Lapses in Treatment - Canicatti's ELA



Why Do Obese Patients Get Worse Care? Many Doctors Don’t See Past the FatBy?Gina KolataSept. 25, 2016Original URL: must lose weight, a doctor told Sarah Bramblette, advising a 1,200-calorie-a-day diet. But Ms. Bramblette had a basic question: How much do I weigh?The doctor’s scale went up to 350 pounds, and she was heavier than that. If she did not know the number, how would she know if the diet was working?The doctor had no answer. So Ms. Bramblette, 39, who lived in Ohio at the time, resorted to a solution that made her burn with shame. She drove to a nearby junkyard that had a scale that could weigh her. She was 502 pounds.One in three Americans is obese, a rate that has been steadily growing for more than two decades, but the health care system — in its attitudes, equipment and common practices — is ill prepared, and its practitioners are often unwilling, to treat the rising population of fat patients.The difficulties range from scales and scanners, like M.R.I. machines that are not built big enough for very heavy people, to surgeons who categorically refuse to give knee or hip replacements to the obese, to drug doses that have not been calibrated for obese patients. The situation is particularly thorny for the?more than?15 million Americans?who have extreme obesity — a?body mass index?of 40 or higher — and face a wide range of health concerns.Part of the problem, both patients and doctors say, is a reluctance to look beyond a fat person’s weight. Patty Nece, 58, of Alexandria, Va., went to an orthopedist because her hip was aching. She had lost nearly 70 pounds and, although she still had a way to go, was feeling good about herself. Until she saw the doctor.“He came to the door of the exam room, and I started to tell him my symptoms,” Ms. Nece said. “He said: ‘Let me cut to the chase. You need to lose weight.’”The doctor, she said, never examined her. But he made a diagnosis, “obesity pain,” and relayed it to her internist. In fact, she later learned, she had progressive scoliosis, a condition not caused by obesity.Dr. Louis J. Aronne, an obesity specialist at Weill Cornell Medicine, helped found the?American Board of Obesity Medicine?to address this sort of issue. The goal is to help doctors learn how to treat obesity and serve as a resource for patients seeking doctors who can look past their weight when they have a medical problem. HYPERLINK "" Dr. Aronne says patients recount stories like Ms. Nece’s to him all the time.“Our patients say: ‘Nobody has ever treated me like I have a serious problem. They blow it off and tell me to go to Weight Watchers,’” Dr. Aronne said.“Physicians need better education, and they need a different attitude toward people who have obesity,” he said. “They need to recognize that this is a disease like diabetes or any other disease they are treating people for.”The issues facing obese people follow them through the medical system, starting with the physical exam.Research has shown?that doctors may spend less time with obese patients and fail to refer them for diagnostic tests.?One study?asked 122 primary care doctors affiliated with one of three hospitals within the Texas Medical Center in Houston about their attitudes toward obese patients. The doctors “reported that seeing patients was a greater waste of their time the heavier that they were, that physicians would like their jobs less as their patients increased in size, that heavier patients were viewed to be more annoying, and that physicians felt less patience the heavier the patient was,” the researchers wrote.Lapses in TreatmentOther times, doctors may be unwittingly influenced by unfounded assumptions, attributing symptoms like shortness of breath to the person’s weight without investigating other likely causes.That happened to a patient who eventually went to see Dr. Scott Kahan, an obesity specialist at Georgetown University. The patient, a 46-year-old woman, suddenly found it almost impossible to walk from her bedroom to her kitchen. Those few steps left her gasping for breath. Frightened, she went to a local urgent care center, where the doctor said she had a lot of weight pressing on her lungs. The only thing wrong with her, the doctor said, was that she was fat.ADVERTISEMENT“I started to cry,” said the woman, who asked not to be named to protect her privacy. “I said: ‘I don’t have a sudden weight pressing on my lungs. I’m really scared. I’m not able to breathe.’”