I have been doing the unthinkable, and the word is out. I am an emergency physician in the District, and I've started talking to my patients about their weight.
It has taken me a while to pluck up the courage to speak frankly with obese patients about this problem.
For 15 years I have broached virtually every delicate subject -- from sexual histories to the cough that is really cancer -- in the noisy, impersonal setting of a busy ER. It is expected of me. It is my job.
So why has it been so hard to talk about this? With an epidemic of obesity in the United States, why are so many doctors skittish about discussing obesity with its sufferers? The truth is, I don't know.
On a recent shift, I treated a woman in her mid-40s who had had pain in her left knee for a month. She had not twisted or injured it in any way that she could recall. There were no signs of infection above the knee. She wanted an X-ray.
She also weighed close to 300 pounds. That's a lot of stress on a joint. Her knees simply cannot keep supporting her weight.
Until recently, I would have ordered an X-ray. Ordering an X-ray makes everyone happy: The hospital charges for taking it.
The radiologist charges to read it. The patient often wants the test and is happy to have more than a three-minute evaluation.
Once the film is developed, I mention something about there being no fracture and seeing some changes consistent with early arthritis. Then I prescribe some pain relief.
The patient would leave feeling vindicated. His or her problem was captured on film, and the interminable wait was somehow worth it.
Ultimately, though, this approach is wrong. When the emergency room is crowded, it is easy to let the preventive aspects of medicine slip away.
Obesity is not only about health risks, which include diabetes, joint pain, congestive heart failure, strokes, back pain, sleep apnea, depression, infertility and erectile dysfunction.
It is also about the root causes and our society's denial of the woeful impact obesity is having on Americans' health.
Let me "not fail to see what is visible" is the line I recall from the Prayer for Physicians attributed to the great physician-philosopher of the Middle Ages, Moses Maimonides, a copy of which hangs over my desk.
Non-traumatic knee pain in an obese patient is a sign that she needs dietary counseling, not radiographic imaging.
Although preventive medicine is not really part of our job description, it has not been ignored by emergency physicians.
More than seven years ago, the Society for Academic Emergency Medicine directed its Public Health and Education Task Force to develop recommendations for prevention that included screenings and counseling.
Possible interventions included pneumococcal immunization for seniors, pap screening for women and pediatric immunizations in children.
They considered screening for sexually transmitted diseases, tobacco and alcohol use, diabetes, hypertension, HIV and domestic violence.
They wondered if we should ask all patients about the safe storage of their firearms and use of smoke detectors.
After reviewing 17 possible interventions, the task force recommended routine screening for alcohol, smoking, HIV and hypertension; immunizations; and the referral of children without primary care physicians to a continuing source of care.
The next time you cut your finger and go to the ER needing sutures, I should speak to you about these conditions.
Have you noticed what is missing?
There are many opinions about what one can say to overweight patients needing long-term treatment. There is, of course, much that we do not know about obesity.
Is it a lifestyle choice, a physical or mental illness, or the result of some genetic trait?
Should those who are severely obese exercise, follow a strict diet, take anti-obesity medications, undergo surgery or all of the above? If it is confusing to me, it must be harder for my patients.
That is why we need to begin this conversation in medical school and continue it through residency and beyond. We need to prepare physicians for this necessary conversation.
As for me, I can no longer hide behind an X-ray monitor and not deal with the potentially life-threatening issue affecting an increasing number of my patients.
If it is appropriate for me to ask if patients have ever been treated for an STD, I think that I and my colleagues should address the real reason some patients feel pain in their legs or shortness of breath after climbing stairs.
I have found patients to be remarkably receptive. And if obesity is not going to be confronted honestly in a medical setting, where will that difficult conversation take place?
There is no question that obesity is a widespread epidemic and that something must be done to educate and combat this ticking time bomb.
Various credible health organizations, researchers, medical professionals, and U.S. and international governments recognize obesity as a disease.
It is obvious that obesity is a major issue as we look around us. However, obesity cannot be classified as a disease or illness because it is the effect of an individual's personal habits that may result in unhealthy and dangerous consequences.
By looking at facts and effects of obesity, we can decide whom or what we can hold responsible and how we should tackle this concern.
Understanding obesity is quite simple. According to the World Health Organization, it results due to excessive fat accumulation in the body, which may pose a threat to one's physical condition, well being, and overall health.
As Americans, we often blame others to reconcile our wrongdoings. Common blames such as community, culture, socioeconomic status, television and convenience food advertisements, family and school influences, and increasingly large portion sizes are all mentioned.
Rarely, cases of obesity may result due to hereditary traits or a predisposition to gain weight. Others place depression, personal loss, anxiety, and boredom at fault.
These things may slightly increase an individual's likelihood to gain weight, and there is no doubt that McDonald's and the rest of the fast food industry offers items that may not be considered healthy according to a nutritionist.
But how can we blame these multi-billion dollar franchises for the fact that we as consumers are the ones fueling their success?
Logically, individuals cannot place any food vendor at fault, because there is nobody forcing them to eat fast food.
Besides, it is virtually effortless to look up the nutrition facts for packaged food; furthermore, it is much more cost-effective and healthy to choose lighter or fresh grocery items.
Food and beverage intake is essentially a series of daily personal choices. Characteristics such as a sedentary lifestyle, an excessively rich diet or a lack of motivation are often not mentioned enough.
We cannot classify obesity as a disease when it is more often self imposed by laziness and personal choice. What happened to the good old-fashioned standard values of hard work and self-discipline?
Even with costs of health care skyrocketing, more disturbing is the harm obesity inflicts on the pocketbooks of Americans who are in good physical shape.
Billions of dollars are allocated to medical expenses due to obesity annually, with Medicare and Medicaid funding much of it.
It is hard to accept that as taxpayers, despite our body type, we are theoretically funding the services to support self-inflicting obese Americans.
Health care should not cover issues related to overeating, under exercising and an overall lack of self-respect.
Obese Americans should learn to push themselves away from the table and take a look at what they are consuming, because it is hurting all of us in the long run.