So I have decided that it is time for an apology, and it’s going to be a big one. The observant among you may have noticed that there is a new heading on the main menu of my website entitled “Other Voices”. Since I started becoming more vocal on social media, people have been getting in touch to share their stories with me. And some of them have trusted me enough to share them with all of you too.
I feel honored and privileged to have been trusted in this way, but the whole process has left me pretty heartbroken. Because time and time again, I hear the same thing. In my opinion, there is no question we doctors are failing miserably, and for some unknown reason no one seems to be doing anything about it.
There’s a social injustice taking place here that needs to be addressed. And more importantly, there is a long overdue apology that needs to be made. So I am going to go ahead and make it.
Why we need a big, fat apology
It all started a couple of weeks ago when Cosmopolitan released the cover of their Feburary edition which had people of different sizes posing on the front cover above a title that said “this is healthy”. And thus began a slew of commentaries, including several notable TV “doctors”, who were all very keen to get their two cents in.
Apparently placing a picture of a large woman exercising on the front of a magazine is actually a way of glorifying ob*sity and it is irresponsible and dangerous. Coupled with the near daily reminders that COVID kills ob*se people and that is why the UK and the USA have higher death rates than the rest of the world, it all got a bit too much.
Because you can’t be fat and healthy, right?
Wrong. That’s the biggest load of crap I have ever heard and I’m sick and tired of our politicians and journalists and, worse of all, the scientific community spreading this lie.
The Big, Fat COVID Debate
Let’s start with the basics. Ob*sity does not increase your risk of dying from COVID. There is a definite link between the two, but that’s all we know right now. Even Public Health England admits that the evidence is insufficient to draw any real conclusions. And that was back in July. Since then there have been studies that have shown that it has absolutely no impact on hospitalization, ventilation or death rates.
Which begs the question, why? Why is there a link between body mass and serious COVID when one is not causing the other. And this, ladies and gentleman, is the bit that nobody wants to talk about. Because it is awkward and uncomfortable and the impacts people in positions of power and authority.
Because serious COVID is also linked to poverty. It is linked to race and ethnicity. It is linked to level of education. And what do these groups all have in common? Well, amongst other things, they have all been shown to receive poorer quality healthcare.
What’s that you say? Surely I can’t possibly be implying that the medical profession does not provide equal care for all? Why yes, yes I am. That is exactly what I am saying.
Why medical fatphobia kills people
When a person in a larger body visits their GP, they are having to fight against the weight stigma and fatphobia that has influenced said GP’s attitude towards them. The doctor takes one look at them and subconsciously decides that they are lazy and lack self-discipline. It’s called size bias and I have already blogged about this.
What? You thought your doctor was above that? Don’t kid yourself. Studies have shown just how prejudiced doctors are towards their patients based on their size and body weight. And there is no question that it affects their diagnosis and treatment plan. Hence inequalities in healthcare provision.
Not only that, but it also affects the doctor-patient relationship. And that is equally as damaging. Time and time again I hear patients say to me “I would have come sooner but I was afraid you were going to blame it on my weight”. Listen to what the patient is saying.
“I was afraid you were…”
This tells me that they don’t trust me. They don’t feel able to open up. The lines of communication have broken down and I’m willing to bet they will be less inclined to follow my advice as a result. We call that poor compliance and we often mistakenly assume that it is down to the patient, when in actual fact the responsibility may lie primarily with the doctor.
“I would have come sooner but…”
This tells me that they have been actively avoiding me. And this is something that we need to start talking about. Let’s all use our common sense for a moment. When you put off seeing your doctor because you are worried that they are going to blame it on your weight, you are inadvertently putting your health at risk.
Especially during the COVID pandemic. Because this disease can cause patients to deteriorate rapidly, and a delay of just a few hours can make all the difference. Furthermore, data from our last pandemic (H1N1 or swine flu) showed that delayed presentation was a really important factor in the link between body weight and severity of the illness.
What you say versus what people hear
It’s easier to blame the individual, isn’t it? Nobody wants to call the medical profession into question. Most people wouldn’t dare. But I’m not most people. I am one of them. And I think that gives me the right to say something.
When doctors tells a patient that they need to lose weight, we are taught to believe that we are doing the right thing because part of our job description is to hand out lifestyle advice. But I respectfully disagree.
Firstly, I may think I am doing right by the patient. But what the patient hears is:
You’re the reason that you are unwell.
