Bad words: why language counts when discussing weight with our patients

A few months ago, there was a HuffPost article entitled “Everything You Know About Obesity is Wrong,” by Michael Hobbes.  It discussed the struggles of people who have obesity and how the medical system has failed them.  It quoted Stephanie Sogg, PhD, a clinical psychologist at the Weight Center at MGH (notice how it isn’t called the “weight loss center”).  In it, Dr. Sogg describes her approach as “being nicer to her patients than they are to themselves.”

Given that this article lambasted physicians for not being able to effectively discuss weight issues with their patients, I contacted Dr. Sogg to find out how we can improve at this.  She provided me with an article she wrote.  This article should be read by EVERY CLINICIAN IN THE COUNTRY.  It is that powerful and important.

In the episode title, I paraphrased an article she wrote entitled, “Bad words: why language counts in our work with bariatric patients.” In it, Dr. Sogg explains how language can influence they way that we think about things.  As physicians, we are authority figures and community leaders, so thereby, the language we use can influence how our patients think about themselves and our colleagues think about their patients, for better or for worse.  This isn’t a discussion on how to lose weight.  This is a discussion on how to effectively discuss a topic that is extraordinarily sensitive and full of landmines.  This is a discussion on how to avoid those landmines and earn the trust of a patient who is struggling and could use your empathy and understanding.

The article that lambasted physicians:

Her article “Bad Words: why language counts in our work with bariatric patients”

Dr. Sogg:


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Unknown Speaker  0:03
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians where Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have learned while we were memorizing the Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers. This podcast is intended for medical professionals. The information is to be used in the context of your own clinical judgment. And those on this podcast accept no liability for the outcomes of medical decisions based on this information. As the radiologists like to say, clinical correlation is required. This is not medical advice. And even though the magic of podcasting may make it seem like we’re speaking directly in your ears, this does not constitute a physician patient relationship. If you have a medical problem, seek medical attention.
Unknown Speaker  0:57
On today’s episode, we have Dr. Stephanie sock a clinical psychologist at the weight Center at Mass General and an assistant professor in psychology at Harvard Medical School. We go through effective ways to discuss weight management with your patients. But make no mistake, this is not a discussion on how to lose weight. This is a discussion on effective ways to discuss weight, which carries with it stigmas from society and the house of medicine. This is hugely important for establishing rapport with your patients who are struggling with their weight and without rapport. Any advice is next to useless. We discussed the power and importance of language, what person first language is, why and how to avoid such terms as obese, more bid exercise polarizing terms like good and bad, and alternatives to the judgment laden question Why? Welcome back to the physicians guide to doctoring. We have a very special episode today. A few weeks ago, there was an article from the Huffington Post, circulating around Facebook among myself. Self and my physician friends, and it was titled, everything you know about obesity is wrong. And it was, in some ways lambasted the medical community for not knowing how to talk to patients if weight was an issue, and it gave many specific examples of patients who had had interactions with the medical community that were so negative, that they remembered it for four years, and it affected them in in severe ways. And so it really illustrated what the wrong way or the wrong way to talk to someone about this is, but the question for us as physicians is what is the right way. So I reached out to one of the PhDs who was quoted in the article, and she was kind enough to respond and agree to be on the podcast today to talk to us about How we can do that better how we can relate to those patients, it’s, it’s so easy to say something without even intending it to be heard a certain way, and the patient hears it that way. And suddenly, they’re alienated, and the entire relationship is destroyed. So we need to be very careful when we choose our words. And appropriately this this individual wrote an article called bad words about all the words that we tend to use that that we might think are okay to us, but as it turns out, are perceived very differently. So So on the podcast today we have Dr. Stephanie sugg, who is a clinical psychologist at the white Center at Mass General and an assistant professor of psychology at the Medical School. She’s also on the Executive Council for the American Society for metabolic and bariatric surgery. So, Dr. Solid thank you so much for For being on the podcast today.
Unknown Speaker  4:02
That’s my pleasure.
Unknown Speaker  4:05
So so the first thing that you mentioned in that article talks about the power of language how, how words can help shape our thoughts, can it can you speak to us a little about that?
Unknown Speaker  4:16
Yes. Well, I think that’s, that is a subject that’s really near and dear to my heart. It’s a part of every interaction that I have with every patient and also with colleagues as well. And as a clinical psychologist, my main tools are my word. But even going beyond sort of the clinician patient relationship, it’s really important to be considering the words that you’re using because we think in words and so the words that we choose shape how we think about things and that shapes our attitudes about things which ends up shaping Our behaviors are emotional responses to things. I think there’s there’s almost nothing more important than really being careful and thoughtful about the language that you’re using to convey the ideas and the sentiments that you’re trying to get across. Whether you’re speaking professionally speaking to patients, speaking to anybody really,
Unknown Speaker  5:23
and especially with with a vulnerable population like this, but as as an authority right there, they’re looking up to us. And so, these interactions are particularly important. So the, the language is important. And first establishing trust. I mean, myself. Exercises always been a priority in my life, right? And so I’m, I mean, it’s going to seem like a humble brag or whatever, it’s, I’m in good shape. And so it’s I think it’s sometimes challenging for the for me to connect with patients. That have issues that I’ve never encountered. So, so Can Can you talk about the importance of of choosing these, these words in in establishing trust? And and what can happen to an individual if that that trust is broken by someone in authority?
