Awkward Scribing Situation

[GoinHardenYaHoe]

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Hey SDN members, looking to get your opinion on this:

I scribe for a very nice and friendly physician who is extremely overweight. I would guess that her BMI is ~45-50. That being said, I find it awkward adding in problems like "Obesity" and "metabolic syndrome" into the A&P when the patient has a BMI of around 35. I mean, aren't I indirectly calling the physician obese, especially when she is clearly larger than her patient.

What would you guys do in my situation? I can't just not put in the problems because the clinic I work at bills at a high level and I need a full chart....

Thanks in advance for your responses

 

[docchocolate]

Just do your job, write your notes, and go home. Your doc's weight is completely unrelated to your ability to do your job.

 

[STcmOCSD]

As a doctor I’m sure she is also aware that her BMI is elevated. It’s not like a doctor can go through 4 years of med school and then think that obesity isn’t an issue. Do your job and what you’re supposed to do. I have a BMI if 37 and still willingly chart “obese” on people who have lower BMI’s than myself because it’s a valid observation on their exam.

 

[JMilo]

Hey SDN members, looking to get your opinion on this:

I scribe for a very nice and friendly physician who is extremely overweight. I would guess that her BMI is ~45-50. That being said, I find it awkward adding in problems like "Obesity" and "metabolic syndrome" into the A&P when the patient has a BMI of around 35. I mean, aren't I indirectly calling the physician obese, especially when she is clearly larger than her patient.

What would you guys do in my situation? I can't just not put in the problems because the clinic I work at bills at a high level and I need a full chart....

Thanks in advance for your responses

You are describing the pt as obese, not the doc. The doc is obese, but you aren't calling her that.

 

[longhaul3]

Obesity is a medical condition. It belongs in the note. Leaving it out is as inappropriate as leaving out any other chronic condition.

 

[GoinHardenYaHoe]

As a doctor I’m sure she is also aware that her BMI is elevated. It’s not like a doctor can go through 4 years of med school and then think that obesity isn’t an issue. Do your job and what you’re supposed to do. I have a BMI if 37 and still willingly chart “obese” on people who have lower BMI’s than myself because it’s a valid observation on their exam.

As a physician, don’t you feel the need to set an example for your patients and live a healthy lifestyle? Not trying to sound offensive but I feel like patients would be more willing to take medical advice if their physician practiced what they preached. In your opinion, why do so many physicians smoke and live lives that lead to obesity if they are aware of the risks?

 

[Osminog]

"Pt. is big-boned - has very pronounced curves."

 

[deleted480308]

As a physician, don’t you feel the need to set an example for your patients and live a healthy lifestyle? Not trying to sound offensive but I feel like patients would be more willing to take medical advice if their physician practiced what they preached. In your opinion, why do so many physicians smoke and live lives that lead to obesity if they are aware of the risks?

I’m going to be a physician, not a life coach

 

[JMilo]

As a physician, don’t you feel the need to set an example for your patients and live a healthy lifestyle? Not trying to sound offensive but I feel like patients would be more willing to take medical advice if their physician practiced what they preached. In your opinion, why do so many physicians smoke and live lives that lead to obesity if they are aware of the risks?

They are addicted. As a pt, I don't care what my doc looks like.

 

[MD-2021]

I’m going to be a physician, not a life coach

Decent amount of overlap. My school's parent hospital network doesn't hire anyone who smokes.

 

[deleted480308]

Decent amount of overlap. My school's parent hospital network doesn't hire anyone who smokes.

That’s about insurance costs not mentoring

 

[MD-2021]

That’s about insurance costs not mentoring

You might be right, but it doesn't mean the two aren't related

 

[Piglet2020]

As a physician, don’t you feel the need to set an example for your patients and live a healthy lifestyle? Not trying to sound offensive but I feel like patients would be more willing to take medical advice if their physician practiced what they preached. In your opinion, why do so many physicians smoke and live lives that lead to obesity if they are aware of the risks?

Because medical examination skills (diagnosing & treating patients) have nothing to do with looks. I dont need a gym trainer as my doctor and I certainly wouldn't expect him or her to have the body of a greek god/goddess. We often hold doctors to a higher standard but forget that doctors = humans still. And as always, $**t happens that cause people to overeat, drink, smoke, etc. Docs are not immune to these vices unfortunately.

 

[deleted480308]

You might be right, but it doesn't mean the two aren't related

By all means, maintain - 15% bmi if you think you owe it to them....you do you

 

[MD-2021]

By all means, maintain - 15% bmi if you think you owe it to them....you do you

I wish... I just signed up for the local gym yesterday after not having worked out for 2-3 months. My body fat % is probably in the 20s.

 

[deleted480308]

I wish... I just signed up for the local gym yesterday after not having worked out for 2-3 months. My body fat % (assuming you meant this, not BMI) is probably in the 20s.

