My online appearance is more important than my physical appearance

I had a great time today reading posts and comments on Twitter about physicians' appearances.

Things I've learned:
1. Some docs really like this article from 2005 (!!!!) on the importance of dressing well for your patients. Remember it can take up to 3 years to publish an article so this data is from 2003 at the latest. Think track suits and Queer Eye for the Straight Guy.

2. The BBC would really like doctors to generally judge everything about their outward selves. This article looks at "scruffy doctors", overweight doctors, and doctors who smoke. They also acknowledge that many patients are expecting the white coated doctor to be male. 

Which brings me to...

3. A separate discussion has been playing out today on Twitter about how young female physicians are perceived spurred by this blog entry. Female docs are often (VERY often) mistaken for nurses. Even after introducing themselves as Doctor SoandSo. I know I've blogged on this before but I can't find it. We are also assumed to be the assistant, the secretary. As an older than average resident, I was usually mistaken for the social worker or my pediatric patients' mother DESPITE wearing an ID badge and my stethoscope. One intelligent staff member asked me 6 times during my 2 month pediatric rotation to fill out the insurance forms for "my child". She was shocked every time that I was *still* a physician. I was once blocked from a code by the nurse who called me to it because she thought I was a family member (again, with stethoscope and badge). 

While I was on rotations in other hospitals, I would carry a small bag with my "pocket" stuff. Pens, a Drug Pocket, my phone. Most "professional" women's clothing prohibits actually using pockets if they do exist. This teeny satchel was usually the scape goat in my mis-identification. 

This is one of those issues that makes me a bit cranky. Have I told you yet about the preceptor who told me that it was perfectly reasonable to be mistaken for the social worker since "doctors don't have long curly hair, you can't expect to be taken seriously"? It makes me see red. 

If, in real life, I'm mistaken for another profession or not a professional at all, based on my hair and my satchel, what must the medical world think of me based on my online profile? 

Some argue that our online presence allows others to see our "true selves" (it's the basis for many relationships that start online). Social media (SoMe), plays a big part in my life. I'm in a tiny rural town, most of my friends are in different provinces. Without my online presence, I would be entirely isolated. My professional online presence is split between The Imposter and Dr. SoandSo. Maintaining my anonymity on this blog is important to my being able to use it as a sandbox for trying out ideas and ways of dealing with patients in a safe environment. As Dr. SoandSo, I have opinions on family medicine and its role among the specialties. As just me, I am on Facebook with my friends and family so I can watch my family grow up from a distance. 

I'm seeing guidelines and suggestions about how docs (and everyone else) should behave online. It's true, many docs are illiterate in the ways of SoMe, but I think that they are aware of how to behave in a crowded mall. The same rules we learned in kindergarten apply. 

1. Share everything. Post your references so others can also be as smart as you.
2. Play fair. Don't overload your online profile so that your friends aren't also visible. 
3. Don't hit people. Don't call them names. Maybe they have had a really bad day.
4. Clean up your own mess.  Untag any photos that you wouldn't want your mother to put into the family Christmas card. 
5. Don't take things that aren't yours. Credit any source that you use. You wouldn't want someone else prancing around in the sweater you took 3 years to make claiming they knitted it themselves. Our intellectual property is just as important. 
6. Say you're sorry when you hurt somebody. Apologise when you make a mistake and correct those mistakes.
7. Wash your hands before you eat. MRSA y'all. 
8. Live a balanced life - learn some and think some and draw and paint and sing and dance and play and work every day some. Your online friends are interested in the new bottle of wine you found just as much as they are the new journal article that you found so fascinating. Share. But please don't overshare. 

Truthfully, first impressions are just that. The patients who mistook me for a social worker trusted my ability to care for their medical needs. First impressions don't matter nearly as much as who we as health professionals truly are. How many times have you heard from your patients the story about the surgeon in his million dollar suit with no bedside manner? Could you possibly sleep well at night knowing that you had treated your patients in a way that would have put you in the corner during kindergarten? My online presence is as close as it comes to knowing the real Imposter and how she speaks with her patients. 

Dress respectfully for your patients but act respectfully (online and face to face) for yourself as much as them. 

Med Students are Biased Against Obese Patients

I want to pull out the original study, but from this article it looks fairly well done.