Unknown Speaker  6:23
Well, I think that if we’re specifically talking now about a population of patients who have obesity is, am I right in thinking that that’s the specific thing that we’re talking about right now?
Unknown Speaker  6:35
Exactly, exactly.
Unknown Speaker  6:36
So people with obesity and I, I’ve been in my current position for 15 years, and I have talked to thousands of patients who have obesity and there’s no one profile, no one type, everybody’s very different from everybody else. But there are some common experiences that I hear from many of my patients and Feelings of self blame are very, very strong. And part of the way that patients get to that feeling of self blame is that they’re given messages of self blame all the time. And they are coming into a medical situation, especially if they’re talking about their weight or talking about illnesses or medical conditions that are related to their way. Absolutely expecting to be blamed and shamed and you can sort of see people sort of emotionally cringing waiting for the recriminations, the scolding the instructions and ordering and to pile on to that one, when your patient is already very vulnerable to proceed. That in the interaction even if it’s not actually there. You know, it’s it’s very, it’s very important to be careful to avoid anything that is judging, blaming, shaming, scolding. It’s very unusual that somebody with obesity does not know that they have obesity. There are some studies showing that there are people out there who have BMI in the range of obesity, but don’t categorize themselves as such. But in general, people who have a high weight are acutely aware of that and are just sort of waiting to be called out about it. So being sensitive in your language and making statements or asking questions in a way that telegraph in a succinct way that you are not blaming them and not shaming them and that you’re here to understand what’s happening with them and do what you can How, right from the very beginning and the interaction is crucial.
Unknown Speaker  9:07
So what you’re saying is they come into this thinking that they’ve done something wrong, almost that, that they might even deserve to be this way and are waiting for the doctor to validate what they’re expecting them to say. And so should we, should we put that out in the open and say things like, this isn’t your fault? I, you know, how do I other than trying to avoid saying something that makes it seem that I’m implying that it’s their fault. Do you think there’s any advantage to just putting that out there and saying there are circumstances that are not in your control that have led to this issue and we can help you But you have to recognize that this isn’t your fault. Is that mean? Is that the type of thing that we should be saying?
Unknown Speaker  10:06
I think if you read with this isn’t your fault, it comes across as a bit hollow or goodwill hunting. That’s what I thought. Yeah, that’s what there’s a ways to communicate that without sort of putting it out there, so baldly. I, I actually do this more at the end of the interview once I have more information from them. But I’ll at the towards the end of the interview, I will ask the patient to tell me, what do you think has been the major contributors to your weight? And it’s very interesting how few of them say, I was played on a depot, Primavera shot and I gained 60 pounds or I, you know, I had an injury and was laid up for Six months, or I think its genetic, because everyone in my family has obesity. The most common answer to that is me. I’m lazy. I eat too much. And so I will take that opportunity to gently say, you know, I’m I’m thinking that there may be some things that you haven’t mentioned. You remember 10 minutes ago when you told me that both of your parents had obesity and that three out of your four siblings have obesity? Do you think it’s possible that genetics are playing a role, or sometimes people have medical conditions that they don’t realize are contributing polycystic ovarian syndrome makes it very easy to gain weight and very difficult to lose weight. And many of my women patients who have PCs when I asked them what contributed to their obesity, they leave that out. And often they didn’t even no one even ever told them that this was a contributor or patients who have diabetes who are on in One don’t recognize and and haven’t really been educated that once you go on insulin, it is really easy to gain weight. And it’s really hard to lose weight. So pointing those things out to patients in a sort of educational way, directly give them the message that you’re blaming them less than they’re blaming themselves. I do want to say it’s important to also acknowledge if there are other contributors that are within the patient’s control that could be contributing, because it’s important to address all of the contributors and I’ve really almost never seen any cases of obesity where it was one major contributor that the person just ate too much. And that was it or they just didn’t exercise and that was it. Usually, there’s a number of things some of which are controllable and not which are and orienting the patient to the approach that we’re going Look at all of the things and we’re going to treat them all equally, and we’re not going to judge any of them. But look at them as contributors that we could potentially address together. That’s where a sense of trust and a feeling of not being judged, comes.
