Friday, September 4, 2009

Costs of obesity this week

3 D&Cs for AUB with thickened endometrial lining on ultrasound. Unable to get biopsies in the office for any of them. BMIs of all 3 are north of 50. I'm charging the insurance companies extra for the degree of difficulty - one of them I had 4 people scrubbed in with me to hold back assorted tissue. Plus you have the whole anesthesia charges. None of my normal vaginal instruments are long enough to work, so I'm Macgyvering solutions. Retractors aren't long enough, so I'm improvising there as well. My overhead lights can not be positioned so that I can see - I'm placing the hysteroscope's light source in the vagina...worked pretty well.

Induction for chronic hypertension, which would likely go away if about 100 pounds were lost.

Long discussion with a patient emphasizing her risk of post-op complications...I'm going to try and do a laparoscopic hysterectomy on her. Talked about wound infections, conversion to open procedure, blood clots. Told her it would be difficult. Her response "Is it because I'm a big girl?" Um, your BMI is higher than my age, so yeah, you're a big girl. And yes, that makes everything far more risky and complicated.

Post-op cellulitis in a c/s from last week.

Yeast infections galore.


Grumpy, M.D. said...

Does this paper gown make my butt look fat?

ER's Mom said...

Oh yes.

Grumpy, M.D. said...

You bring up good points. Jokes aside, this a serious modern health problem.

My BMI isn't ideal either, but not off the scale like that. I do my best, and preach my doctrine of exercise (I particularly encourage Wii Fit or Wii EA Active since it can be done inside).

This effects all of branches of medicine. In my field it shows up as back problems, meralgia paresthetica, diabetic neuropathy, stroke, and many others.

This problem costs more then swine flu ever will, and affects more people. But seems to be a hell of a lot harder to treat.

And, oddly, my verification word is "hearfat"

clazic said...
This comment has been removed by the author.
ER's Mom said...

To adinfinitu:

There are tons (double entrendre not intended) of medical supplies and instruments available for bariatrics.

A single reusable surgical instrument can cost ~$300. Add that cost into hospital is on the edge. We're in a rural area and are it for an hour's drive any direction. And quite frankly, needing to buy beds, chairs, and hydraulic lifts are more important that those instruments.

My week is just a little microcoism of what obesity really costs.

Michelle said...

I just found your blog through Grumpy MD, who I usually enjoy. I know that medical professionals have a tough and unappreciated job. As an obese woman who's worked on her weight her entire adult life, I find the contempt in your post contemptable. I can also tell you that your underlying contempt, although you may not vocalize it to your patient(s) comes through to your patient(s). It's a shame that the expensive medical education doesn't include (or perhaps it did and you didn't absorb it?) compassion and compassionate ethics. I can honestly say, with a straight face and medical records to back me up, that I have felt every drop of contempt that my medical professionals have dripped on me, through misdiagnosis after misdiagnois, usually by OBGYNs. I absorbed that contempt until I almost believed that my obesity was character related. Now I know better, because I found a doctor who actually listened and tried to help, and treats me as a human being, not as the huge blob of fat spread eagle on her table.

As far as what obesity costs, I'm well aware of what it costs, including nasty, sarcastic contempt, destroyed self esteem and unwarranted discrimination.

Maybe I'm being unfair because I haven't read your entire blog. Maybe you just had a bad day. But really, I'm so thankful that I'm done with doctors like you.

ER's Mom said...

Dear Hopeful,
Whoosh...there went the point of the post on you.

I don't bullshit my patients. I don't coddle my kids and I refuse to coddle the adults I call my patients. I explicitly tell them they are too fat. Now I will happily work with them on diet and exercise, but to hold their hand and say "It's alright" is a lie that I refuse to participate in.


Michelle said...

Actually, I did not miss your point. I completely got every contemptible word of it. I called you on it. Deal.

ER's Mom said...

Oh Hopeful,
I shall not get into a pissing contest on my own blog. Obesity is awful, it inflicts a large cost and my experience is just a small part of the cost.

Why should a woman need SURGERY because an office biopsy is undoable (and that's not even mentioning the fact that her weight has a significant risk factor in the disease process...)? There are a ton of risks involved in surgery...and that is part of the cost. The cost is more than dollars and cents, although that is the part easily calculated. You completely missed that point.

