Obese patient gets mad after I tell her to fast.. page

[ulnauy]

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?

[frenchie79]

My advice: s*ck it until you are done your residence. I see a lot of patients like this, heart attacks at 35, diabetic foot, ckd... They ask me what they can change in their diet, I say stop juice and pop. Even diet pop? That is when they freak out !!! Come on, its diet pop!!! The SAD and CW are imbedded in ppls minds, its incredible!

Identify yourself as a primal doc when you are done. We need you!

Primal RN

[Ayla2010]

What frenchie said.
But you can't just jump into fasting, especially if you have a binge eating disorder (very likely that these people do). You need to be fat adapted first, other wise you dive face first into more crap food. Trust me I have been there.
Now I can fast, but not last year.

[workinprogress]

Choose your battles wisely. Get through your residence like frenchie79 suggests. Sorry I couldn't help more, but some battles just can't be won and you need to get through your residency.

[Jac]

I'm in health care too - a lecturer and researcher. As I see it, there are a couple of things to consider here - firstly, you're a med student. You have no relationship with the patients, a very limited time to see them in, and someone very senior who is going to contradict you immediately. What you're doing to these patients isn't ethical. As much as it pains you (and me, too) you need to be supportive and learn as much as you can - even if it's learning about things you won't ever do when you qualify. When you get the opportunity to advise people before 'the man' comes in, do it in the little ways where paleo and your consultant agree, like cutting down on very sweet or highly processed foods like sodas, commercial fast foods etc. Help the patients by putting their immediate needs first and get them onto the right track.

The second thing is, as Ayla pointed out, people who are overweight and have health issues as well are simply not physically or mentally equipped to fast. They're sugar burners, inflamed and probably stressed - your suggestion of fasting is harmful. Do some reading about the place these patients are in when they come to see you, and figure out how to help them get onto the right path. Like Ayla, if I'd tried to fast last year I'd have been shaking, crying, shattered - and I'd have failed, big time.

Having said that, hang in there. You're in the middle of a difficult process, and are pretty powerless. That's temporary, so take the long view and make sure you'll be available to your patients in future years.

[ulnauy]

My advice: s*ck it until you are done your residence. I see a lot of patients like this, heart attacks at 35, diabetic foot, ckd... They ask me what they can change in their diet, I say stop juice and pop. Even diet pop? That is when they freak out !!! Come on, its diet pop!!! The SAD and CW are imbedded in ppls minds, its incredible!

Identify yourself as a primal doc when you are done. We need you!

Primal RN

Looking forward to quite a bit of s*cking as it'll be another 4 years until I am board certified. I will be sure to add my practice to the list of primal-friendly docs. If anyone isn't aware, primaldocs.com is a good registry if you're looking for something different from typical CW medicine.

Btw, it's interesting to see a Canadian using the term SAD but I suppose it isn't much different up there in Manitoba. It's going to take at least 15 years before conventional medicine re-calibrates its position on nutrition. In medicine, it's all about the Randomized Controlled Trial, but these are rarely funded unless there is 1) opportunity for profit or 2) opportunity for career advancement. As a researcher, if you were to come out and say something like: "Whole grains are overrated," you'd be basically saying that hundreds of thousands of doctors around the country are wrong. This is career suicide and so nobody does it. This is evident in a lot of published papers... the results will clearly say, for example, that saturated fat and cholesterol consumption are not linked to dyslipidemia, but the conclusion will be a meek sentence like: "There is not enough evidence to conclude... blahblah... We continue to recommend a diet low in saturated fat and cholesterol."

[Erik W]

This reminds me of a teeth-examining relative, who also has to deal with patients who won't listen to good advice. She says that many act like this: as soon as they are warned of problems they don't want to deal with, and they hear boring advice they don't want to follow, their eyes glaze over and it all flies past them. If they don't think about it, they imagine it doesn't exist.

The one way to make these people listen, apparently, is to tell them about the cost if they have to come back and fix their teeth. They won't care about their health, but they care about losing money. Amazing creatures.

