It’s 4:45 pm on a Wednesday afternoon. I’m in with my last clinic patient of the day. I was running late because I had to admit my previous patient to the hospital for a heart failure exacerbation. I didn’t walk into the room until 30 min after the scheduled appointment time. My brain is kind of foggy since it’s the end of a long day. My patient isn’t happy to be here either.
Her labs obtained after a routine checkup last month confirmed a new diagnosis of diabetes mellitus. She’s unhappy because it’s one more medical condition to add to her growing list of problems: gastric-esophageal reflux disease, obstructive sleep apnea, non-alcoholic fatty liver disease, hypertension, dyslipidemia and osteoarthritis of her knees. She’s doing the best she can to be compliant with doctors’ advice. She’s trying to help raise five young grandchildren and doesn’t always remember to take her pills. She didn’t have time to check her blood sugar levels with the new glucometer we gave her last month.
“My blood sugar must be fine, I don’t feel any different than before they told me I had diabetes,” she says. I let out a small sigh of frustration and begin a 5 minute discussion about how high blood sugars can cause lots of problems without causing symptoms. She tells me she’s more interested in talking about her osteoarthritis knee pain. The physical therapy helped last time it flared, but her friend got a steroid injection which made her feel a lot better without having to go to so many appointments. This isn’t a good time for a steroid injection I tell her. It will make your blood sugars even worse, so let’s try to get them under control first. That makes her more unhappy, “but the doctor knows best” she states. We come up with a plan for her pain. Then after we talk about a few different diabetes medications, we agree on one to begin today.
I grab my stethoscope to move on to the physical exam. As I look the patient over, I think…she’s clearly overweight…what’s her body mass index, or BMI?…I scan the nurses recorded vitals on the computer screen and see “BMI 36.8”. There’s no diagnosis of obesity in her medical record, but her BMI has been the same the past 5 years. After I listen to her heart sounds I casually ask, “has anyone talked to you about your weight?”. She scowls at me and replies “Honey, I have a mirror and a husband, what do you think?”. I give a witty answer and she laughs for the first time. We chat for another minute or two while I fill her medications and complete her appointment summary sheet.
I glance at my watch, and I contemplate having a meaningful discussion about her weight. That if she lost a small percentage of her body weight, she could control her diabetes without medications. In fact, if she ate healthy enough, she might cure every single one of her medical conditions. And for a second, I hide a flash of anger…anger at the whole medical system for investing billions of dollars in medicines that help 1 in 20 people that take them, and that have side effects treated by other medicines…anger at my patients for lacking the discipline to control what they eat…anger at myself for succumbing to the treatment path of least resistance…the flash of anger passes. I start to rationalize. Our medical system has done some wonderful things, like generating treatments for things once thought untreatable, like HIV and cancer. Patients have busy lives. It’s not like they’re trying to be unhealthy, they just do what is convenient. As for me, this is the first time I’m meeting this patient. I need more time to develop a rapport before I can discuss weight and nutrition seriously. She probably wouldn’t implement my advice after one 10 min discussion anyway. But she will take the new medication I give her, at least most of the time.
I tell her the medications are put in the computer, and she can go activate them at the pharmacy. We shake hands and I show her the way back to the front desk. We should see you again in 3 months, I tell her.
I walk back and sit down at my desk to finish my notes. But I can’t stop thinking about how many problems I see everyday that are caused by malnutrition. This is not malnutrition in the sense of poor access to calories and nutrients, like you might see in the impoverished, or in a third world country. This malnutrition reflects people eating unhealthy food when better options are available. And I think to myself, ‘you’re not any better Fill, and you’re a doctor. This is ridiculous…something’s gotta change.’
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