Posted by: notdeaddinosaur | November 25, 2008

Time and Place

There’s a new columnist in the Philadelphia Inquirer; a young ophthalmology resident named Rachel K. Sobel MD. She generally offers a fresh view of residency training, albeit from her vantage point not just of a specialist but of a specialist training at a specialty hospital. But her column yesterday headlined “Prescription: Shape Up” has me flexing my saurian claws:

My patient came in to the Wills Eye Emergency Room with red eyes and the kind of pain that felt as if he had had a headache inside his eyes for several days. I diagnosed a recurrence of uveitis, an inflammation inside the eyes, and treated him with eye drops.

My attending, Donelson Manley, agreed with my plan, and gave some advice: “Sir, we can treat your eyes and your eye headaches,” he said. “But you need to take care of yourself and lose weight. That’s going to give you a bigger headache. If you don’t lose weight, you run the risk of developing arthritis, diabetes, heart problems and more.”

The patient looked shell-shocked and maybe a little mad. He weighed 350 pounds and was less than 6 feet tall.

I too wanted to encourage him, but I kept quiet because he looked somewhat embarrassed and I didn’t want him to think we were ganging up on him. But I was glad my attending had seized the opportunity. Even though the patient’s eye problem was unrelated to his size [emphasis mine] his weight was and would be his biggest medical problem.

The author goes on not only to defend the actions of her attending, but also to express the desire to emulate them in her future practice. The patient, she reports, responded by admitting they were “only doing their job” by alerting him to the health hazards of his weight.

No, Dr. Sobel; you were not doing your job. You were trying to do my job, and you (or your attending, at any rate) weren’t doing it very well. I can virtually guarantee you that any person weighing 350 lbs is all too well aware that he weighs too much. His current physique is NOT the result of ignorance, so whatever “education” you believe you are providing is meaningless. So what have you actually accomplished by pointing out the obvious to your patient, especially when it has nothing to do with the problem for which he specifically sought out your expertise?

What would you have done if the patient had said, “You’re right, doc. What should I do to lose weight and shape up?” Do you have any training or experience in dietary, nutrition or exercise counseling? Do you know what the literature has to say about the efficacy of different kinds of interventions in the treatment of obesity? I doubt it. You’d probably say, “Go talk to your family doctor.” Besides, as an ophthalmologist, you get paid six times as much just for flushing out a plugged lacrimal duct as I would for an hour-long evaluation and management visit, including intense counseling on obesity management as well as other health matters, so it’s not really worth your time.

Do you advise the mother of the baby sleeping in the stroller with a juice bottle in his mouth about the dangers of dental caries? How about warning the teen with the IPod volume turned up to a million about the dangers of hearing loss? Does setting foot in your emergency room turn these patients into a captive audience for all your generic health advice, no matter how badly statistics appear to show that the American public needs it?

Once you choose the identity of specialist, your right to intervene in a patient’s health matters unrelated to that for which he sought you out is forfeit. Your “MD” now gives you no more right to advise patients about unrelated health hazards than anyone else on the street. Do you feel your standing as a physician would permit you to make a comment to an obese individual you happened to encounter at a bus stop? I would hope not.

The concept here is of time and place. I submit that an ophthalmologic emergency is not the appropriate time and place for lifestyle interventions unrelated to the problem at hand. So cut it out.

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