At the end of a busy afternoon, Mrs. MJ was exactly the kind of case I needed.
Two of my patients had come in late but needed to be seen and another was acutely short of breath and refusing to be admitted to the hospital. The chaos had put me almost an hour behind schedule, and I still had to return to the wards to round on my cancer patients. Fortunately Mrs. MJ was on time and at 52 years old “incredibly healthy” (in a relative manner of speaking). The last time I saw her was a year ago when she presented as a new patient. Other than some hypertension and weight issues she was fine.
Glancing at the triage sheet as I knocked on the examine room door, I thought everything was checking out. Her BP was 132/82 and for chief complaint my nurse had scribbled “annual visit.” This meant her blood pressure was under control, and she didn’t have any urgent complaints. Perfect. This would be quick.
When I entered, she was ready for me with a list: medication refill, referral for Pap smear, mammogram scheduled, and her “yearly checkup and blood work.” And oh, almost forgetting, she had a back problem she wanted me to “take a look at.” She had her agenda and I had mine. As medical students we are repeatedly taught that “vital signs are vital.” Temperature, blood pressure, heart rate, respiratory rate — not surprisingly, all of these were fine. But I was worried about another, less established vital sign: her weight. Glancing at my last clinic summary, I saw her weight one year ago was 195 lbs. Today she was 204 lbs. At 5’ 5” her BMI was 33.9, well into the obese range.
I planned out the rest of the visit in my head. Though it may not be readily apparent, there are wide variations in what primary care doctors would do even in this run-of-the-mill scenario. I could focus on her concerns, which would take no more than 3-4 minutes and move on to my other patients. I could do a full physical exam, listening to her heart and lungs, examining her abdomen, though she had no somatic complaints other than back pain. I could ask her about her blood pressure medicine and assess for side effects and adherence. Or I could counsel her about her weight, and even then would need to choose between an almost infinite number of ways forward.
I chose to focus on her weight. There is no evidence to support annual blood work in this patient. A year earlier I had screened her for cholesterol disorders and prediabetes as well as evaluated her kidney function given her hypertension. Likewise, though routine, physical examination of asymptomatic patients is also unproven. Her back pain by history was most likely chronic and musculoskeletal. And while evaluating her hypertension and medication adherence is important, with her BP at goal these concerns were secondary.
I began by asking her what she thought about her weight. She thought she might be heavier than the year before but was surprised to learn how much she had truly gained. When I asked her why she thought her weight was up, she cited an increasingly sedentary lifestyle. I asked her about her diet, which she thought was good, but then probed further to ask about her last three meals. I offered my views on weight loss, emphasizing the importance of monitoring and recording weight and of reducing intake of carbohydrates and in particular refined carbohydrates.
As always I could have done more. But, as always, time was running short. I concluded by telling her that I would schedule her follow up in 3 months. She was taken aback: “Three months! I usually see my doctor every year. I thought everything was fine.”
Clearly I hadn’t gotten through. I tried a stronger message: “Obesity is a serious condition. If your blood pressure was elevated, you would expect to start a new blood pressure medication or watch your salt intake more closely, and then see me again in 3 months. This is no different. Obesity kills tens of thousands of people each year, and is a key driver of hypertension, diabetes, and heart disease. I really want to see you again in three months so we can make sure your weight is going in the right direction and if not, take more aggressive action.”
As the visit came to a close, the conversation became more relaxed. She asked me about my wife, and I asked her how she was enjoying the beautiful Chicago summer. Having re-established ourselves as peers, I felt a little guilty for getting so worked up about her weight. “Sorry to be so tough on you,” I said somewhat sheepishly. “It’s okay. You weren’t tough at all. It was more of a gentle scolding. I needed it.”
To most people, this visit would seem incredibly routine. Mrs. MJ didn’t have an obscure diagnosis, wasn’t acutely ill, and didn’t suffer from a complex set of psychosocial issues. But its “routine-ness” is what makes it so concerning. The obesity epidemic has left thousands of Americans standing with Mrs. MJ at the crossroads between relative health and serious medical illness. And yet, our approach to these patients is non-standardized and highly fragmented. We continue to focus on urgent complaints not overall health, pharmacologic treatment over counseling, and tradition rather than science. When we do address weight gain head on, we use blunt instruments and clumsily at that.
Given that primary care stands at the intersection of medicine and public health, if I feel inept to contend with obesity, where does that leave Mrs. MJ? Let’s hope for her sake that my “gentle scoldings” add up to something real.
Shantanu Nundy is an internal medicine physician and author of Stay Healthy At Every Age: What Your Doctor Wants You to Know.
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