Taking Responsibility: Your Weight, Your Doctor and You
Two not unusual consults were requested the other day.
The first involved a 55+ year old woman with high blood pressure, hyperlipidemia (cholesterol of 252) and extreme obesity (5 feet tall, 190 lbs, body mass index of 37.1; fyi, normal BMI is up to 25, overweight is up to 30, and extreme obesity is over 35). She had a family history that was remarkable for the death of her mother of arteriosclerotic heart disease at age 55.
She was sent by her primary care physician due to some unusual chest and shoulder discomforts which she blamed on lifting a grandchild. A stress test was unremarkable (did not show any evidence of current cardiac disease). Her blood pressure remains out of control because she forgets her medicines, her cholesterol remains out of control because she "can't tolerate" the medications. She'll end up seeing another doctor and remains angry at me for "getting on her" about the weight.
The second case was similar, but the patient was sent to the hospital due to the addition of an abnormal EKG and diabetes. This patient weighed 350 lbs and was 5'2" tall (body mass index was 64). A stress test could not be done on the treadmill because she could not walk from the obesity, and also because treadmills cannot generally tolerate that much weight.
Her heart was stimulated with pharmacologic agents, and it was felt that she was safe to return home. This patient has been repeatedly turned down for gastric banding surgery for psychiatric reasons, and magically believes that if she eats more eventually someone will "take a shot at it."
These cases remind me of one many years ago. I was called in to see a man in the early morning hours for chest pain. I had left the hospital only an hour before and had been up all night. The patient weighed 560 lbs (I don't recall his height), and complained that after a binge of eating (this involved three chickens, several eggs, a gallon of ice cream and some candy), his belly hurt and he had some chest discomfort.
His tests were all normal, and I ultimately sent him home admonishing him that I had no desire to see him further as a patient due to the fact that he didn't seem to care about himself, so why should I. I met him again several years ago when his mother was ill. He now weighs 180 lbs and reports that I was the only one who ever cared enough about his health to tell him the truth. All his "friends" told him when he lost weight that he didn't look "healthy."
There is a lesson here. The doctor can try to maintain a friendly, non confrontational relationship with a patient, and collect the "rent" on the problems that will develop over the years, or can risk alienating the patient by trying to affect change. As a physician I always try to choose the right medical advice, for the best patient outcome, and this is what I have taught over the years.
Believe me, in these cases, it is the weight that is the problem! There is another issue however. If the doctor deals with the problem by pushing the patient in the direction toward better health, the doctor will risk losing the patient to someone who will coddle the patient and find reasons not to discuss the weight.
We need our doctors to be there for us when we are sick, and to prevent us from getting sick. If your doctor is unwilling to be critical and identify things that you could do better to preserve your health, perhaps it is time for a switch. If you are the patient, and at some time, even we doctors are placed in this role, you need to decide whether your doctor is being a bit too gentle and enabling your bad behavior. While we all like the doctor to be a "friend" that is not what he or she is there for. We don't need a doctor to give us uncritical affection. We have puppy dogs for that.