Abstract

1. Targeting White Coats in the War on Obesity: A Qualitative Analysis of an Online Debate About Clinicians' WeightPresentation at Durham University, Jan 2010Dr. Lee F. Monaghan, Department of Sociology, UL.lee.monaghan@ul.ie

2. Abstract Amidst alarming claims about an obesity epidemic, doctors and other clinicians are being urged personally to fight fat lest their credibility, health and effectiveness are threatened. This paper provides a brief overview of two research papers on this topic, which are forthcoming in the journal Social Theory & Health Volume (vol. 8, 2010). Empirically, the papers draw from over 200 postings from an Internet site aimed at a medical audience, Medscape. Four main types of accountability or discursive framings are identified and outlined: the acquiescent, the excusable, the critically compliant and the justifiably resistant. Themes relating to the last type of account are explored more fully. Analytically, critical attention is directed at obesity discourse, which encircles and potentially spoils clinicians’ and patients’ identities, with discussion pointing the way towards an alternative approach that makes sociological and clinical sense.

3. Structure • Critical Weight Studies (Fat Studies, Critical Obesity Research) • Outlining the Medscape Debate: ‘Physician Heal Thyself’ • Explaining the Sociology of Accounts • Modes of Accountability on Medscape: • The acquiescent • The excusable • The critically compliant • The justifiably resistant

4. Critical Weight Studies • Burgeoning critical literature • Endorsing a ‘sociologically imaginative approach’ • Not neglecting clinical practice per se or ‘healthy lifestyles’ but important caveats …. • Lifestyle as indebted to social structure, which may be seen as more important. • Health at Every Size (HAES; e.g. Bacon) or Health in Every Respect (Aphramor and Gingras).

6. Outlining the Medscape Debate • About Medscape • Dr. Dansinger’s (2006) Presentation: Tight white-coat syndrome: Physician heal thyself. Medscape General Medicine8: 42, http://www.medscape.com/viewarticle/531752 • Roundtable Discussion • Discussion Board

7. Most people would agree that excess body weight is a significant health risk, but should doctors be held to a higher standard than the general public for maintaining appropriate weight and fitness levels? We posed that question to the 4 members of our new Medscape Roundtable Discussion group. Centor, R., Marchetti, P., Donnell, M. and Poses, R. (2006) Roundtable discussion: Are overweight doctors a problem for the profession? http://www.medscape.com/viewarticle/541443_1,

8. Started By: Cewiebe, Family Medicine, 3:46PM Jul 24, 2006 Physicians are expected to lead the fight against obesity and serve as role models for the public, but many are struggling with their own weight just like their patients. Are overweight doctors ineffective in counseling their overweight patients? Do they have a responsibility to be fit and trim? Or is this just another burden being heaped on overworked, overstressed doctors? http://boards.medscape.com/forums/.29d574ee?@571.0dIIabwld5Y@ Are Overweight Doctors a Problem for the Profession?

9. Accept Pejorative Status Deny or Challenge Pejorative Status Accept Responsibility Contrition Justifications Deny (Relevance of) Responsibility Excuses Repudiation The Sociology of Accounts Table 1: An expanded accounts framework (Monaghan 2008)

11. Modes of Accountability on Medscape • The acquiescent • The excusable • The critically compliant • The justifiably resistant

12. The Acquiescent: Narratives of Shame, Blame and Meddlesome Advice The old saying goes ‘if you don’t have your health and you don’t haveanything’. Just don’t understand how people who take care of sick people;many who have problems directly related to obesity, can let themselves getout of shape. My greatest motivation is the desire to do anything in my powerto avoid getting into the cycle of poor health that obesity, poor eating habitsand lack of exercise leads to. If you’re one of the doctors complaining of ‘nothaving enough time’, you’re no better than any patient with their excuses.How do you expect patients to respect your advice when you don’t follow ityourself. It’s like the parent who tells his/her child to do/or not to dosomething and they do it themselves. A child doesn’t even respect that way of reasoning, why should an adult patient? (no. 200)

13. The Excusable: Mitigating Accounts & ‘the Will to Innocence’ The entire process of becoming a physician is one of the most unhealthythings a person can do. Hours in a lecture hall, followed by hours workingwithout enough sleep or even time to see your family, let alone exercise,hardly promotes a good healthy role model for patients. If physicians aregood at ‘do what I say not what I do’ this is LEARNED BEHAVIOR. I don’tever remember an attending (or resident when I was a medical student)telling me to take time off to exercise, even though I actually did. In addition,if I had $50 for every meal I was served during training that was patentlyunhealthy (pizza being the worst), I could hire a personal trainer and buildmy own personal gym. Until we address what we put those in trainingthrough, it will do little good to chastise physicians who put on 30–40 poundsbetween the beginning of medical school and the end of residency. (no. 234)

14. Critically Compliant: Still More or Less Credible, Effective and Worthy? From my perspective as both a patient and a professional, I find myselfwanting to shout: easier said than done! Bias against fat people is real andpainful. The letters after one’s name don’t change that. I can becompassionate and encouraging to patients even though I am more thanpleasantly plump, precisely because I share their struggle, and I knowlifestyle change isn’t easy, for me or for them. Yes, it can be done. Yes, itshould be done but judging either patients or peers for inability to do itnow is not constructive. (no. 3)

15. Justifiably Resistant: Fat Acceptance and Towards a Different Approach to Health Relevant themes included: fatness as a ‘natural’ form of body diversity;feeling disappointed and even insulted by other clinicians’ weight-related‘concerns’, which could be compared to bullying and could also hurt patients;resisting unwelcome and unjustified meddling, or injunctions to police otherpeople’s lives; viewing clinicians, who push obesity discourse, as politically andeconomically naive or power hungry; respecting one’s colleagues; ‘fatness’ asanthropologically credited; critiquing obesity science, associated biases andprejudice; the ineffectiveness and risks of weight-loss prescriptions; the possibilityof being fat, fit, healthy and a good clinician; and, the value of what isformally known as Health at Every Size (HAES).

