The Committee: Problems with Obesity Researchers

A couple of years ago, I was on a committee of the American Academy of Pediatrics that focused on child nutrition and problems of overweight. We all agreed there was a problem. Maybe most adults, even those who don't work with children, have seen a generational change.

When I was a child, there was often one kid--if that--who was thought of as fat. I wasn't that child, and that child, at school at least, must have had a tough time. Honestly, I don't remember if there was such a child in the elementary schools I went to. There was a single classmate in grades 7-12, but at the school we shared, it would have been considered rude to make fun of anyone. (Though some were more competitive than others, I don't think anyone would have wanted to appear mean. I never got the impression he was anything but as happy as any of us were as teenagers.)

Things are clearly different now. Not just every school but every class has several overweight children, in every grade. Among these, some are dramatically overweight. Research confirms that though many kids get leaner when they grow into adolescents, many don't really recover from this early obesity. 

Given the lack of easy fixes for this problem, and the obviousness of the extent of the problem, it is a hot topic for research. I've been frustrated, however, by the work that's been done and the people who do it.

In general, I think people should go into fields they're interested in. This is not only important for their own happiness and job satisfaction, but also for their motivation and creativity. I was shocked, for example, to have met in my pediatric career more than a handful of people who don't particularly like children. That's OK, I suppose, but it implies a suboptimal career choice for both doctor and patient.

So, in this statistically-unsupported argumentum ad hominem, let me tell you about the people I've met in the obesity-science world. First, who do you think chooses to go into the field? The professor in medical school who lectured on the topic, and has published quite a bit on this topic since, had nothing in common with me. Rail thin, his lectures were, to my sensitive ears, fire-and-brimstone evangelical sermons on people being their own worst enemies, fast or prepared food of any kind being a narcotic-like poison that eats like a parasite at the very fiber of civilized society. He taught, at least this is what I recall, that eating is like smoking, and should be heavily regulated if not banned altogether. He could be seen in the cafeteria eating a salad without any dressing. I didn't sit at his cafeteria table. He actually said, and I remember this vividly, that doctors need to be models for their patients. I interpreted this to mean that doctors who struggle with their weight or smoking or personality flaws are pretty much equivalent to permitting an alcoholic counsel other alcoholics.

Uh, that actually works. In study after study, though by no means always successful, the Alcoholics Anonymous model--in which recovering addicts share their experience and hard-earned wisdom--has been about the most consistently worthwhile intervention. It has been copied for addictive behaviors of many kinds.

But the obesity research establishment hasn't gotten this message. They haven't even opened the mailbox to see that there might be a message waiting. It's because their aren't looking for this or some other message. They think, like that anorexic professor at Yale whose personal diet is uneconomic and unsustainable for even patients with the most driven eating disorders and who thinks that his obsessive neurosis is the only appropriate prescription for the millions of people with whom he has neither anything in common nor empathy, that they really know how to fix the problem.

So the research they do doesn't, ultimately, tell us much that's actually helpful. Studies that show that if you watch TV 6 hours a day you tend to be fatter than those whose varsity sports team practices 3 hours a day after school. The title is usually something like, 'Varsity sports participation is a protective factor for excessive body-mass-index in adolescents.' Or, 'Proportion of daily calories from fruit predicts lean body mass.'

Knowing the abysmal failure rate when doctors tell their patients they need to lose weight, and the worthless nature of this kind of research for any practical purpose except the resumé-building of the authors, I had assumed that the grind of inevitable progress would, by now, have brought us out of this dark cave. So I looked forward to joining this committee, in which I presumed to be kept at the very cutting edge of child obesity research. I wanted to find out what actually works, what has been tried, and what can I tell my patients and their families that will genuinely help them.

The committee met at a lovely upscale restaurant in San Francisco. I was one of 3 men. There were about 40 women on the committee, but not every member came to every meeting. Though their ages spanned from mid 20's to mid 40's, I feel comfortable, since this whole post is about judging books by covers, saying that they all could have been sisters. A pair of waiters came around to take our orders. You know the rest already, I suppose. Salad with no dressing--not even on the side. Fish grilled without butter or oil, no potatoes, no bread, no dessert. Even so, most didn't eat at the table, and just pushed the food around the plate. At the time, I felt humiliated and ashamed, as if they were all staring at me conspiratorially and silently agreeing that He's the reason we're here.

I thought the committee might address pediatric patients who have a nascent weight problem that needs to be addressed for their health. This group, as a subset of the obesity-research elite seeing to affirm their own dysfunctional relationship with food, was really just an excuse for these doctors to get together and affirm each other's neurosis. The consensus was that

McDonald's = Blackwater. 

