When the resident and the rest of the trauma team entered the patient’s room, they were in for a shock. “The patient’s father was standing there and he says, ‘You know, we can hear you when you’re standing outside the door,’” the resident recalls. “He asked us, ‘You just call anybody fat without regard to their feelings?’”
The resident says the attending trauma surgeon apologized to the family, but then started to make a bad situation worse: “He said if she weren’t overweight, a lot of the complications would not have been happening,” he says. “That almost made things more embarrassing for those of us who had been involved.”
And the junior resident who called his patient a big fat chick? “I’m fairly certain that colleague hasn’t used that term or similar ones since,” the resident concludes.
To avoid embarrassing situations like that, surgeons who operate on obese patients have invented argot that can be overheard by patients without being understood.
Jones says one bit of slang that’s been making the rounds over the last ten years or so is giving weight a geographic distinction. “You ask a colleague how much a patient weighs. The colleague replies, ‘They’re one Chicago unit’ or ‘one Minnesota unit’ or ‘one Wisconsin unit.’ Those are the three most common ones I’ve heard.”
If one Chicago unit means 200 pounds, then a patient who is two Chicago units weighs 400 pounds, a patient who is three Chicago units weighs 600 pounds, and so on. A hospital in Iowa rates obese patients as Iowa 1 to Iowa 4 based on their weight and whether they can fit onto a standard hospital stretcher with both side rails up, one up, or none.
Mark Ryan is also up on the use of geographic slang to identify obese patients. He cares mostly for uninsured patients and those who receive Medicare and Medicaid benefits in Richmond, Virginia, and obesity rates are quite high in his practice. “In Southside Virginia’s low-income communities it was a pretty big issue,” says Ryan. “An obstetrician-gynecologist would say, ‘There’s big, and then there’s Southside big’—Southside big being heavier and more obese than just obese. It was the sense that people there were heavier than in other parts of the state.”
Dr. Marjorie Greenfield of Case Western Reserve University School of Medicine says that at her hospital they used a similar way of saying how much a patient weighs: “Weight was referred to in ‘clinic units.’ Our clinic is our residents’ clinic. The patients who go there are living in poverty and tend to be heavier than the private patients. A clinic unit is about 200 pounds.”
Other hospitals across the U.S. use the clinic unit as a way of estimating weights. Greenfield says she hasn’t heard about clinic units recently, but that doesn’t mean doctors are failing to take note of patients’ weight. “People will say her BMI is 60 and maybe roll their eyes,” says Greenfield. “But I don’t think that that’s transmitted to the patients as much as it used to be, and I think it’s not as socially acceptable as it used to be.”
BMI, or body mass index, is a simple index commonly used to classify weight. It is calculated by dividing a person’s weight in kilograms by the square of the person’s height in metres. According to the World Health Organization, a BMI of 25 or more is overweight and a BMI of 30 or more is obese.
BMI has also inspired a bit of slang that can easily be spoken in front of patients. “I’m sure you’ve heard the term beemer code,” one resident told me. Until he mentioned it, I hadn’t. According to the Urban Dictionary, beemer is slang for a BMW motorcycle and bimmer is argot for a BMW car. I was pretty certain the resident wasn’t referring to either. Turns out beemer is medical slang for an extra fee doctors can charge to care for an obese patient.
“If you’re going to be billing for operating on a patient with morbid obesity, the anesthesiologist will ask the surgeon, or vice-versa, if it is okay to charge a beemer code,” says this resident. In a sign of the growing problem of obesity in North America, both Medicaid and some provincial health-care plans have bonus fee codes for patients with a high BMI; these are meant to compensate the anesthesiologist for the extra work caring for morbidly obese patients.
One physician who detests that sort of language is Dr. Arya Sharma. The internationally recognized obesity guru is professor and chair in Obesity Research and Management at the University of Alberta. In 2005, Sharma spearheaded the launch of the Canadian Obesity Network, which has remarkably transformed the landscape of obesity research and management in Canada. He is a fellow of the Council for High Blood Pressure Research of the American Heart Association.
I’ve got a beached whale in my emergency room—Sharma says he’s heard colleagues say this “on a clinical ward where they had a very large patient and everybody thought that was very funny.” Sometimes health professionals use gestures and tone of voice instead of words to demonstrate contempt.“It’s often not just the terminology,” Sharma adds. “It’s the context in which it’s used. It’s the acceptance that such terminology finds, and I think it’s the state of mind that it puts the provider in that is the problem.
“Very often, it starts with language. If I’ve got a large woman in distress in front of me, my attitude is going to be very different if I say, ‘I’ve got a whale lying here in my in my exam room and I’m going to have to move the furniture out to make enough space to do a physical examination.’”
Disrespectful language and a disrespectful attitude to the patient—whether it’s the tone of the doctor’s voice or body language or the time spent at the bedside or listening or talking—affect the quality of care, Sharma says.
The attitude Sharma is talking about is what experts refer to as “weight bias”—the tendency to ascribe negative personality traits to overweight people. Mark Ryan says that “there’s still a sense among a certain group of physicians and a certain number of health-care professionals [that maintaining a healthy weight] is a matter of willpower: if you just cared more or tried harder, you wouldn’t face this problem. Therefore, it’s a personal failure if you’re obese.”
