Tuesday, June 26, 2007

A medical student grows and learns

Harvard medical students in training at BIDMC are asked to keep a journal about aspects of their training. This excerpt from one, who had a clerkship with our bariatric surgery group, is indicative of the type of transition that occurs as they follow a patient over an extended period of time and learn about the progression of his or her medical condition.


Before
Like most people, I think that obesity is a lifestyle issue -- it is a reflection of our society with gluttony of unhealthy food and paucity of exercise. And like most people, I feel uneasy about "fixing" obesity by reducing the size of the stomach to give the "artificial" feeling of safety and/or to curb the caloric intake by shortening the length of the digested food transit. Is this an appropriate and responsible medical approach? Is obesity a condition indicating for surgical procedure? What kind of people would allow, or even demand, to have one's body altered in such unnatural ways to escape from obesity?

After
Having spent almost one year with my patient, I am beginning to realize some answers.... Health care for obese patients has been hindered by the traditional misconception that weight is not a physiologically regulated variable, but rather determined by gluttonous food habits and hedonistic desires. Indeed, much of our US population considers morbidly obese individuals weak-willed, awkward, self-indulgent, and immoral. This prejudice cuts across age, sex, religion, and socioeconomic status, and often precipitates psychological distress in the obese. [Citing recent studies:] Of the weight loss treatment options presented, extensive research has shown that such options alone have not effectively achieved medically significant sustained weight loss in morbidly obese patients. Even combined with pharmacotherapy, results have been less than promising.....

In contrast to the disappointing results for non-operative treatments for obesity, bariatric surgery was presented as a much more effective alternative.... Surgery effectively "reset" energy equilibrium and defeated the powerful mechanisms for defense against starvation that are inappropriately overactive in obesity. Patients experienced decreased appetite, increased energy expenditure, and a decreased stress response after undergoing surgical intervention, while patients on weight loss diets experienced just the opposite.

[After many conversations with the patient:] Through rich, candid narrative, Z has taught me to relinquish assumptions, to empathize, and above all, to never forget to listen to my patients so that I can offer them what they really need.

12 comments:

RNY said...

Weight loss surgery does offer the client the opportunity to "reset", as even a weight loss of 20-30 pounds makes it easier for a client to breathe or walk. We fix the problem of how much they are eating, but are we fixing the mind/body/environment issues surrounding the client? It is, in fact, what they do with the gift surgery gives them that ultimately makes the difference. We are now seeing clients who have regained weight, either their outlet stretched, or they neglected to make the changes needed in the way they live. What now? They want it fixed again. We fixed it once, shoudnt we fix it again?
I often ask my groups, Why do you eat? The first months following an RNY, their appetite isnt there. They eat because they have to, and as their post op course progresses, eating becomes related to other issues. Is it the sight of food, is it their environment? What can we do to make it better? I dont believe it is gluttony. I believe there is a complicated milleau of events that can lead to obesity, whether it be genetic, environmental, or psychological. with the RNY, we are treating the symptoms and working toward the precursors falling into place afterward. But are we listening to what they really need? Do they know?
The med student clearly identified the listening component of the treatment. Are we listening to what our clients need? The psychiatric component is often neglected. Sure, they understand surgery, and what the risks are, but do they understand the lifestyle changes necessary following surgery.
It's not about how we perceive clients who are morbidly obese, its how we treat "all" of them. Mind, body and spirit.

Paul Levy said...

Well put, indeed!

Anonymous said...

Canning the patronizing judgments is also good. Instead of "treating" people, how about working with them?

Paul Levy said...

I had never thought about "treating" in that way. Your point is very interesting. What do others think?

RNY said...

Given that I consider obesity a disease, I used the word "treat."

Rob said...

Yes. As someone who's wrestled with my weight all my life, can go days on 1000 (and much less) calories a day and not lose an ounce, and is really tired of hearing how he should just "get up and exercise and put down that pastry" when, gee, skinny people have no problem offering me donuts, which I have to politely refuse, more than once, as though I'm insulting them? And who exercises and eats very carefully?

