medical interventions don’t have a great track record of being all that helpful.  Overweight and obese patients are a population we haven’t been able to fix.

So it doesn’t surprise me much to learn (thanks for the tip, Rose!) that we’re not as nice about it as we should be.

Are doctors nicer to patients who aren’t fat?

A provocative new study suggests that they are — that thin patients are treated with more warmth and empathy than those who are overweight or obese.

For the study, published in the medical journal Obesity, researchers at Johns Hopkins obtained permission to record discussions between 39 primary care doctors and more than 200 patients who had high blood pressure.


…when researchers analyzed transcripts of the visits, there was one striking difference. Doctors seemed just a bit nicer to their normal-weight patients, showing more empathy and warmth in their conversations. Although the study was relatively small, the findings are statistically significant.


…expressions of concern and empathy are not remarkable on their own, what was surprising was how absent they were in conversations with overweight and obese patients.

It seems we’re simply not as kind to these patients.  I wish I could say I was surprised by that, but I’m not.  We are no less human than anyone else, much as we’d like to believe otherwise.

In dealing with patients who are overweight, Dr. Katz added, doctors often show the same biases and prejudices as the culture at large. The problem may be compounded by the fact that doctors are trained to deal with immediate medical problems that have specific solutions, like a pill to lower blood pressure or emergency treatment for a heart attack. But obesity is a far more complex problem that isn’t easy to solve, and that can be frustrating to doctors.

“When we can’t fix what is broken we tend to behave badly,” he said.

I should pause here and note that I haven’t read anything but the abstract, linked in the Times excerpt above.  If I were a truly industrious medical blogger I’d use the hospital databases to find the full text and learn more about the measures and analyses.  Because my own biases incline me to believe these results are an accurate reflection of a real effect, I’m willing to grant it more credence than I might a study about which I had a greater degree of skepticism.  YMMV.  (Hope that meets your standards, Nob.)

Anyhow, I can see how all manner of factors might contribute to this disheartening effect.  As much as we ought to know better, physicians are probably still plagued by the notion that obesity is a failure of willpower on the patient’s part.  Add in the frustration of having a clinical problem that resists solving, and it’s no surprise at all to learn that we fail to treat our overweight patients with the same simple courtesies as our other patients.

For my own part, I hope I don’t really fall into that “we.”  I’d certainly like to think not.  The article goes on to mention patient complaints that their obesity seems to become the topic of conversation with their doctor even during visits for totally unrelated issues, and I’m reasonably confident that’s not something I do.  But how to introduce the subject of a patient’s weight and the impact it might be having on health is an extremely fraught question.  I try to allow enough time for the patient or parent to mention it as a concern first.  Keeping in mind risk of eating or mood disorders as a result of weight, I make a point of saying that any discussion is about health, not appearance.  And I try to keep recommendations realistic, attainable and limited.

But given how deeply the bias against obesity runs in our society (which can cut both ways in the physician-patient relationship), perhaps I kid myself to think I’m not affected by it.  Perhaps I am no different from the physicians who participated in this study.  It would dismay me to have it somehow demonstrated.  In any case, my overweight patients are already forced to live in a world that stigmatizes them.  They are more vulnerable and more needing of my attentive courtesy than other patients, not less.  And I am grateful to the authors of this study for the reminder.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. This is very complicated problem and what I call the politicalization of everything.

    Everything seems to be a political issue and there is a lot of talk I see around the Internet about “fat shamming”. The idea seems to be that talking to a person about their weight is wrong, wrong, wrong.

    The problem is that America does have an obesity problem and this causes a whole lot of health issues on a personal and public scale. I imagine that there are also times when a doctor can diagnose a particular health problem to someone’s weight and there is no way around it.

    Now I personally think that there are a lot of non-medical things that cause our obesity problems. We drive too much and do too much sitting work. We also think working long hours is good and this does not give people time or energy to exercise enough and make proper food choices. Those things need to change. Public transportation will encourage more walking. etc.

    FWIW, I weight slightly more than I want. My current weight is 161. I would like to weigh around 147-150 (my height is 5’6″). I find it incredibly hard to get down to this weight without suffering and giving up tasty food.

