I advise those of you with weak constitutions to read the remainder of this post with caution. Pull up the fainting couch, keep the smelling salts handy, and put a fortifying drink on the side table. It’s about to get dangerously real up in here, y’all.
From the New York Times:
Overweight doctors may be less likely than other physicians to discuss diet and exercise with patients, and less likely to make a diagnosis of obesity.
I will give you a moment to compose yourselves. There’s more.
Doctors more frequently made a diagnosis of obesity when a patient’s weight was higher than their own, and overweight doctors were less likely to believe a patient would follow diet advice. Only 37 percent of overweight doctors strongly believed that they were competent even to offer advice about eating and exercise, compared with 53 percent of normal-weight physicians. [emphasis added]
That I am wholly unsurprised by these results is perhaps obvious by now. Doctors are people, and their own experience is going to color how they interact with their patients. It wouldn’t surprise me at all if doctors who smoke (they exist! still!) are less apt to either counsel their patients who smoke to stop (at least with much gusto) or to put much stock in the effectiveness of their advice.
For my own part, I know that I am probably a better doctor for some patients than others. Ideally I’d be uniformly suited for all of them, delivering care that was consistent from one child to the next. I certainly strive to be. But I think it’s naive or disingenuous to maintain that I am actually capable of doing this. No matter how much I may educate myself about sports medicine and the common injuries that occur from one sport to the next, a patient who sees me for a running injury is going to have a better experience than one who sees me for a lacrosse injury. I run, I’ve had running injuries (including one right now, as it happens), and I know what they feel like and how the various remedies also feel. I can talk about what worked for me, and empathize with a young runner frustrated by the need to rest for two weeks. I don’t think I’ve held a lacrosse stick in my life. (That’s what they are, right? Sticks?) I’ve never been whacked in the ribs with one. The problems of a lacrosse player will always remain somewhat abstract, no matter how many I see.
The person a medical provider is plays a big role in how they practice medicine. I have no doubt that I am a much, much better pediatrician now than I was before I became a parent. (In fact, I’ve often commented that I feel like I should call five years’ worth of parents and apologize for how worthless I fear I may have been.) And it’s not surprising at all that physicians who have trouble with their own weight might bring that trouble into their practice, as well.
Obviously, there’s a downside to avoiding conversations about healthy lifestyle modification. Simply ignoring the health risks related to obesity does those patients a disservice. But there’s a flip-side to that, as well. Reading on in that Times report:
Sara N. Bleich, the lead author and an assistant professor at the Johns Hopkins Bloomberg School of Public Health, said that finding ways to remind doctors to pay attention to their patients’ weight and diet was essential.
“If you can effectively address the weight issue,” she said, “you can address a whole host of adverse health conditions as well.”
I’ve written before about how hard it is to lose weight effectively and lastingly. It is apparently very, very difficult, far more so than I think most people who have never struggled with their weight understand. Including doctors. I doubt that overweight doctors are more inclined to forget the importance of addressing obesity with their overweight patients than are thin doctors. It’s likely many elide the subject for fear of seeming hypocritical or ridiculous. But more to the point, I suspect they may be more skeptical about how they can “effectively address the weight issue” than their svelter peers, having seen how hard it has been for them to lose weight themselves, and this skepticism may inform their relative reluctance to address the issue.
I wonder if the authors of this study thought to ask that question.
My smoking has very few upsides. One of the few it does have, I think, is that it helps Clancy talk about it with smoking patients. “Look, I know it’s difficult. I’ve watched my husband struggle with it for years…” and that seems to loosen people up. She doesn’t smoke, but somebody she loves does.
A good doctor would, I would think, be able to translate their own trials and failures with weight loss or smoking cessation in a way that the patient can understand. “I’m trying, you know. We all gotta try.” I do think there is a little bit of the pot/kettle that keeps afflicted doctors quiet. Which, on the whole, isn’t really a catastrophe. I am not convinced that doctorly lecturing on such things does a whole lot of good when it’s coming from a doctor who has never been through it. There is a lost opportunity, though, because I think a doctor that has struggled with it might be particularly well-stanced to pierce through the armor of defensiveness.
If nothing else, I’d like to see an overweight doctor saying “exercise. Yes, it’ll hurt (a little). do it anyhow.” Because there are serious health benefits that people get, even if the scale stays the same.
I always recommend physical activity as a benefit unto itself. And I encourage overweight patients who are physically active to remain so, even if they never see a change in weight.
yeah. and a bit of a lecture on “more exercise will increase your metabolism” and what that does to someone’s body (and ability/need for food).
