The Responsibility Project^®. Exploring what it means to do the right thing

My Patient, Myself

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July 15, 2010 by Danielle Ofri

I had to be honest—I was uncomfortable with my new patient, a woman in her late thirties, in my office for a general medical check-up. Ms. M. was petite in stature, but wide in girth, a medical condition we’d term “morbid obesity.” Her face was entirely swallowed up in thick fleshy layers of neck and jowl. Her belly was so overgrown and pendulous that it hung like a third appendage between her legs. Her hips and legs were so wide that her gait was impeded.

She struggled onto the exam table with difficulty. The metal table shuddered under her weight. When I lifted her shirt to listen to her lungs, I gained an up-close view of bulbous waves of adipose tissue that spilled over in tiered layers. When I palpated her abdomen, my hands were engulfed in a sea of fat. My job is to be nonjudgmental, but the reflexive discomfort was impossible to deny, and I was upset at my unease.

So when I read a recent study in the Journal of General Internal Medicine that doctors seem to express less respect for obese patients, I wasn’t surprised—but I was dismayed. Why do medical professionals react that way?

No doubt one reason is that obesity—like alcoholism and drug use—is considered to be self-induced, even by doctors who are well aware of genetics and the other confounding factors involved. From the perspective of a group singularly steeped in the discipline and deprivation that got us through medical school and residency, it’s hard to jettison the idea—despite mountains of scientific evidence to the contrary—that these medical conditions could be alleviated by simple personal responsibility.

Perhaps in obese patients we see the feared reflections of ourselves, should we lose our carefully honed discipline. My own adolescent battles with weight and body image—however modest compared with my patient’s—left me with an aversion to junk food and overeating. Maybe Ms. M. represents my worst nightmare, what I would become if I stopped being vigilant and lost control altogether.

Maybe the pure physicality of obesity is the issue. In a society that worships svelte and fit bodies to an unhealthy extreme, even a well-groomed, tidy person like Ms. M. can be perceived as slovenly just because of her weight.

These reactions are entirely irrational, of course; but emotions were never billed as rational, and doctors are as susceptible as anyone else. I don’t want to be the type of doctor who prejudges her patients, and I certainly don’t want to contribute to the very real stigma that obese people face in so many aspects of their lives. Yet I couldn’t help the automatic discomfort I felt.

The more I actually talked with Ms. M, the easier things became. She was soft-spoken and talked forthrightly of the stress of raising three children and tending her to her own medical problems, many of which stemmed from her obesity. She admitted that she had trouble controlling her eating, that stress only caused her to eat more, and that being overweight made her depressed. And she spoke of a family history of obesity, poverty, emotional abuse, and neglect.

After we finished our visit, I thought about my reaction to her. Was it any different than racism, any less repellent? Even if her condition were self-induced, even partly, how could I countenance how I felt?

Over the years, I’ve cared for patients who were potently malodorous. I’ve tugged off socks with lives of their own. I’ve changed dressings on putrid, oozing wounds. I’ve encountered maggots, roaches, and diarrhea during physical examinations. I’ve gagged and felt close to vomiting many times—I’m as squeamish as the next person. I can’t control my physical reactions, as I can’t control some of my emotional ones. But I can control what I do with them; they are internal experiences and can be tamed with my outer behavior.

But is that enough? Even if I hide how I feel about an “undesirable” patient, my feelings still may subtly influence how I respond and interact, in a way that results in poorer medical care. This is a genuine fear of mine. Marginalized groups of all stripes have tended to avoid the health care system. The barriers are many—financial, logistical, language. Studies suggest that the feeling of being disrespected, even covertly, also plays a role.

So how do doctors change our inner landscapes? How do we control our gut feelings? One step is to own up: to be honest about our feelings (in the appropriate forum, of course), however distasteful these feelings may be. Another approach, to borrow a technique from psychology, is to “act as if.” If a doctor can act as if an obese—or smelly, or irritating, or alcoholic—patient doesn’t bother her, perhaps in time it really won’t. More important, her behavior serves as a model to the students, interns, and medical staff around her.

