Obese patient gets mad after I tell her to fast..
I am a medical student going into primary care with a special interest in weight loss. I'm rotating through a clinic now where I see many obese patients. Most are diabetic and hypertensive, about half have GERD, and nearly all want to lose weight. I usually get to talk to a patient for 10 minutes before my attending comes in. I use this time to convince them to eat Paleo and live primally. But I run into two problems.
1) My attending believes in hardcore CW. Immediately after I tell a 300lb type 2 diabetic with debilitating vascular foot disease to cut down on carbs, avoid grains, and eat more fat, my attending tells them (with a lot more confidence and gravitas) to get 40% of their calories from carbohydrates, mostly whole grains. He then goes on to tell them to strictly avoid animal fat and eat plenty of dairy and legumes. He has a thing for soybeans and tries to convince every patient to eat them. He believes potatoes are an absolute no-no due to their high glycemic index. He emphasizes to never skip a meal, and to eat 5-6 small meals throughout the day. When one patient asked him what oils to eat, he said vegetable oils! Another asked him if corn counted as a vegetable and he said of course. Nearly all of his patients are over-medicated. He gave a 25 year old woman with a blood pressure of 135/80 and a slightly abnormal lipid profile (normal TG and HDL, slightly high LDL) a beta-blocker and a statin! I can't say anything because he is doing my evaluation.
2) A lot of patients come in wanting lap band surgery. In most cases they saw an advertisement or knew a friend who lost weight after getting the surgery. The problem is that they believe the lap band is a panacea. I try to explain to them that they will still have the same appetite. The difference will be that when they eat more than their reduced stomach volume can handle, they will feel absolutely terrible and vomit. They are basically paying for self-punishment. Furthermore, weight loss that occurs after lap band surgery happens because their diet drastically changes out of necessity. If they make the exact same diet changes without the lap band surgery, they will get the same results. Unfortunately, this convinces almost no one.
I remember one patient with a BMI of 50 telling me: "I will do absolutely anything to lose weight. I have tried everything. Nothing works. You seem confident you can help me to lose weight; I will do anything you say. I am willing to try anything."
I told this patient to fast. She became incredibly angry and demanded to see the real doctor.
What do I do? I don't have an abrasive personality. I'm not rude or demeaning. But I want to tell the truth. If you weigh 350lbs and are desperate to lose weight, the best thing you can do is to start a fasting regime. I offered this patient my personal cell phone number and my services as a weight loss coach. I talked about setting up a comprehensive plan for her to fast safely without nutritional deficiency. In the end I felt like I should've just kept my mouth shut and written her omeprazole and a referral for the general surgeon.
I want to help people lose weight. I would love to work in a weight loss clinic one day that focuses on Paleo/Primal living without polypharmacy. Any suggestions on how I can become more persuasive?