“That’s the problem with obesity,” she said the doctor told her. “Have you ever considered going on a diet?”It turned out that the woman had several small blood clots in her lungs, a life-threatening condition, Dr. Kahan said.For many, the next step in a diagnosis involves a scan, like a CT or M.R.I. But many extremely heavy people cannot fit in the scanners, which, depending on the model, typically have weight limits of 350 to 450 pounds.Scanners that can handle very heavy people are manufactured, but one?national survey?found that at least 90 percent of emergency rooms did not have them. Even four in five community hospitals that were deemed bariatric surgery centers of excellence lacked scanners that could handle very heavy people. Yet CT or M.R.I. imaging is needed to evaluate patients with a variety of ailments, including trauma, acute abdominal pain, lung blood clots and strokes.When an obese patient cannot fit in a scanner, doctors may just give up. Some use X-rays to scan, hoping for the best. Others resort to more extreme measures. Dr. Kahan said another doctor had sent one of his patients to a zoo for a scan. She was so humiliated that she declined requests for an interview.Problems do not end with a diagnosis. With treatments, uncertainties continue to abound.In cancer, for example, obese patients tend to have?worse outcomes?and a higher risk of death — a difference that holds for every type of cancer.The disease of obesity might exacerbate cancer, said Dr. Clifford Hudis, the chief executive officer of the American Society of Clinical Oncology.But, he added, another reason for poor outcomes in obese cancer patients is almost certainly that medical care is compromised. Drug doses are usually based on standard body sizes or surface areas. The definition of a standard size, Dr. Hudis said, is often based on data involving people from decades ago, when the average person was thinner.For fat people, that might lead to underdosing for some drugs, but it is hard to know without studying specific drug effects in heavier people, and such studies are generally not done. Without that data, if someone does not respond to a cancer drug, it is impossible to know whether the dose was wrong or the patient’s tumor was just resisting the drug.One of the most frequent medical problems in obese patients is arthritis of the hip or knee. It is so common, in fact, that most patients arriving at orthopedists’ offices in agonizing pain from hip or knee arthritis are obese. But?many orthopedists?will not offer surgery unless the patients first lose weight, said Dr. Adolph J. Yates Jr., an orthopedics professor at the University of Pittsburgh School of Medicine.“There are offices that will screen by phone,” Dr. Yates said. “They will ask for weight and height and tell patients before they see them that they can’t help them.”But how well grounded are those weight limits?“There is a perception among some surgeons that it is more difficult, and certainly some felt it was an added risk,” to operate on very obese people, Dr. Yates said. He was a member of a committee that?reviewed?the risks and benefits of joint replacement in obese patients for the American Association of Hip and Knee Surgeons. The group concluded that heavy patients should first be counseled to lose weight because a lower weight reduces stress on the joints and can alleviate pain without surgery.ADVERTISEMENTBut there should not be blanket refusals to operate on fat people, the committee wrote. Those with a body mass index over 40 — like a 5-foot-5-inch woman weighing 250 pounds or a 6-foot man weighing 300 — and who cannot lose weight should be informed that their risks are greater, but they should not be categorically dismissed, the group concluded.Hospitals Wary of PenaltiesDr. Yates said he had successfully operated on people with body mass indexes as high as 45. What is behind the refusals to operate, he said, is that doctors and hospitals have become risk-averse because they fear their ratings will fall if too many patients have complications.A lower score can mean reductions in reimbursements by Medicare. Poor results can also lead to penalties for hospitals and, eventually, doctors.A recent survey of more than 700 hip and knee surgeons confirmed Dr. Yates’s impressions. Sixty-two percent said they used body mass index scores as cutoffs for requiring weight loss before offering surgery. But there was no consistency in the figures they picked.“The numbers were all over the map,” Dr. Yates said. And 42 percent who picked a body mass index cutoff said they had done so because they were worried about their performance score or that of their hospital.“It’s very common to pick an arbitrary B.M.I. number and say, ‘That is the number we won’t go above,’” Dr. Yates said. Yet a person with an index of, say, 41 might be healthy and active, he said, but in terrible pain from arthritis. A knee replacement could be life transforming. “It’s a zero-sum game, with everyone trying to have the lowest-risk patient,” Dr. Yates said. “Patients who may be at a marginally higher risk may be treated as a class instead of individuals. That is the definition of discrimination.”Surgery involves anesthesia, of course, giving rise to another issue.There are no requirements for drug makers to figure out appropriate doses for obese patients. Only a few medical experts, like Dr. Hendrikus Lemmens, a professor of anesthesiology at Stanford University, have tried to provide?answers.His group looked at several drugs: propofol, which puts people to sleep before they get general anesthesia; succinylcholine, used to relax muscles in the windpipe when a breathing tube must be inserted; and anesthetic gases.Propofol doses, Dr. Lemmens found, should be based on lean body weight — the weight of the body minus its fat. Using total body weight, as is routine for normal-weight people, would result in an overdose for obese patients, he said. But succinylcholine doses should be based on total body weight, he determined, and the dosing of anesthetic gases is not significantly affected by obesity.As for regional anesthetics, he said, “There are very few data, but they probably should be dosed according to lean body weight.”