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For Medicine, a Growing Problem
Doctors, Hospitals, ERs Struggle to Handle Wave of Obese Patients
By Ranit Mishori
Special to The Washington Post
Tuesday, September 23, 2003; Page HE01
On a chilly October day a few years ago, a 44-year-old woman lay in the internal medicine ward at Georgetown University Hospital. Pockets of infection were breaking through the skin on her abdomen as she received an intravenous drip of powerful antibiotics for her chronic non-healing wounds.
I was a third-year medical student, and she was now my patient.
After reviewing her medical history, I went to order a magnetic resonance image (MRI) to give me more information. There was only one problem. She was what we call "morbidly obese," weighing more than 350 pounds. The hospital's MRI machine was state-of-the-art, but my patient was too big to fit inside.
I explained the situation to my superiors and asked for advice. Their answer startled me: Call the National Zoo and schedule a session with the zoo's MRI.
Some of my fellow students snickered. I felt protective -- embarrassed, actually, for my patient. I wasn't sure I should take this instruction seriously. And if so, how was I supposed to tell my patient she might have to wait in line behind an elephant or a panda for her turn at the MRI?
No room for the obese -- to a lot of heavy Americans, that seems to be a slogan for the entire American health care system. And this is no minor issue: According to the National Institutes of Health, nearly two-thirds of the population is overweight or obese.
About 9 million Americans are "extremely obese," with a body mass index, or BMI, over 40; they have a substantially increased risk for illness and premature death.
These are people who should be going to the doctor more often than others, but in many cases they are not. Studies suggest this is because they believe the health system doesn't want to deal with them, or is out to humiliate them.
Here is what they experience: gowns that are too small; waiting room chairs they cannot squeeze into; scales placed in public view; exam tables that tip over; procedures (such as pelvic exams) that turn embarrassing when extra staff is required to lift the patient's middle.
And always there is The Lecture: being told, repeatedly, that "all you need to do is lose weight, and only then can we get a handle on your other health issues."
Hally Mahler, a public health expert specializing in HIV and AIDS, remembers getting The Lecture for the first time when she was 8. "He would say to me, 'You're getting too fat, you have to lose weight, it's now or never.' It was embarrassing. It became embarrassing going to the doctor."
Today Mahler is 35 and still big. But that childhood memory lingers. "As a child it was terrible, I resisted it, I did not want to go to the doctor, ever," she says.
Even as an adult, she has found medical personnel not only unsympathetic, but sometimes manifestly hostile. During one recent visit to the doctor's office, she recalls, "I walked in, and the nurse looked me up and down, saying, 'You're too heavy for this table. How much do you weigh?' And she looked me up and down again, in a really nasty way, and she just stormed off."
If overweight patients like Mahler sometimes suspect that practitioners dislike them because of their condition, perhaps they are not being paranoid. Rebecca Puhl and Kelly D. Brownell of Yale University reviewed the literature about doctors' attitudes toward obese patients and published their findings in the journal Obesity Research in 2001. They discovered a whole collection of studies that suggest doctors and nurses do harbor negative feelings about obese patients.
For example, in one nationwide study of 400 physicians that appeared in the Journal of Family Practice in the 1980s, one-third included the obese among patients who cause them feelings of "discomfort, reluctance or dislike." (Other groups provoking such feelings included drug addicts and alcoholics.)
Studies on nurses' attitudes found similar results. In one, a study of Canadian nurses that appeared in the journal Perceptual and Motor Skills in 1989, nearly a third of those queried said they prefer not to care for the obese at all -- 24 percent labeled the obese "repulsive."
Other studies suggest that doctors see obese people as lacking in self-control, or as just plain lazy.
Uri Barzel, an endocrinology and metabolism expert at Montefiore Medical Center and the Albert Einstein College of Medicine in New York, admits that the overweight patients he sees in his practice frustrate him.
"Because the patient does not take charge of himself," he says, "they do not let me practice the best medicine. And the best medicine is [for these patients] to have a weight which is appropriate for their height."
"What I face as a physician when I see a patient like that is a mixture of feelings. I feel pity for the patient, because I know this patient is not going to end well. I know the person will need to take medications for diabetes, hypertension, for cholesterol, and will probably need to have knee replacement, hip replacement, because their joints cannot withstand the weight."
This is frustrating, says Barzel, "because we as a society and we as medical professionals are unable to bring about any reduction in weight."
After years of handing out diet sheets and dispensing advice to patients who, in his view, were not making enough of an effort to reduce their weight, Barzel simply says, "I'm not trying anymore."
In listening to doctors describe treating obese patients, I have heard a litany of tales that explain physicians' frustrations as well as patients' feelings of humiliation:
• The man who came to the hospital with shortness of breath. Doctors suspected he had a pulmonary embolism. At 402 pounds, he was two pounds over the weight limit for the CAT scan machine, so they pumped him full of a diuretic, hoping to shrink him down to treatable size -- but it didn't work. He left the hospital against medical advice and without a diagnosis.
