Thursday, August 25, 2005

The Little General speaks

A doctor friend wrote this. With permission, I'm reposting it here. The referenced article is about a doctor being investigated by the medical board and attorney general for telling an obese patient she was obese. This is definetly making the rounds; I've seen this doctor giving interviews on CNN, NBC, and ABC just in the past two days.

This article saddens me. Unfortunately it doesn't surprise me. As a doctor I hoped that what I was experiencing was a local phenomena, apparently I was overly optimistic.

We are encouraged not to call fat people fat. They're large, they're overweight, not fat. Fat might offend people. Our CT scanner has both a weight limit (the table can't move more than 350 lbs) and a girth limit (you can't be more than 70 inches around). I have to explain to a patient at least once a week that their "habitus prevents us from doing a CT scan." Their habitus...not the fact that they are significantly larger around than I am tall. Other technologies aren't any better. "I'm sorry Mr. Smith, the ultrasound was non-diagnostic -- the surrounding tissue prevented an accurate assessment of your gallbladder." In other words, you're too fat for sound waves to penetrate.

We're encouraged NOT to tell people to lose weight. ED docs can suggest that they cut back on foods that are high in fat and cholesterol and tell them that they should make healthy lifestyle changes, but telling someone that they should lose weight is verboten. It's more appropriately done by their primary care doctors. Except, as the article illustrates, it's not.

This is not a cosmetic issue. This is not because I think they would look better in a bathing suit if they didn't have a spare tire. This is my trying to explain to a 600lb woman why her knees hurt without mentioning her weight and without admitting I can't find the bones of her knee to do a good exam. This is trying to provide care to a 900 pounder when standard drug doses are based on a 70kg patient. This is trying to clean a diabetic ulcer in a 450lb man when the ulcer is hidden under folds of fat...and he's dropping crumbs from the moon pie he's eating on my head. This is trying to intubate a 375lb man who is losing his airway and finding out I don't have enough upper body strength to lift his jaw with the laryngoscope. This is trying to achieve adequate sedation using pediatric-approved doses while setting the broken femur on a 62 pound TWO YEAR OLD.

Fat is killing these people. More importantly from my perspective, it's a huge drain on the health care system. Their fat is causing them huge amounts of morbidity while we pick up the tab in high insurance premiums or lower wages to keep insurance. Fat people cost more to take care of. They require zoo-sized scanners, special operating tables, special elevators, three people to put in a foley catheter instead of one, a vein finder to put in a simple IV; they don't fit in standard sized wheelchairs or standard sized hospital beds or standard sized hospital bathrooms. So health care costs more for everyone who uses the hospital.

Somewhere along the line grossly morbid obesity became acceptable and sanctioned and it is interfering with my job. I can not physically, with the limitations of our technology and the hospital, give these people adequate care, I am not, however, allowed to give them less than the basic standard of care (regardless that the standard was based on a 145lb patient) and now it appears that I am not allowed to tell them how to change their life so that I can give them good care.

Why have we allowed this to happen? When did my patient's ego become more important than their health habits?

The PCness is spreading: a few months ago I was yelled at by a patient for counseling him to quit smoking. He said it was none of my business....and the head of the ED that day backed him up. Mind you, he was there for an asthma attack.

There are days I think I should be a bookstore owner.


The Squire said...

Why do I think I'll get five such complaints within a year of leaving medical school?

Blue Cross of California said...

Great blog I hope we can work to build a better health care system as we are in a major crisis and health insurance is a major aspect to many.