It ain't that I'm lazy, ok? I am very very sick of seeing "morbidly obese" on the chart but never, not once, ever, being listened to when I say that simple diet and exercise don't work. Of course they work, after all, I must be LYING, because otherwise my physician must be WRONG.

Ahem.

Clearly our understanding of metabolism is due for an updating, as are prejudiced moral judgements instead of medical help.

Dave said...

I consider "obesity" to be multifactorial. In some cases it is clearly a pathophysiological (e.g., hormonal) condition, in some cases it is a consequence of psychological issue, and in many others it is simply eating too much. The first of these three, while tempting to assign as a major cause, is the least prevalent. We haven't grown obese and "gluttonous", as the author says, from gene mutations. We have developed an epidemic based on poor diet and lack of exercise, underlying both of which is a form of laziness and a clear lack of education - nutritional and overall - and at times inability to pay for more expensive foods. Throw in processed foods and the like if you wish.

The bottom line is that we must help people overcome these issues while not excusing the gluttony issue or not being direct about limiting caloric intake and optimizing exercise. It's vogue among the educated to be politically correct and not tell people what they need to hear. In population at large, it's vogue to say that obesity is a disease.

The trends and the geographic focus on the United States (even Canada isn't as fat as us) suggest the environment and our culture is the issue. I am glad the young idealist medical student will push forward tolerance, but physicians and society alike must not condone these things based on our desire to be kind-hearted. In the end, that will be a greater disservice than a dose of honesty and bluntness.

Anonymous said...

I am of two minds on this question. I agree with Dave that obesity is probably a heterogeneous disease, but its skyrocketing incidence is probably due more to lifestyle than metabolism. Anecdotally, I have had one friend who was very physically active, seemed to eat normally, but was still obese. Another, a secretary in my office, complained her "diets" didn't work, but then would order and eat half a chicken when the office ordered out lunch for a treat once in awhile. God knows what she ate for dinner.

I worry that bariatric surgery can be seen as a panacea unless the patients are carefully selected, as
rny indicates.

As for "working with them" vs. "treating" them, I think one has to do with the surgery and the other with the before- and after-care.

I am most impressed with the eloquence of the medical student, however. What a writer!!

Anonymous said...

From a public (or population) health point of view, obesity can lead to different questions and answers, compared to the individual view that this student has taken. Perhaps the student should ask:

"why is obesity more prevalent in lower socio-economic groups in America (and other developed countries)?"

or "why is high calorie, high fat food cheaper than fresh, non-processed food?" or

"why aren't our communities built to encourage incidental exercise (such as walking to the shops)?".

This may lead to less of a focus on individuals and more detailed examination larger structural issues such as food subsidies, or food insecurity or city design and possibly even some structural change to prevent obesity in the first place.

Anonymous said...

A person goes into a surgery training program as a skeptic and, after seeing almost nothing but surgery for the past few months, comes out thinking that surgery is the best answer? I'm not surprised.

No one denies that many cases of obesity are out of the patients control, but the rapid increase in obesity in America cannot ignore the effects of sedentary lifestyle and unhealthy food choices.

Paul Levy said...

Good points, anon 7:36 and 11:38. A student in this situation can be highly impressionable. And, for sure, the national problem with obesity -- derived from food choices an dexercise choices -- is undeniable.

To anon 5:01,
from what i have seen, this kind of surgery is never viewed as a panacea. It carries significant risks, which must be communicated ot the patient, and it is the last resort for morbidly obese people who have tried everything else. The MA DPH has very comprehenesive rules for this procedure that address these points.

Labor Nurse said...

What an eloquent and encouraging journal entry by that student.

Having been on both sides of this coin (now on the bigger coin, if you know what I mean) its nice to see that someone that might take care of me isn't going to being calling me lazy, weak willed, or frankly...disgusting, regardless of why I am fat.

I hope that this student carries this lesson with them while with each patient.