A Country Doctor Reads: January 26, 2019

Average is No Longer Normal – The New York Times & The British Medical Journal

I didn’t have a real handle on what the average weight or BMI in this country is. But recently NYT announced:

“Meet the average American man. He weighs 198 pounds and stands 5 feet 9 inches tall. He has a 40-inch waist, and his body mass index is 29, at the high end of the “overweight” category.

The picture for the average woman? She is roughly 5 feet 4 inches tall, and weighs 171 pounds, with a 39-inch waist. Her B.M.I. is close to 30.”

https://www.nytimes.com/2019/01/14/health/height-weight-americans-cdc.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

So, cause for pause: In a few years, the average American will be obese. Will someone then advocate for redefining obesity?

I also didn’t have the exact correlation between BMI and all cause mortality, so I googled for an answer and came up with a 2016 paper in the British Medical Journal with a systematic review of 230 cohort studies with 3.74 million deaths among 30.3 million participants. This paper puts ideal BMI between 22 and 24, and the relative risk at the average American BMI of 29 is in the 1.2 range compared to people with ideal BMI.

It is sobering to look at the exponential increase in death risk when BMI exceeds ideal: 20% excess risk for even average Americans, 50% greater risk at a BMI of 35 and double the risk at a BMI of 40.

https://www.bmj.com/content/353/bmj.i2156


Better Words for Better Deaths – The New England Journal of Medicine

I appreciate the philosophical pieces in many of the major medical journals. Medicine isn’t only about technology.

Ours is a vocation of emotion and communication; we work with words and need to use them wisely.

Linguist-turned-doctor Anna DeForest writes about the words we use for when patients die and also of the words doctors use when we acknowledge that death is inevitable.

DeForest writes about how she stopped using the D-word:

“I was an intern with a half-year of training, and we saw five deaths in the first week before I stopped counting. “He’s gone,” we’d say. “She passed, we lost her.” Or when we felt dark, we’d say among ourselves, “He was transferred to the morgue.” At first I tried to just say “died.” Physicians, at least, should call death what it is. It didn’t take me long, though, to begin using the euphemisms. The families weren’t the only ones who needed consolation.”

She also writes about the expression “Withdraw Care”, pointing out that withdrawing efforts to cure should in no way mean we stop delivering all care.

“I have a reflex like the snap of a ruler when I hear someone say that. When the end of life is inevitable and patients or their families consent, we may withdraw aggressive therapies or medications, or stop interventions, but we should never withdraw care.”

She describes a situation when, as an intern in the ICU, she ordered a patient to be extubated by respiratory therapy and was not there herself to help manage the patient’s process of dying:

“I do regret that we did not make the time to find the right combination of morphine and glycopyrronium or atropine to prepare her for extubation, to spare her sons the trauma of seeing her die that way. Our inattention to her symptom burden at the end of her life represents a real withdrawal of care.”

https://www.nejm.org/doi/full/10.1056/NEJMp1810018

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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