    • Fat shaming isn’t about pointing out the health costs with obesity. It’s about making the obese person feel bad about their weight. Or suggesting that they could get a handle on it if they just tried harder (that’s not entirely “fat-shaming” as I think of the term, but we don’t have a term for that and it is interlinked with fat-shaming).

      • I am increasingly convinced that sleep deprivation plays a much larger role than we talk about.

          • The notion that sleep-deprivation causes weight-gain didn’t actually come to me from some study I read or even the common belief that weight-gain is tied to stress which is tied to sleep-deprivation. It came to me from watching my wife put on a lot of weight during residency (enough that, unconscionably, they chose to make a joke of the weight gain during the residency graduation ceremony, accompanied by a picture on the slide-show of her eating an Oreo… I’m still pissed about that) despite not having time to eat loads and loads of food and getting not-insignificant exercise that comes with residency.

            With that in mind, the light pollution thing makes sense, too. It required her to sleep a lot during the day.

          • (I should add that most of my wife’s residency weight came off afterwards, despite a not-huge change in her diet and probably less exercise, on the whole.)

          • Not a particularly insightful comment from me, but I felt compelled to note that the joke made about your wife’s residency weight gain sounds incomparably dickish.

          • Will,

            I think this points to a more general naivete or ignorance about how the human body works. For instance, whenever I resume a regular exercise schedule after a period off, I’m always surprised to find that I have a higher and more consistent energy level, despite expending so much via the exercise. But when I step back, I realize that there is a certain logic to this being true. Weight gain/loss isn’t as simple as eating more or less.

  2. It’s not just the doctors, of course. I’ve been obese, and I’ve been trim. The difference in treatment is across the board. Given the givens with doctors, I think it becomes particularly true in that arena.

    Great post, Doc.

    • Particularly pernicious when doctors refrain from giving positive advice to someone because they’re fat…

  3. I find conversations surrounding obesity to be fascinating. In reading about some of Dove’s recent campaigns, I’ve been encouraged to see that they are accepting women whose beauty falls outside modern* western norms. However, I’ve also seen conversation surrounding those ads in which women (it always seems to be women) discuss how any criticism of obesity is wrongheaded and discriminatory. They say that even pointing out the health risks of being morbidly obese amounts to “fat shaming”. Which I find really remarkable. But I’ve been really struggled with weight. So it is a hard topic for me to weigh in. No one wants to hear what the naturally thin, trim guy has to say about the experiences of those who struggle with obesity, and rightly so. I tend to fall along the lines of respecting people’s right to make individual decisions about their body and their health and to avoid the oh-so-easy tendency to link these decisions to their character, value, self worth, or degree to which they deserve respect. However, I also don’t think we should pretend that the facts about obesity and diet and exercise don’t exist. There are certain things we can look at and say they are objectively better, from a health standpoint, than others. We need not beat people over the head with this information, but we also shouldn’t consider it mean spirited to acknowledge it.

    * I say modern because we need go back only a few generations and see that the ideals were once quite different. Certain “traditional” western beauty norms persist, but body image has seemed somewhat variable, within a certain range.

    • Kazzy, read my above link. Keeping in mind, that goes beyond what obesity does, and touches on what we do to the obese.

      With that in mind, it is incredibly hard for me to think that an inability to discuss the health risks of obesity should even be on our radar. Arguably, our fixation with obesity is a bigger problem than obesity itself. And if it isn’t, the fact that studies have demonstrated a very clear inability of the obese to take the weight off and keep it off, leads me to think that a lot of the “we need to talk about the health risks of obesity” in a category more like “we need to talk about the health risks of being a little person” than “we need to talk about the health risks of smoking.” (Hard as it is, at least some portion of people who attempt to quit smoking eventually succeed.)

      While we shouldn’t lie, and there are things we should do to try to curb obesity rates, I struggle with the notion that it’s important to talk about what is objectively healthier. Particularly as long as the social costs of obesity amount to more, in my view, than the health costs of it.

