Anti-bullying signal-boost.

[gaudior]

People have been talking about bullying lately. Dan Savage's It Gets Better Project has drawn attention to the suicides of gay teenagers, and has inspired the Make It Better Project, to give youth and concerned adults the tools they need to stop bullying in the schools. (I strongly recommend MIBP's Take Action page, which has such useful links as information about The Safe Schools Improvement Act (H.R. 2262/S. 3739) and how you can support it). And both homasse and seishonagon linked to an insightful and useful article by Kate Harding, On Good Kids and Total Assholes.

I'm glad people are talking about this so much-- it's making me think about my own childhood, and how much I accepted kids making fun of me, ostracizing me, and generally making me miserable as "just the way things are." That understanding of the universe and my place in it had long-lasting effects, and I am delighted and grateful that people now are talking seriously about how to stop bullying.

(I may at some point make a larger post, but at the moment, I wanted to signal-boost. Yay, signal-boosting.)

--R

Comments

[tiamat360.livejournal.com]

I could deal better with the Fat Acceptance community if their attitude was, "You know what? We'd rather live less time and less healthily in exchange for not worrying about what we eat and how much we exercise." That would at least make conceivable sense. Instead, though, this movement is actively arguing that there is no problem with being fat, and that is toxic as hell.

Yes, this. To me, this comes down to the concept of informed consent and the ability to make rational health choices for oneself. If you are fully aware of the consequences of your health decisions, then decide on a particular path, it would be ethically (and probably legally) wrong for a physician to force you to do something different.

However, if you have not been provided with correct information (say, because you read Kate Harding's blog), or you cannot understand or refuse to understand the consequences of your decisions (say, because you're a member of the Fat Acceptance movement and don't believe that being overweight carries significant health consequences), you just aren't capable of making an appropriate choice for yourself. At that point, it's the physician's duty to make sure you're aware of the implications of your decisions, at the very least.

I know it's difficult, with our society's stigmas, to be told by someone in authority how detrimental your weight is, even if they don't care about what you look like but rather are concerned about your health. However, I think a physician who doesn't try to make their patients aware of the consequences of overweight/obesity and encourage them to change is as morally wrong as a physician who doesn't offer chemo to their cancer patient.

[pastwatcher]

So, how can a physician inform a typical overweight American patient in a way that society and media haven't already done? Given that an overweight person already almost certainly suffers from stigma, it is likely that they feel powerless to change anything about their weight, and would wish to change it even without being aware of health risks. From a doctor's point of view in wanting actively to help patients, what is a good way to make people aware of the problem without worsening the effect of stigmas on them? I would be really curious to hear your opinion, or what you have learned in medical school on the issues of communicating effective action to a patient.

The reason I am responding this way: I imagine one needs a really strong focus on positive messaging, telling the patient a concrete course of diet and exercise combined with advice as to how to happily maintain or gradually acquire such a routine (since I hear people often start out by adopting regimes they can't maintain, and give up). If I read you correctly it seems that you assume the patient should work all this out for him/herself based on concrete facts presented by a doctor with no regard to his/her feelings. Am I misrepresenting you?

[tiamat360.livejournal.com]

If I read you correctly it seems that you assume the patient should work all this out for him/herself based on concrete facts presented by a doctor with no regard to his/her feelings. Am I misrepresenting you?

That...isn't at all what I said. So, yes, you are misinterpreting me. I'm really not sure how you went from "inform the patient and encourage them to change" to "ignore the patient's feelings and don't help them at all." Furthermore, I would think that you know me well enough to know that that's not the kind of thing I'd advocate.

Don't get me wrong, I don't like how the media portrays overweight/obese people. But there's a big difference between telling someone "you're fat and ugly, because you can only be attractive if you're thin," and "you would feel better and be healthier if you lost weight" (notice there's nothing about appearance in the second example??). Certainly people are hypersensitized to this issue, both because it really is a huge problem in this country (70% overweight? 25+% obese??) and so it's difficult for anyone, doctors or otherwise, to discuss it with people.

BUT.

That doesn't mean that the "Fat Acceptance" movement is going about things the right way. Support for people who don't fit the perfect American image? Totally awesome. Help for people who are overweight/obese? Fantastic. Telling people that being fat is not unhealthy, and ridiculing people who are trying to lose weight? Um, not cool. Also, hurtful to people in the long run.

