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We were on the post-take ward round. The consultant was working through the list of patients with her usual brisk efficiency, and I was trying my best to keep up, juggling notes and observation charts and scribbling down as much of the detail as I could.
Next up was a relatively young man who had a cough and high temperatures. He was also overweight. ‘Observations satisfactory,’ I wrote. ‘On examination: crackles left base.' ‘Impression: left lower lobe pneumonia.'
The consultant explained the diagnosis to the patient and told him we would give him some antibiotics and he would probably get home in a few days.
‘And by the way, what are you doing about this?’ she asked, prodding him in the belly.
He seemed to take a moment to understand the question. ‘Oh, well you know, I’ve been… It’s difficult with my job...’ He gathered himself together defensively, ‘I’ve lost a few pounds over the last few months’.
‘Well good, keep it up.'
And we moved on to the next patient.
It wasn’t exactly classic ‘motivational interviewing’ technique. And I don’t know about the patient, but it certainly made me feel uncomfortable. I wonder whether it ultimately helped him to be healthier or not.
It’s always an awkward question for doctors, whether and how to broach the subject of a patients’ weight.
There’s a strong argument that we have an obligation not to ignore something which has significant implications for people’s personal health and, ultimately, for wider society.
But weight is an emotive issue. Unlike smoking or drinking too much alcohol, being fat is not something you do, it’s something you are.
So if you tell someone they’re overweight, it’s personal. It’s something that has mostly negative connotations in the eyes of society. Even if you put things sensitively, you run the risk of alienating or even offending your patient.
And because, rightly or wrongly, people tend to see obesity as the fault of the obese person, it’s difficult not to seem accusatory.
Of course, doctors also come in a range of shapes and sizes, and your body type inevitably colours the conversation too, adding another layer of awkwardness. If you happen to be slim, it can be even harder not to seem judgemental. If you’re not, you run the risk of being accused of hypocrisy.
So is it worth the all the awkwardness? Does raising the issue actually make a difference?
Maybe there is a place for honest confrontation. But I think there’s not much point simply stating what’s usually already obvious, to the patient as well as everyone else, unless you’re going to offer some constructive advice or support to do something about it. And coming up with that is often an even trickier prospect.
By the Secret Doctor. Read more experiences at the Secret Doctor blog and follow on Twitter
Having a blanket policy of telling all patients who seem fat that they should lose weight is probably a bad idea, especially because you can't necessarily guarantee that you're helping them.
However, if you have sensible reason to believe that the BMI of your patient is causing them harm then it falls within your role as their physician to try to help them remove that obstacle to their wellbeing.
Of course, that said, it's also part of your role to do so professionally - and effectively. 'Good care' when it comes to motivating lifestyle changes is unfortunately harder to measure than pharmacological interventions, however I suspect that simply barking orders to lose weight at a patient is going to be just as effective as spraying tazocin into the hair of someone with lobar pneumonia.
Nobody's going to get it right all the time or be perfect, but if you sit down for a friendly, honest chat with a patient to discuss their weight and explore sensible lifestyle interventions, you'll surely do more good than harm.
As an orthopaedic registrar working in an arthroplasty team, I am frequently telling my patients to lose weight. I think you can be direct and compassionate at the same time but I tend to develop a rapport with the patient first and leave it to the discussion of management. In orthopaedics most of these obese patients are in too much pain to do any meaningful exercise so after the direct but sensitive "you need to lose weight" statement, I counsel them on portion control, healthy eating (it sounds obvious but it is staggering how little some people actually know about simple dietary information) and let them know that I am going to refer them to a dietician. I try and empathise and encourage them to join a weight loss group as being surrounded by like-minded people will keep them motivated. I also explain that weight loss is exponentially related to reduction of forces across the hip and knee joints- so a little bit of weight loss will reap benefits. Finally I always measure their BMI. Give them a target and see them in another clinic a couple of months later so they know they are not being "fobbed off" as being to fat for a joint replacement and they have something to aim for. If it is said nicely and one is matter of fact, offering constructive advice then I find it is usually well received.
Obesity influences outcomes in complex spine procedures. Given that one of the risks of epidural access and deep spine infection is paralysis, it is fairly easy to have a conversation about this. It does need to be handled sensitively and non-judgementally, but equally, focusing on the facts can help patients realise that this isn't rationing for the sake of it. Sometimes losing weight can mean a patient is more mobile and doesn't want an operation. For me it's fairly easy to have a rational discussion about it. Either way, though the caricature you describe probably does need a bit of improvement in their social skills if they don't want to spend hours dealing with the deluge of PALS complaints they will generate, rightly or wrongly.
At 81 years of age I am obese. My weight gradually increased after the menopause and my daughters are experiencing the same phenomenon.
Earlier in life with long hours on call & on my feet the problem was how to maintain a healthy weight as did many of us who qualified in the 1950s.
Then with a young family, a home to run & dogs to walk as well as work things stabilised for a while. However this taught me the lesson that an individual's BMI is individual to their lifestyle, so it is an area not worth approaching unless you have both some time and privacy. Finally in paediatrics both child & parents must be handled with delicacy & sympathy. Even such a counsel of perfection does not guarantee results.