      • Good points, Will. I’m talking about what I perceive to be a very extreme ideology. The mantra seemed to be, “I like how I look so I’m healthy, it doesn’t matter if I’m 5’2″ and 500 pounds. Healthy is a state of mind.” I’m sorry, but that is wrong. If you love yourself and your body and have a positive self image when meeting those measurements, more power to you. But there are demonstrable health risks associated with them.

        Now, if someone is 5’2″ and 500 pounds and happy with their life choices and not interested in changes, I think they should be left to that. They need not be preached to or otherwise “shown the light”. They should not be offered unsolicited health or diet or exercise advice. I recognize their are arguments based on the externalities of such decisions on the health system and what not but I’m not particularly partial to that.

        However, if those people want to rail against efforts to more broadly promote healthy eating or getting kids active… they’ve gone full lunatic fringe. Those are the people I’m referring to.

        I’d offer links, but I sort of randomly stumbled upon them and can’t think of an appropriate Google phrase that might bring them up.

        • I don’t doubt it. I’m just really not alarmed by it. Yeah, it’s wrong-headed and counterproductive. I just consider it sufficiently removed from the national discussion to not be noteworthy, compared to the overwhelming opposition they face.

          (Not that I blame you for bringing it up. If nothing else, it provides me the opportunity to say that’s not what I am saying. Not that I thought you thought I was, but as I go to the mat for the obese here, it’s an important point to make.)

          • Oh, indeed. I was holding it up more as an example of just how complex the conversations can become. But I don’t really disagree with anything you’ve said or anything written in the link you’ve offered.

            Weight discrimination is wrong. Offering unsolicited health/diet/exercise advice to people is offensive. Fat people are people too, deserving of the same respect, worth, and dignity of other folks.

  4. Oddly enough, I once saw an interview with Ricky Martin where he made a really salient point. To paraphrase, he stated that America is uniquely situated in that it is simultaneously criticized for being too vain and too image conscious AND for being too lazy and fat. Now, these criticisms tend to be directed at different segments of the population, but I think it was an interesting point and perhaps speaks to some broader divides that contribute to the phenomenon. To what extent are those two groups lobbing those criticisms at one another?

  5. Due to my recent experience with a very slight weight loss (that’s right, 10 lbs, baby!) I can’t help but focus on education. I understand that overweight people do not want to feel lectured by thin people that they need to lose weight, but man do you learn a lot when you are willing to talk about it. And I’ve never been”fat, and always prided myself on eating tons of healthy food with very little junk food, or so I thought. Just teaching someone how many calories are in something or how much fat/cholesterol/whatever is in an item of food really empowers them to make the choices they are comfortable looking at themselves in the mirror after. No one is perfect, but making informed decisions will change a persons lifestyle.

  6. Russell, this is a great post. While you didn’t really say anything about it in the post, the comments have sort of shifted to talking about what does or doesn’t affect weight, so I am going to continue on the same tangent.

    I’ve been fat-shamed pretty much my whole life (even when I wasn’t actually fat by *any* definition, just robustly hour-glass-shaped and an unpopular middle school kid). College was a nice 3-year break – Montrealers like curves and I was in the best physical shape of my life, so it was only my own internalized criticisms I had to worry about.

    For this past decade, I’ve really struggled with my weight. I’m about 5’7″ and I’ve varied between a high of 314 (yes, really!) and a low of 186. The really high highs mostly had medical correlations (hardcore medicines for other things; problems regulating my thyroid; crippling knee pain; etc.), and the low low was when Jay and I were on South Beach and it pretty much had to Take Over Our Lives to work … but it was so nice having lost the weight that we didn’t mind at first. Just, it wasn’t sustainable to have “keeping weight off” be our major hobby. We had other things to do.

    Through all of this, I *really believed* that I’d worked out my emotional issues around obesity. That I was healthily skeptical about a great deal of the “medicine” that surrounds weight loss. That I had gotten over blaming myself, and that while there were things I could do that were healthy or less healthy, I’d gotten good at living in the moment and being gracious to myself. (It helps that my current doctor is extremely empathetic and sensitive – the first primary care doc that I’ve had like that.) So, I thought I had a clear understanding of everything.