“Bad outcomes because of inappropriate dosing do occur,” said Dr. Lemmens, who added that 20 to 30 percent of all obese patients in intensive care after surgery were there because of anesthetic complications. Given the uncertainties about anesthetic doses for the obese, Dr. Lemmens said, he suspects that a significant number of them had inappropriate dosing.Yet for many fat people, the questions about appropriate medical care are beside the point because they stay away from doctors. “I have avoided going to a doctor at all,” said Sarai Walker, the author of “Dietland,” a novel. “That is very common with fat people. No matter what the problem is, the doctor will blame it on fat and will tell you to lose weight.”“Do you think I don’t know I am fat?” she /Editor Picked comments on the original article:As a physician, I am quite comfortable saying we are more than equipped to care for the typical obese patients. Disappointingly, the majority of my patients in the Bronx are overweight to obese. These patients pose the usual challenges we deal with on a daily basis in taking care of heavier patients - medication dosing, moving them about, tests etc. Nothing too hard here.The super obese, the ones pointed out in your article - these we cannot easily help. We see them too often. I took care of a ~650lb man in the ICU last week. We could not get him into our scanner, our ultrasounds would not penetrate his chest well enough to evaluate his heart, our invasive lines were difficult to place, the surgeons wouldn't touch him when we discovered the issue - these are hard things to get right all the time in the normal sized, let alone the very large. Our primary care physicians in the community, the ones tasked with taking care of all facets of care in 15-20 minutes - this group has the most challenging job. They see the obese population day in and out. They send the referrals for pains, shortness of breath, chest pain, leg swelling. The specialists managing these ailments have 15-20 min to discuss the issue and provide a diagnosis, not a solution to the problem beyond "weight loss".Your article actually asks too much of the physicians paid for by our current medical system.--A reply to Comment #1: As a 44 year old RN who was fit and strong, I sustained a 3 level cervical herniation from re-positioning a 412 pound patient. At that time, 1999, approximately 30% of the ICU RNs were out on disability leave due to neck or back injuries dealing with obese patients. My life was destroyed in a nanosecond. Not only did I lose my career and ability to earn a living, but my injury and subsequent chronic nerve pain developed into ME [myasthenic encepholopathy] which is a frequent side effect of neck injuries. I have been dealing ever since with not only physical disability but chronic, unrelenting pain. Thank you "[the comment #1" for pointing out how absurd this is.It seems a strange investment of limited resources to need super sized medical equipment of every description, at every location. A better investment would be free weight loss intervention. And, as a former nurse, spare a little compassion for those whose jobs are made exceedingly more difficult, even dangerous, in the care of people who require a team to roll over post surgery, never mind getting the patient ambulatory. Obesity makes the work of many medical professionals almost impossible, and other patients are shortchanged, waiting for care from over burdened staff. Where's the fairness in that? I'm sorry, but this is absurd.For those of you who consider this article to be merely "physician-bashing," let me preface my comments with the fact that I am married to a recently retired board-certified family physician. I have struggled with my weight from the time I was six months old. I am now 68. I have been on every diet, every restriction, tried every possible thing to lose weight that has come down the pike. My highest weight was 253. Eight years ago, I made a decision: I was going to stop depriving myself (as in, "Never eat sugar, never have fat, never have anything you 'shouldn't'") and instead control my portions. If I wanted a cookie, I would have a cookie. That was enough to get me out of deprivation mode. It took two years, but I lost more than 50 pounds and have kept it off for nearly five years.I have always been very active, no matter how much I have weighed. I played basketball in college, play tennis competitively now, and work out 4-5 times a week, doing 45-50 minutes on an elliptical machine. My primary care physician is board-certified in bariatrics, and she "gets" my efforts. However, new doctors who don't know me prejudge me every time. They don't even let me tell them that I have lost and kept off the weight. I am down under 200 for the first time since I was in the 9th grade! But