It was my first week of family medicine, which happened to be my last clerkship of third year. Naturally, I was asked to shadow the first couple of days in order to learn the lay of the land before tilling the soil on my own. A particular patient encounter seemed to be panning out similarly to the other fifteen patients we had seen earlier that day: update screening, refill medications, hear reports of a vague complaint about difficulty sleeping and talk about weight that is up-trending in the setting of an already overweight body mass index (BMI).
“You know, not all of us can be small,” the patient, a well-appearing woman in moderate anxious distress, said as she motioned with her hands and rolled her eyes towards me. “It’s disgusting,” she added. I leaned on the counter beside my young, female preceptor as she commented in a non-confrontational way that the patient’s weight had gone up.
I looked at her, deer-in-headlights style, with my dropped jaw thankfully hidden behind a surgical mask. As a new medical student, I thought to myself, I couldn’t possibly speak my mind or show that I was both offended and made uncomfortable by her remark, which was a direct reference to my physical appearance. To be honest, I don’t even remember how my preceptor responded.
Flash forward to a patient later in the day, this one a pleasant, overweight, elderly, white female in no apparent distress accompanied by her daughter, whose age I would estimate as 55. “My goodness, she is tiny!” exclaimed the patient as my preceptor and I entered the room, her daughter beaming at me in approval and apparent agreement. Greetings and introductions had not yet been made, but I had been labeled by my body. Once again, my mind was racing so fast that I do not recall how my preceptor responded.
We exited the room after that encounter. My preceptor turned to me once we were in privacy, threw up her hands and let out the steam of exacerbation. “Patients making comments about my med student’s body — I just don’t understand why people think that is okay. Didn’t someone even call you disgusting?” Truth be known, those were only two of about five comments made that day referencing my appearance.
“It’s definitely interesting,” I replied with a flat look on my face. “It is sad though. I know why they’re doing it.” She looked at me, seemingly intrigued. “It’s a defense mechanism, you know, the Freudian ones we have to memorize for the MCAT and Step 1,” I told her. “They are making comments about my body as a way to cope with insecurities they feel about their own. Which one would that be? Give me a second … either displacement or projection. I always get those two mixed up.” I pulled out my phone.
She looked at me, silent, with inquiring eyes. “I’m going with displacement,” I said. “AMBOSS defines displacement as ‘shifting an emotion to a less threatening or neutral object or person.’ The example provided is that ‘a mother demonstrates feelings of anger towards her child instead of her husband, who is the actual source of her frustration.’”
“Wow. I mean I can’t read minds, but that theory sure does make a lot of sense. They don’t feel confident about themselves, so they are displacing their own insecurities on you,” she said.
What my preceptor and those patients didn’t know is that I am currently at my heaviest weight in over 10 years. They don’t know that nine years ago, I fell into a five-year, vicious cycle of disordered eating which would be best classified by DSM-V criteria as bulimia nervosa with excessive purging in the form of excessive exercise, and anorexia nervosa, binge eating/purging subtype, though never formally diagnosed. They don’t know that I wrote the Wikipedia page on functional hypothalamic amenorrhea for my undergraduate senior capstone after finding that one didn’t exist when I Googled something along the lines of “what is it called when you don’t have a period for three years.”
The truth, however, is that I have been the patient sitting in the chair with vague complaints of fatigue and poor sleep with an often low-normal BMI, stone-cold-normal labs and vitals remarkable only for bradycardia, never questioned about my diet or my relationship with food. I was the patient sitting there knowing exactly what was wrong, praying that something I said to my provider would allow me to admit my truth but leaving the appointment feeling that I was clearly fine if they hadn’t brought it up.
They also don’t know that after recognizing my behaviors as problematic, I broke the vicious cycle myself by completely revising my internal narrative surrounding food and physical activity. Today, in an unanticipated role reversal, I heard patients verbalize those problematic thoughts but let them leave without asking the key questions I had wished a physician would ask me.
In a strange twist of fate, our last patient for that day was a late-40-something, stylish, white woman being seen for a depression follow-up. She was polite and talkative, but she told us her medications were not working. Her BMI was on the cusp of being overweight at about 25.5, up from 23 at the same time last year. Evidently, she had been considered obese several years ago and lost nearly one hundred pounds through diet and exercise. In my mind, this always raises the question of whether she lost weight healthfully or resorted to restriction.
“One thing that is really bothering me is that I keep gaining weight despite doing everything right,” she said, unprovoked. “I know the menopause is not helping, but it’s really frustrating to do all the same things I used to do and see the opposite results.” “Can you tell me what you mean by ‘doing everything right?’” my preceptor asked. “I’m tracking all of my macros and even following up with a nutritionist, so I know I am not over-eating. I constantly worry about gaining weight. I don’t think my depression will ever get better if I can’t get my weight back under control.” She began to cry.