Essentially, 3rd year medical students in North Carolina were shown drawings of a thin or obese person and the time to associate positive traits was measured. 1/3 were moderately to severely biased against the obese diagram.

This isn't shocking - we've seen it before with practicing docs.

When planning my education objectives in residency, I often hear warnings about recognizing that there are things I know I don't know, things I know I know, things I don't know I already know and things I don't know that I know

Something I like here is that they point out that we need to find a way for students to be aware of their bias. This is a tricky thing to teach since it often falls into the category "what we don't know we don't know".

Teaching students to recognize bias must be a lot like doing psycho therapy - challenging the thoughts that go on behind our actions. It may be that teachers acknowledging their own biases during case presentation may make it second nature for students to include acknowledging bias in their own work. Providing a positive role model to med students is important. We know that clerks are sponges for behaviours they see on the ward. It seems reasonable that positive behaviours can be picked up this way as well. Possibly, we need to devote class time to learning about distorted thinking. We discuss the biases which are inherent in most medical research but often miss the bias we bring to our everyday life.

"If doctors assume obese patients are lazy or lack willpower, they will be less likely to spend time counseling patients about lifestyle changes they could make," he said. "Doctors also may be less likely to recommend formal weight loss programs if they assume their patient is unlikely to follow through. "

Miller said bias might also make doctors less effective. "If a patient senses his or her doctor doesn't like them or doesn't respect them," he said, "that will damage the trust that is key to an effective patient-physician relationship."

This is an issue for more than just obesity. We see this in substance abuse and alcoholism as well. If we don't ask, don't offer help for change, we are cheating our patients.

More importantly, if we allow our biases to lead us, we are teaching the next generation of docs to do the same.
- Posted using BlogPress from my iPad

Our Worst Enemies

My Facebook Newsfeed has been covered with the Dove Beauty Debate.

It's a fairly powerful video for those who have every felt ugly. Most of us recognize this is untrue, but it's a message that is deeply ingrained. It is unacceptable in many cultures to be confident in one's looks. Our superficial self is less important than how we act "beauty is only skin deep".

Women learn to go to the washroom in groups and complain about our appearances. I remember being so proud of myself for dancing with a boy for the first time in 7th grade but feeling an overwhelming need to put myself down while in the washroom with the grade 8s. It's not like I was tied up and told that I was unattractive. Since I was able to pay attention I was susceptible to all the messages about what beauty is. I was not beautiful.

Speaking of these messages, what about those Ax ads? You know, the ones where women go running after boys who spray themselves with Ax body spray? Yuck. Unfortunately, Ax is owned by Unilever, the same company that owns Dove. Does it matter? I don't think so. The message of the Dove ad is just as valid.

A counter ad has also been making the rounds. Personally, I don't think they get it. It's about how guys are self confident and women try to make them feel bad about themselves. Thanks for supporting the previous ad.

Why does this matter? So what if women secretly think they are pretty but are afraid to admit it in public? There are thousands of articles on pubmed looking at the correlation between low self esteem and health, they speak for themselves. Women in my office have a hard time telling me what it is that is actually bothering them because they don't consider themselves important enough to take up my time. I'm astounded by the number of women I've seen in my very short career who have ignored the signs of cancer until it is too late to do anything.

We are taught in med school to address the patient as a whole. Is there a link between feeling beautiful and caring for one's health? There may be. Honestly though, I didn't find as much evidence as I expected. There are many studies on eating disorders and body image, as well as self esteem and cancer and sexual dysfunction.

Helping parents to raise men and women who are strong, who love themselves, and who will treat their bodies well is important to me as a family doc. I'm happy to see my colleagues, family, and friends debating the topic.

How can someone who moves as quickly as you do be so big?

It's hard not to be offended when patients make comments about my body size. It's something that I am incredibly self conscious about, like most folks who struggle with their weight. 

So far, most comments have been fairly benign, but some patients are unwilling to discuss their concerns about their weight with me because they don't believe that I am a valuable source of advice. I think more than most of my colleagues, I'm on top of this information.

The Obesity Society publishes a monthly journal which I read and pull out the most relevant information for my patients. I'm looking at what may and may not work for my patients' health. That I'm not doing the same for myself is, well, it's hard to talk about.

When NJ Governor Chris Christie was considering running for president, he received considerable criticism about his ability to run a country when he couldn't control his own weight. The Obesity Society published this statement about fat bias.