all they see is "obese white elderly female in no acute distress."I had a knee replacement in March and am already back on the tennis court. But in the eyes of many doctors, I'm just a fat blob.I'm no fan of "fat shaming", which dehumanizes good people.At the same time, obesity doesn't happen on its own. With the exception of disease-related obesity, this sort of weight gain is the triumph of self-gratification over self-discipline. We need to be compassionate about that, but also firm: "You need to lose weight" is not insensitivity, it's scientific fact. Just like "You need to stop smoking", or "You've had enough" from bartender. The goal of medicine should not be to accommodate the super-obese with special equipment. It should be to stop them from arriving at that point in the first place. If that means bluntly saying "You need to lose weight", then, for heaven's sake, so be it.My sister is enormously obese, and it has affected her health in numerous ways. Miscarriages. Knee surgery. A mild stroke. Chronic infections. But the focus of her life is food and more food, and that will never change. How can a doctor be expected to help someone like that?I'm a medical student and I've seen this behavior. I'll never forget the time another medical student asked why obese people can't just lose weight. Like it's that simple. Another student told me of a resident instructing a patient who said he was too poor to buy groceries to purchase some kale to help him lose weight. We (including myself) are a sheltered and privileged bunch. I can count the number of overweight medical students in my class on one hand. Thus, there is less empathy for bigger patients. It's terrible, and even more of a problem when dealing with brown and black patients.As a sonographer, there are so many times I can't see a thing on a morbidly obese patient. They may get worse care because we simply can't image through that much adipose tissue. Chronic skin changes can make the skin tough and hard, like an alligator....it's just hard to get any image. Many times we have to say "technically difficult exam due to patient body habitus", unable to visualize such and such area. Skin breaks down under the heavy folds beneath the belly and we can't scan without drawing blood. Or the Pannus hangs down to the knees, too heavy for the patient to lift, requiring a second person to lift and hold it up while trying to scan. This lifting and moving of immobile weight causes frequent strains and injuries in the sonographers arms,shoulders,neck, even legs while trying to brace yourself to hold a steady pressure trying to get a diagnostic image. Techs are being injured trying to help obese patients. Sometimes you just want to cry when one walks in the door. You know its going to hurt and you may not even get anything useful. The doctors will say that the patient wont fit in the CT or MRI, just do the best we can.The judgment in the comments already is disappointing, but I've come to expect it even here.You don't know anyone else's story, and those of you who "remain unsympathetic to how they got there" are likely missing a lot of information about the journey along the way.I am, by current standards, obese. And you can hold me in contempt all you want, but I've actually lost about 90lbs from my highest weight. Now, the average person looking at me isn't going to know that, but why is it any of their business? Why do fat people have to justify their weight to anyone, let alone passing strangers in the grocery store? We know we're fat. Trust us, we know. Your contempt is not helpful.-I skipped a few non-useful or anecdote-driven comments-9. Two problems. One, doctors are woefully unschooled in nutrition. Two, America's supermarkets contribute to obesity by the foods they sell. In the case of doctors who know next to nothing about nutrition, the smart ones hook up with registered dietitians who then work with their patients. At least in that case, doctors are smart enough to know their limitations. As for supermarkets, it is quite apparent that at least 90 percent of what they are selling are items that harm the heart and tax the pancreas. The old advice to shop the perimeter of the supermarket (produce, meats, and dairy) is rarely heeded and every time I check out I see just about every other shopper with a basketful of heavily processed foods, high in bad fats like trans-fats and empty calorie carbs such as snack foods, sugary cereals, white bread, deli-meats, and prepared frozen foods such as fried chicken encased in breading. It gets worse. Try dining in a hospital cafeteria, yes, a HOSPITAL cafeteria. Might as well eat at a fast food restaurant. So, until doctors start receiving instruction on nutrition in med school and until the FDA takes supermarkets to task, the obesity epidemic will only increase. For now, obese and overweight people can help themselves by keeping a daily journal of what they consume and eating low-glycemic, non-processed foods such as green leafy and cruciferous vegetables, lean grass-fed meats, and nuts, with about 64 ounces of water each day. ................
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