You ought to be ashamed of yourself.
I am not interested in helping you until you meet my standards of what is acceptable.
You are wasting my time.
You deserve to be sick.
You’re going to die soon and there is nothing we can do to help you.
Don’t come back until you’ve changed.
Fairly and Without Discrimination
Now look, it may seem like I am being hard on my fellow healthcare professionals, but I do know that almost all of them are good people. We don’t want to hurt our patients. We got in to this profession to help people. So is is easier to just accuse the patient of overreacting or imagining things.
[Just like when we say things like “racism is not the issue” or “women have just as many rights as men”. Riiiiiight.]
Let’s be real for a second. I’m willing to bet that there are many doctors who do believe that fat people are wasting their time. That they are to blame for their own illness and don’t deserve the same treatment that their thinner counterparts do. I’m sure there are lots of people out there that would agree with them.
But that’s irrelevant. Because in order to hold a license to practice medicine, we have to uphold the key principles outlined by the GMC. They include the duty to do no harm and to treat all patients and colleagues fairly and without discrimination.
In fact, every year we undergo an appraisal in which we have to demonstrate that this is the case. In other words, people don’t need to prove that we are discriminating against them. The burden of proof is on us.
This is how we are supposed to do it
So here’s a set of questions I believe a doctor needs to ask themselves before handing out weight loss advice:
- What are the risks of advising weight loss? These include the risk of damaging the doctor-patient relationship, putting a strain on the person’s mental health, and the metabolic consequences of long-term dieting.
- What are the actual proven benefits of advising weight loss in this individual situation? If you’re talking about heart disease, use the QRISK calculator. If it is a musculoskeletal condition, what do the actual studies show?
- On the balance of things, do I believe that the benefits of advising weight loss in this particular situation outweigh the risks? Seems simple enough, but you can’t stop there.
- Is there a chance that I am allowing my own prejudice and preconceived ideas about this patient’s health to cloud my clinical judgement?
- Am I confident that my own failings and inadequacies as a well-intentioned but nevertheless flawed clinician have not resulted in a lazy diagnosis and treatment plan?
- Do I understand how weight stigma has influenced this patient’s life and have I taken the time to get to know them as an individual rather than just seeing the number on the scale?
- Am I prepared to believe them when they say that they are doing the best they can, and can I accept that ‘best’ does not always equate to weight loss for a variety of reasons?
It doesn’t end there
And here’s the kicker, folks. Even if I answer yes to all 7 of these questions, I still don’t get to hand out weight loss advice. Why? Because I’m not a parent or a life coach. I’m a clinician. It is not my job to simply dispense advise and be done with it. This is not the 1950s, and doctors no longer get to sit on high and tell people what to do.
A doctor’s job is to help our patients to make their own individualised, informed choice. That means outlining a set of options going forward including the option of no treatment. For each one, we must explain the risks and benefits and ensure the patient has understood what we have explained to them. Finally, we must respect their autonomy and continue to act in their best interest no matter what they chose to do.
[I took my first ethics and law class over 20 years ago, but Professor Len Doyal had literally written the book on medical ethics and I listened avidly to every word that came out of his mouth.]
The Big Fat Apology
That’s how we were taught to practice medicine. That’s the standard we should be holding ourselves up to. We can’t tell people that we “never want to see that number on the scale again” or we “don’t want our time wasted”. We can’t tell people that they “need to lose weight or else” unless we have the evidence to back it up. And we never really have the evidence to back it up, because the evidence just isn’t out there.
Enough is enough. This needs to end. We cannot keep practicing like this without being challenged. It’s not fair. It’s not right. And it’s not in line with GMC regulations. Which calls in to question our fitness to practice medicine.
So I promised you a big fat apology, and I am sorry that you have had to wait until the end before I delivered. As you can see, I had a few things to get off my chest first. But here goes.
To every single person reading this who has ever felt judged, belittled, dismissed or despised by their doctor or nurse of other healthcare professional. To anyone who has ever received unsolicited weight loss advice or felt that their weight was unfairly blamed for something that turned out not to be the case.
I. Am. Sorry.
On behalf of the entire medical profession, I am sorry. We failed you. You deserve better. Now tell us how to fix it.
No seriously, tell us how to fix it. Comment in the box below. Get in touch. Get involved. I’d love to hear from you.