Saturday, April 28, 2007

Shaming the Patient

Last week in my "Women and Literature" class, one of my students gave a presentation on Lucy Grealy's powerful memoir of disfigurement, Autobiography of a Face. From there, we moved naturally into a discussion of body image and physical beauty.

Many of the students, all too predictably, had struggled with appearance, especially around issues of weight. We were talking about shame, and I mentioned how often, at the hospital, I hear medical staff lecturing patients about how they have to stop smoking, stop drinking, or lose weight. My sense has always been that the patients already know this, and that by shaming the patients about these subjects, doctors and nurses just make it more difficult for them to seek medical help when they need it. It's a lot harder to go to the doctor when you're ashamed of yourself, especially when you expect the doctor to try to make you feel more ashamed.

This offhand comment on my part loosed a passionate flurry of anecdotes from my students, who -- it turned out -- had felt shamed by all kinds of people who were supposed to be helping them. There was a series of stories about people at health clubs doing body-fat or BMI measurements resulting in a label of "obese." My students had strong, articulate opinions about why BMI measurements are inherently faulty, especially for anyone whose weight is primarily bone or muscle, rather than fat.

One student, who used to be anorexic but has successfully overcome her eating disorder and attained a healthy weight, talked about how miserable she was when a personal trainer at a health club told her she was fat. ("Fat," by the way, is the last word I'd use to describe her.) "They'd taken a health history. They knew I'd had an eating disorder, but they still told me I was fat. How could they do that?"

One of the most disturbing stories came from a student who has a medical condition that makes her gain weight, and also makes it difficult or impossible for her to lose that weight even on a restricted diet. "So my doctor told me I had this condition, right? And then I went back the next month or whatever, and he told me I was too heavy. And I was like, 'But you know why I'm heavy! You diagnosed it!' And he told me I had to eat less, and I told him I'd hardly been eating anything, only one small meal a day. And he said, 'No, no, that can't be true, or you wouldn't weigh this much.'"

Medical professionals live in the same culture that has shaped their patients' attitudes towards food, health, and beauty, and no doubt many of them struggle with body-images issues of their own. But it seems to me that shaming patients violates the prime medical directive of "First, do no harm." Shaming patients about something they can't -- or shouldn't -- change is counter- productive at best, and simply cruel at worst. Even when change is medically mandated, there must be healthier ways to motivate patients to achieve it.


  1. A friend (who is also a medical student) and I were just talking about this very topic two days ago. In truth, we were griping about how unrepresentative our class group is of the general population in terms of weight, etc.... She and I have both struggled with weight, for various reasons, but both also have the lab test results of a highly-trained athelete, which are rarely appreciated by those around us, even our doctors. Neither of us expected to feel like the "fat" members of our respective classes. How, we wondered, will these young, thin atheletes be able to sympathize with the shame and struggle most of our patients will be facing?

    At the same time, I have to acknowledge that many of my classmates feel ashamed of their bodies, regardless of their size/athleticism. In truth, they probably feel more ashamed than I, since I am fairly comfortable with my body and its so-called foibles. Will they be able to see that feeling in their patients? Or will they run from their own imperfections, placing the shame onto the shoulders of those in their care, avoiding it themselves?

    Out of curiosity, would you and your friends feel more comfortable with a doctor who says, "I know this is a serious struggle, but I'm concerned about your weight for x,y,z reasons, and I'd like to talk about ways we can help you achieve a healthier state," or would you prefer a doctor who didn't mention it at all? I find myself ethically drawn to the former, since for some people, weight can be risk factor for many diseases, but I can also see how not saying anything at all might be a kindness as well.

  2. Alexis -- I can't speak for my students, but I myself would feel far more comfortable with the former. I'd never suggest that doctors not raise issues of concern, but many of them do need to find kinder ways to do so.

    My health club, by the way, is decidedly health-based, and cheers people on just for being there. When they're giving tours of the facility, they point out the scale but say, "We're just showing you this if you want to use it; we're not suggesting that you do."

    There are lots of very heavy people there; I suspect they feel safer and more comfortable there than they would at many other clubs.

