“First do no harm.” Probably most people don’t realize that this isn’t even actually part of the oath that you may or may not have taken when you became a doctor. I think most people don’t know a lot about what it’s like to be a doctor, or what being a doctor meant to you when you started med school, or what it means to you now. I’m pretty sure you have pressures on you that most of us don’t know about or understand, that you are nearly as much a victim of a system that does not care about patients as are your patients. I know your job is hard, and I understand that you are human, and fallible, and that people expect unreasonable things from you, and that is a lot to deal with. I understand.
I still need to talk to you about doing no harm. Even if that was not an oath that you agreed to, and even if that seems like a tall order when medicine is messier and more human than pop culture makes it out to be, I still think it is a fair expectation. I think it is fair for patients to expect to consult your expertise and not come away worse for the experience.
I can’t speak to all of the other ways in which doctors sometimes cause harm to their patients, I only know how I have been harmed as a fat person. So I will tell you how to do better when you meet people like me.
I am fat. This is not a temporary condition and you do not have a cure. Diets do not work. I know this because I have spent my life bouncing from diet to diet in search of the one that will finally fix the fatness that doctors like you told me was definitely deadly, definitely fixable, and definitely my own fault. I have engaged in disordered eating behaviors (and at several points could have been diagnosed with an eating disorder if doctors had been concerned about my behaviors instead of encouraging them). I cannot think of a time in my life until very recently when I was not either attempting to lose weight or rebounding from those attempts. I have spent my entire adult life trying to change my body, and it is not changing. I am fat, that is just a fact, and I need to accept that and work with it.
I need you to do that for me, also. I need you to recognize that, even if my risk of a particular disease process is heightened because of my size (which is not a clear-cut as we have all been led to believe), that is simply the set of circumstances that exist in my health portfolio. It is not something that I can change – and not for lack of trying – and it is not good medicine to focus on the most difficult, least changeable thing and ignore everything else that could help me.
This is my body, and it is your ethical obligation to treat it with the same care and compassion you offer to thin people. I am not asking for special treatment. I am asking for the same treatment. I am asking for evidence-based, compassionate, whole-person care.
Going to the doctor causes me considerable anxiety. My fight or flight mode is activated as soon as I wake up on the day of my appointment and it doesn’t shut off until long after, sometimes a day or two – especially when the appointment goes as poorly as I feared it would. As it often does. Here is an incomplete list of my experiences which explain this apprehension:
- When I was diagnosed with PCOS almost 20 years ago, I was told that my weight caused it and losing weight would basically cure it. I was not offered anything beyond weight loss to manage my symptoms and no doctor ever explained to me that PCOS was more than just a reproductive issue. I was shocked to meet a thin woman who also had PCOS (because I had been told it was caused by my fatness); she assumed that I was on Metformin like she was, because her experience with the diagnosis and treatment of PCOS was drastically different from mine despite the major underlying concern – insulin resistance – applying equally to us both. No doctor ever told me that insulin resistance was part of PCOS, and despite the many times I was screened for diabetes, no doctor ever told me that my PCOS – rather than merely my body size – was a reason to screen for diabetes regularly. In other words, despite considerable time, energy, effort, money, and anxiety spanning decades, instead of the most basic information about my specific health concerns, I got generic catch-all fat person advice that made my health worse, not better, and paid countless doctors for what I consider very negligent care.
- Nearly every doctor I have seen in my adult life has either recommended an extremely restrictive diet, a fad diet, weight loss pills, or weight loss surgery, regardless of my presenting concern and regardless of the state of my metabolic or other health markers, without any discussion of the drawbacks, without asking if I was interested in this counsel, and without considering the possibility of an eating disorder.
- I have overheard medical staff making disparaging comments about my body and my appearance in an area where other patients could hear them. I have had more than one doctor make disparaging comments to my face. A gynecologist who had given me muscle relaxers to make the endometrial biopsy easier (for her, not for me, as it turns out) became frustrated that my legs did not easily open wide enough and disgustedly told me that it was my fault because I didn’t take care of myself. There was a medical student observing her at the time, as well as a medical assistant. Nobody commented or reacted, and I was impaired by the muscle relaxer and could not defend myself, so I cried the rest of the day. When I returned for the follow-up, I called her medical student into the office with me so I could explain that what she did was unacceptable and I deserve more respectful care, she dismissed me in the same clipped tones. I went to retrieve my medical file and found that her synopsis of these events was “grossly morbidly obese; advised weight reduction to improve symptoms, but patient became defensive”.
- When I began having gallbladder attacks, I went to my primary care doctor, to several different urgent care clinics, and to several emergency rooms over the course of six months of increasingly severe attacks. The treatment I received ranged from a recommendation to eat less greasy food (despite the fact that I was terrified to eat anything most of the time because even lettuce would cause an attack and that doctor did not bother to ask about my diet in general or that day in particular), to the standard weight loss advice fat people always get, to one curious referral to a cardiologist despite a totally normal heart workup (I was 29 and have no family history of heart disease or heart attacks). None of these doctors ordered an ultrasound of my abdomen, which I understand is a pretty commonplace diagnostic step when faced with my (fairly textbook) symptoms. It took six months of torturous attacks culminating in emergency surgery to diagnose and treat my gallstones. I cannot be sure if this is solely a result of weight bias, but each individual appointment included assumptions and mischaracterizations (including one accusation of exaggerating my pain) that definitely were a function of weight bias.