• The patient who was taken down to the loading dock to be weighed like a piece of freight before being admitted to the hospital.
• The patient who was so heavy that the ER staff had to call the fire department to lift him onto a stretcher with hoisting equipment.
• The patient who died in bed. Five nurses tried to pick up the body and failed. Finally, they left the corpse, covered with a sheet, until more help was found.
The Impact of Obesity
So it is something of a standoff: Patients say doctors are hostile, and doctors say the patients are not doing enough to help themselves. In the meantime, the nation keeps gaining weight and overweight people keep getting sicker.
The list of conditions associated with excessive weight is long: diabetes, hypertension, heart disease, arthritis, sleep apnea and cancers of the breast, uterus, kidney, gallbladder, colon and rectum. Obesity is also associated with high blood cholesterol, complications of pregnancy, surgical complications and dementia.
It's evident that seriously overweight people should be seeking medical treatment. And yet many are shying away from the system.
"We are not going after preventive care," says Lynn McAfee, who, at 425 pounds, has experience as both a patient and a patient advocate for the Council on Size & Weight Discrimination, a nonprofit based in Mount Marion, N.Y. "We're not getting ourselves diagnosed with a lot of conditions that could be fixed."
"It is killing us," she adds.
Research demonstrates that the overweight are under-served. Puhl and Brownell cite a 1993 study in Women's Health that showed that the heavier a woman is, the less likely she is to undergo a pelvic examination. Another, a 1998 study in the Archives of Family Medicine, concluded that higher BMI measurements were associated with fewer preventive procedures like Pap smears and breast examinations. Yet another, published in 1994 in the Archives of Family Medicine, demonstrated that the higher a woman's BMI, the more likely she is to delay or cancel a visit to the doctor.
It is not a matter of the system refusing to treat the obese. It is the obese choosing not to use the system, because they feel put down by it, constantly reminded that they should do what so many of them seem unable to do: lose weight.
"I am just not sure it is the best use of a doctor's time to lecture somebody who's nearly in tears, somebody who could barely get themselves to the doctor for treatment and will probably not come back when they should," says McAfee. "Yelling at us louder is really not that effective. We heard you the first time."
Something needs to change, and McAfee, Mahler and others argue that it is the system.
'I Know That I Am Overweight'
A recent article in the Archives of Family Medicine, "The Sensitive Treatment of the Obese Patient," is one of the first to offer recommendations to doctors about the medical interaction itself. The article discusses how to improve the office space -- armless seats, large speculums for gynecologic exams, a scale with a wide base located in a private area. The article also advises that practitioners display the right attitude: "avoid any display of frustration or distaste when doing a difficult examination."
Some practices and hospitals are making efforts to accommodate large patients. The emergency room at the Montefiore Medical Center in New York just purchased some double-size stretchers, extra-large wheelchairs and oversize gowns.
While McAfee applauds such efforts, she would make one further change, simple but radical: Ditch the scale.
"Fear of the scale," as she puts it, is a huge barrier to care. "You internalize that fear so much. And even if the doctor says nothing about your weight, sometimes just getting weighed in that setting is so traumatic that people avoid doctor visits."
Hally Mahler simply refuses to be weighed. "The first thing that I did to empower myself as an adult, when I went looking for my first doctor . . . was to tell them that they couldn't weigh me. I know that I am overweight, we can see that. But it is my business."
And how did the nurses react? "Most were so taken aback that they'd say, 'Oh, okay,' " Mahler says. But not always. "Some have tried hard to convince me to get on the scale. Some have said. 'You can't do that.' I just try to be firm and say, 'Talk to the doctor if you have a problem with that.' "
Mahler is the kind of patient McAfee seeks to develop -- the empowered patient.
"I suggest people get a health partner," McAfee says. "In case you are very ill or in the hospital, someone who would come in and advocate for [you]. Put things in writing: Have a form that is basically a patient history form, with bullet points for what you want out of the visit."
McAfee's own health form has the following statement: "Lectures on the dangers of obesity and the value of weight reduction are not appreciated."
Better than The Lecture, McAfee argues, is a doctor who focuses on treating the conditions associated with the patient's obesity.
She believes in telling doctors to "spend your energy being creative about how to help me right now. What can you do if I can't get imaging right now; if we're dealing with my diabetes right now and I can't lose weight?" Or as the authors of the article about the sensitive treatment of obese patients recommend, "Focus on the person, not the obesity."
There is just one problem with this reasoning, according to Caroline Wellbery, a family physician from the District. "Preventive care includes treating obesity," she says, "and obesity is the underlying problem."
Asking doctors to accommodate obesity is one thing. Asking them to look past it is something else entirely, and goes against every aspect of their training.
In courses on obesity, doctors are urged to bring the subject up even during appointments unrelated to weight problems. To do otherwise is, according to many doctors, to fail the patient.