I tell her that if it doesn't work, she should just give them the advice and then wash her hands of the whole thing. They are adults, it is their responsibility, and her work is done when she has given them the advice. If they don't follow it, that is up to them. Much like in my own work; I add something to a piece of merchandise, and if it is not a good piece of merchandise, that's not my problem. If the producers don't want their products to sell, then okay. I get paid either way.

We have work ethics. We take pride in improving things. Whether we improve patients or goods or services. But sometimes you have to remind yourself to just give the customer what he wants, or doesn't want, and then the rest is up to him and none of your concern.

Now, about becoming more persuasive. Funnily, I discovered that in a group of people who are all reasonably intelligent and eloquent, the one who is the most convincing is the muscular guy who works out a lot. You want to be on that guy's side. Strength is impressive.

But other than that, we can only talk with an authorative, professor-type voice. Simply sound like we know our stuff. You, ulnauy, are in a difficult situation. There is not much you can do when your attending steps in and gives bad advice like that. Except maybe to slip them the URL to the Success Story Summaries. Did you ever see a more convincing collection of stories? It's what made me go primal last fall.

Other than that, there is not much to do except wait until you can see patients on your own. Life sucks. But hey, at least we don't have to live on a farm that is invaded by the Huns anymore. Instead we just have diabetes and traffic lights to worry about. That thought always cheers me up.

[ulnauy]

I'm in health care too - a lecturer and researcher. As I see it, there are a couple of things to consider here - firstly, you're a med student. You have no relationship with the patients, a very limited time to see them in, and someone very senior who is going to contradict you immediately. What you're doing to these patients isn't ethical. As much as it pains you (and me, too) you need to be supportive and learn as much as you can - even if it's learning about things you won't ever do when you qualify. When you get the opportunity to advise people before 'the man' comes in, do it in the little ways where paleo and your consultant agree, like cutting down on very sweet or highly processed foods like sodas, commercial fast foods etc. Help the patients by putting their immediate needs first and get them onto the right track.

The second thing is, as Ayla pointed out, people who are overweight and have health issues as well are simply not physically or mentally equipped to fast. They're sugar burners, inflamed and probably stressed - your suggestion of fasting is harmful. Do some reading about the place these patients are in when they come to see you, and figure out how to help them get onto the right path. Like Ayla, if I'd tried to fast last year I'd have been shaking, crying, shattered - and I'd have failed, big time.

Having said that, hang in there. You're in the middle of a difficult process, and are pretty powerless. That's temporary, so take the long view and make sure you'll be available to your patients in future years.

You make some good points. I wasn't telling these patients to immediately jump into a fast, but rather come up with a plan to gradually introduce elements of fasting into their routine with the necessary adjuvant care. But I see what you're saying about them not being my patients. Still, it's frustrating because if these patients do what my attending says, they'll get sicker and be back more often to get more powerful drugs and more invasive operations. A resident friend of my calls it medical masturbation, and although I don't believe doctors have any ill-will, a lot of what they do harms more than it helps.

[ulnauy]

Now, about becoming more persuasive. Funnily, I discovered that in a group of people who are all reasonably intelligent and eloquent, the one who is the most convincing is the muscular guy who works out a lot. You want to be on that guy's side. Strength is impressive.

Haha, I'm 5'9 and 130lbs. My attending is 6'5 with a deep authoritative voice.

I've been adding resistance training into my routine and have gained 5lbs of muscle over the past 6 months. My goal is 145lbs. Now I have another good reason to bulk up

[frenchie79]

I hear you! I usually keep my primal principles to myself because it is really unpopular here. As a nurse, I do not feel comfortable saying to my patients what they should and should not eat. I keep it neutral. The dietician we have in our small hospital here is vegetarian. (Must be why she is so grumpy). How can she not be biased in what she preaches? I find it hard sometimes to see people so sick without knowing that if only they could cut down on grains... Oh well!