I'm on vacation (well, was when I started this post) and I finally get to read some real books. On the flight, I quickly got through Dr. Brian Goldman's "The Secret Language of Doctors". It's a worthwhile read. I've read or listened to some of his work before and while I always tend to find a point or two I disagree with, on the whole he's done a great job making medicine accessible to the wider public.
A major part of this book concerns how healthcare professionals view certain patient populations and how those views translate into their speech, sometimes towards patients, but most often towards each other about patients. Frankly each one of the patient populations he describes deserves a post, but I'll focus on one in particular - the obese.
Obese people face discrimination, in medicine and out of it. They are perceived as being lazy, negligent, or at fault for any medical conditions they might have. They're made fun of by healthcare providers of all types. There's a prevailing attitude towards these patients in medicine that can seriously prevent them from getting optimal care.
However, obesity is a medical condition associated with numerous negative outcomes, at almost all stages in life (being somewhat overweight - but not obese - may be protective for elderly individuals, but that's still an ongoing topic of research). For the sake of someone's health, it's something worth addressing in most if not all patients. Obese patients are also considerably more difficult to treat. Every procedure, from simple venipuncture to complex surgeries, has additional challenges in obese patients. Diagnostic tests, particularly imaging studies, are harder to obtain and less reliable in obese patients. All other things being equal, an obese patient is a more difficult patient. When someone makes your job more difficult, it's natural to be a bit less enthusiastic about helping them.
Still, there are plenty of other patient populations who make clinicians' jobs more difficult as well. Cancer patients, for example, are considerably more difficult to treat than non-cancer patients, even for conditions unrelated to their cancer. Bringing up venipuncture again, I'll much rather try to draw blood from a typical obese patient than a typical cancer patient. Yet, with a few unfortunate exceptions (ie those with lung cancer), clinicians are often more than happy to go the extra mile for cancer patients.
The defining factor seems to be a sense of responsibility on the part of the patients. Obese patients are believe to be obese because of their own actions, while cancer patients have cancer through unlucky chance. And there's a degree of truth to that - after all, those who exercise frequently and eat well are generally slim, while those who never exercise and chow down on fast food tend to be obese. Yet, people are typically products of their environment - if you were raised rarely going outside and eating junk, it's very hard to change those habits, even with the best of intentions and considerable effort. Adult environment contributes too. A person's income and where they live are good predictors of likelihood to become obese. Obesity is also self-entrenching. Someone who has always had a BMI of 25 will have an easier time maintaining that weight than someone who once had a BMI of 35 and got it down to 25. Our bodies' compensatory mechanisms have a preference for retaining fat once it's acquired. Genetics come into play as well. While the current epidemic of obesity was not caused by genetics - after all, the human genome really hasn't changed in the past 150 years, yet obesity has skyrocketed - but it does explain why some individuals stayed slim and others put on the pounds, as the changing world environment preferentially affected those genetically predisposed to obesity.
I think the recognition that obesity cannot be assumed to be the fault of obese individuals is necessary when treating these patients. There are modifiable factors than should be addressed, but even then, making those modifications won't necessarily lead to the kind of weight reduction desired, even with highly compliant patients. We should keep negative perceptions about obesity to the condition itself, not to the person with the condition, even if it is at times hard to separate the two.
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