And if they said “Neither!”, I would answer “Oh, so you must want placebo. I know a really great acupuncturist, let me give you her number.”

I’d also include “or (1) actual examination of what you’re doing that makes your life better and what you’re doing that makes your life worse, and how you can do more of the former and less of the latter, and (2) examination of what important life skills you lack, and exploration of ways for you to develop them and/or work around their absence,” with selection of that one to be followed by “okay, let me refer you to a therapist, that’s not really something I can provide in 20 minutes once a month.”

My impression is that the chance of this reducing to “mildly condescending platitudes” varies with the patient’s intelligence and social class, from “wait,you’re saying I should get a good night’s sleep? I never thought of that before!” among confused schizophrenics, to “of course I’ve used black-market d-cycloserine to potentiate the effects of cognitive-behavioral self-help workbooks, what kind of moron do you think I am, you’re wasting my fucking time” among people I talk to on Tumblr.

When I tried the “Wow, you mean diet and exercise help lose weight?  Goodness me, in all the years I’ve been fat, I never heard of that, much less tried it!” retort to the “mildly condescending platitudes”, it didn’t end well.

So you’ll have to take the platitudes plus the side-effects if you want any treatment at all.  Be nice to get the “talk to me like a human being and even an averagely intelligent one at that” option but doesn’t happen often (did happen with one doctor which is a refreshing change but not too frequent, alas!)

Be even nicer if the “I can’t take that medication you want to prescribe me and are pushing me to take, because it will react badly with a medication I’m currently taking, and no I didn’t just read that off the Internet, the last time I got prescribed that I turned blue in the face and had to be rushed to the ER” option was on offer, but we can’t expect miracles, now can we?

Though re: social class and judgements of status and intelligence, I don’t know if this is more pronounced over here, but because I’m (a) fat (b) naturally talk widda native aksent like, bye, I do tend to get the “plainly thick as two short planks, do the condescending talking down bit and the ignoring what they’re saying bit” unless I use my “the nuns at school taught us elocution lessons” voice and then I get the “hey, evidence of a brain here, talk to them like a real person!” reaction.  But it needs to be finely judged, if you show too much intelligence that triggers the “who do they think they are, I’m the doctor here” reaction which also goes badly.

Which is kind of a shame, given that I have the same level of comprehension and intellect in both instances, and only my vocabulary and diction has changed.

I think the problem is that there are lots of genuinely…let’s politely call them “confused” people who don’t realize even very obvious things, and if you don’t know your patients well enough to predict who they are you might as well just give the “eat well, exercise, and get a good night’s sleep” spiel to everybody. But it sure does sound condescending if you’re not the right target.

(and this gets harder when we go into subtler things like “have you tried sleeping in a cool room with good white noise” or “have you tried melatonin” etc)

Again, I wish I could just ask “Are you aware of basic things that it would be very surprising if you weren’t?” but everyone would define this differently and it would be useless.

I’m going to go out on a limb here and suggest the wild’n’crazy notion that if a fat person is going to a doctor semi-regularly (e.g. this is not their first appointment ever with a medical professional), they kinda sorta maybe have heard the “do you realise you are fat?” part before, even if they are as dumb as a rock.

I realise that there’s not really a tactful way of going about it, but suggesting (rather than assuming they have no idea that “eating more = putting on weight”) that if they’d care to discuss their problems with weight loss you might have some suggestions that would be helpful could work out better.

And there are physical conditions which do make weight gain easier and weight loss harder; again, I know that the idea that fat people like to blame their “glands” and it’s only an excuse has some basis in reality, but for instance - when I found out very late in life that I had PCOS and that this contributes to weight gain, I was about fit to kick in a window.  Nobody had ever explored this with me before, nobody believed me when I was saying ‘no, honest, I really am trying to diet and exercise and the weight is not coming off’ and all the years since puberty when the weight started to pile on and I was feeling guilty (because “blaming your glands is only an excuse, the reason you’re fat is because plainly you’re eating too much of the wrong food”) and miserable and fighting with my mother over my weight and going on crash diets that didn’t work as soon as I went off “you eat one bowl of soup a day”so the weight all came back and hating myself for being fat and ugly and stupid and all the other things society tells you that being fat means about your character and intelligence - well.

Yes, eating too much of the wrong food is to blame there, but there was a real, physical, not in my control cause there as well, and had I known, that would have made a difference.

tl;dr - yeah, sometimes us fatties are stupid and ignorant and it is eating too much and not exercising enough.  But sometimes there are other real medical problems there too.

On the one hand, I totally sympathize with what you’re saying and I understand it must be really annoying.

On the other hand, this has actually been discussed and studied, and current very-carefully-considered recommendations are to say the thing. See eg The Impact Of Physician Discussion Of Weight Loss In US Adults, GPs Should Not Worry About Offending Obese Patients Study Finds, et cetera.

As always, none of these studies is unimpeachably super-impressive, but considering the low risk I think it’s fair to do this even on weak evidence.

I am not convinced the risk is low. I’ve seen someone specifically instructed by a doctor to immediately discontinue physical therapy and exercise because it was resulting in muscle mass gain which was increasing BMI. I’ve also seen someone need a year of asking doctors about unambiguous medication-side-effect weight gain before a doctor actually condescended to even read the side-effect list for the medication and admit that this could be related.

In short, the risk is not “the risk of offending the patient”. The risk is doctors persistently completely disregard any and all information about a patient that fails to conform to the “fatty is lazy and stupid” narrative.

That risk is what people are concerned with. We are not talking about merely-annoying. We are talking about refusal to provide basic medical care at all to fat patients. We are talking about actively life-threatening advice given to patients.

In short, I think the study results are sort of irrelevant to what people are talking about here. They’re covering “is it possible that you’re fat because you eat too much”. Other people are talking about spending months to years going through tests and results and everything with a doctor looking at weight, saying “well, weight is still high, therefore everything you’ve said about exercise and diet is lies”.

… And that is something that I have seen so consistently, from so many overweight people, that I am starting to strongly suspect that refusal to provide basic medical care to fat people may be a statistically significant contributor to the computed “risks”. Like, I do not actually know a fat person who has not been outright refused medical care for something not-weight-related based on “but you’re fat”.

Thanks, this is a good point.