Category Archives: Caregiving Help

How Doctors Should Talk To Patients About Obesity, An Open Letter To Doctors

Last week I had surgery, a long surgery that required over an hour of operating room time, but the operation was not my greatest fear as I approached this process.

What concerned me the most? I feared having to get a pre-op clearance from my internist; a simple visit that would require less than 10 minutes of contact time. You may be thinking that my primary care physician is mean, rude, and evil. Of course, this is not the case. He appears to be a nice man and a good doctor. If I felt otherwise, I would not work with him.

So Dr. Mike, what is the problem? First a little more background information.

As a person who has battled obesity all of my life, I have become acutely aware of the stigma that comes with weighing excess pounds. Few human attributes can be ridiculed and condemned in the millennial “microaggression” culture of 2018. Imagine criticizing or mocking someone because of their race, sex, religion, sexual preference, gender identity, physical stature, or a multitude of other differentiating human characteristics.

Making fun of “fat people,” is an acceptable national sport, even though the CDC reports that over 70% of adults in the US are now overweight. Of course, as the overweight population explosion redefines the concept of what is normal weight, there will always be those outliers who exist beyond a standard deviation from that norm. There will always be a group to abuse with fat jokes, both overt and covert criticism, and outright disdain. If you are obese, it appears that it is OK for others to assume that you are lazy, dirty, and stupid.

We would never make such assumptions for other medical epidemics. Imagine someone undervaluing you because of your high blood pressure, or your fasting blood sugar? Just like obesity, these illness are caused by multiple factors: genetic, environmental, and lifestyle. Unlike obesity, there are good medical treatments for these ailments, making them easier to treat. The majority of folks with high blood pressure can significantly reduce health risks with medication management alone. However, the majority of obese people will continue to be fat despite diet plans, medications, exercise, and shaming television shows.

I lost over 100 pounds about 3 years ago. I did this after failing many traditional techniques of weight loss. I feel that my weight loss was indeed a miracle that was fueled by common sense, rather than modern medicine.

We are humans, not machines. We are motivated and influenced by a multitude of factors. This variability can be considered a weakness, but it should also be acknowledged as one of our greatest strengths. We are complicated, and as such simple blanket solutions have marginal utility.

Over the three years since I lost weight, I have regained a small percentage of my weight. Most people have told me that I look better with a few extra pounds. They say I look less gaunt, and more vital with this increase. Additionally, I have long shifted from judging myself based on a number on a scale. My lifestyle changes have been just that, they are not strategies to lose weight and thereby achieve some sort of false utopia. “My life will be good if I am not fat.”

Three years into this process:

I still can wear my same wardrobe.
I still exercise every day, walking from 3.5 to 8 miles.
I still avoid all forms of concentrated sugar.
I still practice healthy eating.
I still make an effort to eat more natural foods.
I still assess and correct hidden forms of weight gain, like emotional eating.

When I determine my current status I would say that my efforts continue to be successful, but what about the matter of my small weight gain, does this one objective parameter signify failure? I would say, “No.”

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I sit in a chair opposite from my primary care doctor who is staring at a computer screen.

“You have gained weight.” My doctor says. My initial impulse is to apologize for my failing. I resist. My second impulse is to defend my position. I resist and remain silent. “Are you exercising?” I reply that I am and had already walked four miles before our appointment. “But what about cardiovascular exercise?” He retorts. And so it went. Three minutes of questioning that felt like three hours of interrogation. Pain always feels worse when inflicted on an open wound.

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Dear readers, I’m am a resilient person. Besides, I am good at using the counterbalance of logic when dealing with my emotional exaggerations. However, there is more to this story than just a detailed account of me stepping on the scale and my emotional response to that event.

Being a physician, I understand the power that doctors have over their patients. Patients come to us in an extremely vulnerable state looking for help. Studies have shown that a statement like, “You need to quit smoking,” will convert some active smokers into former smokers. Unfortunately, in medicine one size does not fit all. It is easy for physicians to generalize the above truth and think that simple pronouncements can be used to motivate all lifestyle change. However, a doctor’s command is a partial solution at best, and should only be used when wielded within a broader understanding of what causes people to change.

Many of the illnesses that physicians treat on a daily basis have a strong lifestyle component. My weight loss eliminated my need for blood pressure tablets, high cholesterol medication, and a CPAP machine. So why is it that physicals don’t learn and employ simple motivational techniques so they can move their patients towards health? I don’t ascribe to know all of the answers to this questions. However, I do know some of them.

Physicians in the US work in a production model. We get paid by the volume of the work that we do. See fewer patients, make less money. As medical practices get bought up by business investors the push for physicians to do more continues to increase. A good business model consists of finding ways to spend less and make more. This fact is contrasted by a simple truth; we are caregivers, and most of us want to provide care.