I was relieved recently to read a new study, the largest of its kind, that found that the medical care given to overweight patients is no different than what the general medical population receives. Despite an ingrained societal bias against obesity, one that affects physicians as well, the medical profession seems to able to overcome it and deliver quality treatment.

I’m not sure that suffices, though. Doctors may swallow their gut feelings, hold their noses, and adequately treat patients whom they deem undesirable. But even that approach conflicts with a general tenet of medical professionalism, that we treat all patients with compassion. Compassion can’t be faked, or put on for the moment. It presumes genuine sentiment, within which lies respect.

When we train medical students, we talk a lot about empathy. In its most literal sense, empathy is the attempt to appreciate the emotions of another, to feel the world from their perspective. As I talked more with Ms. M. during her visit, I began to get a sense of what her life was like. I couldn’t presume to actually know how she felt, but I could begin to imagine it and how I might cope with an extra hundred pounds and the attendant stress.

When I saw her in my office recently, I felt a difference in myself. The physical exam was still a little difficult for me—I’m being honest—but I worked to keep Ms. M. in the forefront of my mind. My emotions pulled but felt more manageable.

Maybe that’s what doctors should strive for—to prod our negative feelings out of the shadows, however awkward the process. The truth is, disrespect has no place in the doctor-patient relationship. To provide good medical care, doctors must first ensure that every patient feels comfortable in their presence. If doctors don’t feel comfortable themselves, we must be honest about it; only then will the biases have the chance to dissipate.

Danielle Ofri is a writer and practicing internist at Bellevue Hospital in New York City. She is the editor-in-chief of the Bellevue Literary Review and the author most recently of Medicine in Translation: Journeys with My Patients, published by Beacon Press.

10 Comments

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• July 19, 2010 by Jody

  Thank you for writing this. As a soon to be formerly obese person, trust me when I say we feel bad enough and the judgementalism of others is so painful and devastating. When we feel judged by a doctor, we quit going and that can have a negative effect on our health care. You know what I really wish? That primary care docs would take some time to get educated on the options available and really understand the cycle of obesity. If only my doc had referred me to a bariatric practice and educated me on the fact that a lot of insurance covers the surgery instead of not looking me in the eye and mumbling how simple it is. Diet and exercise and the world will be perfect. Sorry, for a lot of people, we are just too far gone and have lost hope and need more care from people who understand the syndrome. I had a Vertical Sleeve Gastrectomy in March, down 62 pounds already and my bariatric practice gives outstanding and understanding support. Things are looking up, finally.

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  • September 22, 2010 by Maryann Gomez

    If you know of any 'kind, compassionate and understanding' family practice doctors in Essex County New Jersey, I would like the referral. It seems that I detest going to any physician because the lecture on my weight always triggers such a sense of depression and failure in me. As a result, I need help but cannot find anyone that I am comfortable seeing. It is a very sad situation but not unusual for overweight people. I have lost 100 pounds on three different occasions only to gain it back within a year or two. It all depends on what is going on in my life! However, I still need medical care and don't know where to turn without feeling so tense and upset. If you hear of anyone in this area, please email me. Many thanks and good luck to you and your recent success.

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• July 21, 2010 by very interested in obesity

  I was wondering about the article you mentioned in the Journal of General Internal Medicine - I could not find it - Could you please post the hole article 's reference or the link - Thanks

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• August 14, 2010 by Gail

  As a Family Physician and thinking about my morbidly obese patients, I think the feelings of "despair" "helplessness" is closer to what I feel. I recall two such people, both men, one in his thirties, the second, somewhat older. I would talk to them for hours about how to deal with the problem, trying to understand them. Yigal had undergone bariatric surgery years before but was back to square one. Moshe was too scared to try. I took them both on as personal challenges and as time passed, I realized that I was failing big time in both cases. Nothing helped, actually not true, Moshe managed to change his behaviour patterns for a while when he enrolled in a multi-disciplinary clinic which regarded change as the measure of success and not necessarily numbers on the scale. As time went on I became frustrated and despairing and that was what I conveyed to them. We had poor quality visits as a result and I never seemed to deal with them in any different way. Thank you for putting your thoughts about your patient on paper; it helped me understand my attitude better.