"I see these people marching into terrible dependency," says Barzel. "They are not going to be able to take care of themselves. The care that they require is huge. The drain on society is going to be much, much bigger than lung cancer was. . . . Just like smokers, overweight and obese patients do not seem to recognize -- or they deny and suppress the notion -- that they are likely to end up in a state of serious ill health and a lifelong dependency on others."
If anything, the medical establishment worries that overweight patients aren't hearing the "you-need-to-lose-weight" message often enough. A study of more than 1,200 physicians that appeared in the journal Preventive Medicine in 1997 found that doctors dealing with obese patients "did not intervene as much as they should, were ambivalent about how to manage obese patients and were unlikely to formally refer a client to a weight loss program."
It is not clear where the happy medium is. On the one hand, you have patients like Mahler, who demand that the system change to fit her: "You need to have a table that can hold somebody, even somebody who weighs 500 pounds." On the other hand, you have doctors like Wellbery, who suspect that accepting the fat may actually contribute to the problem. "Think of smoking," she says. "The negative connotation helped curb the habit."
And yet everyone agrees something is wrong. "When occasionally I have a patient who lost a lot of weight," says Barzel, "I am happy like a kid who has found a toy. But it is so rare. The fact is, we all talk about it, but while we all talk about it, society gets heavier and heavier."
Giving Doctors a Hand
That last point is indisputable. And so is the reality that even the most sensitive doctoring is not going to solve America's obesity problem. Solutions, many experts believe, will also have to come from outside.
Barzel, for example, having all but given up his own efforts to cajole patients into losing weight, says that doesn't mean there aren't other ways to get through to those patients. "The only things that work, at least partially," he says, "are programs like Overeaters Anonymous or Weight Watchers. But these are not medical interventions."
Indeed, some in the medical profession say doctors should recognize that counseling patients on obesity is not a burden they need to shoulder alone. Susan Yanovski, who directs the obesity and eating disorders program at the National Institute of Diabetes and Digestive and Kidney Diseases, contends that many physicians may not have the necessary expertise anyway. She suggests that many physicians would be wise to refer obese patients to programs that emphasize nutrition and physical activity.
"I don't think physicians need to do it all," she argues. "Not every physician is going to be an expert in counseling their patients in weight management. I think what every physician and health care provider can do is serve as a resource and coordinator of care. I don't see anything wrong with physicians referring their patients out to other programs."
Still, because obese people need to see doctors and because doctors will continue to worry about the weight of those patients, ways are being sought to improve interactions between the two groups.
For frustrated patients, there are support groups -- "fat-friendly" organizations like the National Association to Advance Fat Acceptance, which has urged doctors treat obese patients "with gentleness, tact and concern. Remember that many fat people have had years of negative experiences with health care providers, and some have been denied treatment, or given inappropriate treatment, because they are fat."
For frustrated doctors, the National Institutes of Health has issued a handbook for clinicians that covers everything from how to diagnose diseases associated with obesity to ways of getting their patients help outside the medical system. (And yes, there is advice on being more sensitive to their patients.)
"All physicians are now treating obese patients, from the pediatrician to the geriatrician," Yanovski says. "More education will come through workshops by professional societies, articles in medical journals, Web-based continuing education and training for clinic staff -- from the doctor to the receptionist."
Yanovski cites a study from 1998 and a more recent, not-yet-published one by Tom Wadden, an obesity expert from the University of Pennsylvania, showing that obese patients are beginning to report increased satisfaction with their medical care. The preliminary findings, she says, show that "fewer patients have been reporting negative interactions with their doctors regarding their weight than had been reported in previous studies."
This change, she says, may be partly a product of new discoveries that point to biological and genetic causes for obesity. "There is less of a perception that this is just a matter of willpower," Yanovski says.
And that, in a sense, is all that patients like Mahler are asking for. "People who are obese crave what anybody else craves," she declares, "which is just respect and dignity."
Meanwhile, Back at the Zoo . . .
Respect and dignity. It sounds straightforward, but not when you're being told to call the zoo to book an MRI for a patient. I later learned that I would not have been the first to do so. Sharon Deem, a veterinarian at the National Zoo, says she receives calls from doctors all the time trying to get humans in the animals' MRI.
It turns out, however, that the zoo's MRI is not large enough to accommodate humans or other large animals.
The better option is an open MRI, a relatively new type of imaging machine that does not include the narrow, enclosed tunnel of other models. Designed primarily for children and patients who are extremely claustrophobic, the open MRI can also solve the size issue for obese patients, although the image it delivers provides generally lower resolution. Open MRIs are becoming more available, especially in and around major metropolitan centers.
As for my own patient who would not fit: Her condition improved quickly enough that she no longer needed that MRI, so I never did call the zoo on her behalf.
The truth is, I'm not sure how I would have told her she needed to go to the zoo.
They just don't teach you that one in medical school.•
Ranit Mishori last wrote for Health about the care that patients receive in teaching hospital in July, when new residents arrive.
© 2003 The Washington Post Company