[gaudior.livejournal.com]

Support for people who don't fit the perfect American image? Totally awesome. Help for people who are overweight/obese? Fantastic. Telling people that being fat is not unhealthy, and ridiculing people who are trying to lose weight? Um, not cool. Also, hurtful to people in the long run.

This makes sense to me. (Assuming that you mean that "help" is both "help losing weight if they want to" and "help dealing with their other problems conscientiously and supportively if they say they're not interested in losing weight right now. But I do assume you mean that.)

[pastwatcher]

(I loaded this page onto my computer and read it on the train--frustrating not to be able to post my reply now it's written.)

I'm sorry for misunderstanding, and the rest of your comment makes a lot of sense. I certainly don't think you would advocate disregard of patients' feelings! But I do think there is a problem with the way doctors tend to disregard patients' feelings, and wanted to know how much you thought about that general problem. It is also true that the way in which other people's weight affects my life is primarily a problem of others' psychological state; whereas it affects yours primarily in terms of medical problems.

I think we are reacting to different aspects here, as you said to ashnistrike below. We're agreed on media; my perception of practicing doctors isn't as bad as some of the stories below, but the communications from my doctor are nothing like as good as those I get from my dentist (who is still trying to help my teeth deal with the effects of a mediocre orthodontist and an absent-minded me). In fact, perhaps due to being thin, I have /not/ been talked to by enough doctors about nutrition; while I have made my lifestyle significantly healthier over the last two years, I still haven't had anyone analyze my (easy to describe) diet and probably should--e.g. next time I see a doctor I should ask about milk, if only I remember to do so.

My perception of the fat acceptance movement, on the other hand, is that I've seen it do the things you said are "awesome/fantastic" and figured there were only a few nutcases who did the "not cool" bit. Apparently your experience is not at all concordant with mine, and that explains the different priorities.

[nightengalesknd.livejournal.com]

I can tell you what I learned in medical school about communicating with patients. We learned the stages of change model. Basically, for someone to make a change, it doesn't work to tell them to change and then walk away. That's actually a great way to make them discouraged and not change anything at all or want to come back to see you ever again. People make changes slowly. Most of the research in this was done with smoking cessation counseling, and the phases are:

Precontemplation
Contemplation
Preparation
Action
Maintance

The idea is to figure out where the patient/client is, and go from there. You can generally help someone go one step. So if a person hasn't considered smoking cessation, you don't tell them to quit. You ask if they would think about quitting, point out some of the health risks in a non-judgemental way. If a person is thinking about quitting, you can then help them create a plan. Even then, you don't give them a pre-printed generic plan. You help them figure out a specific, personal plan.

That's what I was taught in the classroom on a few specific occasions and have rarely seen used in practice. What I was taught by observation in most cases was generic advice being handed out without a current understanding of what the patient actually is or isn't doing. And then behind the scenes, an awful lot of judgement and ridicule.

[pastwatcher]

Now that you mention it, I think I may have learned something like that in high-school health class. I've never stories of doctors applying such a technique, so as you imply it would be good if they did. Thanks for your answer, and your other comments are interesting and useful.

[nightengalesknd.livejournal.com]

Comparing obesity to cancer is comparing apples to oranges, here.

A person with certain kinds of cancer is currently objectively sick. The likelihood of survival without treatment is stastically very low to nonexistant. And even then, as you say, the physician can and should offer treatment, not force treatment or insist upon treatment or refuse to stop seeing the patient if they refuse a certain kind of treatment.

A person who is overweight may or may not be currently objectively sick. The person may be at increased risk, based on population data or family history, and those issues should be addressed. But population data does not equal personal risk, and I don't treat populations in the exam room.

If there is borderline or elevated cholesterol, addressing diet with this in mind is certainly the right thing to do. If there is evidence of insulin insensitivity or PCOS, than recommending exercise and helping the patient find a feasible exercise regimen is the right thing to do. If there is arthritic knee pain which may be improved by loosing weight, addressing the weight directly may be helpful, with the caveat that the pain itself may preclude many typically suggested activities.

Further, it's been shown that, for some conditions helped by weight loss, comparatively small amounts of weight can make a large improvement in health outcomes. Such a patient may lose some weight, derive health benefits, but still be objectively overweight and continue to be the recipient of negative weight-based comments.

If physicians would talk about health related behaviors with all patients, regardless of weight, council patients based on their current exercise and eating routines rather than an assumption of what those routines are, and address patient's particular complaints directly, I think it would go a long way towards improving the tenous relationships often held between the health care community and the people it is trying to reach.