Our contact with patients is reduced by the use of physician extenders. Someone else takes our patient’s blood pressure and obtains their chief complaint. We employ electronic medical records (EMRs), which provide a clear notation of our treatment plan, but does so at the cost of patient interaction. Patients now have the “privilege” of answering our questions as our eyes are focused on a computer screen instead of them. Patients want care from us, and we want to meet their needs. There is a pill for everything, and today’s EMR makes prescribing absurdly easy. Is writing prescriptions the same as providing care? I believe that it is only a part of our job, and it should not define us in total.

When I retired from private practice, I was fortunate to have patients write goodbye letters to me. Almost universally they said that they valued their time with me because I listened to them, didn’t judge them, and guided rather than controlled them. To do these things I needed to spend time with them. I would have made more money if I saw 6 people in an hour, rather than the two that I scheduled. However, I would not have known my patients as well, and more importantly, they would not have known me as well. Trust is a function of integrity multiplied by time. Trust by itself offers a positive corollary to patient satisfaction and well-being. Besides, a career that includes connecting with others is eminently more satisfying to we providers than one that does not. A win/win.

One factor needed to motivate change is time. Unfortunately, extending the length of appointments may not be possible in today’s corporate medicine climate. There are indeed a variety of stop-gap strategies that doctors can do to build a connection, such as deliberately spending a few minutes directly with the patient before turning to a computer screen. Such simple changes can make a patient feel more connected, but they still don’t address the elephant in the room.

How should doctors interact with patients to create change? Fat people know that they are overweight, and should lose weight. Alcoholics know that they drink too much, and should stop. Diabetics realize the importance of blood sugar control, and that they shouldn’t eat that extra donut. We live in a culture that shames, and it is likely that some will avoid being humiliated by their physician by avoiding seeking necessary medical care. I admit that I have been an avoider in the past.

Big problems become smaller when shared with someone. I am willing to tackle projects that I would not usually attempt when I have someone at my side. This phenomenon is even more evident if that “someone” has expertise that I lack. If you have been reading my prior post, you know that I have been converting a cargo van into a camper. I dare to significantly modify my van because I am doing the project with a friend who has expertise far beyond mine in such manners. We, physicians, have expertise far beyond our patients in such manners as health. Most reasonable patients accept this, despite the advent of the Internet. A colleague of mine has a cup in his office that reads, “Please don’t confuse my medical degree with your Google search.” However, most patient’s intrinsically understand our expertise, which is why they are seeing us.

Doctors need to connect with their patients as human being to human being, and they need to do this on a level that patients can relate to. We need to become trusted knowledgeable friends rather than overbearing, critical parents.

We need to understand where our patients are coming from, and how willing they are to make change. We need to problem solve with them. Imagine if my doctor asked me, “Are there any barriers that prevent you from seeking medical attention?” Or, “Are there any ways that I can help you with your lifestyle change?” Those simple questions would instantly change my relationship with my care provider. I would want to meet with him, and I would look at setbacks as problems to be solved, rather than justifications for criticism.

Once a patient’s cards are on the table, all things are possible. Is the doctor’s goal the same as the patient’s? What are the barriers to achieving the desired goal? What steps should be tried? How will progress be measured? How is a reversal of progress addressed? Empathy joins, criticism divides.

A meaningful connection with a patient doesn’t happen all at once. Relationships develop over time. However, imagine helping your patients make a significant and real change. Imagine the satisfaction of having a substantial connection with them. What would it be like to work with real people instead of being a reviewer of lab data? What would it be like to end your workday with the knowledge that you truly connected with someone in a meaningful and significant way that changed their life? What would it be like to move from treating diseases to treating people?

We blame our patients for their failings, while we steadfastly hold on to methods and techniques that simply do not work. Imagine if our relationships with our patients were more as a knowledgeable and caring peer rather than a stern and critical parent? Imagine yourself as the patient. You are aware that you have a problem and you need help. Who are you going to ask? Someone who tells you what you already know, makes you feel bad, and offers no real help? Probably not.

Patient Mike

Kathy’s Story: Life As A Caregiver

Life doesn’t always turn out the way that you expect it to. This is the story of Kathy.

Kathy sits across from me sipping a herbal tea, at 71 she is active and tells me that she is going dancing after our interview. Kathy has been a widow for 4 years, and she is trying to adjust to her new life.

She met her husband at a dance when she was 19. He was the older brother of one of her friends, and after the dance, he got her phone number from his sister.

Dave asked Kathy out on their first date by posing her a question. “If you can tell me the color of a red pencil, then you can go out with me.” She liked her husband Dave because he was smart, funny, and a little sarcastic. “I got tired of the sarcastic part pretty early on, and I let him know that.” Dave had a significant limp from a bout of childhood Polio. He was born before the advent of the Polio vaccine and contracted the disease as a baby. Growing up he worked hard to compensate for his handicap by regularly working out in his homemade basement gym.

On the surface, Kathy felt that they were dating casually. However, six months into the relationship she ended a connection with another man. Clearly, there was a part of her that knew that there was something special about her future husband.