Once obesity is mentioned one has a duty to suggest ways to tackle the problem that the patient can sympathise with. A 5% reduction would show it is within patient's ability, and 10% will reduce a wide range of potential conditions. We should offer a body composition DXA scan to show the site of fat depots, and the volume of visceral fat, with a very low radiation exposure. Repeat at 12/24 week interval after starting weight reduction plan will illuminate whether FMI and not just BMI is improving.
As a junior doctor I witnessed many a weight obsessed consultant insult a patient. As a GP now I have had too many patients than I care come to tell me about the rude doctor who insulted them about their weight where the so called advice succeeded in only getting their backs up and no meaningful behavioural change and often their approach is counterproductive.
Weight advice falls under the 'lifestyle advice' tick box yet as the author points out it is different to talking about smoking or alcohol. That is something you do, telling someone they are overweight is how they are. Too few doctors appreciate this. I rarely mention weight these days but will talk about instead about needing to change eating habits or do more exercise, same end results but patients tend to engage more with this advice as it feels less personal.
Of course obesity needs to be tackled and can't be ignored. Most patients aren't stupid though and realise the implications of their weight. Whether they want to do anything about it is a different matter but being ticked off or humiliated by a doctor is hardly going to help. The reasons for obesity are often complex, often psychological or a range of compounding factors. Rarely does telling someone what to do actually help. These days I ask my patients what they think they can do to change things.
Most significantly overweight patients are deeply ashamed of the way they look, not happy with how they feel and have had many failed attempts to lose weight and keep it off.
Most people can 'go on a diet' and lose some weight but few people can 'diet' for the rest of their life - and this is what maintaining weight loss requires.
I personally feel that discrimination on the basis of weight within the NHS is as abhorrent as on the basis of race, gender or anything else.
A sensitive factual discussion about the increased risks associated with weight may be necessary when directly indicated - just as I could discuss the risks of a haemoglobinopathy when relevant based on ethnicity without being racist - but treatment should never be denied as it often is now.
As a T and O arthroplasty consultant I have no qualms about confronting people regarding their excess weight. The evidence is clear. Whilst the obese gain functional benefit from arthroplasty the risks are higher especially in BMI > 40. Easy to talk in euphemisms about lifestyle rather than weight when the reality of an infected total knee replacement in an obese patient could be amputation. No matter how comlex the reasons behind obesity, a surgical complication is a huge equaliser and a personal disaster for that patient. I wouldn't be doing my job if I didn't highlight this Pain is an anorexic. Most people put on weight post joint replacement. Therefore I encourage weight loss pre op. As Scotty once said to Captain Kirk "ye cannae change the laws of physics". If the energy going in exceeds the energy used patients will put on weight. I'm afraid even in the era of GANFYD ( get a note from your doctor), patients have to start taking personal responsibility
Commonly we see overweight patients, but in the context of "you need to lose weight, just because you do", is pointless. However if just a little bit more time is put to it, even if it means you go over it in detail a bit later after ward round and when important jobs are done, in context, so eg being overweight means there are limited options of treatment if the patient is wanting contraception/a procedure, and signposting them to the right places if they seem genuinely motivated, is so much more useful!
Actually, the patient was reminded of a remediable health problem, relevant to his current admission, in a good natured but non-technical manner. He showed that he was aware of it, and taking steps to address it; after which his action was commended and he was encouraged to maintain his efforts. All that in fifteen seconds, with no expensive or invasive investigation, as an aside after his main illness had been properly managed.
How likely was it that one of his medical attendants had a spare hour to raise the matter discreetly, have a full discussion, outline a management plan and arrange follow-up, after the ward round? Not very, I suspect. Important not to fall into the trap of doing everything possible, as comprehensively as possible, without regard to practicality. Equally, ignoring the problem because it is a little difficult is merely to abrogate proper responsibility.
The consultant did good!
I find it can be helpful to discuss diet briefly: it is astonishing that some people do not realise that fizzy drinks, crisps and chocolate can be very fattening - and that just a slight modification to what they eat can make a real difference.
There cannot be anyone left who is not aware that being overweight is a health risk. So, if there is no time to deliver any useful help, why bring it up. It makes the patient feel uncomfortable and achieves nothing, except possibly make them more avoiding of health professionals in the future.
If I have time, and it seems appropriate, I will ask patients if they would like some help with losing weight. (Often weighing them as a GP triggers this discussion, the patient themselves saying they need to lose weight.) Mostly they say yes. I would then offer brief advice/encouragement or follow up if appropriate, tailored to the patient.
Obesity is almost literally the elephant in the living room. There are so many obese people & so few resources to deal with them that it is very tempting for doctors to focus on other aspects of their patients' care.
The NHS needs to do more to address the issue of obesity, but so does the Government. It could start by introducing 20% VAT on sugar which might persuade the food industry to use less sugar in its products.
I am a consultant anaesthetist and I always say something- also about smoking and alcohol intake. Otherwise the message is:" the doctor thought I am alright!"
I try and be sensitive about it as I am not Twiggy either.
I have had patients who have thanked me for pointing it out and have had someone loose a stone in the month prior to surgey as it prompted them to stop eating chocolates!