Monday, November 07, 2005

I Know I Should Love Them All the Same, But ...

There are patients I enjoy, and patients I enjoy less. Oh, who am I kidding, trying to be all PC. There are patients I can't stand. I have something of heirarchy when it comes to how much I like patients. I think most clinicians do, though the order can be very different.

At the top are the smart patients. Not educated, smart. They can be smart and follow all my directions, or they can be smart and ignore everything I say. I don't care. In fact sometimes the latter are the most interesting. I have one patient who smokes two packs a day and coughs and wheezes like a sick cat. I tell him to quit smoking, and he tells me, "Now you know I'm not going to do that!" But he doesn't ask me to fix his cough. He just comes to chat, and I love to chat with him.

Next are the crazy patients, provided that they aren't dangerous crazy. I didn't used to mind dangerous crazy, but one punched me in the face once and split my lip, so I'm a little more careful these days. (He wasn't my patient, by the way -- he was just walking by me in the psych ward and didn't like the looks of me.) (I always feel compelled to add this. Otherwise I'm afraid everyone will think I'm just annoying as hell and that I make my patients want to punch me in the face.)

Next are the dumb patients who do what I say. Boring and a little scary, these people.

Last are the dumb patients who ignore everything I say. God how I hate these folks. I have one guy who is cheating on his wife and keeps coming in for STD's and wants me to give him pills to slip to his wife in her food. (No, of course I don't give them to him!) (Should I?)

The other day I saw a woman who is five feet tall and 300 pounds. She said the same thing that 99.9% of really fat people say when the subject of weight comes up:

"I don't know why I keep gaining weight. I don't eat anything."

Now, this statement in itself is not the dumb part. Like I said, 99.9% of people say this. But I have a stock response that works 99.9% of the time:

"You may be right, and it's not fair, but however much you eat, it's too much for you."

Most people will nod sadly on hearing this. And it's not a line on my part; hyper people who jump around all day and jiggle their legs until the person sitting next to them on the couch screams "Would you cut it out?" can eat a lot more than serene folks. And most of the people on the planet are the product of generations of surviving starvation -- that Pack It On gene is powerful. I do practice what I preach -- I exercise, I don't drink soda and juice all day, and I try to avoid eating a lot of junk -- but I know that I have it easier than many people. For a lot of people, telling them to eat less is like telling them to breathe less. Especially in our society, with a Starbuck's and a McDonald's on every corner.

But this woman wasn't buying it. She stared at me for a long, long, moment, and said,

"No, I don't eat too much."

I was flummoxed. Finally I said, "Well, why do you think you gain weight?"

"Because there's something wrong. You need to do tests."

OK. A lot of people think thyroid disease can make you gain weight. And it can. But it can make you gain 15, 20 pounds, max. Not 180 pounds. But she didn't even think it was her thyroid, because her thyroid had already been tested multiple times. She believed that there was some other condition that was making her gain weight and that I hadn't tested her for this condition because I was either incompetent and didn't know about it, or evil and deliberately withholding it from her.

Oh, and I also needed to do tests to find out why her back hurts. And her knees.

I'd like to think I treat all my patients equally, but I know that's not possible. I have a pretty good poker face, but I'm sure my expression was less than entirely nonjudgmental and empathetic as I tried to explain to her that I was not withholding some magic treatment for obesity from her. And I offered her pills for weight loss. I don't mind doing this. They don't work very well, but I'm happy to have people try them. But she didn't want that. She wanted to know what was Wrong.

It reminded me of those plants -- you know, "Magic Plant! It Grows On Air!!!!" She could be a "Magic Human! She Absorbs Fat from the Atmosphere!!!!"


Orange said...

Magic Human! Heh.

My (thin) husband does a lovely job of sitting for extended periods of time, but if I'm on the couch with him, that leg is jiggling. He's just lucky we don't keep saws in the house.

Diana said...

Oh, yeah. You won't win with her. I had a male patient who could have been her twin, at least in the attitude. We did run tests, lots of tests. Shockingly, his thyroid was completely normal. He then went to another physician, who threw him on some thyroid pills and threw him into a. fib. Guess who got to care for him in the hospital.

Orange said...

Did you see that NYT article a couple weeks ago? Written by a physician who so enjoys her patients, like the longtime smoker with COPD who coughs when he crosses the street and is convinced he's coming down with avian flu. Precious!

DoctorMama said...

I can recommend counseling, but I don't know as anyone's ever taken me up on it. The ones who really need it don't believe they need it, is the rub.

I didn't see the article, orange -- I'll have to try to hunt it down.

My husband and I sit and jitter together. And we wonder why our baby is in the 5th percentile for weight -- the poor kid is homozygous for fidgeting.

Anonymous said...

Oy vey, thou dost strike a nerve with this one.

I am very careful with eating.

I have never been fat.

Most everybody at my job is fat and they say things like, "well you're lucky!"

No. I don't eat a Coke and a Snickers bar for breakfast, you idiot.

elswhere said...

Whoa there, Anon above.

I don't eat a Coke and a Snickers bar for breakfast either, and I'm--if not obese, then well into the "overweight" category I don't exercise, and I'm not especially careful about diet, but I eat healthy food. This is about the same food-and-exercise regimen (or lack thereof) I had when I was 20, and I wasn't overweight then.

So, maybe some people put on weight more easily, especially as they get older? Maybe they don't necessarily have your self-control, but that doesn't make them idiots.

Hmm. Yeah, guess this *does* strike a nerve.

DoctorMama said...

Absolutely. Being overweight DOES NOT equal being an idiot. Snickers bar for breakfast, well, not a great idea, but not necessarily to blame for fatness -- I've known some serious candy addicts who were also skinny.

I had a little lesson in what hunger feels like when I first got pregnant. I was probably slightly underweight at the time, and I developed a RAVENOUS appetite. I was hoovering down everything I saw. I gained a pound every two days for two weeks. I was a little scared -- at that rate I would gain 250 pounds over the course of my pregnancy -- but I felt entirely powerless to stop it. If that's what dieting feels like, it's no wonder people don't lose weight. (I then got all-day nausea that lasted the next couple of months, and ended up gaining a reasonable amount -- phew).

But there are differences in metabolism with age, as well as in predisposition to gain and hold onto weight that have nothing whatsoever to do with willpower.