When I was a smoker, a doctor lecturing me on the dangers of smoking would probably succeed in ensuring that I never returned to his or her office. The doctors I did see usually phrased it in a, “you know you need to stop that, right?” way. No lecture, no condescension, no insulting my intelligence. It was a far better method.
Should my doctor whether thinner than me or not (currently, she is thinner than me) begin lecturing me on weight issues (rather then reminding me that I really am bigger than I should be), I imagine her lectures would not have the intended effect.
Okay… I forget where I was going with this. It’s almost lunch time.
My wife’s line is something to the effect, “It says here you smoke. You know what I have to say about that, right?” Rarely does more need to be said, though it does provide the patient an opportunity to announce that they are trying to quit and inquire about help, if they are so inclined.
That seems like a good line. I’d have no problem with a doctor saying that.
Had a discussion about twenty years back with my two cousins, the orthopedic surgeon and the eye surgeon very much along these lines. The orthopedic surgeon contends the problem really started about the time reliable anesthesia machines and the first mainstream antibiotics emerged. Suddenly doctors would really save lives. Surgeons became gods, pediatricians could treat serious ear infections — in our times, we have no conception of how many children died of (what to us are) routinely treatable conditions. Go to any older graveyard, you’ll see what I’m talking about, all those little tombstones.
I come from a family of surgeons and anesthesiologists. I’m more than a little in awe of them. Me, the software guy, they ask me all sorts of questions about what I do. They seem to be a little awestruck by the idea of robots and machine intelligence, though there’s nothing particularly interesting in the solutions themselves: the problems are the more-interesting parts. But let’s face it, a physician in a white lab coat carries a freight of gravitas some guy with a computer and oscilloscope just doesn’t.
I simply cannot imagine a more honorable career than being a physician. Saving lives. I’ve spent many years trying to save lives in my own way but I still live in awe of the physicians. This gravitas must be a terrible problem for physicians of all sorts. For truly, if ever anyone stood on the shoulder of giants, it is the physicians: the unseen platoons of researchers, pharmacologists, anatomists, chemists, microscopists, toolmakers and thousands more. We only see the front line of medicine. The rigors of the profession are enormous: all that costly education, the privations of years of residency, the dedication required drives off all but the most resolute.
Yet I’m not sure we do the medical field any real justice in this. If we see the physician from the two-point perspective of awe, it is not a particularly good viewpoint. Physicians are human beings. Their chief weapon is still Galen and his Doctrine of Signs. They must get us to tell them the truth about all the stupid stuff we do to ourselves or they cannot help us and for all their wisdom they cannot cure our stupidity. People will still overeat, drink to excess, refuse to exercise, smoke cigarettes. Our lives and theirs are filled with stress, the great unseen killer of our times. Divorce rates are high in the medical profession and I am told it’s particularly easy to fall prey to prescription drug addictions in their ranks.
How can we ever see the physician as a mere mortal, sitting there naked on that paper sheet rolled out onto his examination table? Me, when I’m in that undignified state, I think of the Vitruvian Man of Da Vinci, standing there in his circle. The human body is magnificent, I try to tell myself, as the physician’s index finger prods my old prostate.
The secret, it seems to me, is to realize the physician is just as vulnerable as the rest of us. Someone’s going to have to prod the physician’s prostate, too. He’s not immortal any more than he’s omniscient or omnipotent. If medicine has advanced over time to the point where a cure to some life-threatening infection is as close as the nearest pharmacy, physicians watch their patients fade away and die from conditions tomorrow’s doctors will be able to treat.
It’s a terribly inexact science, medicine, and patients don’t do what their doctors advise. It must be a tremendous temptation to nag the patient to lose weight, stop smoking, quit drinking so much and the like. I’ll bet a very substantial fraction of diabetes would disappear if patients lost weight. What does the doctor do when confronted by such obdurate idiocy? He prescribes more insulin and that’s all he can do. When the patient’s retinas fail and his extremities get in trouble, it’s past time when any advice would do any good: the good doctor is obliged to resect the gangrenous toes.
Twenty years ago, I was sitting on my cousin the orthopedic surgeon’s back porch in the company of his sister and her husband, a prominent malpractice lawyer in the Atlanta area. The surgeon wryly asked his brother-in-law “If I detected an osteosarcoma in a twenty-five year old man’s femur, resected it, saved him life, would I be entitled to a fraction of his lifetime earnable income?” The lawyer grumbled a bit and said “It doesn’t work that way.” The surgeon poured himself another scotch and savagely snickered into his glass.