    Then, I went through all of the family stuff I went through this fall, which is definitely more of a cocktail conversation than something I want to talk about here and now. While hugely traumatic, the stuff also had the huge silver lining of freeing me from a lot of awful things I’d been carrying around without even being able to talk about them – and even the other awful things that I still had to carry, I could at least talk to my friends about. (Note that most of them had NO IDEA I was dealing with all of this, before this year. And the rest only had a sketchy one. I didn’t seem broken and hurting, these past however many years – I seemed, and mostly felt, just fine.)

    Within a month, I’d lost 20 pounds. (I started at 304. Grad school is stressful enough all on its own.) I was a bit appalled, actually, because I was so stressed that I was barfing all the time (5-6 times a day) until I got put on a real anti-nauseant, and so I felt like the stress was burning me up.

    Within 2 months, I’d lost 40 pounds, despite eating lots and lots of whatever the hell I wanted and getting almost no exercise. Well, I thought, this is still a bit weird, but okay. Whatever adjustments we need to make, and NO BEATING MYSELF UP when it comes back.

    In January, I went in for a follow-up, having eaten whatever the HELL I wanted whenever I wanted on a 24/7 basis, and having slothed about for most of the month. Seriously seriously unhealthy eating and activity habits. Ah well, I thought, I will have gained 10 pounds, but that’s fine. It’s been a hard year and I’m allowed to be less than perfect. Stepped on the scale and I had lost 10 pounds.

    So, within 4 months of my traumatizing but healing set of life experiences starting, I weighed, no joke, 50 pounds less than I had before everything started. My doctor (carefully, gently) asked me what I was doing to take the weight off, and I almost fell off the table laughing. I did NOTHING, at all, that you are supposed to do to make those things happen… well, except to do my best to take care of myself emotionally – meditating and spending time with friends and the like. But, no real exercise, and I ate whatever crap I wanted whenever I wanted. (The rest of my bloodwork? Also great. Across the board. Even the stuff that was bumpy before.)

    Just in the last week or so, I suddenly have ENERGY again. I don’t have to make myself exercise; I get fidgety if I don’t get enough long walks. I skip. I run up and down stairs 3 or 4 times in a row because I forgot stuff I don’t really need. I even jogged half-a-block the other day when I was late for something and it was FINE. I feel great all over. When stressful events happen, I’m fine the day afterward and things don’t cling in my brain.

    So …
    1) I never realized how much I thought weight was simply a matter of calories and exercise (despite KNOWING BETTER because of reading so much about stress and metabolism) until I had incontrovertible evidence in my own body that it was a lot more complex than that.
    2) I feel the need to point out that, actually, all the education I was subjected to by health professionals (or that I subjected myself to) didn’t really help me. It just made me frustrated that this was a known solution, and it Did Not Work For Me. And the thing that helped me? Pretty non-replicable.

    It’s not all that straightforward, still. I might put a lot of weight back on. I might lose another 50 pounds. But wow, is it more pleasant to see that as “what happens, happens” than to invest all that energy in worrying about it…

    • PS During all this weight loss? I was also having a lot of trouble sleeping. Just saying. Human bodies are SO SO WEIRD. I sort of figure in 400 years, they will be as appalled by the stuff we don’t understand about metabolics and immunology as we are by the stuff people 400 years ago didn’t understand about bacteria.

      • PPS not the too-much-thyroid-hormone kind of not sleeping. This was the existential sort of insomnia. My thyroid is well-balanced, overall.

    • Maribou,

      Thanks so much for sharing this. It matches my experience very closely. Not all of the emotional aspects (it’s different between men and women, and our emotional experiences are our own), but the emotional relationship with weight resonated a great deal.

      The more I struggled with trying to lose weight, the less successful I was. I was at about 285* when I left Estacado. That was after numerous attempts to lose weight. Then I landed in Cascadia and I didn’t have time to concern myself with it. But then I started eating The Magic Cereal. I wasn’t thinking to myself “I’m going to eat this magic cereal and I’m going to lose a ton of weight.” Instead, it was a single, small step, that for whatever reason started a chain of events that lead to significant weight loss. I reached 210 at one point, but it’s been creeping back on me.

