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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
The problem with obesity is that it is such a varied condition and for some it is very much the same as smoking or alcohol. It is something which many individuals can tackle once encouraged to recognise it as a problem. Something obvious to the observer may well not be obvious to the patient. Just ignoring (condoning) it may be poor care , yet that is the option here to some extent. Help some , upset others is a cruel choice but sometimes there are clues towards making which is appropriate. Perhaps , as with alcohol one needs to have a back-up team to whom one can offer referral. Unless life is much more leisurely these days , pressures of work really hamper good communication - but perhaps not enough to justify totally ignoring the problem. A one-liner is often all there is time for - how would it have been if the doctor had been obese and said - "I see we share a problem - anything we can do to help?" What was the outcome - this might have been just the jolt this patient needed ? Presumably , if the blogger did not like the comment made she/he popped back to discuss the matter with the patient in a more constructive way ?
One might start with the patient's food intake. 'But I hardly eat anything, doctor' is an answer I today would treat as a cue to change the subject, but I'd always make a note that I'd raised the matter. 'Elevenses don't count' is another shut-out. Diet failure? 'Oh, I thought the extra healthy food as well as my usual food would slim me'. A patient's comment on 'healthy' food: 'Rabbit food!' A bulging handbag might indicate a stash of chocolate..... 'In case of emergencies'. It's thus well worth looking at a street atlas of the locality, taking time to mark the site of the clinic, the parient's home and all the fast-food outlets etc between.
Tobacco and obesity are a deadly combination; I think tackle one at a time, Frederick the Great fashion? Tobacco first? Cope with the weight gain, then diet? I'm not sure.
Oddly for the obese, many don't know how to cook, and swathes of society have no idea how to cook fish for example. (Also, too often a salt, fat and sugar item - pizza or whatever - in the microwave is the usual.) E.g. also cabbage is boiled whole 'but not until it's yellow. I'm a good cook, doctor' was one memorable reply.
Only one authority on slimming ever really attacked the matter head-on: This was the splendid Channel 4 programme 'Secret Eaters'*. Fibs galore! What I'm saying is that one needs HONESTY on the patient's part to start with. I weigh 70Kg and am 6ft tall; I was accused of being 'all skin and bone' by one obese patient.
(Diabetes is the commonest, obvious pre-existing matter requiring action. Fear of the needle needs action, and fast. I dieted off my type 2 tablets, and stayed off; my alcohol is now 2 units month except social occasions. No tobacco of course!)
* I belong to a media organisation; I had the chance to ask the Chair of Ch4 to repeat the series. Bless him! He did.
Sorry to sound so negative, but at age 69 I've heard most of it before.
Discussing weight loss has to be done sensitively, just as we would encourage patients to stop smoking, reduce alcohol intake etc.
It is however important to encourage patients to consider this and reflect on how this might improve their health. I find that if it is done sensitively and positively, especially with advice on support, it is well received and often acted on.
What is clear to all of us is that we're trying to tell patients something they usually don't wish to hear. The one case of the reverse I well recall from decades ago was a gent who was falling asleep at his machinist employment - he was 23 stone with a high pC02. We admitted and dieted him 800 cals/day. At 21 stone he was fully awake, saw the point and continued down to about 16 stone and stayed there. Still heavy, but his was a real achievement. A real goal, a real gain if one can agree on it seems the best solution; a significantly heavy tax on sugary drinks seems sensible.
At the other end of the scale was a woman 5ft tall and 15 and a half stone, very alert and indignant at the idea that she might be 'a little on the heavy side'. She wrote that she ate 'very sensibly' and didn't return; I retained an interest and later learned that she was having problems with her husband. (I never learned what her family doctor thought of all this.) This is a common emotional cause, I suspect, of dietary excess; a further negative matter is unwillingness to excercise. The latter: Any ideas? I think gentle swimming's the best, otherwise long walks or - say - golf.
As a Paediatrician I am constantly otting heights and weights of all children I see. I use this to show parents and young patients what it means. I discuss about healthy eating and weight. Most parents are very accepting and seek support. Teenagers are difficult especially young teenage girls who are already conscious about body image , one has to be very sensitive how I approach , but try to get the young person to take the responsibility and motivate them
I work in psychiatry and the majority of drugs I prescribe can cause weight gain. Also they can have an impact in the heart. I always approach the subject by talking about healthy lifestyle, asking them what they eat, how much exercise they have. I never go straight to tell them that they are overweight because they feel judged. I had some successes. We can ignore the impact that obesity has in somebody's health but it can be done without hurting patients feelings.
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I have been a GP for over 30 years and although people are living longer they are getting stouter. I use the scales as a way of bringing up the subject. If the patient wonders why ,I say it is the Government who requests that everyone needs to be weighed at regular intervals.