This statement resonates with me.

A person’s body weight provides no indication of an individual’s character, credentials, talents, leadership, or contributions to society. To suggest that Governor Christie’s body weight discounts and discredits his ability to be an effective political candidate is inappropriate, unjust and wrong.
Caution should be taken in making assumptions about a person’s lifestyle behaviors based on physical appearance alone. Individuals who are not struggling with their weight are not necessarily healthy. A lean body does not reveal whether or not a person smokes cigarettes, drinks excessive alcohol, eats a balanced diet, exercises regularly, or wears a seat belt. To single out a political candidate on the basis of body weight is discriminatory. 
The criticism of Governor Christie is an unfortunate example of the weight bias and stigmatization that is pervasive in North American society. The prevalence of weight discrimination in the United States has increased by 66% in the past decade, and is now on par with rates of racial discrimination.

I think that a large part of why it provokes an emotional response in me is because I have just as much weight discrimination against myself as anyone else does.

Obese Physicians

The January web volume of the journal Obesity contained an article "Impact of Physician BMI on Obesity Care and Beliefs".

It found that physicians with normal BMI were more likely to engage their overweight and obese patients in conversations about weight loss than their obese colleagues. These docs also had greater confidence in their ability to counsel obese patients about exercise and diet. These docs also felt that the patients of doctors who are themselves obese would not trust those obese docs to give advice about their patients' obesity.

They also found that 93% of the docs would only diagnose a patient with obesity if they were confident that the patient weighed more than they did.

There are a couple of implications to these findings that I find concerning.

The first is that obese docs don't trust themselves to help their patients with obesity. It makes sense. Obese docs may feel ashamed that they are unable to control their own weight. I see it more like an AA sponsorship though. A doc who has dealt with weight issues may be better able to share their experiences and help patients avoid pitfalls. There may be less judgement. Though in AA, a sponsor has achieved sobriety. With obesity, it may be the doc who reaches a normal BMI who is best able to provide this support. One study showed that the patients of obese docs are more likely to have a normal BMI than the patients of doctors with normal BMIs. The Cardiac Exercise Research Group compared this to smoking doctors who are less likely to counsel their patients to stop smoking.

The second is that docs with normal BMIs have so little faith in their obese counterparts. Given the squeals of "ew" when images of MRIs of obese patients were shown in class during med school, I shouldn't be so surprised. I wonder what it would take to change these beliefs?

A third is that docs are most comfortable diagnosing obesity in patients who weigh more than them. The implication here is that even docs who have a normal BMI are judging their weights against that of their patients. That's sad.

What I find most disturbing about this article though is how other media have been presenting its findings. E.g. "Fat Doctors Can't Help Fat Patients"

While I wasn't able to find articles on patients' perceptions of fat doctors, the comments on some of the articles I looked at speak volumes. Essentially that they wouldn't give a fat doctor's advice on weight loss much weight, if you pardon the pun. I wonder if this would be different though if they actually met the doctors and developed a relationship with the doc.

When you learn about the ways to help a patient lose weight, we learn about motivation and goals. It may be my goal to be a doctor with a normal BMI, but my motivation is to be a doctor who will earn the trust of her patients. Further motivation for me to follow my New Year's resolution of following the advice I give to my patients.

Fat Bias in medicine

It happens all the time. You'll hear comments like slob and stupid associated with obese patients. Surgeons in particular have a reputation for commenting about their patients girth in a less than kind manner. I've heard of one patient who, before her surgery, wrote across her abdomen "no fat jokes". It was written so that it was legible from her feet - no easy feat for a pt in hospital. Clearly this is something she was worried about. And she should be. If we don't like our patients or feel that there is something unpleasant about them, we are less likely to treat them well. It's well documented that our psychiatric patients are less likely to have their routine care up to date compared to their counterparts with no mental health concerns.

I did a quick pubmed search looking for obesity discrimination by health care providers. There is a definite dearth of information on the topic. All I know is what I hear. As a larger than average resident, I don't hear as much as what others might, but what I do hear is concerning. In a perfect world, all patients would be seen as equal, no wackiness based on how a patient looks.

We know that role modelling plays an incredibly important part in every medical student's education. Given that medical students start with a bias, it's even more important that those acting as mentors to their students be aware of how their own prejudices can shape attitudes.