- A gynecologicist who performed a D&C on me persisted in recommending weight loss long after I clearly explained that I was not interested in discussing it and simply needed treatment for my hyperplasia. Ultimately he attempted to sell me diet bars made primarily of fiber that he said would trick my body into thinking I wasn’t hungry and allow me to eat only 800 calories a day. When I firmly and frustratedly rejected his fad diet, our rapport crumbled and he shortly thereafter sent me a referral to a different doctor, citing workload changes I’m still not sure I believe.
- At one point, because doctors had convinced me that I would definitely have *some* deadly disease by middle age if I did not go to any lengths necessary to drastically reduce my body size, I went to a presentation by a local bariatric surgery center on the Roux-en-Y gastric bypass. I work in university classrooms and I’ve been through enough bioscience classes to have multiple degrees (if I were getting credit), so I am reasonably well-versed (for a lay person) on biology and anatomy/physiology. When the surgeon explained the specifics of the surgery, I realized that some important steps in digestion could not possibly work the same afterwards. I raised my hand and asked if malnutrition was a concern, and she laughed and said “she’s here for weight loss surgery and she’s worried about malnutrition”. She never answered my question, just mocked me for asking it, and as it turns out, my question was medically insightful, since weight loss surgery recipients do, in fact, have permanent issues with nutrient absorption.
These are the incidents I remember. There are definitely more, and there is also the general frustration of constantly receiving counsel to improve my eating and exercise habits without first being asked what they even are, the noticeable displeasure some doctors display when they have to touch my body, the clear disposition that I read (based on experience) as a lack of investment in my care driven by a belief that I am not interested in my own health. Not to mention the consistent characterizing of each of all of my individual symptoms as separate weight-related ailments instead of acknowledging that nearly all of my medical history has been treatment of the collective symptoms of one disorder – PCOS. (arguably, even my gallstones are a result of my PCOS, in that they were most likely caused by my weight cycling, and I mostly pursued weight loss in an attempt to treat my PCOS symptoms).
I don’t believe that doctors do these things to me intentionally. I think they mostly don’t know they’re doing them. I think they don’t know that I understand what it means when they shrink back, don’t make eye contact, sigh, shrug, rush me out the door. I believe they most likely became doctors because they wanted to help people, and I believe they do many of these things because they don’t know what else to do. I believe that they – that you – are most likely good and compassionate and don’t mean to cause me harm. But in spite of all of this, the fact is that very often, you do. And the impact of these harmful incidents is cumulative. I have a wonderful primary care doctor now, and despite our great rapport, her willingness to offer weight-inclusive care, and her general pleasant disposition, I still wake up with anxiety on appointment days.
I know you don’t want me to feel this way. I know you most likely do care about your patients. I know you’re busy and overworked, and I know you are beholden to policies and “best practices” that you didn’t create for how to deal with bodies like mine. I am not asking you to take a bunch of workshops or to loudly defy the powers that dictate your compensation. I understand that you have hoops to jump through. I also understand that the status quo is pretty powerful, and despite mounting evidence that medical weight bias is causing harm and that the so-called obesity crisis is overblown, change is incredibly slow and we are stuck with what we have in the meantime. I know.
Here is what I do want: I want you to listen before you advise. Hear my actual concerns before you jump to a conclusion, especially if that conclusion is that my fat is causing my problem. Let that be a diagnosis of exclusion rather than your first impulse, because when you offer me that and only that, it is the same for me as if you are saying there is nothing you can do for me. If that is really true, okay, I accept that, but it is only actually true if a thin person who came to you with the same concerns would get the same answer. I want you to ask me the same questions you would ask a thin person, offer the same advice you would offer a thin person. I want you to think of other possible causes for my concerns besides my fat, and discuss all of them with me. I want you to respect the boundaries I put in place regarding measuring my weight or discussing weight loss, acknowledge those boundaries as a lack of consent, which I am entitled to.
I want you to recognize that mental health is an important part of my overall health picture, that focusing on my size is detrimental to my mental health, and, because I have a history of a clinically diagnosable eating disorder (even though weight bias ensured that I never got diagnosed or treated), weight loss is simply not a good solution for my health concerns because, no matter how much you may believe it would benefit my physical health, it would devastate my mental health. I want you to read up on Health At Every Size principles and Intuitive Eating principles, to expand your repertoire of possible treatment approaches for people who, like me, would experience worse overall health if weight became the focus of their care.
I want you to spend the same amount of time with me that you spend with thin patients, smile, talk to me, and touch me as much and in the same way as you do thin patients. You don’t need to do more for me than for them; if you are not one to smile, you don’t need to smile for me. If you don’t do small talk, you don’t need to do it for me. I just need you to reflect on whether your serious expression and clipped sentences are your general temperament or your emotional response to my fat body. I usually know, so I want you to notice this, too.
I believe you can provide me with the kind of care I need. I believe you want to help me. I hope we can have a better relationship moving forward, because I think that is essential to improving both the quality of the care I am receiving and the satisfaction you feel when providing it.