The wounded surgeon plies the steel
That questions the distempered part;
Beneath the bleeding hands we feel
The sharp compassion of the healer’s art
Resolving the enigma of the fever chart.
Our only health is the disease
If we obey the dying nurse
Whose constant care is not to please
But to remind of our, and Adam’s curse,
And that, to be restored, our sickness must grow worse.
The whole earth is our hospital
Endowed by the ruined millionaire,
Wherein, if we do well, we shall
Die of the absolute paternal care
That will not leave us, but prevents us everywhere.
The chill ascends from feet to knees,
The fever sings in mental wires.
If to be warmed, then I must freeze
And quake in frigid purgatorial fires
Of which the flame is roses, and the smoke is briars
The secret, it seems to me, is to realize the physician is just as vulnerable as the rest of us. Someone’s going to have to prod the physician’s prostate, too.
As a pediatrician, thankfully I am spared having to perform prostate exams. However, there are still awkward bits of the physical exam. Sometimes I tell visibly uncomfortable patients, “Don’t worry, man. I don’t like it when my doctor does this, either.”
Over time, I’ve had good and not-so-good doctors. The best ones were the most-human.
When I was a little boy, I was stung by a scorpion and went into shock. My mother carried me up to the dispensary, injected adrenaline and stripped me naked. I came to, my mother’s worried face came into focus. “Don’t worry or be ashamed,” she said “your body is beautiful. That’s why wear clothes, you know.”
I wonder if the overweight doctors might be a bit embarrassed to tell anyone to lose weight. That it’s not just that they know how hard it is. They worry that people might find the advice faintly ridiculous.
Rose –
I just read your comment on Russell’s January thread about overweight. Do you mind if I ask you a few questions about your experience? What drug did you take to control your insulin? What specific diet did you follow?
The drug is metformin. The diet is a cobbled together mish-mash of stuff I’ve tried from a bunch of different diets and seems to work. I am fully aware this diet makes me sound like a total nut job. I don’t pretend to know what science it has behind it, except that if I do it I can lose weight (slowishly) or maintain as needed, not think about it, and not be hungry.
1. As high fat in everything as possible. Lots of butter, olive oil, fatty meat, eggs, etc. Everything I eat has to have fat. If I eat an apple, I eat cheese too. All my cholesterol, etc., numbers actually improve when I do this.
2. The less processed, the better. Generally aim toward whole foods. No diet soda. I do use splenda.
3. No wheat, corn, barley, oats, etc. Even whole grain. For some reason, I can eat relatively small amounts of rice (inc. rice noodles, rice crackers) and potatoes (sweet and white) with no problem. I eat small amounts of fruit.
4. Little to no refined sugar, honey, juice, etc.
5. No vegetable oils, canola oil, soy oil, corn oil. Just olive oil, butter, coconut oil, ghee, and animal fats.
6. Never let yourself get hungry, and always eat as much as you feel like eating.
7. Cheat often. Like twice a month. And definitely for every food holiday, dinner out with friends, etc.
So, basically lots of eggs, meat, fish, veggies, fruit, rice, nuts, cheese, yogurt.
Your diet doesn’t sound in the least bit nutty.
At the end of last year, I went on a 60-day juice fast, and lost 46 pounds. At the end of the fast, I felt as health, energetic, and balanced as any time in the last 20 years. I transitioned to a more normal diet very carefully, but found I was gaining 1.5 – 2.0 pounds per day. I kept a food log, and I was eating 2,200 calories a day, so it didn’t make any sense, by normal measures.
A friend recommended that I read Gary Taubes book Why We Grow Fat, in which he posits that we are fat mostly because of carbohydrates, and the insulin insensitivity it causes. Having nothing to lose, I tried his recommended diet: next to no carbohydrates, and shoot for 70 – 80% of your calories from fat. It managed to end my weight gain, but I didn’t lose any additional weight. The diet you describe is pretty much exactly what he recommends: if you’re really interested in the science, he makes a pretty compelling case (if you’re more scientifically inclined, his previous book Good Calories, Bad Calories gives a detailed rationale.
Do you still take metformin? I’m really hoping that I can achieve a healthy, stable (lower) weight without need of medicines, or onerous food logging, and the like. But I’ll do whatever it takes.
Thanks. I have a very supportive doctor, so perhaps he’ll let me try what you’re doing, and see if it works for me.