"A total of 76 clinical-level medical students were randomly assigned to interact with a digital, virtual female patient who was visibly either obese or non-obese."

The students looked at the virtually obese patient less often and anticipated poor compliance from her. In general they displayed negative stereotyping towards the obese "patient".

Our world is not entirely dim though. Another study has shown that a brief intervention providing anti-bias teaching about obesity is effective in decreasing these negative stereotypes. I worry though that if it's this easy to change an attitude, will the off handed comment of a consultant cause the patient to change back to their previous biases?

"Things will get easier, people's minds will change, and you should be alive to see it"

I know it's cliche, but our media is not doing teenagers any favours.

Ellen's talk about the teen suicides in the US that are following bullying is powerful and long overdue. Not just by her, but by adults and media in general. Everywhere they look, media is focused on teens and telling them what to do, how to look and who they are expected to be. Bullying isn't just taking place by other kids targeting children kids who are different, who may or may not be gay.

Idiots on the net are suggesting that the kids who are killing themselves to escape the bullies were mentally unstable before the bullying began, that being gay is a form of mental illness. They clearly forget how hard it is to be a teenager. It's incredibly difficult to keep your wits about you while figuring out who you are and dealing with surges of hormones. There are few teens who are mentally stable to begin with. Add bullying to the mix and it's surprising there are more episodes of suicide than there already are.

I was one of those kids who was teased about being gay before I had discovered for myself that I wasn't. To me though, this teasing meant nothing because I didn't see anything wrong with being gay, as long as they didn't call me fat or stinky I was OK.

Again, movies, TV and magazines tell us that if we do things perfectly -by wearing the right makeup, dressing in tight clothes, sleeping with whoever we please, drinking alcohol and still being brilliant at school, friendly, athletic and thin - we will have more friends than we know what to do with.

No pressure.

Hard to imagine why kids struggling to define themselves are struggling so much. Each teen is fighting this battle and has a difficult time recognizing that they have peers fighting similar battles. It results in them feeling isolated and ignored and trying to find a way to be seen. They become bulimic, goth or emo; buy crates of makeup and perfume; dress like sluts; slowly self destruct.

I've spent a few weeks with the child psychiatry team and these messages and how teens deal with them have been at the forefront of my mind. There isn't a fast solution to the problem which seems to be systemic. All I can hope for is a change in the content of the messages being broadcast to our youth.

Imagine you're a ten year old kid. Your thinking is still very concrete; sarcasm and shades of grey are completely lost on you. If someone tells you that you are too chubby you believe it. If someone tells you there's an obesity epidemic - that being fat is unhealthy - you believe that too. Then you start to pay attention to other messages from media, school, peers and adults. Foods low in calories, low in fat and sodium are healthier choices. Empty calories that you get from foods like the pop and chips you enjoy occasionally with your family are not good. Rules for eating and exercising begin to be formed in your head, all because you want to be more healthy.

Congratulations, you now have an eating disorder. Not because you think that you are too fat and need to look better, but that you are unhealthy and want to become healthier. Without countering the restrictive messages with messages of balance, enjoyment and the importance of certain nutrients like fat, this ten year old can become an eleven year old who is so malnourished, has a heart that is so wasted of muscle its SA node no longer function and an EKG tracing shows a junctional rhythm. The only option is to put this child into the hospital, provide him with nutrients at a rate that will not cause refeeding syndrome, and teach him the way to feed himself in the future - a balanced approach to be healthy.

Adults and especially health care professionals have a responsibility to keep the messages kids receive safe. Ellen is right. This is a crisis.

Fat makes the news

A thin woman was kicked off a plane to make room for an obese teenager.

I'm not sure how I feel about this one. I get that airlines have a difficult time with keeping obese and normal weight customers happy. What seems wrong though is that a person can take up 2 seats but pay for one. If the seats were too small to begin with, that's fair, they should give fat folks 2. If not, it seems right that they charge for 2 seats. It's what musicians have to pay to keep their instruments close.

What a political nightmare though.

Who am I kidding?