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• November 13, 2010 by MARY LYNCH

  YOU ARE A HUMAN BEING BEFORE A DOCTOR!!! SIMPLE AS THAT, AND I SEE NOTHING WRONG W/ HAVING NORMAL HUMAN THOUGHTS.....

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• March 16, 2011 by Not Who You Think

  ""I was relieved recently to read a new study, the largest of its kind, that found that the medical care given to overweight patients is no different than what the general medical population receives. Despite an ingrained societal bias against obesity, one that affects physicians as well, the medical profession seems to able to overcome it and deliver quality treatment.""

  Funny, because that study stands out in sharp contrast to literally hundreds of other studies, which have found completely the opposite.

  But I can see this is the study that lets you feel good about yourself, so this is the study you prefer.

  Here is a good place to start a real inquiry: http://www.nutritionj.com/content/10/1/9

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• April 9, 2011 by none

  I experienced covert disrespect from a doctor who probably did not notice what she was saying. I went for a general check-up and I accepted the comment the doctor made about losing weight for health. But she also said the following: when you lose weight you will feel more comfortable being around other people and engaging in activities you like. I met her for the first time that day. The assumption was made that because of my weight, I was somehow not as engaged with life and it was appropriate to make assumptions without hearing anything about my life beforehand. The assumptions do come out.

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• November 10, 2011 by Drdonwheels

  I am both a physician and morbidly obese. I think that in treating the obese, one of the problems for physicians is that it is so intractable and complicated to treat. The rewards and successes are often small and too slow for both the physician and the patient. The physician is offended and dismissive of patients who can not "simply" push away from the table or "go to the gym". The patient, already sensitized to societal perceptions (BTW, it is not 'human' to feel this revulsion, it is cultural), finds no respite in the doctor's office.

  I am dubious of the large study cited that states that medical care to the obese and the non-obese was equal. Just from personal experience, the average physician's office is not equipped for morbidly obese patients (it would represent an enormous capital investment for scales, heavy duty exam tables, etc.)

  Let's face it. The repertoire of treatment modalities currently available for obesity are, for the most part, primitive and limited. Despite our lack of understanding of obesity, we blame the patient. I can think of no other human malady or condition where we demonize the patient for not 'healing' themselves.

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• December 9, 2011 by Sarah Walsh

  My mother had a surgeon whom she really treasured. She was a difficult and anxious patient. He had the patience of a saint and the humor of the devil. I once complimented him on his bedside manner. He told me that 40 years prior when still in medical school an elderly patient said to him: "there are two kinds of doctors son, those who re-tie a patient's hospital gown after the exam and those who don't and you need to decide which kind you want to be." I am a social worker and a psychotherapist who is privy to the vulnerability of human nature, and this struck me as a simple yet brilliant guideline.

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• December 25, 2011 by Susan CW

  My personal experience . I was morbid obese and I myself hated and hated Going to the Dr. Number 1. Was getting weight . I was told over and over I needed to lose weight and I was dying slowly as I have diabetes type 2 , asthma , sleep apena , hight blood pressure and other health issues from being morbid obese . I was ashamed . promises my self tomorrow was different . I had gastric bypass in Diec 2007 ( still dealing with complications) . 6-8 post surgery I became angry . I was getting tired of hearing how nice I was looking . Men and Woman treated me different ( doors were opened for me and people actually looked me in the eye) I was dealing with the lost of food . I ate over all feelings . ( good ,bad) I am so grateful that I was directed to OA . Which is where I learned and now believe that I am powerless over food . No different than an drug addicted . I attend meetings , surrender my life and will over to My Higher Power . I am a different and I treat people differently . I have been saved from myself . No Doctor , Diets , Weight loss Surgery can do what has been given to me . I knew way to live . One more thing I am going to mention , I can have all the surgery done on my stomach but My complusive overeating is in my mind .

  Thank you for a very up front article .

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