She was still in school, and Dave returned to college studying at Lewis University. Kathy recalls a letter that he sent her around their 3 month anniversary. In the letter, he thanked her for the brownies that she made him and told her that he would also like some cookies. Although humorous, that simple comment foretold of things to come.

They had little money, and it took them 6 years to save enough to get married. Dave eventually became a special education teacher, and Kathy taught elementary education, both for the Chicago public schools.

They saved and bought a home on a large lot in the country. They traveled a bit. They raised a family. This was the American dream of the 1980s. Dave loved to eat. In fact, Kathy says that he was obsessed with eating. Dave started to gain weight and went from thin to morbidly obese. Along with his obesity came diabetes. Along with diabetes came diabetic neuropathy. Along with diabetic neuropathy came immobility. He was already limited by the aftermath of his polio, but his neuropathy made him disabled. It became difficult for him to walk or maintain his balance. This made it hard for him to contribute in a meaningful way at home.

Slowly, but progressively, more and more of the home tasks fell on her. This is how she describes a typical morning in those days:

“I would get up at 4 AM and walk the dog. Then I would throw clothes in the clothes washer, and empty the dishwasher. In those days I made a lot of oven breakfasts, and so that would be cooking. After breakfast, I would get my kids ready and drive them to school or the sitters. Then I would go to my full-time teaching job.”

Kathy was feeling tired and stressed. Despite this, she put one foot in front of the other and pushed forward. “I didn’t think about it, I just did it.”

Dave’s condition continued to worsen and his doctors came up with a new diagnosis, Post Polio Syndrome. Post Polio Syndrome is a syndrome that occurs many years after a person has contracted Polio and it is characterized by muscle weakness, fatigue, and pain. Dave went from using crutches to being a wheelchair user in 1996. It was becoming increasingly difficult for him to get out of the house, and once out he could only go to handicap accessible locations. This was not only difficult for him but his entire family.

Kathy continued to push forward, but her life was becoming further limited, and she was avoiding social gatherings because of the enormous difficulty in transporting Dave. Her world was closing in.

In 2009 she started to notice another change in Dave, he was beginning to stutter. Dave was a bright and inquisitive individual, but now his logic seemed way off. Simple things, like learning how to use an electric wheelchair, were beyond him. He was complaining of vision problems, although his eyes tested OK. He had trouble writing. In 2011 an ophthalmologist examined him and thought that he may have Parkinson’s Disease which can be confused with another illness called PSP. Dave was seen by a Neurologist who did an MRI of his brain. That test showed an unusual hummingbird pattern which is the classic sign of PSP or Progressive Supranuclear Palsy, a disease that destroys part of the brain. This explained the stuttering, lack of coordination, problems with logic, and the fact that Dave had gone from being a nice person to a nasty one. Dave started to show a lack of empathy, and at the same time, he was becoming progressively needier. If Kathy was out of his sight for a moment, he would bang on the walls or call her cell phone to get her attention.

She now had caregivers coming in, but they were only present 3 hours a day. “Sometimes that was the only time I could sleep as Dave would often be up at night.” Another symptom of PSP is dementia. Kathy’s situation was similar to someone who had a spouse with Alzheimer’s disease. It was a tough time. She had discovered a Facebook group for PSP caregivers, and that served as a lifeline for her. “Connecting with other caregivers, I started to understand that Dave’s behaviors were due to his disease.”

The course of PSP runs from 6-15 years, and on August 17, 2014, Dave passed away at home.

Kathy spent much of her marriage taking care of Dave, and through the process became ever more isolated from the outside world. A part of her wanted to live, to experience, to explore. In many ways, she was like a person who had been released from prison after spending 20 years in confinement. She had a desire to move forward, but her life had been so structured that she didn’t know how. “My friends in the PSP group talk about this. That first year is go, go,go. It is like you are trying to make up for all of the years that you couldn’t do anything. You move forward, and you make mistakes. I joined a dating site, but I didn’t understand that there are predators that lurk on these sites. Let’s just say that I got hurt.”

Kathy continues to move forward, but at times it is difficult to know what forward is. She is starting to do things for herself. She travels more, she has joined a gym, she is taking dancing lessons, she casually dates, she learned how to swim, she learned how to ride a horse, she is a regular at a senior MeetUp group. Despite this she is lonely. She has gone from being a caregiver to being free. However, being a caregiver was her identity. She has lost her identity.

“I decided that it was time to talk to someone who could help me figure out where I go from here. I need to accept that fact that I may never have another partner. I need to be happy with myself.”

Kathy says that she is still a work in progress. She continues to expand her experiences, but at a less frantic pace. She is enjoying her friends, family, and grandkids. She continues to learn and grow.

We never know where life will take us. Every day is a gift. Good days have bad in them. Bad days have good in them. It is our task to extract what good that we can from every day, as we will never be given that day again.

Kathy is a heroic person who is trying to live by that philosophy. I wish her well.

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Kathy