In the article above, Drs Rippe et al discuss the enormity of our health care dilemma in America. He pleas for us to make the changes in ourselves to move towards better health.
In this section (you be the doctor), Thindex will present you with a patient for you to treat. This patient is coming in to see you and is loading their problems on you. You are the doctor. These patients are real, except for the first one. Names are changed to protect the innocent. These patients are chosen for having obesity and de-conditioning issues. You will be presented with enough information to see why they are having problems. Your job is to lay out what you would discuss with them in trying to motivate them to make changes improving their health. There is no right or wrong here. We just think that seeing someone else’s problems may make it easier for web visitors to solve their own problems. Who knows? You may come up with a strategy that can get America moving toward better health. From what I see so far, no one around here has yet found the answer for obesity and de-conditioning.
#1. Monica. Monica is coming to your office to see you. Yes, you are the doctor. This is her first visit with you. You are a family medicine doctor. You take a look at her chart in the slot in front of the door. You take a deep breath and walk in.
She is seated with her arms crossed in front of her. After introductions, you ask why she is in to see you. She replies that she is a single mom and her daughter is about to turn 18 which will mean that the public subsidy will end. The thought of getting a job is troubling because Monica has no job skills. She thinks her prospects might be better if she could lose some weight and get in better shape. She is thinking about cosmetology or being a flagger for traffic.
She has filled in your medical form. She is 5 feet 6 inches tall and weighs 220. She can walk a mile in 15 minutes. Her thindex is eight below zero, her BMI is 37 and her VO2max is 30. Her BP is 140/95. Pulse is 80.
You discuss her medical history. Her mom is still living. She has adult onset diabetes and is overweight. “We are all fat in my family”. There is no history of cancer. Her mom takes “a ton of pills”.
You summon the nurse and perform your exam. She has some cavities in various teeth. She has a wax ball making it impossible to see the right eardrum. Her heart and lungs sound fine. She has good pulses. Her abdomen is soft and without pain, but difficult to examine due to her obesity. You ask her to do a few strength and balance tests. She can not do a sit up or a push up. She can not balance on one foot. She can only reach to her mid shin in trying to touch her toes.
You now need more information. You know she is obese, hypertensive, and physically weak. You ask what she does all day. What does she do? She gets up and makes breakfast for her daughter. She then straightens up the apartment. She turns on the TV and does a crossword puzzle. She lives by the mall and will walk over there and shop and get a snack. She meets friends there and they will sit and chat. She will watch daytime TV in the afternoon. After dinner, her daughter does her schoolwork while Monica reads or watches TV.
In summary, this is a middle aged single woman who is about to lose her subsidy and is worried about being homeless. She would like to work but never has. She is coming to you for help. Where do you start?
This lady has a body that is doing what it is told. It gets too much food and not enough exercise so it grows bigger and weaker each day. How do you get this lady to buy into the concept of becoming stronger and eating less to become thinner?
You think to yourself that if all your patients were like this you would shoot yourself. You ask yourself “Why did I go into medicine anyway?” But you do the right thing for the first visit, which is to schedule her to get the wax irrigated out of her ear and you put her on the wait list for the free dental program and order blood tests to check her lipids, chemistries, and fasting blood sugar. You schedule her to come in again in two weeks. Her labs will be back then. She needs to bring a list of what she eats and drinks every day – the food diary. She also needs to bring in the amount she sits each day.
As you walk out of the room, you ask yourself what are the chances of helping this lady? Should you just be sure she does not have diabetes yet and sever the relationship? On the plus side, she does have all day to walk if she were so motivated. She is worried about becoming homeless, so that is good external motivation. You decide that if she does get her labs drawn and does keep her diary and isn’t an “excuse machine”, then you will do your part and get her to self motivate into different person who does active things throughout the day rather than sit.
How would you handle this first visit?