More than one of the members of this committee proudly boasted that she had never, not once, eaten or even been inside a McDonald's.

I'm no apologist for McDonald's. But I think there's deep truth about patient care that these starvation-junkies have missed.

On a personal note, by the third meeting or so, I looked forward to the dinners. I would ask for extra butter on my mashed potatoes, ranch on the salad. At one point, about 25 people indicated that they didn't want dessert. I asked for an extra crème brûlée. It wasn't passive aggressive, it was just aggressive. The committee disbanded when the American Academy of Pediatrics realized, I suppose, that it would be cheaper to pay for these doctors to stand around outside of the restaurant rather than go inside and order food they didn't eat. And that it would not be possible for even less to get accomplished.

Next: what's missing from obesity research.
After that: some hope, or at least some reality, from recent research

Cultural Sensitivity

A delightful couple, pregnant with their first child, came to the office to interview me, to help them decide if I was the right pediatrician for their baby. We had a lovely chat and I felt that I was doing well. At the very end, they asked a question. “Do you have many Asian patients? Do you find you have to ask questions a different way with them or that you have to take a different approach?“ I took these questions as an inquiry about my level of cultural sensitivity. I had a long answer. For the record, though, these people looked by their facial features to be of Asian ancestry; the last name appeared to be of Japanese origin.

“It’s the Bay Area, “ I replied. “What are the odds?“ They agreed it was pretty likely that I had some Asian patients. This was the beginning of my reply.

I told them I took care of a group of about 8 or 10 families from Mongolia. They all live near each other because only a couple of them speak any English at all, and the language barrier is substantial. Taking care of them has sometimes been a challenge. there are no patient-education materials available in Mongolian. AT&T has available translators via telephone in dozens and dozens of languages, but Mongolian is not among them. I called UNICEF at the United Nations in New York. They did send people to Mongolia, but they had no patient information. Same story when I contacted the World Health Organization in Geneva, Switzerland. At one point I had a polite exchange of emails with the Minister of Health in Ulan Bator, Mongolia. He or the person composing the emails under his direction and signing his name, had good English-Language skills. His office had no written materials on child health in Mongolian. These families are Asian. Am I culturally sensitive with them? Probably not. Since communication is so difficult, we need every extemporaneous sign language technique we can come up with just to convey information.  So cultural sensitivity is not helped by a language barrier. I take care of these Asian patients, but do I take care of them differently? Yes, I suppose so, but it’s not because of a cultural divide.

I’m reminded of a classmate in medical school. When he was 14, his parents and he joined many others on a small boat headed blindly from Vietnam out into the South China Sea. Obviously they made it, and he’s now a fine surgeon. What should I know to deal with his family in a Vietnamese-friendly way? Are Koreans different?  What about Malaysians of Chinese descent?

When I was in business, there were no courses that were required, but everyone knew that Japanese investors and businessmen expected certain salesmanship behaviors when they were entertained in New York. In Japan, a completely different set of rules applied. It wasn’t called cultural awareness, it was called good business. In Hong Kong, it was often thought best not to mention that you’d just had a successful series of meetings in Tokyo.

So what was this nice couple asking me? If I had other patients who, by their visible bodily characteristics, appeared to be of Asian descent? Nearly half the human race is of Asian descent. Were they asking if I treated my patients of Japanese descent as if they were Japanese? I don’t know. How many generations of their family have been born in the United States?

I take care of a nice family, for example, with a hyphenated last name. They are all American citizens. They say that they are Brazilian. When their kids were born, I encouraged the parents to speak only Portuguese to them at home. The mother’s ancestors were from Portugal. She looks like a European might. The father’s ancestors were Chinese. He looks Asian. The kids are…adorable. Is this an Asian family? I don’t think even the father’s parents speak much Chinese, back in Brazil. How Asian to you have to be to qualify for a checkbox of ethnic identity? How Asian to you have to look?

No institution with which I have been associated over the last 20 years or so has failed to offer--actually require, I think--a course of some sort in cultural sensitivity. As demanded, I have wasted valuable hours in these courses. In one, the head of a fabulous Spanish-language health clinic gave a presentation on cultural awareness doctors should have to the Latino community. Assuming that language wasn’t a barrier, what could I do with that? Ask a proud Ecuadorian if they identify more with Mexicans than with Americans? Ask someone from Spain if they relate better to a Dominican than a Californian? Will I learn about the distinctions of all those who speak Spanish in a short course or lecture on cultural sensitivity?

I have a family from Yemen. Devout Muslims, they appreciate that I never extend my hand to the mother. I try to be respectful and to the point. I don’t even close the exam-room door when I see their kids and the father isn’t with them.

