Fat Patient, Bad Doctor (June 12, 2018)

There are a million things (give or take a couple, I guess) that could be said about the different relationships between people who are obese, their health and the medical system that is supposed to care for them. But there is one thing in particular that is especially important to keep in mind for anyone who is, or knows, an obese person. (Which these days is everyone, since one in three American adults is obese.) And that is this: The more overweight you are, the less likely you are to get good medical care. 

The reasons for this are many and varied. To begin with, obese patients have not been studied much as a group. That means that there are a lot of medical assumptions that don’t apply to them. For example, the standard rules for calibrating medications result in underdosing and overdosing when used on the obese. This is especially true of anesthetics, with frequent, nasty results. Obese people also heal more slowly than people who are not obese. This is true even when they have normal blood sugar. That makes injuries more burdensome and recovery from surgery more difficult for them.
 
But technical problems such as those are far from the whole story. Doctors spend less time with obese patients than with those who are not obese. They often fail to refer them for diagnostic testing. They are less likely to be prescribed medication for any given condition and more likely to be directed to lifestyle modification than a patient with the same condition who is of more standard weight. (There are pros and cons to that last, of course. There are an awful lot of people who SHOULD be thinking about lifestyle modifications rather than popping pills. But in this case it should be viewed as an indication for how seriously the doctor is taking the patient’s problem.)

Doctors like their jobs less as their patients increase in size. The larger the patient, the more “annoying” he or she is found to be, and the less patience said doctor has for the patient. And doctors report overall that the heavier the patient, the more that they feel that treating said patient is a waste of time. Nice, eh?
 
Now, people make snap judgments about others all the time. Everyone does this, not just Judge Judy. In an evolutionary context, it’s a useful technique.The ability to size up a situation in a second or two can be a very valuable one, because in a less civilized (hah) society than this one, a couple of seconds might be all the time you get to decide on a course of action. Is that a dog or a wolf approaching? Is this weird-looking guy a friend or an enemy? and what IS that thing he's pointing at you?

But it’s not their lizard brain that a doctor is supposed to be using to size up a patient. S/he is supposed to be using those much-educated and much-revered frontal lobes. Yet when this very privileged group of people sees someone who is not like them, all too often the reasoning parts of the brain aren't the ones that kick in. Why? 

Because, to paraphrase an anonymous commenter on one of the articles I used for this writeup today, everybody has biases and medical professionals are no exception. When studied, the literature is clear: patients receive different treatment when they don't look like their doctor, when they don't talk like their doctor, when they are elderly, or young, or female, or a member of a minority group. Also if they are over-insured or under-insured, or a smoker, an alcohol-user or are opiate disordered, unkempt, ill-behaved, and/or -- yes -- overweight. Heigh ho.

And ultimately that is why I picked this topic today. Because although any of us can be subject to a clinician's inherent biases under the best of circumstances, modern American assembly-line medicine increases the likelihood of its occurrence. Anyone who walks into a harried, overbooked doctor's office can wind up with the unpleasant end of the diagnostic stick, even if some groups (like the obese) have the deck particularly stacked against them. 

So. You need to keep a sharp eye on the quality of the care you're getting. That's especially true if you are a member of a group that physicians look down on -- which, all too often, is pretty much anyone who doesn’t belong to their country club.

With that in mind, here are a few pointers.

--    Be ready to talk about what brought you to the office that day. At least eighty percent of diagnosis comes from the patient's history. The more you can tell your physician about your problem, the better off you'll be.

--    Take someone in with you. They will be emotional support for you and if you miss something, they'll probably hear it. Plus with more than one of you there, your doctor will feel outnumbered and automatically will take you more seriously. You don't even have to pretend that your companion is a lawyer.

--    Ask questions. Even if they sound a little pointed. “Would you tell me to quit vaping if I wasn't covered in tattoos?", or "why is it my weight that makes my ankle hurt when the other ankle is just fine?" In particular, don’t let the doctor blow you off by telling you it’s 'just your weight' if your complaint is new or sudden or scary -- or like in my example, if it's just on one side of your body.

--    If the solution you are eventually offered does not fix your problem, don’t stop there. See someone else. And then someone else. Until the problem is fixed, OR until you personally are genuinely satisfied that everything that can be done, has been done.

Obesity is technically considered to be a medical condition. But we all know that it is not viewed the same way as other medical conditions. (The same is true for mental illness, by the way.) There is an element of moral judgment there. And don't forget this -- you may need to lose weight, but so do a lot of other people. There are a LOT of people out there who need to lose weight, or quit smoking or drinking or staying up all night watching reruns of Everybody Loves Raymond. We aren’t perfect, and most of us know what we need to do to better ourselves. But there is no reason not to have ourselves taken care of properly because we don't meet some standard of moral perfection -- or to put up with nonsense from someone who isn't doing their job.
 
In the end, what do you expect from a doctor visit? A serious consideration of the issue you are presenting, as good an evaluation of the problem as can be made from the viewpoint of good medical decisionmaking, and an appropriate solution based on both of those factors. In the case of very overweight people, or of other people that are subject to the judgment of others, that is very often not what happens. And that’s wrong. It’s ok to speak up to keep that from happening – so whenever necessary, please do. 

--dr. diane holmes
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