* * Anonymous Doc

Tuesday, July 5, 2011

"We need to talk about your weight."

"Oh, it's been stable."

"You weigh 317 pounds!"

"But it's been like this for years."

"And that's what we need to talk about."

"Look, it's just because my metabolism is slowing down."

"You're 39 years old. That's not the answer here."

"It's because of the water pills I take."

"They should be having the opposite effect. How many times a week are you eating fast food?"

"Clearly whatever I say, you're going to say it's too often."

"Maybe, but I want to know where we're starting from."

"You tell me-- how many times a week should I be eating fast food?"


"Well, it's more than zero."

"How much more?"

"A lot more."

"Give me a ballpark figure."

"I wouldn't say I eat fast food every day, but there are days I eat two or three meals that are fast food, so on average, probably nine or ten meals a week."

"That's too many."

"I knew you were going to say that."

"And let's talk about exercise."

"Do I look like I exercise?"

"No. And that's the problem."

"You can't tell me the problem is the food, and the exercise. You have to pick one."

"It's a combination of both."

"That's not fair."

"My weight is stable. Isn't that enough?"

"Not if you want to stay alive."

"I don't believe in all of this."

"In all of what?"

"Medicine. Doctors."

"Then why are you here?"

"Because of my chest pain."

"Which is caused by your excess weight."

"I don't think so."

"I can't help you if you're not willing to make some effort to listen and commit to a plan to be healthier."

"I'm not looking to be healthier. I'm just looking to not have pain."

"It all goes together."

"I'm not falling for the doctor tricks."

"There are no tricks."

"Just give me some kind of pill or something."

"That's not the answer."

"I'll pay cash."



  1. It's funny, this patient's "problem" seems so obvious, and yet, I understand that sort of "shutting down" to the problem first hand when I was told that I had to make diet & exercise changes in order to lower my blood pressure and my cholesterol -- but not to lose weight (my weight normal). But I was like, "whaaaaaaaat?????" when the doctor told me to make the changes "or else". And I work in medical research! It's like it just didn't compute. I felt like an idiot -- it took me a month to figure out how to actually implement the diet/exercise changes. It sounds so simple when the doctor tells you "eat low-sodium, low fat, and exercise more". But when you actually DO it, well, it's way more complicated than one would think.

  2. I'll pay cash--bwahahaha.

    Sell them a copy of Good Calories, Bad Calories.

    I eat bunless fast food burgers and still lose weight (assuming I don't have Exogenous Cushings or that the steroids in general aren't mucking me up).


    HA! Word verification was 'difflyme' which is a combo of C. Diff and Lyme.

  3. If the patient had chest pain, did you do a work-up? Obese people are VERY likely to have CVD. And was she tested for Type 2 diabetes?

    Second, simply saying "lose weight" is like handing a child a book and saying "learn to read". Obesity is complex, and when someone weighs as much as this person, "eat less and move more" just doesn't work. They need more intensive intervention than that, including psychological, nutrition, and supervised exercise (I know, I know, insurance doesn't pay for it). But could you at least have offered some referrals, so this poor woman could get some help?

  4. Looks like you were no help at all with this patient. You need to get him / her to understand you are on his side first.

    Too often doctors come off as saying what one should not do, but giving no alternatives. It would be better if you had started with explaining how much fruit and vegetables the patient should have every day, and work backwards from that to defining how much junk food (No, not zero) and how often. Same for exercise - Tell him what to do, don't just complain that he isn't doing an undefined amount.

  5. I think it would be great if doctors would hand out prescriptions for sites like Kalyn's Kitchen (http://www.kalynskitchen.com/ Southbeach style eating) and tell patients to eat like that for the rest of their lives.

    It would be fantastic if medicine could finally take a stand and say 'cereal will kill you, so will pop and fruit juice' but I have yet to meet the MD who will cross that line.

    I think it could be more effective that what we do now.

    If you look at how nutrition science has evolved and how much the food industry has warped our perceptions, it is not surprising that people struggle with weight. Politically and socially, we are set up for failure and there is not much one doctor's visit can do to compete with that pressure.


  6. @ Natalie: obviously these conversations are distillations of the true conversations in order the illustrate the point and be humorous. He isnt going to transcribe a 15 minute visit, there is no point. I think we can assume Anon did his due diligence (I doubt that obesity is correlated with CVD, diabetes, and a host of other comorbidities is news) and discussed ways in which to eat healthier and lose weight. In a previous post he describes talking to a patient about parking slightly further away when he gets to work in order to walk further every day. Also, why do you assume this patient is a female?

  7. I thought I saw a reference to the patient being female, but I just reread it, and found that I was wrong! Sorry! :-(

  8. Sounds like we're all a bunch of low carbers. I just read Gary Tabues' "Why We Get Fat and What to Do About It" (easier read than Good Cals Bad Cals) ... It's pretty simple. Cut the crappy carbs (cereal, bread, soda (duh), sweets, and some fruits.) There's a good documentary called Fat Head about a guy who loses weight eating nothing but fast food - without the pops/fries ... and his chem lab numbers improve. The fact is nutrition/medicine has been wrong about how to lose weight/improve health for the past few decades. It's time to own up to it and stop giving patients advice that will never work and may even backfire. I realize it's hard for individual docs when the mainstream won't back them up ... but still, how many people are suffering/dying by the wrong advice?

  9. i hardly think you can accuse anon of being "no help at all to this patient" based on an excerpt of the conversation.