I think that doctors--people in general--look fake when they try to be someone they’re not. I also think that doctors can be particularly culturally insensitive. But I think it’s cynical political correctness to require learning cultural sensitivity. What they really need to learn is just sensitivity.

If physicians are going to be culturally sensitive, they must first spend enough time with the patient to listen. Maybe they can take a course on reading body language and eye contact, tone of voice or listening skills. Maybe they can learn to interrupt just a little bit less. This would go a really long way towards sensitivity to what a patient really needs. I don't think it's helpful to put on an air of paternalistic cosmopolitanism—like an anachronistic white man's burden—that says to patients that overeducated well-to-do Americans can feel inappropriately self-confident about learning in an hour what patients have taken a lifetime to master.

It's nice if you and your auto mechanic grew up in the same neighborhood. But it's a lot nicer if you find a mechanic who treats you well, listens to your complaint, and actually fixes your car. Which one would you choose?  The one that shares your background/language/heritage or the one who listens to you, does a great job, and doesn't rip you off?

Medical management (and this applies equally to corporate management) shows astounding hubris to impose an unsupported belief that patients will perceive as a better experience a visit with a doctor who has memorized a few facts about your grandparents' country of origin. Whether the patient is from Mongolia or Malaysia, Brazil or Burundi, I don't pretend to be something I'm not. If doctors could spend more time, could simply have more empathy, listen to their patients and think about what it's like to live a day in their shoes, cultural sensitivity would just be sensitivity.




The photograph from my collection is by Keith Carter and is titled, "George Washington."

Slow Medicine

What is Slow Medicine?

Berkeley, California is the epicenter in America of the Slow Food movement. It has gradually developed over the past 20 years or so as a response to Fast Food.

The idea, I think, is that food should be very fresh, as local as possible, as organic as possible, and prepared just before serving. Michael Pollan has written a lot about these ideas in his books about food. Alice Waters has written cookbooks that emphasize these priorities and has a fabulous restaurant here that puts the concepts into practice.

I think it's time for a similar revolution in medical care. So I'm inventing the term Slow Medicine.

At business school, I first learned of the existence of Hamburger University, near Chicago. One of my smartest professors would often go and teach a course there. What he taught was Industrial Production, ways of ensuring the consistency and high quality of the final product, produced in the most economical and fastest way. Hamburger U. is run by McDonald's, and is where they send most of their best managers for training, and where they develop new systems for service. McDonald's makes great products--delicious food that's fast and inexpensive, and can almost always be counted on to be consistent in quality whether ordered in Berkeley or Brooklyn.

A few years ago, I had the honor to serve on a panel discussion about the quality of medical care. On the panel were health plan administrators, state health officials, insurance plan managers, a few professors of health policy and medical practice, and me. (I met one of the professors in the hotel elevator, and introduced myself. He asked what I did, and I said that I was a primary care doctor. He huffed and said that he didn't understand why they invited me, since he was an expert on primary care and head of the department of primary care at a major medical school. I asked him politely if he took care of patients. He said he didn't, except for the 3 weeks a year he has to supervise medical residents in their clinic. Though he was invited, I presume, as the expert in 'primary care,' I was the only practicing doctor.) The organizers went around the room, and I learned a lot! What is called 'quality' as it applies to medical care is really a code word meaning consistency, efficiency, and the lowest acceptable standard of care at the lowest average cost. In the back of my mind rang familiar echoes of chain restaurant strategy and Hamburger U. When it was my turn, I pointed out that this is not at all what my patients would think of if they were asked about the quality of their medical care. The view of patients on medical quality just didn't matter. The quality debates occurring at the moment are dominated by healthcare institutions and insurers. They want consistent, if minimal, results for the least cost.

This industrial model of the provision of medical care is everywhere in America. Because doctors are paid per visit (just as with sweatshop workers, it's called piecework), there's a lot of pressure on them to do as many visits as possible per day. That's why when we see our doctors (me, too) we sometimes get 10 minutes or less. In order to provide minimal standards of consistent results (quality), the medical assistant might have us fill out a questionnaire first or give us a lab form. Chances are that the doctor doesn't know us, our issues or questions, or our concerns. I have been to doctors where I was told that I can only ask about one problem. Another problem is another visit. In what I'm calling the industrial model, patients are the raw materials and payment is the factory output.

The people that run our healthcare companies and institutions are generally nice people with families like the rest of us. They know what good medical care is and they want it, too. But the qualities we all really want are difficult to measure and hard to define. We all want a doctor who knows us and cares about us, and tries to do their best for us. But what we get is Fast Medicine.

Do you want fries with that?

Next Post: Why Slow Medicine might actually work.