“Do you mind if I ask you a couple of questions?” I spoke out. She wiped her tears and shook her head with bright eyes fixed on mine. “Do you feel like most of your thoughts revolve around tracking your food?” I asked. She nodded fervently. “Would you say that tracking your food so closely is increasing your anxiety about your relationship with food?” Once again, she nodded in agreement. “So, while tracking gives you anxiety, you would also fear losing control of your food if you stopped tracking. Is that correct?”
“For as long as I can remember, what I eat has been a source of anxiety for me. Ever since I started losing weight, really. Honestly, I feel like I probably do have an eating disorder. I just figured that since my weight is pretty normal and I’m not making myself throw up, I must be okay.” Somehow, she actually looked relieved. My preceptor looked at her and said, “Mackenzie brings up a good point. It sounds like you may have developed a pattern of disordered eating when you lost weight originally.”
“Can I give you a piece of advice?” I then asked. My preceptor and the patient looked at me with interest. “While tracking macros is a great way to meet weight goals, it can be psychologically detrimental to those who have a tendency towards disordered eating,” I explained. I think it would be best if you try to apply the knowledge you’ve obviously learned through previous successes on your own rather than religiously relying on tracking. When you can prove to yourself that you have the skills it takes to maintain your weight without relying on the log, you might find that even when your meal composition is not ‘perfect,’ there is not a magic switch that goes off and upends all of your progress. You are in control, not the macros.”
The United States Preventive Services Task Force (USPSTF) issued a Grade I recommendation earlier this year with regards to universal screening for eating disorders in asymptomatic adolescents and adults, concluding that “there is currently insufficient evidence to assess the balance of benefits and harms for screening” and noting the need for more research in this area, including randomized testing of standardized assessment tools. Naturally, this sparked discussion in the medical community and caught my own attention.
On review, in conjunction with previous statements from the American College of Obstetrics and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), the USPSTF recognizes that, in the paucity of sufficient evidence, it is imperative for clinicians to recognize at-risk groups for eating disorders, to identify signs of disordered eating and to screen at-risk patients. However, only the AAP provides concrete examples of subtle behaviors and comments that patients with underlying disordered eating may make, leaving much of the burden on clinical judgment.
When patients present without overt signs such as low BMI, dental erosion, amenorrhea, a comorbid history of psychiatric illness or the other correlations we have memorized, providers must rely on prior clinical experience. While my clinical experience is low, I inherently know the subtleties outlined in these guidelines from my own first-hand, personal experience.
As medical students, we often have the following stream-of-consciousness reaction when seeing patients: extract history, think quickly – using tools we studied in Step 1 prep or by reflecting on topics that were the focus of Anki cards or a UWorld question, give a good presentation and get honors. We often forget that prior to medical school, we had at least 20-some-odd years of life experiences that can be applied to patient care. Remember all of the times that an advisor told us that medical schools look for attributes other than grades when deciding who to select for admission?
Our attendings and residents will always surpass us in years of clinical experience, which allows them to see key clues in patients that we may overlook, either due to inexperience, the stress of performing well in order to get a grade or a combination of both. Yet our life experiences have made us experts in specific areas of practice that allow us to relate to patients in ways that our superiors have not necessarily had an opportunity to experience. To those students who have grown up in a household with individuals who have autism spectrum disorder or are recovering from stroke or are dependent on insulin, you may be the real-life expert for patients with these conditions. Some medical students might be experiencing the struggles of infertility themselves.
I, for example, have insights regarding female and rural patients that my male and urban colleagues do not. I would be foolish to assume that any amount of training could grant me the emotional intelligence to relate to patients of cultural and ethnic minorities or from the LGBTQ+ community that my colleagues who are members of these demographic groups have themselves. Why then, do we often forget the value of these insights during patient encounters and fear retaliation for sharing our knowledge even when given permission to do so?
After this experience, I was given full permission to counsel patients on weight management both with and without my preceptor present based on her confidence that I had the skills and experience to provide solid advice. Each time, my preceptor would allow me to explain my coined phrase of making weight loss a “lifestyle change” rather than a diet and to “enjoy all things in moderation” in order to achieve sustained success when starting a weight loss medication such as a GLP-1 agonist.
My experience also informed me to cautiously praise patients on their planned weight loss in a way that did not focus on their appearances, but instead on the positive impacts they were making on their health after I screened for extreme weight-control measures. After all, I know from my own struggle with recovery and relapse that achieving a healthy weight is often a mental battle much more so than it is a physical one.
Yes, the female patients around my age with obesity would often scan various elements of my body and avoid eye contact when I would start my dialogue with them. “Hey,” I would say and look them directly in the eyes, “no one said this was easy. Take it from someone who has been there.” After that, they would listen.
They don’t know my story, but they understand that I am not just regurgitating the same message to “be healthy” like the weight-loss advertisements they have heard on television, or reciting a phrase that I learned to tell patients in medical school. Something in my life has allowed me to relate, and that is enough to build trust. I’ll never be able to return to the patient who implied that my petite body habitus was disgusting and apologize for not hearing her silent cry, her silent plea for attention, her hidden truth masked in the form of a complex defense mechanism. I wish I could let her know that she does not really think I am disgusting and that her weight is not disgusting, either.