Unknown Speaker  13:16
So you’re not completely absolving them of responsibility because I can almost feel some of the doctors listening thinking that like, you can’t just take away all of the personal responsibility there is there has to be an element of personal responsibility. But at the same time, there are a lot more people that have obesity now than there were 20 years ago. And it’s not because there are now many more people who are weak willed than there were 20 years ago. There are external factors that are out of their control that are increasing the likelihood that this is going to be a problem for for For more people, so we have to address those external factors, and that they can account for, as well as addressing some of the internal factors you have to. So what you’re saying is, rather than this is your fault, this isn’t your fault. Where is this coming from? There are certain things that we can control and certain things that we can’t control. Let’s see what we can do about the things that we can control.
Unknown Speaker  14:28
Exactly. And I would also know that to give a patient the message that all you know that the obesity is being driven by things that cannot be controlled, is equally damaging. And I have had patients who, when they’re get when they get the message that there’s there’s biological, genetic and other factors that are contributing, and it isn’t their fault. What they hear is, it’s hopeless, nothing can be done. And that’s very discouraging, also. So you, you really want to get away from what do we blame for this too, let’s look at all the contributors and try to sort out the ones that we can and and don’t get down on yourself about the ones that can’t be controlled. Not that they should get down on themselves about the things that can be controlled, because that doesn’t help them control those things, either. But really looking at, let’s understand the factors contributing,
Unknown Speaker  15:28
you come up with a strategy, you lay it out, lay lay it out there, this is what these are all the things that are contributing, this is what we can do about the ones that we can control. And let’s let’s get to work on that. That that that sounds realistic, and reasonable, and something that that we can do to change how we discuss that in the office rather than just, you know, one some one size fits all because sometimes what happens is People come in and say, Well, what do you think about the ketogenic diet? What do you think about going to CrossFit? What do you think about this? And the answer is, well, it’s a whole lot more complicated in that than that, that that it’s never going to be that simple. So we have to talk about everything.
Unknown Speaker  16:24
Absolutely. And because every person with obesity has different kinds of contributors, contributing in different proportions, there isn’t one treatment that’s going to work for everybody. So the doctor that puts everyone on the Mediterranean diet or the person that is just always prescribing the same medication or sort of touting CrossFit everybody that’s that’s not gonna work. You need it. Obesity is a multifactorial condition and you need an arsenal of Lots of different kinds of approaches.
Unknown Speaker  17:03
So that is actually going to be one thing that we talked about in the pre interview is what those approaches are is a podcast episode unto itself. Oh, yeah. Many. What we’re talking about today is choosing your language carefully. That’s, that’s all we’re going to talk about today. So if you’re, if you’re, if you’re waiting with bated breath with the right diet to recommend to everybody clearly, that’s not what you’re going to be finding here or, or in the future. Or actually everywhere because that information is everywhere, and they’re all trying to sell something. Yeah. Yeah. So I think it’s interesting the way you’re you’re phrasing something in particular, you’re saying that patients have obesity. You’re not saying obese patients. You’re saying patients have obesity KK You talk about why you’re phrasing it that way.
Unknown Speaker  18:03
Yes. So, there’s a concept in healthcare I’m guessing that your listeners are familiar with this concept from from other areas of medicine of person first language, where instead of saying a diabetic patient or worse a diabetic, like this person is the adjective you are talking about the person as having the condition or attribute in question, and I think I would emphasize condition over attributes, especially here in the realm of obesity. Obesity is now recognized by the AMA as being disease. It is a medical condition that is characterized by having an amount Or proportion of body fat that is known to pose risks to a person’s health and be associated with. Many, many people talk about comorbidities, but a colleague of mine talks about complication of obesity, because these illnesses don’t just happen at the same time or happen with it, but are directly caused by obesity. So, I think that talking about somebody as being obese, that’s an adjective, you’re equating the person with the condition, instead of talking about the person having the condition and you’re separating the person from their condition. There’s a great quote from an article that was published in the journal obesity. And the authors are Ted Kyle and Rebecca pool, or it might be Rebecca bull and Ted Kyle. I, I’m sorry, I don’t remember what the order of authorship was. But they say the beef is an identity. Obesity is a disease. And that’s the most profitable way. And I don’t mean profitable in the sense of money but productive and effective way to be thinking about obesity.
Unknown Speaker  20:15
The word obesity has such negative connotations already, that to turn it into an adjective that you’re equating with the person makes it much worse. And that also gets back to what you said at the beginning about the power of language. Because if you as the physician are talking about your obese patient, in your mind, inadvertently, you’re going to be equating the patient with their illness and attributing things that you would attribute to someone with obesity, right, a lot of the stigma is right, individual and and changes the way you think about that person. But if you can separate them in your language, that it can work to separate them and your thoughts and again, because you’re that authority If you discuss it with them that way, it can help them to start thinking about it differently as well.