Many patients will have had several measurements. I can show them the graph and how the weight is piling on. The scales never lie. I ask them about their diet and whether they have been on diets before. Often Weight Watchers and Slimmers World are mentioned. They usually had lost weight and then I asked them why that had happened. They usually concede that it was because they ate less and were motivated because they had paid to lose weight.
Most people have no idea about food. Fortunately, the media are now putting the blame on carbohydrates rather than fat which is about time.
I then recommend a low carb diet such as recommended by Dr Charles Clark. I also remind them of all the programmes on television about obesity. I remind them that their bodies are incredibly efficient in conserving energy in the form of fat. If they eat more than their bodies need they will put on weight. It is obviously rather more complicated than that but it is a simple explanation and easy to understand.
There is no quick fix for all overweight patients.The penny has to drop before they can make progress regarding changing eating habits and increasing exercise.
Whether I actually help people with my approach I don't know. A few undoubtedly benefit.
As anaesthetist I told a female patient that she was obese as part of the preop visit. Nothing demeaning,, just facts stated. She was anxious anyway and she bolted - did not want the procedure. The next thing I heard was a letter of complaint.
I have lost interest in telling patients that they are fat. If I can get on with them I do, if I think the risk is too high for me to take I send to colleagues with bigger balls.
I struggle with this as a nurse. I'm newly qualified and as with all of us, (rightly) closely watched by the ward sister with little room for real autonomy. Her viewpoint is similar to one of the posters above - everyone knows being overweight is bad for you so why hurt their feelings? - an area which has been a point of contention for me. You all know the health risks associated with being overweight so I won't bother going into any of that, but there's also the other problems - healthcare costs that can be attributed to obesity go well beyond the strictly medical and on a daily (more often on surgical wards) basis will also include the requirement for additional HCAs on duty to wash/bedpan/transfer obese patients - jobs which can be easily done with one member of staff for most people of a healthy weight and without spinal problems, but end up needing 2-4 people for something as simple as getting someone to the toilet (on more than one occasion we've needed 8 members of staff to transfer a morbidly obese patient). There's also time spent by nurses and HCAs phoning round wards or external companies trying to source specialist equipment to cater for these patients.
Through 2 years as an HCA, 3 years of nursing training and 6 months as a qualified nurse, I'm yet to hear a single nurse mention to a patient that they could stand to lose some weight. We were told that we should in lectures, but it's fiercely discouraged in the real world.
People DO know that obesity is bad for them but there's also a growing movement of 'body positivity' wherein the morbidly obese brainwash the general public into thinking that if someone is telling you to lose weight, it's because they're just bitter about something in their own lives. Also with growing numbers of obese people (as I think someone previously mentioned) the public perception of what qualifies as overweight has been grossly distorted - including by registered nurses. I'm roughly 57kg/167cm and tend to drink high-fibre smoothies for breakfast and high-protein salads for lunch and everyday without fail I get comments from people telling me that "there's nothing on me", that if I lose any weight I'll be unhealthily skinny" and that I should "go and get a burger" - the concept of eating healthy food just as a choice rather than as a means of losing weight is entirely lost on the majority of registered nurses I know, let alone the general public.
So in conclusion, yes, I think Doctors should be telling patients, and if they don't have time or don't feel able to approach it sensitively, ask a nurse whom you trust to mention it.
<a href="www.google.assignment.co.uk/">Zain Guru</a>
Yep doctor yesterday blamed me for my condition (which I don’t think he will find I actually have when he sees test results) and so today I’ve cancelled going out with friends because I am too ashamed of myself. And I eat little and healthily and know am unworthy in every sense
Hi... I am not a doctor but came upon the thread. When I was 17 a medical doctor pointed out that I was overweight and that I should do more exercise and watch what I eat. This was in 1989 ... and yes... will be forever grateful to that doctor!!
I have clinical depression and anxiety disorder ...though back in the 80s and 70s it really wasn't talked about. In grade 12 I basically just started to eat my feelings and indulge in overeating and sugar.
I also had asthma which was not being medically treated. ( meaning my mother actually refused to let me get an inhaler... I almost died a couple of times).
At any rate those words from that doctor was the wake-up call I needed. I started to walk everyday watch what I eat and take care of myself. Had she not had the courage to say something I would have just continued to keep eating and eating and likely been well over three hundred pounds by now.
(Well maybe not... but close. ?)
I'm healthy an active and my asthma is under control and I'm 46. I am about 15 lbs over my ideal weight at the moment but am actively aware and working on it!
So please... Tell your patients they need to start being concerned about their weight if you see the evidence!!
Please! The earlier the better! 17 year old me is forever grateful.
I think doctors should say if you are overweight especially if it is damaging your health