Dr. Christopher Kinsella, a second-year general surgery resident in St. Louis, Missouri, says he and his colleagues call obese patients slugs. “Slug is a huge, huge term for us,” says Kinsella, who blogs under the name Topher. “I’m deeply in love with that term. When someone comes in and they’re fat and they’re clearly lazy, you just know that this person’s not going to heal on schedule.”
What Kinsella says and what Ryan has observed is backed by studies showing systemic weight bias by health professionals. A study of nearly 2,300 physicians who practise in the United States published in 2012 in the journal PLOS One demonstrated a strong preference for thin people and both implicit and explicit anti-fat bias. Another study by internist and researcher Dr. Melanie Jay and colleagues published in 2009 in the journal BMC Health Services Research concluded that 40 percent of physicians surveyed had a negative reaction toward obese patients. Interestingly, compared to internists, pediatricians were more positively predisposed to obese patients and psychiatrists were less likely to have low expectations of treatment success with overweight patients.
Rebecca Puhl, a clinical psychologist and director of research for the Rudd Center for Food Policy and Obesity at Yale University in New Haven, Connecticut, says physicians ascribe some of the most contemptible patient characteristics to people who are obese. A study of more than 600 doctors found that more than half said obese patients were unattractive, socially awkward and unlikely to take medication as directed. In a review article published in 2001 in the journal Obesity Research, Puhl and co-author Kelly Brownell cited research that showed 24 percent of nurses say they are “repulsed” by obese persons.
The weight bias among health professionals is in part a reflection of similar bias in society at large. A study found that two-thirds of Americans are biased against overweight people.
“It’s that social acceptability that’s it’s okay to make fun of fat people because they deserve to be made f
un of,” says obesity guru Sharma. “It’s okay to say obesity is their fault and if they can’t be motivated and worried enough to look after themselves, then they really deserve contempt.”
It’s overt contempt that distinguishes how physicians treat obese people compared with other patients. “You would not make a racial slur to a patient,” says Sharma. “You would not have a gender thing going on. You would not even dream of doing it. You would be banished from your profession and lose your licence and be kicked out of the hospital because that is completely inappropriate. But when it comes to an obese person, people say, ‘Here’s the fat guy in room so-and-so.’”
And health professionals don’t just make up slang. They spread rumours and make jokes too, says Dr. Simon Field, an ER physician in Halifax. Field was taking a course in the United States when, during a lunch break with a couple of colleagues, the talk turned to massively obese patients and how newer CT scanners were too small to accommodate them safely. “One physician from Texas said his local hospital was sending so many patients to the Houston Zoo to use the zoo’s veterinary CT scanner that the zoo complained the humans were jumping the queue on sick and injured animals,” Field recalls.
A physician from Florida added that his hospital sent bariatric (obese) patients to Sea World, where the killer whales apparently had their own CT scanner. “Massively obese patients in Orlando ended up in Shamu the killer whale’s CT scan machine,” Field says the Florida doctor told him.
Sorry, folks, but there’s little evidence these alleged transfers actually occur. Here’s what a 2007 article in the Houston Chronicle had to say: “It’s a long-standing urban legend that zoos have jumbo versions of such equipment to help diagnose illnesses in elephants and other huge creatures. But to the disappointment of some doctors, zoo officials must tell them they have no such device.”
A story published in the British newspaper The Telegraph in January 2012 said National Health Service (NHS) hospitals have resorted to asking zoos and vets to do CT scans on patients who are too obese to fit into hospital scanners. According to the article, Britain’s Royal Veterinary College said its CT scanners, “customized for horses, could be used to accommodate patients weighing 30 stone [420 pounds] or more but they would need to get a special licence to scan humans.”
But spokespeople for the NHS and the London Zoo both said no such referrals had either taken place or had even been recommended.
An article by Telegraph medical correspondent Stephen Adams published in November 2012 said that as an emergency measure, the NHS would rely on scanners usually operated by veterinarians. But, like almost everyone else who has written or spoken about this, the writer was relying on the quotes of sources; I have not seen any articles in which the reporter witnessed obese patients being scanned by a CT designed for large animals.
As for the Shamu scanner, without proof, it’s a whale of a tale and probably nothing more.
Legend or true, stories like these prove Sharma’s point: even doctors think it’s okay to turn obese patients into a punchline.
* * *
But if you think doctors’ belittling of the obese is simply a case of “weight bias begets a bad attitude,” you haven’t spent time recently in an operating room caring for patients with morbid obesity—those who are 100 pounds over their ideal weight. Almost without exception, the surgeons, obstetrician-gynecologists and anesthesiologists I interviewed spoke at length about how difficult it is to care for patients with a BMI north of 40.
“I do think it makes many surgeries much more difficult,” says Christian Jones, who can rhyme off a long list of reasons. “The amount of time we have to spend in the operating room is significantly increased by someone who is morbidly or super-obese, compared to someone of normal stature. It is difficult to get a proper look at where we’re operating. It is difficult to move things around. Surgery is associated with more and more complications. They have terrible wound-healing problems and very often get wound infections. And patients who are obese tend to have kidney problems, diabetes, skin ulcers and so forth.”