Keep your defensive blinders on though, if it makes you feel better. I openly advocate for what is best for my patients...whether they want to hear me nag them about smoking, call them out on the domestic violence, tell them that Mecca will take pregnant women for detoxing and that they should go, or that they are too fat and need to lose weight. My patients are the ones that no one else wants...and sometimes they just need a good swift kick in the ass to try to get somewhere with their health.

I recognize however, that I cannot make the horse drink...but I can lead to water. AND THAT IS AN INTEGRAL PART OF BEING A DOCTOR. So I do not apologize for calling someone out for being fat. A spade is a spade, no matter how fancy a term you use.

Michelle said...

Wow. This is the first response from you on this issue that has some semblance of respect. We also agree on quite a few points.

Am I defensive? Of course I am. Do I have blinders on? No. I see in the mirror the same thing you see when you look at me. I never disagreed that obesity doesn't have costs. I simply pointed out to you the emotional/human expenses. Those expenses come with "compound interest", if you will, when medical professionals, the ones we're supposed to trust, don't treat us with respect. Contempt results in a lack of respect. That's what I got from your original post, specially from the statement, "Um, your BMI is higher than my age, so yeah, you're a big girl." It was mean. Honestly, would you have said that directly to the patient, in those words? I really hope not, and after reading your last response, I think not. I don't think I once asked you, or told you, that you should coddle your patients. People know that they're fat. Your role is to educate - we agree on that. Your role doesn't require hand-holding. We agree on that, too, although there is something to be said about a decent bedside manner. Your role is not to be nasty, and it's not the role of the patients, either. If a patient resists your attempts to educate, then that's on them - I think we probably agree on that, too.

We also agree that there no need to get in a pissing match. However, you put something out on a public blog, and I responded publically. I bet if we were to have this discussion voice-to-voice or face-to-face instead of through the written word, we may find that we have both misinterpreted each other's intent and that we actually have a lot in common.

I apologize for the harshness of my original comment. You are probably exactly the type of professional I would want in an emergency or a difficult situation. However, I still think the comment I mentioned above dripped with contempt. I still hope you didn't mean it that way. I call a truce, and I won't trouble you again.

student dr. blaze said...


The particular part of the post that upset you is directed, I believe, at the vast majority of people who don't realize they're overweight. I commend you for recognizing and dealing with your obesity--I only wish more people would do the same.

It's upsetting and frustrating for healthcare practitioners to have to deal day in and day out with patients who are in denial about their health issues (whether that's obesity, diabetes, smoking, high cholesterol, drinking, etc, etc). Whatever the health concern, health care practitioners exist to improve and maintain patient well-being. The problem is, they can't help anything alone. The patient has to be a willing participant in the process. And not all patients (even doctors as patients!) can be/choose to be participants in their care. The reasons vary and are vast.

The point, though, is that it's terribly frustrating for the health care practitioner not to be able to help because of patient denial. So, I encourage you to keep speaking up--but remember it takes both sides and not all overweight patients are like you. People really *don't* always know they're fat. There inlies the rub...

Debbie Does Nothing said...

This is an old post so I doubt anyone's still reading but I have to speak up. First, I love the blog. Second, the tone of this post was full of contempt but I read it as just venting and not the same way you'd deal with a patient.

Third, and the reason I'm commenting, I understand the frustration medical pros feel over obese patients. But imagine being the fatty.

Every time you go out in public, you get the looks and the comments. I seriously doubt there's any patient who doesn't know she's fat and that it's going to kill her, but you get to a point where you feel helpless to change so you pretend it doesn't matter.

When you've tried every diet known to man, Overeaters Anonymous, therapy, meds, and the end result is you keep getting fatter, you get to the point where you just give up.

I overeat because I don't have the balls to blow my brains out. It's a slower form of suicide. I'm working on the depression (meds, therapy) but that's where I am right now and I suspect an awful lot of obese people are right there with me. Thank god, I have a PCP who's compassionate and understanding.

The best I can do is go in for my check ups, manage my carbs well enough to keep my A1C under control, and take my meds. If my doctor kept reminding me that I am the elephant in her exam room, I'd just stop going. My prescriptions would run out and my death would soon follow. One less fatty to deal with would certainly make her life easier.