Unknown Speaker  21:08
Absolutely. And your column and to model that for your colleagues as well. Yeah.
Unknown Speaker  21:17
Because you’re going to have plenty of colleagues that that don’t necessarily put as much gravity into something like this. Well, you know, it’s they, if they’re not motivated enough, then I’m not I’m not going to try I made my recommendations they can choose to do with them what they will. So for those individuals, if you start speaking about it differently, you can kind of you can have this subliminal effect on possibly how they they think about the topic as well.
Unknown Speaker  21:46
Exactly, exactly.
Unknown Speaker  21:48
What about the word obese? We had talked about that article. What’s in a name? People that have obesity. How does They prefer what what are the words that they prefer to hear from us?
Unknown Speaker  22:06
Yeah, so there was a great study done many years ago now and sort of variations of it had been replicated in different populations and younger people, and with parents of kids who have obesity, where it looks at what what people’s responses are to various words that might get used by a provider to talk about weight. And, you know, which will rate them up front on a scale of really negative to neutral to positive and obesity is one of the and I would say probably more the adjectival form of that obese is one of the words that patients sort of despise the most because it carries a lot of baggage with it. I think there’s an argument to be made in the Modeling to patients by using the word obesity as a medical diagnosis and a medical condition and always using it in a person first way, always using it in the noun form and out of the title form. But even then patients can be sensitive to it. Patients, you know greatly prefer things that are more neutral like your weight, or your BMI, your body mass index. I think a lot of people these days know what the body mass index is. I’m not sure that everyone knows how it’s calculated or why we have that measurements or what’s the kind of cut offs are for BMI is and which BMI is would be in the range of obesity versus healthy weight, etc. and another word that is sometimes uses fatness That one’s not very popular with patients. fat and fat net gentlemen Why they shouldn’t do the show should be avoided. Even things like unhealthy weight are preferred to obesity. I will sometimes talk about when I’m getting a history of someone’s weight, I’ll say, you know, when was your weight first over the healthy range? Or when did you first become concerned about your weight? And when I’m asking about family history of obesity, I usually don’t say, you know, Did either of your parents have obesity? I’ll say did Did either of your parents have a high weight? Or I will, when I’m talking to kids, and I will ask them sort of to tell me what what they like and don’t like about their way I’ll say, what are some of the things that you are good or that you like about being your size? And what are some of the things you don’t like about being your side, very little kids sometimes think I mean their height so that can be
Unknown Speaker  24:59
very Young Children sometimes get confused by that.
Unknown Speaker  25:03
But just using language that sensitive, but also not completely shying away from the word obesity, if you’re using it in a way that is clearly positioning it as a medical condition that you are treating the patient for, rather than judging the patient about
Unknown Speaker  25:19
for some of the doctors that might not be used to thinking about it this way, these patients are reminded many, many times a day, about their weight. It’s not like you are never the first person to bring this like you said at the beginning of August. You’re never the first person to bring this to their attention. This is something that they’re that they’re very cognizant about and they’re constantly reminded of and so it’s, you know, saying something like, you know, when did you start realizing that your weight might be a problem? You can very easily phrase something like that rather than saying, When did you become obese? Or what did you mean? When did you When were you diagnosed? Because they don’t need to be reminded of
Unknown Speaker  26:06
it. They know it happened. Yeah, they had 24 hours a day. Maybe not when they’re sleeping, but people are conscious and they’re made conscious of it all the time. Yeah. But I will say that the one the one permutation of the word obesity that I strongly suggest avoiding completely is the term morbid obesity, which is it’s a it’s a medical term, right? It’s accepted medical terminology. The term morbid obesity technically simply means that the person’s weight is causing harm to their health. Although it often gets used to simply signal the severity of the obesity which technically isn’t correct. If you have somebody who has very severe obesity, their BMI is 60. But they don’t have any health. condition technically wouldn’t quite be correct to call that morbid obesity because there isn’t morbidity there. At least there’s not Yeah. And, and there’s also a terrible term that is used sometimes in in my field and in articles that I read super obesity, or sometimes super super obesity was just to me it sounds it just sounds terrible. But there is a classification system class one class to class three work class one is a BMI between 30 and 34.9. And class two is between 35 and 39.9 am class three is BMI of 40 and above and there’s even class three a class three B class three C, and I actually don’t remember what those are. But that is not judging the way more of it is. But you can also talk about perhaps, severe obesity, which does if you want to be emphasizing greed of the condition, then you can say, severe to mean the BMI is, you know, particularly high or what have you. But morbid obesity doesn’t really serve much of a purpose. And it and if you think about what the Latin root is for the word morbid, it’s associated with death and dying, right? That’s, it’s not particularly helpful when you’re talking to patients. And I would say it doesn’t really add much incremental information or usefulness in professional dialogue either.