When he was doing his residency, Jones recalls, he worked with an attending surgeon who operated frequently on obese patients—not as a bariatric surgeon but as someone who was called on to fix the complications caused by other surgeons. “Since these patients tend to have more complications, very often they need to have repeat surgery,” says Jones. “It is quite frustrating.”
And it’s not just obese adults. Increasingly, surgeons have to operate on morbidly obese adolescents and children.
“I had [an obese] kid who came in with appendicitis that was ruptured,” says a resident who is training in the Midwestern U.S. When that happens, the usual plan is to admit the patient to hospital for several days of intravenous antibiotics to treat the inflamed appendix and the infection that has spread through the abdominal cavity. Then, once the inflammation has settled down, the patient is discharged from hospital for several more weeks of antibiotics until surgeons deem it safe to remove the appendix. Thin patients usually require three or four days in hospital. His obese adolescent patient was hospitalized much longer than that.
“This kid was here for a record two weeks,” says the resident. “This was a kid who was just very overweight, a kid who I think has physiologically deranged her body. It took two weeks for this kid to get to the point where she could evacuate her bowels, have her pain controlled with pills, and walk. There’s no good reason for that.”
After all of that, the resident says, the teenager will still have to return to hospital to have her appendix removed—a prospect he was dreading: “She’s not going to recover from surgery on schedule. She’s not going be an active participant in her own recovery at all.”
Here is what another resident said to me when I told him that story: “You hate that person as a patient. You operate on them because you have to.”
The sense I’ve gotten from talking to surgical residents is that they didn’t sign up to operate on bariatric patients. They look with envy at mentors who are a lot closer to the end of their careers and won’t have to spend too many years operating on large patients.
If it makes them feel better, it’s not just residents who are doing the complaining; so are experienced attending physicians, including Dr. Marcus Burnstein, a colorectal surgeon. “I don’t think the lay public knows how much of a risk factor obesity is for abdominal operations. Non-surgeons may not fully appreciate it either. Getting in and out of the abdomen for open or minimally invasive cases, exposing the operative field, handling the tissues—everything is much more difficult. And patients have a tougher time in the post-op period.
“You have to fight the urge to get angry at the patient for being so fat that the usually simple task of exteriorizing a segment of bowel [creating a hole, or ostomy, on the abdomen so that bowel movements go into a bag attached to the abdomen] has been turned into a nightmare.”
The more Burnstein talks about operating on obese patients, the more frustrated he becomes. “It is also physically much more demanding on the whole team to operate on obese patients. Holding retractors to help with exposure can become exhausting. And if there is a huge pannus, the weight of the apron of the fatty abdominal wall can put stress on the abdominal wound and on the stoma [the opening where the bag is attached] and create healing problems.”
A pannus—also called an abdominal apron—is a flap of excess skin, fat and tissue at the bottom of the abdomen. It occurs in overweight and morbidly obese patients as well as on people who have lost large amounts of weight and have excess skin. Obese patients can have difficulty moving around because the pannus hangs down over their knees or between their legs. A bulging pannus can make it difficult to tie shoelaces and even to see one’s feet. It makes it difficult to bathe properly and therefore to remove offensive body odour. It’s also a frequent cause of back pain.
Those are some of the obese patient’s probl
ems. When it comes time to do an emergency Caesarean section, the excess weight becomes the obstetrician’s problem.
Surgeons who have to deal with a pannus have given it some unflattering nicknames. In the U.S. Midwest and in Boston, it’s called the “Milwaukee goiter.” In the southern United States, they call it a “Bojangleoma,” a nifty bit of slang. The suffix –oma means “tumour.” Bojangle comes from Bojangles’ Famous Chicken ’n Biscuits, a restaurant chain in the American South.
Whatever you call it, a pannus is bad news for the surgeon or resident who has to cut through it in order to operate underneath it.
“You’re digging into a hole with the edges falling in,” says a former OBGYN resident who switched careers to become a GP. “You can’t fortify the edges of the hole or the pit—horrible to say. You can’t see as well. You need special equipment for the physicians to get high enough to be able to dig deep enough into the belly to get the baby out. I’m a tall person and I remember once being up on a riser and having to be in the belly up almost my shoulder trying to feel for the baby.”
It’s also a lot of extra work—for more than one person.
“You need at least two extra people, i.e., four more hands, to retract a pannus,” says the former obstetrics resident. “The junior resident and the medical student would be the pannus holders. To hold it is a sign of being the lowest on the food chain. It’s super slippery and it’s usually pretty smelly. It’s shameful that we as a profession would feel a little degraded by holding the pannus.”
Dr. Marjorie Greenfield, the OBGYN at Case Western University School of Medicine, says Caesarean sections are physically demanding operations when the woman is morbidly obese. Greenfield wouldn’t dream of using derogatory slang to describe obese patients. But she—like everyone else I interviewed—recites chapter and verse on the extreme challenges of caring for large patients in her line of work.
The Secret Language of Doctors Page 19