16. I am more and more convinced that I decided to do the right thing and quit medicine after 30 years and go to law school. Lawyers can be nasty to each other but there is NOTHING worse than a member of a ‘caring’ profession who just doesn’t care. How difficult is it to see that most obese people struggle with a problem? I know I do. And I was a thin, athletic kid. Now I look just like all my maternal uncles – is there a message there? It’s disgusting for one physician to kick another physician when he’s down. You might as well have obese physicians put down like a sick horse. Thin self-righteous bastards! (no. 198) It is no other doctor’s business if another one is obese, too short, too skinny or any other burdened with any other so-called public health problem. Frankly, I was insulted by the headline, when I saw it slither into my email box as much as I am by the continuation of health care disparities. Doctors can truly be shallow and now that they have no power to control their own destinies or profession are they turning on one another? (no. 76)

17. After ‘weighing’ in early during this discussion and coming back to read all of the postings, I am incredibly discouraged to think there are so many fatphobic physicians treating patients with eating disorders. Our profession (and obviously many others that address obesity) needs a swift kick in the compassion lobe. (no. 237) Amen. Michael Dansinger, MD, is the doctor I want to avoid – just eat less and exercise more – what a cop out. Obviously he doesn’t have a clue about the complexities of obesity. Only someone who has struggled with this issue (and believe me, most of us STRUGGLE – it is never off our minds) can really know the devastation of going through life ‘less than’ in so many aspects. (no. 96) In Indonesia, just as a developing country with 1 physician for 12 000 people, most of us are lean doctors which means also ‘undernourished’, except those living in the capital Jakarta. Fat doctor is a symbol of prosperity and good conducts so will have more patients. Usually they have also good practice, cars and houses. People do like fat physicians. (no. 141)

18. The oft-repeated message that there is a link between weight and disease is never accompanied by the fact that no one has ever proven a causal relationship. For all anyone really knows, the same thing that causes diabetes II (for example) also causes obesity. The Roseto Cardiac study showed that in a loving community, even those who were obese and ate foods rich in saturated fats had the same level of cardiac health as the general population. It wasn’t until residents of the town became more exposed to American mores that they began to have health issues that were in excess of the general population. Those results lead to the inevitable question: Does obesity itself lead to disease, or is it the result of the stress caused by being marginalized for not maintaining a socially (and arbitrarily) defined level of attractiveness? (no. 133)

19. We continue to fail to differentiate weight loss from the acute changes occurring as a result of changed eating practices. We are so convinced that weight loss is the answer that we fail to consider the immediate effects of not having to catabolise large amounts of ingested fat and sugar solved a patient’s health problems. I am yet to find a significant body of research that differentiates between the two. (no. 131) In the arena of weight management we are doing serious amounts of harm. We focus on obesity and say it is the root of all evil instead of focusing on the lifestyle that produces it. Our focus on the fat leads to exploding levels of body image dissatisfaction that leads to distorted eating patterns that lead to weight gain that leads to further BID. We the medical establishment are no better than snake oil merchants in this area. We can at best offer 10% body weight loss on a diet that is almost universally regained after 2 years. (no. 131)

20. I am very overweight, I have been there and done that with regard to the eating less crap they push for over 25 years. The trouble with obesity is that the cure doesn’t work, and when it doesn’t work then the patient is blamed, after all doctors are patients too. If there was a cancer drug that only had a 5 per cent success rate what would they do with that drug? Would they blame the patient? Why do they blame patients then when they are unable to follow the ‘cure’ for obesity when that cure is precisely not the cure at all? (no. 119) As a nation, we have our priorities mixed up. Is what the scale says really a determinant of the quality of life and our longevity? It is time we STOP focusing on a single number as the be-all-end-all predictor of health, well-being, and worth for health care providers as well as our patients. It would be more effective to focus on behaviors that HAVE been shown to improve health, such as regular physical activity, eating foods rich in antioxidants and fiber, nurturing positive relationships with friends and family Forget about what the scale says. (no. 37)

21. If an overweight or obese doctor believes strongly that ‘exercising more and eating less’ is easily doable for everybody and will result in immediate and long-lasting weight loss, and tells that to his or her similarly overweight or obese patientsthen sure, he or she is a hypocrite. But if an overweight or obese doctor believes strongly that people come in all shapes and sizes, that everybody can benefit from fitting physical activity into their lives, that everybody can benefit from eating healthier, that your weight is one of many health indicators and not necessarily the most important one, that individuals have a right to determine the priorities in their lives, and spending several hours a day maintaining a low weight is not always the most important one, and generally in a ‘health at every size’ approach, and they follow this belief in their own lives: then there is nothing hypocritical about telling your patients the same thing. And that can serve as more valuable a role model than a doctor who is simply thin. (no. 118)

22. Conclusion • Four main modes of accountability or discursive framings on Medscape • Not rejecting the relevance of clinicians and patient care (e.g. advise about risks of weight-loss and ineffectiveness; the role of HAES) • Challenge obesity discourse outside of the Internet: Being Sociologically Imaginative • Not only relevant for clinicians, but also patients