Unknown Speaker  28:34
I think words like that might have a role in a scientific study, if you are, but then the classes then take the place of morbid obesity. If you’re studying a group with a BMI greater than 40 or greater than 45 or greater than 50. Fine, you need you you might decide to use a term to classify those those individuals, but when you’re speaking to an individual patient, I don’t really see the role of adding that modifier of merit, or even severe obesity, right? It’s not like they don’t recognize the severity of the problem because of what they’re experiencing, they know that it is severe. And then but driving more attention to it, I don’t think is of any benefit to them. Because right, that’s even more of a stigma they’re going to make, it’s going to make them feel even worse about it. They’re going to internalize that, and, and it could really put them on on a bad path. So I would even argue that not even modifying it at all, outside of a scientific study, when you’re doing you’re discussing it with the patient themselves,
Unknown Speaker  29:41
right. And even in the scientific study, there’s no need for the word more but there’s other terminology that can be used. That’s actually more precise. So
Unknown Speaker  29:54
there was a the next part of the article talks about good versus bad, and my My sister in law she’s listening is a pastry chef, and was trying to convince me that dark chocolate is good for you. And as a doctor, I see it as it’s candy. No, it’s bad for you. But your point in the article is that we’re both wrong. So can you you elaborate on that and how that applies to the good versus bad and how that applies to our word choice.
Unknown Speaker  30:30
Yeah, I mean, this is something that I harp on so much with my patients that they learn to kind of pets themselves and self correct. Mid sentence when they’re talking to me. I really advise patients to avoid thinking about certain foods as being good or bad. The problem with good or bad is that that is a clear dichotomy. Those two things are mutually exclusive. They’re categorical. And so you only have two choices either something Good or bad. And if you’re talking about food, and you think of certain foods as being bad, and you shouldn’t have them, well, that may help you not eat them or eat less of them for a while, but eventually you’re going to end up eating these things. Because the things that patients say are bad foods, those are actually delicious. What I would call good food, right, you’re going to end up eating food like that that’s a part of life. It’s an important part of life, to sometimes have the foods that are higher in calories and fat and sugar. But the problem is that if you think of certain foods as being bad, and then you have some of that food, your it’s an all or nothing proposition and you’re going to feel like you blew it, you’re going to conclude that you have no self control, and our beliefs about ourselves, very solid, continue to determine our behavior. If you believe you have no control. If you believe that you’ve blown it, you’re going to behave in a way that make sense if you’re thinking that way, you’re going to say, well, doesn’t matter, I blew it might as well, you know, quite literally in for a penny in for a pound. And that that kind of dichotomy of thinking is it’s part of the human condition, the human brain has evolved to think in terms because it’s quicker and usually more efficient. But it also then lends itself to some negative side effects. And this all or nothing good, bad the economy can be really problematic. So, you know, when I a patient something like a when I eat something bad and I say, Well, what do you mean by bad? And they’ll say, oh, like brownies, I’ll say brownies are bad, they’re good. They’re not. If you have a lot of them, they’re not good for your health. But I tell patients to try to reserve the word bad for foods that tastes bad or have gone bad or are poisonous. And They’re right in thinking they shouldn’t eat any of those foods. Don’t eat foods that taste bad, certainly don’t eat food that’s gone bad or the poison. But everything else it’s a matter of is it more healthy or less healthy, even dark chocolate, even milk chocolate, you know, occasionally, that’s something that’s an enjoyable treat, and we shouldn’t think that is bad and you should never eat. And there’s also other foods that that more more clearly illustrate this. Avocado, right? And we actually talked about avocado is being high in good fats, there’s some fats that are actually helpful for your health. If you eat tons of avocado, then you’re going to be taking in more fat and more calories than is good for your health. nut, peanut butter. Nuts are incredibly high in protein. They’re high in fiber, they make you feel full. These are you know, these are foods that in moderation are quite healthy for you. If you eat lots of them. It’s going to have an adverse impact. On your health and on your way. So if you can’t really say if food is good or food is bad, unless you’re talking about how it tastes, then I’m fine with it. And and patients also use those words to describe their own behavior. So they’ll say I had a bad week or I was bad. And I always really jump on that and request that they restate that in a more objective way by simply describing what happened without judging it. I ate McDonald’s four times last week, we don’t have to call that good or bad. We can say that was three more times than you intended or three more times than they would have liked. But just calling it bad. Not only doesn’t help but it kind of gets in the way. Because if you’re feeling crummy about yourself, eating in a healthy way and maintaining that indefinitely, which is what all of us have to do to maintain a healthy weight or try to control our weight, that’s hard. It takes a huge amount of emotional energy. And if you’re using up a lot of that energy, by feeling crummy about yourself You’re not going to have a lot of energy left over to be taking care of yourself and doing these difficult things that are required to manage your weight and your health.
