Unit 5  Section 2Exercise 6 Physicians’ AttitudesBailin's Challenges
You have already encountered Dr. Bailin’s musings on difficult patients in Unit 3. Now, as a physician specializing in eating disorders, especially in the disordered eating of obesity, Dr. Bailin offers her thoughts and wisdom on what is involved in helping people lose weight. See Dr. Bailin's website at http://ownyourshape.com/aboutUs.html
OK. So the topic is: Challenges In Getting People To Change Their Eating Habits – or something along those lines. © Heike Bailin, MD
How do I? me? get
people to change their eating habits? Funny you should ask. It’s simple,
from my position of authority I command, eat less, exercise more, write it on my forgery-proof prescription pad.
Alright, turn down the noise a
notch.
First of all I (or you) don’t get anyone to do anything. If
I do I haven’t done my job. At best I’ve succeeded at manipulation of another,
usually temporarily.
Look Pavlov’s dogs: They’re hungry, they smell feed, they salivate, they’re fed. Next
they’re fed at the sound of a bell. They salivate at the sound of the bell. The
sound of the bell makes them hungry. Or does it?
Tell the dogs who want to know how to stop salivating to
smash the bell. ‘Oh, but it’s such a sweet sound’, some say. Nostalgia fills
their eyes. The limbic loops spinning in high gears. Salivation is pleasure of
anticipation. The best of eating is the look, the smell, the first touch to the
tongue, crunch with the teeth. Behind the gullet it’s all down hill. What was
so great about that …? Burp, groan, bloated, feeling like a
beached whale.
So it’s not as simple as classical conditioning. Knowledge
is power, especially when it comes to eating.
I ask, do you sleep enough, think enough, play enough, listen enough. Do you rest, recreate. How good are you at
multitasking? The worse, the better.
The funnest
part is the exploration with each individual of how to disconnect their gut
from their brain, or better: re-connect them meaningfully, with intent.
Recognize the emotion behind drives to satisfy. Identify the locus of need. Is
it a craving for sweetness on the tongue or sweetness in the heart.
What needs sweetening here. What’s inside or what goes
inside. The tension between internalization of needs
and externalization of wants is a serious battle indeed.
So, where do you, doc, fit in if you don’t get anyone to do
anything. Definitely you don’t get people to lose weight. Liposuction’s proved
that wrong. It all grows back.
Actually this is one where the biopsychosocial
model needs to be revamped: kinda
like locatiolocationlocation in real estate it’s socialsocialsocial. OK ## sociopsychobiomedical model
might prioritize it a bit better. Prescribing “eat-less-move-more” on your
precious licensed script pad is a waste (almost).
The Socio-
We’re herd animals, right? Even the most rugged
individualists among us (usually self-described and misperceived) are subject
to a network of friends (the few they have) and family (what’s left of it).
See advertisements and runway standards where the heroin
addict look makes us believe drop- dead gorgeous is when you’re make-up is
heavier than Tut’s sarcophagus look, you’re
rib-counting skinny and have the latest Versace rag hanging off you. These days
only the playboy bunny silhouette still has boobs. Thanks to your plastics
colleagues who don’t accept insurance for those jobs and their patients shell
it out as if they had had a plugged heart artery to repair.
So social monkeys we are.
Self-help but not alone. Ask your
patient to enlist a friend, the family or colleagues. Go over sources with them,
there’s a lot of garbage out there. Start a group if your practice permits.
Sometimes strength really does lie in numbers.1 Develop overall
strategies with each person, tactics for everyday scenarios, validate their
sense of loss and gain, esp. if they’ve done The Surgery, set an example if you
can2.
The Psycho-
Subtitle: The Three Ws of Eating: what (portion and
balance), when (includes where) and why (recent and remote) do you eat.
CBT (cognitive behavioral therapy) has been shown an effective adjunct in the treatment of
many disorders, including eating disorders (google Judith Beck, PhD, she’s done
a lot of great work in that field). Oh no, not the dog-n-pony show. But really,
try googling stress and weight gain, sleep and weight gain, drugs and weight
gain, parents and weight gain,
school and weight gain. You get the idea. It’s mostly not even about eating but
about living.