  3. Many healthcare providers are not only NOT learning about therapeutic communication, but they are also not practicing ethically. Ethical practice entails involving patients as empowered sentient humans with inherent worth. One does not lecture DOWN to patients, but instead, an ethical nurse or physician asks questions to obtain an understanding about how the patient views health, what roles are important to the patient, how the patient learns, what framework of values and education the patient uses to make health-related decisions, the resources they have to move toward and maintain health, etc. But this type of assessment, and then the counseling, partnering and teaching that should follow in a developing professional relationship are not generally reimbursed by third party payers. So checklists and cheat sheets are used instead, with a cursory, if any, discussion held with the patient. Handouts and videos are handed to the patient without any understanding of whether they are appropriate or relevant to the patient. It's a one-size-fits-none approach to health education and patient decision-making. It is impersonal, offensive and objectionable. Unsurprisingly, it is also ineffective. I believe it causes harm to patients, and your post, Susan, illustrates just one kind of harm.
    As a tangential point, although it is known that almost all patients who have been in critical care settings have symptoms of post traumatic stress disorder as a direct result of having been confined in that care setting, there are no standards of nursing care or practice for mental health needs of any kind of hospital inpatients outside of behavioral health (psychiatric) care settings. That is a huge gap in ethical care.
    Sorry for the lengthy rant.

  4. Sadly, I think it's also a matter of time. In the given system, 15-30 minutes is often not long enough to engage in meaningful dialogue, and patients change providers so frequently that it's hard to develop the kind of relationship you need in order to have many of these conversations in a sensitive way.

    That said, thanks, Susan! I store this sort of input away, and practice it on the patients I see now (who are often very kind, knowing that I'm still learning), so that when I'm launched into the "real system," I know what I want to do, even if sometimes I won't get the time/chance.

    Three cheers for your health club! Mine is mostly the same way, or at least they don't ever talk down to anyone (probably because they're also a physical therapy center in addition to a club) or give people labels. So many facilities are objectionable, so it's good to know there's some supportive ones out there.

  5. Alexis -- You're welcome, and I suspect you're going to be a very good doctor! The time issue, though, certainly is a large factor, especially in an ED.

    N=1 -- No need to apologize for the rant; it was very interesting. I was especially intrigued by your point about critical-care and PTSD. Are there articles or studies about this I could read?

  6. Hi Susan:

    Let me nose around for the studies. I had found them via a hard copy search and left them with a colleague for further perusal - now don't remember the specific journals. The American Association of Critical-Care Nurses and the Society of Critical Care Medicine are the two most likely sources for them as they publish the bulk of that type of research. Hope your trip home is smooth and uneventful!

  7. Anonymous9:40 AM

    There are doctors who have the capacity for empathy with their patients, and doctors who don't. Never stick with one who makes you dread going into his/her office. That kind of stress is extremely damaging to your body, in my opinion, and easily avoided. If you decide to dump a "shamer" , be sure, when you see a new doc to have an upfront conversation with him/her about the unhelpfulness of shaming and what feels like shaming to you.

  8. my guess would be the girl has PCOS and one small meal a day will backfire ... and if she doesn't eat several small meals a day she will in fact gain weight.

    To keep the metabolism constantly working is the only way to loose weight ... it's backwards but true.

    I've had an eating disorder for most of my life ... I also have metabolic syndrome and PCOS ... I hate food with a passion, yet, when I eat just one meal a day, or worse, don't eat body goes into starvation mode and it saves everything I give it because it thinks that I'm not going to feed it again ... and I gain like crazy.

    If I eat small and regularly ... it will come off slowly but surely.

    Weird .but true.

  9. Cushing's Disease is marked by weight gain, it was my first symptom - face swelling & weight gain. It is absolutely impossible to lose weight even when I do not eat. The most common cause for Cushing's Disease is a pituitary tumor, and the statistics for pituitary tumors are 1 in 5 people! It is under-diagnosed and commonly misdiagnosed as PCOS.

    Just my 2 cents on the Fat discussion. I've seen at least 40 doctors over the past 20 years and I am finally going to surgery at the end of this month.


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