Unknown Speaker  35:09
And I think that even circles back to something we were talking about earlier, right? The the personal responsibility, and you know, this is your fault. This is this is not your fault. If they’re saying things that are negative about themselves, that then shapes their thoughts, they internalize it, they feel even worse about themselves and then then they end up you know, you it’s very hard to get out of that hole.
Unknown Speaker  35:35
Absolutely. And, and I one thing that I would bring in here is that there’s a very prominent concept in psychology called self efficacy, and I don’t know if that’s something that is, is featured in physician training. But self efficacy is a concept that was the term was coined by a psychologist named Albert Pandora. It is exactly what it sounds like. It means have your own beliefs about whether you are capable of doing something. And it turns out that research very robustly shows that the best predictor of whether somebody performs an intended or desired behavior or reaches a goal, the biggest determinant of that is their self efficacy, whether they believe they can do it or not. So if people are developing these beliefs about themselves that they can’t control themselves, they have the willpower. They’re lazy, that is going to impede self efficacy and it’s actually going to create a major barrier to making change.
Unknown Speaker  36:48
I think I think it was America. Ferrara had written an op ed in the New York Times a couple of years ago about training for the New York City Marathon. And when she was training her coach, right, because she’s a movie star. So she has a coach to help her the marathon. Her coach said something about the thoughts in her head, like something relating to what is going on in your head. What are you telling yourself that’s preventing you from from doing this? And apparently, you know her, she was telling herself that she couldn’t do this. Who she, Oscar, she shouldn’t be here. Who does she think she is trying to run a marathon. She can’t do something like that. That’s not who she is. And once he helped her get past that, then it was like a weight had been lifted off of her shoulders. And so it was the negative thoughts that she was telling herself about herself that were really holding herself back. So any way that we as physicians can help our patients without, like you said, The Good Will Hunting moment. It’s not your fault. It’s not your fault, right without being too saccharin about it. anything that we can do to help our patients think more powerful. positively about themselves are going to help them for that reason.
Unknown Speaker  38:05
But not not just generally more positively. It’s not a you know. But yeah, beliefs about their capabilities. And again, it would be a whole different podcast episode to talk about ways that you can approach helping patients with behavior change that foster higher self advocacy and more success. That’s a different podcast.
Unknown Speaker  38:31
But I think something simple like just catching them when they are saying some negative attributes of themselves. It can be as simple as that, right? Like, I’m so stupid. I showed up late for another appointment right? catching them when they do something like that. I don’t mean you’re, you’re good enough. You’re smart enough and Gosh, darn it, people like you. I mean, just catching something simple like catching them. When they do say something negative, or attribute, give themselves a negative attribute. To to help the right.
Unknown Speaker  39:02
reframe, right. I mean, I, I had a moment like that last week that a patient was trying to show me something on her iPhone and couldn’t figure out how to make the phone do what she wanted to do. And she said, dummy to herself. And then she showed me whatever it was, and I, you know, I said, You know, I want to take a moment and look at at something that you just said that you you. You couldn’t do this thing on the phone and you called yourself a dummy. And I was really struck by that. And you know, I’m wondering what you would do if some somebody else called you a dummy. Would you put up with it? Or would you if a friend of yours was struggling with her phone? Would you call her a dummy? No, why not? Well, that’s really mean it’s not fair. And helping people to notice these patterns of internet Oh, I was just making a joke and I think No, but that, you know, that was the word that you use. And it gives us a little bit of insight on how you’re thinking about yourself. So, you know, I really harp on language a lot, but not yet I try to make it clear that I’m not being pedantic and I explain to patients why I’m, you know, being so vigilant about language and the difference that it makes. And I find that it’s very effective and that it makes a big difference. I think there’s there’s another piece here to looking at overall, all of the different things we can do to avoid making patients feel blamed and shamed and scolded, which is the concept of weight bias, which you kind of alluded to earlier that there is a pervasive bias about people and stereotypes about people who have a high weight or who have obesity, that they’re lazy, that they’re not as smart that they don’t have self control. And what’s Interesting and the research about this is that most stigmatized group, members of those groups don’t also believe me stigmatizing ideas about themselves. But people with obesity are pretty much the only stigmatized out group that also holds stigmatizing beliefs about people with obesity with their same condition. And this is challenging and worrisome for a lot of reasons. But there’s a new line of research and more and more as being contributed to this body of knowledge, all the time looking at internalized weight bias. So, how much does the person stigmatize themselves because of their weight and believe various biases about people with obesity and themselves and it turns out, that being subjected to wait by us from other people, is actually less damaging than if you’ve internalized the weight bias and internalized weight bias is being found to be associated with all kinds of adverse mental and physical health outcomes, that it’s related to eating disorder pathology, it’s related to cardio metabolic risk factors that people with internalized weight bias are at more risk for having these cardio metabolic risk factors and depression and all kinds of other you know, very adverse outcomes. So anything we can do to not only not subject people to weight bias, but to try to model and elicit a change in someone’s own internalized weight bias. Is, is really important.
