Elephants

“We need to address the elephant in the room – which is your size.”

I gasp.

Surely I just heard incorrectly and the physician did not actually just say that to my patient.

I witnessed this encounter back during my first week of rotations as a third year medical student in an outpatient family medicine clinic. The office was almost completely empty that afternoon as most of the residents were in a meeting, and I was assigned to work with the one remaining resident and a covering attending (who shall remain nameless).

As I introduced myself to this attending, he informed me that he was a self-proclaimed nutrition expert and that he had recently written a book on that subject. Being the daughter of a dietician, I was excited. I liked being able to speak to patients about making positive lifestyle changes and I figured he would be a good example of how to implement such change.

Boy was I wrong.

The first patient that afternoon was an 85 year old women coming to establish care at this clinic. I go in to get a full history and talk with her about her long list of medical problems. She had all the usual stuff – diabetes, hypertension, chronic pain and a BMI of 33 (actually not all that impressive these days). I ask her about diet and exercise and she tells me that she has been unable to exercise for the last 10 years due to a car accident followed by chronic back and leg pain combined with severe osteoarthritis of her knees.

She was a very sweet lady who seemed genuinely interested in improving her health and quality of life as much as she could. She told me about how she used to be a runner and that she never had any of these problems before her accident.

So when I go out and give a brief story to the resident and attending before they head in to come up with the final plan for her, I am looking forward  to seeing how this attending can help such an eager patient to make some realistic, practical changes to improve her quality of life.

But as you can tell by what was basically the opening statement by this attending – that did not happen.

I understand that some physicians endorse a “tough love” approach with their patients, and I have seen it work really well when that physician has a good relationship with their patient. However this encounter had no resemblance of relationship building. This was no “come to Jesus” conversation. All that happened was three people of authority walking into a room and telling a woman everything that she is doing wrong – which believe me, she already knew.

When we forget to add the “love” part to the tough love conversation, all that ends up happening is shaming – and no one has ever been promoted to change by being shamed or made fun of by their physician.

I have no answers for how to make sure we maintain the love. For now, when I am tempted (which is several times daily) to forget to have compassion for my patients I remember the look on this poor woman’s face, take a deep breath, and try again.

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