You can give someone a hammer and a screwdriver (no not that
kind) – cognition - but you can’t make ‘em a carpenter. Practice, practice, practice – behavioral – using that
tool set. Changes in habit of years of thinking and doing will take time
to undo. And then there’s the entropy of emotion. It happens when the old
midbrain with its limbic loops unplugs itself from the cortical ueber-policeman. A smell, not enough sleep, a failed exam
(ok not failed but it shot my 4.0), a boss (they’re all alike, believe me). It
doesn’t take much to succumb to the call for comfort.
So toxic behaviors can be un-learned, but you have to know
them first. See what works within your patients’ life. But it’s not simply
classical conditioning of dogfood-spit-bell-more spit
– too static a model. Applying strictly operant conditioning with the
assumption of volition dictating eating behaviors, esp. maladaptive ones, could
also not be very productive.
Understanding why? Is the big one. Many of us don’t want to
go there unless it’s just so damn painful we can’t stand it anymore. Try
dysfunctional. It may help to pick one of those pesky habits of your own that
you haven’t been able to break. Look at it why? Look at proximal and distal
causes. Not to get too Freudian here but there’s the dog who ate your homework
but there’s also you who never wanted to do it in the first place. Note: I
don’t even want to know whether you did the homework. I don’t necessarily ask
for numbers with every visit, how many pounds, but for changes in behaving,
emoting and being.
Oh, on the note of therapy: If you think you’re a great doc
and haven’t done a stint on your favorite analyst’s couch think again. If you’re
not on your toes about your own conceits and preconceptions, if you can’t
recall your last act of transference and countertransference,
you will not get anyone to do anything. Not even yourself. So hurry up evolve!
You’re a doctor, furchrissake! So
don’t be afraid to be human, supportive, and in touch with yourself. You can
vent about the hard stuff with your best friend in a safe environment. Help
yourself to be well more often than not, and your patients might believe you
enough to follow your recommendations. Oh, sorry, don’t use don’ts. When you’re
fixed on the oncoming car’s headlights you’re more likely to steer right at
them.
Biomedical
Sure I can give you B12 injections maybe even daily –
and take your money. It doesn’t work. But it worked for my friend she’s down 12
lbs (from320) after only 2 weeks, says your fluffy client eager to lose a few.
It’s surprising how much non-EBM is out there, or even downright quackery.
You dispense some of those drug company samples of the
latest and newest weight loss drug, write a script and have ‘em come back in a
month (if you can squeeze ‘em in that soon) and, no
weight loss, doc, that week’s samples didn’t last all month. The meds woulda cost me 300, 200 with the Canadians. I can’t even
afford my saw palmetto. Or (2) How
long will I have to stay on this,
doc, I don’t like the idea of staying on meds for the rest of my life.
You want to quip, how about those modified fats, refined sugars and alcohols
you put into your finely tuned machine of a body (now burdened with DM, CHF and
degenerative joint disease). But you don’t want to destroy all rapport. On a
bad day something slips out, your Tourette’s acts up,
and that patient never comes back. Guaranteed. (see psycho above, under shame).
PS: a nod to my surgical colleagues: discuss all options
openly with your patient. Know your own biases and those of your patients. Some
Centers of Excellence in the field of Bariatrix have
done wonderful work. Diabetes may well be a “surgical disease” in the right
patient, the hands of the conscientious surgeon, and an accessible team.
-
D.
Renjilian, A. Nezu, R. Shermer, M. Perri, W. McKelvey, and S. Anton. Individual versus group therapy for
obesity: Effects of matching participants to their treatment preferences.
Journal of Consulting and Clinical Psychology 69(4): 717-721 (2001)
- John La Puma, Philippe Szapary, Kevin C. Maki. Predictors of physician overweight and obesity in the USA: an empiric analysis.
Nutrition & Food Science 35(5): 315-319 (2005)
Study questions
- Does some of Dr. Bailin’s personality come through? How would this be relevant to the treatment of obese patients?
- Dr. Bailin emphasizes the biopsychosocial model. Look for published guidelines and reviews on recommended approaches to obesity. Are all elements of the biopsychosocial model addressed? What added value does Dr. Bailin’s essay offer to the practitioner?
- What are the obstacles and frustrations physicians face in treating obesity?
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