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I appreciate this and the long way Dr. Gordon has come from the anti-fat medical education system. My request:
Dr. Gordon, you mention that you hardly look at weight in patients’ charts. That’s great! But I highly recommend you stop taking weights altogether as part of the routine check-in. Shove the scale in a closet for those rare occasions when it’s medically necessary. If a patient asks, that’s one thing, but generally speaking, weight simply isn’t necessary. In the case of drastic changes that are medically significant, I guarantee that a patient will bring it up or you can ask about it in a qualitative way: “have you noticed any changes you’d like to discuss?” Or “is your clothing fitting the same as it usually does?”
Just seeing a scale always puts me on edge and I bet you’d build trust even faster if it was out of sight. (And if it’s already out of sight and not part of the routine check in, thank you!!)
Totally agree. Unfortunately there are a lot of administrative barriers to completely doing away with weighing patients in my office. That's not an excuse, but it continues to be an ongoing challenge. I hope that provides some context.
I'm not a fan of weigh in if it's for the doctor to then use it against me in the weight-loss talk, but as someone with hypothyroidism, it is one of the tools I use to monitor if my thyroid starts acting up (or actually the reverse lol). So perhaps not a throw out totally, but compassionate convo regarding when we use it for quick data to support some blood tests? I think about folks that lose weight and are not aware as well. I wish I noticed, but sometimes I don't 🤷🏼♀️
That's why I think the weight-in could be changed so it's only done by request and kept out of sight for so many people who have been harmed by it.
In my experience, weight alone wasn't an indicator of my Hashimoto's (it was missed for 20 years because they kept diagnosing me as fat and prescribing weight loss), so I feel pretty strongly that it's a very personal thing and requesting to be weighed would give the patient more control over their care, rather than putting them on the defense fresh out of the gate.
I've also had celiac disease since I was a toddler, but wasn't diagnosed until my 30's because I was too fat. (Specifically: "People your size don't get celiac.") I have been misdiagnosed and undiagnosed my whole life because all doctors could see was the number on the scale, and I don't think that will change until there is a massive change in how healthcare is delivered.
There are other medical reasons to justify weigh-ins besides thyroid issues (measuring water retention for heart or kidney issues, for example), but again, I think it should be on the patient to request and/or for a trauma-informed professional to approach this in a more personalized way (such as a flag on the chart, or politely asking if the patient would like to weigh-in AFTER taking blood pressure readings).
I've also known way too many people whose cancer went on too long because they didn't have the weight loss symptom that doctors expect to see. A change in weight is much more significant than the weight itself, but even then, too many people are falling through the cracks because doctors put too much weight (heh) on weight.
Absolutely. When I talk with my students about decision-making around ordering clinical tests and imaging, we say that "every test should change management." There's no reason to order a test if it won't change the way we take care of the patient. We shouldn't just order tests for fun.
We also talk about the "pre-test probability" of a test being positive or negative, since all tests inherently have the possibility of error.
Weight is absolutely crucial in many scenarios: heart failure, chemotherapy dosing, medication dosing for children, etc.
All this is to say -- there may be a role for weight to be more of an "as-needed" test, if we have a high clinical suspicion it might change the way we care for a patient. We don't get an x-ray on everyone who walks in the door; we only order it if we're worried something is wrong. We could approach weight the same way.
However, weight is currently viewed in most health care settings as a "vital sign," a basic test that every patient NEEDS, regardless of their pre-test probability of anything being wrong.
Thank you Dr Gordon! We need more of you! I’m so glad you’re teaching. I just wanted to reaffirm what you said about how being weight neutral affects patient trust — in my experience as a patient that has been very true. It was also interesting to read that you are aware of the “doctor as judge” thing — I cannot tell you how many appointments I have postponed in my earlier life because I wanted to delay “the verdict.” (I thought I was the only one!) One question I have as a patient is how much insurance companies influence this arena. My understanding is that insurers require “weight counseling” over a certain BMI threshold? That must make this road much more difficult, if so.
Hi Alison. The idea of "required" weight counseling over a certain BMI threshold is *sort of* true. I actually wrote about it on my substack: maragordonmd.substack.com. The topic is "Why does my medical record say I'm fat?"
Basically, doctors can get paid more to counsel patients about their BMI. And some health systems use it as a "quality metric" -- so if doctors check the box that they've "counseled" a patient with a high BMI, that doctor is counted as "providing higher quality care." That can affect pay, too.
Wow…that billing code chart in your post was especially chilling! Looking forward to digging into your archives and probably depressing myself even more. :)
Thanks for having me! What an honor to be included in your work and community, Ragen.
This is a refreshing read! I've bookmarked Dr Gordon's pages so I can read more. Thanks, Ragen, for introducing us to her.
