The casual fatphobia of the doctor's office

Why primary care should be so much more than an audit of your body size

In the TV series The Handmaid’s Tale, there was a scene I found particularly haunting given my job as a primary care doctor.

Emily Malek, the scientist played by Alexis Bledel, escapes her life as a handmaid in Gilead and seeks asylum in Canada. She’s endured unspeakable physical and emotional trauma. So when she arrives in Toronto, she sees a doctor for an evaluation. She then emerges after the appointment, bewildered.

“They told me my cholesterol is high,” she says.

Oof. Is that what doctors do? Nag our patients about their cholesterol, no matter how horrific the circumstances?

Unfortunately, many of my patients seem to think so.

Rory Gilmore escaped Gilead. But her doctor was more interested in her cholesterol.

As a primary care doctor, it’s my job to think about both preventive care — which, yes, includes monitoring my patients’ cholesterol — and what doctors call “problem-based care.” That means when my patients come in to talk about issues like back pain or asthma flares, I’m also gently encouraging them to get their mammograms done.

(As a brief aside, insurance companies try to distinguish between problem-based and preventive care, which has always struck me as out of touch with the way most people access primary care. The Affordable Care Act mandated that preventive care — like cancer screening or smoking cessation visits — should be accessible without any co-pay or deductible costs borne directly by the patient. Sounds great, right? It mostly is, but most people come in for their preventive “physical” with at least a few aches and pains they want to discuss with the doctor. As soon as a patient brings up a “problem,” the visit is no longer considered preventive care, and people are often surprised by the co-pays they’re expected to pay.)

Navigating the balance between preventive care and my patients’ urgent concerns is an art, not a science. If a patient is in distress because she’s about to get evicted, it can come across as callous to change the subject: “Hey, let’s do your Pap smear!” That Pap smear, of course, can detect cervical cancer in its earliest stages, which can prevent serious illness and death. So it’s important, but may not feel important in the moment compared to the impending eviction.

Lately, my patients have been going through some serious shit. I guess we all are, what with the state of the world and everything, but things have seemed extra tough as of late in the small, low-income city where I work. People come in for a checkup, and all of a sudden we’re talking about their fears of getting deported or losing their house; the risk of getting shot by a cop or losing their job to a robot.

The stress is chronic, and it’s also acute. You can see the lines of worry on people’s faces. We keep tissues ready for the tears in every exam room.

And yet weight keeps coming up. My patients can’t seem to shake the sense that that is what you do at the doctor’s office. They see primary care as an audit of their body size.

These conversations wax and wane. And yet they often meander back to weight, in a nonlinear train of thought that’s sometimes hard for me to follow. Weren’t we talking about something else? Why did weight come up, again?

I saw one patient recently who had sought asylum in the United States from a politically repressive country, and his wife and young daughter remained there. I asked to see a picture of his child, and he showed me a smiling toddler on his phone, sitting in a garden filled with lush flowers. In New Jersey, he works in a factory, where he spends long hours moving equipment in the same repetitive motion, over and over.

“I want to eat the bread we eat at home,” he told me. “It reminds me of my daughter. But I’m worried it has too many calories.” He was fearful of getting fat in this country, he said.

I glanced at his chart. Over the last year, he had gone from a BMI of 25 to a BMI of 26.

“You should eat the bread,” I told him.

Another recent patient was tearful as soon as I walked into the room, grieving the unexpected death of her sister in a hit-and-run accident. She was hurting, it was clear, with the loss of her sister and many, many other stressors: money, a pulmonary nodule that had just been picked up on a lung cancer screening test, wanting to move to her own place, the outrageous cost of her asthma inhalers.

We had a long and rambling conversation, in which I said very little. But she kept circling back to her body size.

“If I could just lose some weight, it might be easier,” she said.

As a size-inclusive doctor, I’m not the one initiating these conversations about weight. My general practice is to not bring up my patients’ body size, except in rare circumstances. It’s most certainly not my style to chastise my patients about their weight when they’re suffering so acutely.

But these patients’ expectation is clear. They’ve internalized the message: No matter what horrific things are going on, primary care is the place you go to get yelled at about your weight.

Of course, I am happy to discuss what my patients want to discuss. If patients want to pursue intentional weight loss, I’m always willing to have that conversation. (I’ve had it about ten times this week, already!) My goal is never to dismiss my patients’ concerns, about body size or anything else.

What worries me is the way weight creeps in to so many conversations, and how people confuse fatness with so many other issues — medical and otherwise.

These conversations are about painful, difficult issues that don’t have a quick fix. In turning the discussion to weight loss, I worry people believe — often unconsciously — that losing a few pounds will be a miracle solution that makes all those other problems go away.

That, of course, is diet culture talking, the superstitious belief that getting thin will solve everything. It puts the onus not on systems, but on individuals. It absolves us of our collective responsibility to each other, because you just weren’t trying hard enough to cut the calories.

Does this internalized fatphobia come from the culture at large, and patients are hoping that medicine can address it? Or have doctors been so persistently fatphobic over time that a primary care visit has become synonymous with a body size evaluation, and people just expect it?

I’m not sure I know the answer. But I know these conversations often make me feel sad. And when patients hope weight loss will be a panacea, I feel even sadder.

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A note about patient confidentiality: Trust is at the core of all of my relationships with my patients, and as such, I don’t share their stories publicly. Any story you read here — or in any of my writing that isn’t in the electronic medical record where I write thousands of words a day, ha ha — either has details removed so patients can’t be identified, details changed, or is a composite story that combines information from multiple patients.

The essence of every story I share is true.