      But you know what? I wasn’t any less a lazy slob at 210 lbs than I was at 285. I’m not less disciplined now at 235 than I was at 210. The difference, for me, was The Magic Cereal**. And I think the weight came back in part because I got sick to death of The Magic Cereal after five years of eating it every day. I plan to try to figure something else out, but I’m not going to freak out about it. Because it won’t help, may hurt, and worst of all would deflect from the positive energy I need for my wife, my daughter, and myself.

      This is why I have come to feel so strongly about fat-shaming and blaming-the-fattie. I was much, much more moralistic about weight when I was heavy. I was frustrated with myself and I felt like a failure. You know what’s not conducive to losing weight? Feeling like a failure. But looking back, there was no amount of “sheer willpower” or complicated planning that would have gotten me here. Rather than feeling accomplished when the weight came off, I felt blessed. And I learned that the fat me wasn’t any less worthy, less disciplined, less knowledgeable, or just weaker a person than the less fat me.

      * – Maribou probably remembers this, but I should note somewhere that I am kind of on the tall side. I am kind of stunned when I look at old pictures of myself, but I don’t want to suggest that even I was struggling with my weight to the same degree that other people sharing their experience were or are up against.

      ** – And it may well have had nothing to do with the cereal. I know that I’ve told others about the cereal and it did nothing for them. It didn’t work for Clancy, but what did work for Clancy would never have worked for me. And on and on.

      • ” Rather than feeling accomplished when the weight came off, I felt blessed. And I learned that the fat me wasn’t any less worthy, less disciplined, less knowledgeable, or just weaker a person than the less fat me.”

        Yes. Exactly. *smiles at you*

    • Maribou,

      My respect for your willingness to share all this is really through the roof. This is not easy stuff to talk about publicly, but it helps people to see that it is possible. I (of course) wish you and Jaybird the best on all issues health-related (including managing school and job stress).

      • 🙂 Thank you. Also, fwiw, it’s really not hard to talk about publicly for me at all these days. More difficult to not blurt out to everyone I know – it’s just so STRANGE, you know? 🙂

        • Totally, and that’s awesome. As I said, that makes it easier for everyone else for whom it is still hard, which is really a prereq for making changes.

          Also: I wish you guys the best generally, not just on health issues. Didn’t want to leave that possible implication open to question.;)

    • Losing 20lbs a month is … kinda worrisome.
      Glad you got in for some bloodwork!

      And congratulations!

      I think support, and de-stressing, are things that are replicatable,
      to some extent.

  7. I’m under no misconceptions that my weight (obese) is impacting a portion of my health – namely a higher risk for diabetes and the like.

    I am, however, very lucky to have a GP that doesn’t ‘treat’ me any differently because of my obesity. I get my yearly physical, bloodwork, etc. My BP is fine (110/75), my cholesterol is fine, and since leaving the casino environment I’m no longer asthmatic. (I’m still allergic to dogs and cats, though).

    Do I need to lose weight? Of course I do. I’m not stupid. I’m working on it.

    I gained a lot of weight in the decade after ripping out my ACL – each time I tore it further, my mobility decreased. I finally had the ACL reconstructed in ’04 – I was at the point where I could feel my lower leg sliding back and forth under my body with each step I took.

    If I’m stressed, I eat. It’s a coping mechanism to get my mind to focus on something other than what’s stressing me. When my sister was dying from breast cancer, I ballooned up to ~370 pounds. It’s hard to be an ocean away from a loved one when you know their days are numbered, and you _cannot_ be with them.

    I’m hovering around 300 today, and my personal *ideal* weight would be about 180-190. I’ll get there. It might take me a decade, but I will get there. It’s a lifestyle change, not just ‘a diet’.

  8. Russell, my problem is prejudice against overweight doctors and nurses. They of all people should know better but seem to be unable to execute their knowledge. How can they help?

    Our obesity problem stems from our evolution. When we had to worry about food and shelter in our primal days, the path of least resistance to obtain those things worked for our survival by limiting our energy expenditures. But today, with food and shelter fairly plentiful, the path of least resistance by sitting, driving, and taking elevators is working against us. Somehow we need to get up and move more and accept the fact that a little discomfort is good for us.

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