I appreciate this and the long way Dr. Gordon has come from the anti-fat medical education system. My request:
Dr. Gordon, you mention that you hardly look at weight in patients’ charts. That’s great! But I highly recommend you stop taking weights altogether as part of the routine check-in. Shove the scale in a closet for those rare occasions when it’s medically necessary. If a patient asks, that’s one thing, but generally speaking, weight simply isn’t necessary. In the case of drastic changes that are medically significant, I guarantee that a patient will bring it up or you can ask about it in a qualitative way: “have you noticed any changes you’d like to discuss?” Or “is your clothing fitting the same as it usually does?”
Just seeing a scale always puts me on edge and I bet you’d build trust even faster if it was out of sight. (And if it’s already out of sight and not part of the routine check in, thank you!!)
Totally agree. Unfortunately there are a lot of administrative barriers to completely doing away with weighing patients in my office. That's not an excuse, but it continues to be an ongoing challenge. I hope that provides some context.
I get that. Definitely not an excuse, but still important to acknowledge and fight back against.
I'm not a fan of weigh in if it's for the doctor to then use it against me in the weight-loss talk, but as someone with hypothyroidism, it is one of the tools I use to monitor if my thyroid starts acting up (or actually the reverse lol). So perhaps not a throw out totally, but compassionate convo regarding when we use it for quick data to support some blood tests? I think about folks that lose weight and are not aware as well. I wish I noticed, but sometimes I don't 🤷🏼♀️
That's why I think the weight-in could be changed so it's only done by request and kept out of sight for so many people who have been harmed by it.
In my experience, weight alone wasn't an indicator of my Hashimoto's (it was missed for 20 years because they kept diagnosing me as fat and prescribing weight loss), so I feel pretty strongly that it's a very personal thing and requesting to be weighed would give the patient more control over their care, rather than putting them on the defense fresh out of the gate.
I've also had celiac disease since I was a toddler, but wasn't diagnosed until my 30's because I was too fat. (Specifically: "People your size don't get celiac.") I have been misdiagnosed and undiagnosed my whole life because all doctors could see was the number on the scale, and I don't think that will change until there is a massive change in how healthcare is delivered.
There are other medical reasons to justify weigh-ins besides thyroid issues (measuring water retention for heart or kidney issues, for example), but again, I think it should be on the patient to request and/or for a trauma-informed professional to approach this in a more personalized way (such as a flag on the chart, or politely asking if the patient would like to weigh-in AFTER taking blood pressure readings).
I've also known way too many people whose cancer went on too long because they didn't have the weight loss symptom that doctors expect to see. A change in weight is much more significant than the weight itself, but even then, too many people are falling through the cracks because doctors put too much weight (heh) on weight.
Absolutely. When I talk with my students about decision-making around ordering clinical tests and imaging, we say that "every test should change management." There's no reason to order a test if it won't change the way we take care of the patient. We shouldn't just order tests for fun.
We also talk about the "pre-test probability" of a test being positive or negative, since all tests inherently have the possibility of error.
Weight is absolutely crucial in many scenarios: heart failure, chemotherapy dosing, medication dosing for children, etc.
All this is to say -- there may be a role for weight to be more of an "as-needed" test, if we have a high clinical suspicion it might change the way we care for a patient. We don't get an x-ray on everyone who walks in the door; we only order it if we're worried something is wrong. We could approach weight the same way.
However, weight is currently viewed in most health care settings as a "vital sign," a basic test that every patient NEEDS, regardless of their pre-test probability of anything being wrong.
Thank you Dr Gordon! We need more of you! I’m so glad you’re teaching. I just wanted to reaffirm what you said about how being weight neutral affects patient trust — in my experience as a patient that has been very true. It was also interesting to read that you are aware of the “doctor as judge” thing — I cannot tell you how many appointments I have postponed in my earlier life because I wanted to delay “the verdict.” (I thought I was the only one!) One question I have as a patient is how much insurance companies influence this arena. My understanding is that insurers require “weight counseling” over a certain BMI threshold? That must make this road much more difficult, if so.
Hi Alison. The idea of "required" weight counseling over a certain BMI threshold is *sort of* true. I actually wrote about it on my substack: maragordonmd.substack.com. The topic is "Why does my medical record say I'm fat?"
Basically, doctors can get paid more to counsel patients about their BMI. And some health systems use it as a "quality metric" -- so if doctors check the box that they've "counseled" a patient with a high BMI, that doctor is counted as "providing higher quality care." That can affect pay, too.
Yup..... We have a lot of work to do.
Wow…that billing code chart in your post was especially chilling! Looking forward to digging into your archives and probably depressing myself even more. :)
Wow. I hate that this exists!
I would very much like to read Dr. Gordon's book when it's available! I haven't read nearly enough books on similar subjects, and I wish more existed.
Looking forward to hearing more about Dr. Gordon's book. Thanks for the interview!
Immediate follow. I wish all doctors were like Dr. Gordon!