It wasn't just being older than my class mates that I was worried about, it was being so much fatter. It was justified. Anytime a slide was shown with an MRI, an X-ray or surgery that showed a fat person, there was a chorus of "ew! Gross!" from behind me. At one point, a google image photo was used to demonstrate a risk factor for gout, excess weight. That got a giggle from the class. I was roughly the same BMI as the woman in the picture. That was upsetting, but not as upsetting as when someone put the photo into her profile pic on Facebook because he "thought it would be funny".

I recognize the hypocrisy in a medical student who is obese learning about how to counsel her patients on losing weight, I'm fat not stupid, but I can also recognize the difficulty in losing weight while under the pressures of medical school.

I'm actively trying to lose weight, joined an online weight loss program, have been working out at the gym a lot. I've lost 10 lbs in 5 weeks, and 10 cm off my waist. I was hoping to have more off before heading back to school so that it will be obvious, but that doesn't look like it will happen.

end confession

Prejudice is a four letter word. No really, count again.

Prejudice is live and well in the medical community
:: waits for the shocked gasp ::

One of my tutors firmly believes that everyone has equal access to health care and that Americans are well off with respect to wait times and ability to get care. I get so angry. Then I blather on and on about other things because I know if I don't change the subject I'm going to punch her in the mouth. She goes on and on about the 350lb man with a donut in hand who comes in complaining of >insert whatever illness we're discussing that week<

She also assumes that people who work blue collar jobs are a) idiots that aren't capable of understanding a treatment plan and b) don't care about their health.

If Canadians, rich and poor, have equal access to health providing opportunities, then why are babies born to teen aged moms significantly smaller? If it's not the reduced counselling about prenatal nutrition received compared to women in their 20s and 30s, and the lack of medical support for this demographic, then I just don't know what it would be.

I recently came across this blog called "First, Do No Harm"
It's terrific, horrifying and well written. Fat people who have been treated like garbage talk about their experience accessing health care in the US. I know it's the same here just listening to my tutor.

I'd go to church but I don't like the wine

I keep waiting for someone in a white coat waving a cane to come running into the classroom, pointing at me and yelling that I'm not supposed to be there. So far this hasn't happened. It's only been 5 weeks though, there's plenty of time for that.

Before coming to school I was incredibly torn about what I was going to do for orientation week. Here I am, significantly older than my classmates, not able to hold my liquour (as a lovely going away party proved) but still wanting to make connections with my classmates. These are the people I'll be working beside, not only for the next few years but as my colleagues for the rest of my life. I want to make a good impression. I want to be someone that people will study with. But mostly, I want to be liked. Whoever said that med school is just high school, take two, wasn't exaggerating. The class is quite clearly divided, not just physically into front vs. back, left vs. right but also the partiers, the jocks, the book smart, the religious and me. I don't fit into any of the groups but seem to have been adopted by the religious.

It's weird. It's not that I don't like like religion. Many of the best religions serve wine at service which I can't help but endorse. It's just that it's not me. It's not just Christians in this group, there are Muslims as well. What will they all do to me when they realise I don't go to church? Will they wave a cane and kick me out as well? What will happen when even the religious nerds don't want me?

Due to logistical issues (I was commuting from another city) I didn't hit the major parties in O-week, especially toga. This meant that I missed out on a huge opportunity to meet a large portion of the class. I wanted them to get to know me before making judgements about me based on my age and my non-athletic nature. They will know soon enough that I've only got an average intelligence, that I'm not very quick on my feet and speaking of feet, mine spend most of their time in my mouth. I wanted them to get to know the fun me first.

As long as I can keep my mouth shut for the next few weeks, there's always Hallowe'en.

She was sick too

This post http://kateharding.net/2007/07/12/fat-hatred-kills-part-one/ shook me, and hit too close to home. My mom was never diagnosed with problems with the blood vessels in her legs and almost died because of them. Her doctor always told her that the pain in her legs was due to her weight. I'm proud of Mom. Despite this, she knew something was wrong. Yes, she was fat, but her life didn't have to be so painful. She eventually had an angioplasty done and now works out almost every day. She's still fat, but she's living her life too.

It's easy to judge someone, make a snap decision about what their problem will be. I do it all the time at my job as a reception clerk. When I see someone coming to my desk, I decide before they reach me what their problem/question/quirk will be. 98% of the time I'm right (I'm just that good), but the times I'm wrong, I'm really wrong. It's often humbling.

I hope that I'm able to remember that it's not just that my patient is fat, she's sick too.