Unknown Speaker  42:54
Sounds like there are a lot of powerful opportunities there for that will be little Take advantage of
Unknown Speaker  43:01
Yes, I think of especially the first meeting with a patient is being full of lots of opportunities for what I actually have a I call the mini interventions were just the way you phrase a question or little bits of education and information can be very, very powerful.
Unknown Speaker  43:22
And so we’re kind of running short on time now. So there were two more issues that that I wanted to discuss. And one of them is exercise. What is the one exercise that you tell all of your patients to do? Clearly, that’s not recommending here, but exercise among certain circles is considered a four letter word. Right? So some people love to exercise some people don’t. So clearly, it has health benefits, one of which may not be weight loss. So first, can you can you can you men, Can you discuss that and too, how is it that you do discuss exercise? And was giveaway answer that you just exercise with your patients. So
Unknown Speaker  44:08
I’ll start I’ll start there and say that I almost never use the word exercise with patients if you think about it, and for people who are listening right now, when I say the word exercise, think about what picture immediately comes into your mind. Some of you may have wonderful, happy pictures coming into your mind. But even though I’m someone who does physical activity six days a week, when I hear the word exercise, I imagine my miserable experiences in gym class not being able to climb up the rope or having to run laps, or, you know, whatever it is, people have
Unknown Speaker  44:49
very many getting picked last frickin right.
Unknown Speaker  44:51
Well, uh, certainly or being first out in dodgeball or you know, whatever it is. But people have various There’s a lot of negative baggage and connotation to the word exercise. And and people think of exercise in a really circumscribed way they think of it as something that has to be hard and unpleasant. And that you’re sweating a lot or that it’s painful and that whole No pain, no gain thing. So I refer to exercise almost exclusively as physical activity. Because, first of all, you get away from the painful connotations of what exercise is. And second of all, you’re just by using that phrase, you’re opening up the menu of things that people can do. That will get them moving, you know, rev up their heart rate, burn calories, make them stronger. You know, a patient will one of my patients, walks a half an hour to and from the office. Every JY say what are you doing for physical activity? They say nothing. And then they say, Well, except I just I walk to and from work well, they’re walking an hour a day I said, let’s just go activity, we’re when we’re trying to find ways of increasing physical activity, looking at things that can be done that might be enjoyable, or at least not miserable. So a lot of people feel I’m not going to run. I’m not going jog. And I say, you don’t have to run running that required running is actually very hard on your body. And if you don’t love it, absolutely don’t do it. Let’s find something that you find pleasant. So I often prescribe 20 minutes daily dance parties for my patients and their partners and my patients and their children. And I have a patient who her son is putting together a playlist for her to do and there. He’s making them an increasing length, but he’s putting together a list of songs that she can dance around the house to, by herself or with him. That’s fun. And people don’t think of that as being exercise. But if you’re moving around and your heart rates going, and you’re sweating, just because it’s fun doesn’t make it not exercise. So our I talked about, you know, instead of driving five minutes to the store, walk 20 minutes to the store, that’s physical activity. So it broadens the realm of things that can be done and include things that might be fun or enjoyable, or at least not miserable.
Unknown Speaker  47:27
So we tend to, we tend to be very prescriptive about exercise, right? You have to do it this number of days a week, your heart rate needs to get this above this amount. It needs to be for this period of time. And the fact of the matter is, if you tell your patients to do that, they’re not going to do it. And that helps them exactly, exactly. So maybe additional benefits to raise your heart rate rate past x are doing it X number of times a week for x period of time, should probably have different variables than just x but we should stop being so pretty scripted and work from their current, why, and go to y plus one. So we take what they’re currently doing. And one, allow them to recognize that they’re doing it. And that should be something that they can internalize is something positive. Oh, I thought of myself as such a lazy person. But now you’re telling me because I walk an hour a day, maybe I’m not that that lazy, maybe I’m not this lazy person, maybe I am an active person. And if they start thinking of themselves differently, and I think that even gets to like Carol Dweck, mindset research about, you know, changing, changing their mindset. I am an active person and I can be more active.
