A 55-year-old woman comes to the physician for a follow-up appointment due to problems with low energy, difficulty losing weight, and joint pain. She works in sales and says that it is difficult to be on her feet all day. She has a 10-year history of hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Her current medications include metformin, atorvastatin, lisinopril, and naproxen. The patient has no polyuria, polydipsia, or blurred vision. She has gained 4.5 kg (10 lb) over the past year despite a diabetic diet and repeated counseling about the importance of weight loss and exercise from her physician. She says, "I start off the day eating healthy, but by the afternoon I am so tired and ravenous that I just have to have a snack. No matter what I do, I just can't lose weight. It's depressing." When the importance of exercise is discussed, she says, "I want to exercise, but it's hard when I have pain in my knees and ankles." The patient drinks a glass of wine daily and does not use illicit drugs. She binge eats (a box of cookies or a whole pizza) once a month when stressed. Her blood pressure is 140/90 mm Hg and pulse is 84/min. She weighs 145 kg (319.7 lb). Finger-stick glucose is 210 mg/dL, and she admits that she stopped off at a donut shop prior to this morning's visit. Which of the following is the most appropriate response by the physician?

Question

A 55-year-old woman comes to the physician for a follow-up appointment due to problems with low energy, difficulty losing weight, and joint pain.  She works in sales and says that it is difficult to be on her feet all day.  She has a 10-year history of hypertension, type 2 diabetes mellitus, and hypercholesterolemia.  Her current medications include metformin, atorvastatin, lisinopril, and naproxen.  The patient has no polyuria, polydipsia, or blurred vision.  She has gained 4.5 kg (10 lb) over the past year despite a diabetic diet and repeated counseling about the importance of weight loss and exercise from her physician.  She says, "I start off the day eating healthy, but by the afternoon I am so tired and ravenous that I just have to have a snack.  No matter what I do, I just can't lose weight.  It's depressing."  When the importance of exercise is discussed, she says, "I want to exercise, but it's hard when I have pain in my knees and ankles."  The patient drinks a glass of wine daily and does not use illicit drugs.  She binge eats (a box of cookies or a whole pizza) once a month when stressed.  Her blood pressure is 140/90 mm Hg and pulse is 84/min.  She weighs 145 kg (319.7 lb).  Finger-stick glucose is 210 mg/dL, and she admits that she stopped off at a donut shop prior to this morning's visit.  Which of the following is the most appropriate response by the physician?

Quizplus · Accepted Answer

Explanation: This patient has been repeatedly counseled about the health consequences of obesity. Her nonadherence to recommended lifestyle changes (diet and exercise) presents a challenging situation for the physician. Frustration, anger, and hopelessness on the part of the physician are understandable reactions. However, the physician must contain these negative feelings and maintain an empathic and nonjudgmental attitude toward the patient. A patient-centered approach that avoids blaming the patient and encourages her participation will improve rapport and adherence to treatment. Because she has failed self-directed diets and exercise, a collaborative approach to implementing a structured program would be the most appropriate response. (Choices A and E) These statements have a judgmental tone. The patient has already received counseling about the negative health effects of obesity and is likely already aware that the physician has these concerns. Although it would be helpful to explain how weight loss may improve her current problems of low energy and joint pain, this must occur in a nonjudgmental fashion so that she does not feel blamed for her difficulties. The physician's response should be more focused on finding a more effective method of assisting this patient. (Choice B) Exhorting the patient to "try harder" is likely to be ineffective and perceived as judgmental. (Choice C) Although underlying depression may contribute to the patient's weight gain, there is insufficient evidence to recommend psychological counseling as a primary intervention. Physicians should resist the tendency to refer difficult and challenging patients to another provider as it often represents unintentional avoidance. Educational objective: Managing patients with chronic medical problems related to nonadherence to recommended lifestyle changes requires a patient-centered approach that is empathic, nonjudgmental, and collaborative. References: Obesity bias in training: attitudes, beliefs, and observations among advanced trainees in professional health disciplines. (http://www.ncbi.nlm.nih.gov/pubmed/24124078) Family physicians' practices and attitudes regarding care of extremely obese patients. (http://www.ncbi.nlm.nih.gov/pubmed/19282824) Managing difficult encounters: understanding physician, patient, and situational factors. (http://www.ncbi.nlm.nih.gov/pubmed/23547575)

A 55-Year-Old Woman Comes to the Physician for a Follow-Up