Unknown Speaker  48:50
Definitely. And I think going from not saying okay, the guidelines for weight loss are and they actually are that you should do 300 minutes of aerobic activity per That’s detail that told it to almost anybody. And it just sounds like impossible. Certainly anybody who’s got a life who’s got a job, who’s got a partner, kid. That’s a lot of time. But if you simply talk about what are you doing now? What, in what way? Could we increase it beyond what you’re doing now and just sort of progressively increase it? Again, I think we’re getting into territory where it’s a whole different podcasts about behavior change and SMART goal setting which I’m happy to talk about it another time. But I think that starting off with the language that you’re using and talking about physical activity and what activities could be done that are enjoyable or at least tolerable, rather than saying you need to exercise more people know they need to exercise more, they’re not going to thank you for telling them that and telling them that it’s not going to make them
Unknown Speaker  49:50
do it. And what I find with my patients is that is often the first thing that they say like a defensive Well, you know, I don’t have any time to exercise. And then being able to reframe that, I think is very helpful. And the other the other is, which is something that we’ve discussed before is not saying something like, Well, why aren’t you more physically active or why aren’t you exercise?
Unknown Speaker  50:23
What do you what are you doing for physical activity? Nothing, why not? That is, that is the wrong way to ask about it because it is certainly overtly sounds judgmental, why not? And it puts the patient on the defensive and they feel the need to be giving excuses. And it’s interesting because so the way I asked about this is not why not. I say what gets in the way and I Choose those words very deliberately. Because just by asking the question in that way, you’re acknowledging that are things that get in the way. And that they’re not just being ludicrously lazy. By not being active. There’s reasons why they’re not active. And so I will say what gets in the way. And very, very often, the patient will call me I’m lazy. And I’m usually very much able, by that point, to counter the patient and to point out evidence, some things I’ve already learned about them in the interview, to show that they’re not lazy. They’re working three jobs plus raising kids on their own or, you know, they, you know, they’re they have earned a bachelor’s degree going to night school or, you know, things that clearly indicate that they’re not lazy. And I say, Well, you know what, a lot of people come in here and try to tell me they’re lazy, but the fact is, here’s the evidence that you’re not lazy. And and in fact, if I just accept that you’re lazy, that really doesn’t get anywhere. That doesn’t, that doesn’t get us anywhere, because there’s not much that we can do about that. But instead, if we take a look at what the reasons are, so a lot of his patients will a patient will say, Well, I don’t really have a lot of time, but I know that’s just an excuse. And I’ll say, Listen, you know what, I don’t think about this in terms of excuses, or good reasons or bad reasons. I simply look at reasons and whatever the reasons are understanding the reasons that you aren’t doing more physical activity will point us to the right intervention to help you increase it. And, you know, like, I had one patient who initially it looks like the reason she wasn’t doing any physical activity was that she was too busy, but in fact, the real reason she wasn’t doing it is that she found it really boring. And if we were able to find something that she found engaging, that was something she felt she could make time for. So really understanding the reasons and not judging the reasons as being valid or not. But if someone said, I don’t go to my gym, because someone died in there, and now I think it’s I wouldn’t say well, that’s ridiculous. Just go to the gym I say, all right, well, let’s, could we get a priest in there to do an exorcism? Or, or a more parsimonious solution might be to find a different team or to do some stuff at home or outside walking around in your neighborhood instead of going to that gym instead of getting caught up in back a dumb reason. Okay, that’s the reason what do we do about it? You know,
Unknown Speaker  53:46
that seems a pretty good way to alienate your patient lately.
Unknown Speaker  53:49
I had a patient who had a real phobia, he had bad asthma. And so he was really convinced that if he did any physical activity, he’d have a asthma attack and die. And he walked around everywhere with for asthma inhalers on him like a backup to the backup to the backup. And this was such a such an extreme fear really was it really met the definition of a phobia. And I actually sent him for cognitive behavioral therapy to address the phobia. And I wasn’t going to say, Look, your doctor said, You’re fine, you’re pulling all this and you’re fine. Just go do it. He had a phobia. So we address that. So why doesn’t help. But if you ask, what are the barriers, what’s getting in the way that leads you and the patient together to a solution for that’s a much more productive way to be having a dialogue about it.
Unknown Speaker  54:43
Well, this was really a very comprehensive talk, and we didn’t even get into effective methods for for weight loss. As we knew we were going to it’s just the topic of how to even have that conversations. So there are many wrong ways to do it. But I think this was a great, great in depth detailed look at how to do it most effectively. So I really appreciate you taking the time to talk to us and help us have these difficult conversations more effectively. Is there anything else that you want to mention before we close the conversation? Well, I think
Unknown Speaker  55:25
that there’s dozens of other things that could be said, but I think, you know, this, this was a pretty good sampling and and thanks for for being such a good guy through these topics and being so interested. I’m always thrilled when someone cares about these things and want to learn more. So that’s
Unknown Speaker  55:42
wonderful. So thank you so much for for taking the time. Thank you. It has been a pleasure.
Unknown Speaker  55:49
Alright, have a good night. That was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, Google podcasts or wherever you get your point. gasps and write us a review. You can also visit us on slash physicians guide to doctoring. If you are interested in being a guest or have a question for a prior guest, send a message or post a comment.
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