Clearly you are a bad doctor😉

 

[pewpew95]

So what part of this whole situation is awkward?

 

[LizzyM]

You are stigmatizing the diagnosis of obesity, observing that the physician appears to meet the criteria for the diagnosis of obesity and feel awkward noting "obesity" in a patient a less severe form of the disease than you have observed in the physician. It all stems from the fact that you have stigmatized the disease.

If you observed that the physician had swan neck deformities of the finger joints, would you feel awkward writing "finger joint deformity" in a patient's A&P? What about alopecia (lack of body hair)? Don't stigmatize obesity and you won't feel anything recording it in the record.

As a physician, don’t you feel the need to set an example for your patients and live a healthy lifestyle? Not trying to sound offensive but I feel like patients would be more willing to take medical advice if their physician practiced what they preached. In your opinion, why do so many physicians smoke and live lives that lead to obesity if they are aware of the risks?

Based on some people I know, I've come to believe that people who get as big as the attending physician often have had an eating disorder at some point in life. While the disorder may be under control at this point, getting the weight down can be very, very difficult because the metabolic rate can be very low in these individuals. (Basically, got that way through compulsive behavior, messed up their metabolism due to binging and dieting, trying to get down to a reasonable weight becomes very difficult.)

 

[GoinHardenYaHoe]

You are stigmatizing the diagnosis of obesity, observing that the physician appears to meet the criteria for the diagnosis of obesity and feel awkward noting "obesity" in a patient a less severe form of the disease than you have observed in the physician. It all stems from the fact that you have stigmatized the disease.

If you observed that the physician had swan neck deformities of the finger joints, would you feel awkward writing "finger joint deformity" in a patient's A&P? What about alopecia (lack of body hair)? Don't stigmatize obesity and you won't feel anything recording it in the record.



Based on some people I know, I've come to believe that people who get as big as the attending physician often have had an eating disorder at some point in life. While the disorder may be under control at this point, getting the weight down can be very, very difficult because the metabolic rate can be very low in these individuals. (Basically, got that way through compulsive behavior, messed up their metabolism due to binging and dieting, trying to get down to a reasonable weight becomes very difficult.)

You’re right. I definitely feel this way because I have stigmatized obesity. I guess I feel this way because it’s a disease that can be controlled with good habits (I mean, it’s all about calories right?). I need to reevaluate how I feel about certain diseases and their etiologies. As a physician, it will be my job to treat and not judge, while offering realistic advice at the same time. Thanks for pointing out the flaw in my way of thinking; I learned a valuable lesson!

 

[LizzyM]

It is about calories but not everyone metabolizes food in the same way. We have much to learn about the microbiome and its influence on metabolism as well as its effect in appetite.

 

[HomeSkool]

To piggyback off @LizzyM, I believe the role of addiction in the obesity epidemic is underappreciated. I regularly see patients who've had sleeve gastrectomies and then overeaten until the remnant stomach pouch is stretched out to the original size of the stomach. Surely it doesn't feel good to do that to oneself (physically or emotionally), so why do they do it? Cultural inundation with images and access to food. When's the last time you went to a social event where food wasn't featured prominently? Never? How about TV -- have you ever watched even a ten-minute stretch without some kind of advertisement for food and drink? Probably not. So we become socially conditioned to have food present at all times. Doing nothing? You need a snack. Reading a book? You need a snack. Going out? You need a snack, and then a 2,000-calorie meal.

Obesity is a disease state that involves a large number of genetic, neurohormonal, and psychological factors. Addiction may or may not play a part in the etiology of any given person's obesity. It's well-established at this point that the dopaminergic pathways in the limbic cortex become "rewired" in addictive disorders. This happens regardless of the "drug" of choice: substances, gambling, sex, food, you name it. So it's not as simple as "she's a doctor, she should set an example." Telling a food addict (if indeed she is one) to simply "eat less" is like telling an alcoholic to "just stop drinking." If only it were that simple.

(Also: I'm not saying that all obese people have food addiction. I strongly suspect that many of them do, though, and that it's more prevalent than we recognize.)

As for feeling awkward about putting obesity, metabolic syndrome, etc., in patient charts, I agree that it's due to the stigma that you personally associate with obesity. You have to break that stigma. I routinely tell patients, "Your weight and body habitus put you at risk for being a difficult intubation, so we're going to do X, Y, and Z to secure your airway." You'll need to have similar frank discussions about patients' weight throughout your career. (By the way, to answer your question about whether you're indirectly calling the doctor obese: maybe, maybe not, but she is obese, so it's not a rude thing to say.)

And...I just can't help myself...

 

[Goro]

As a physician, don’t you feel the need to set an example for your patients and live a healthy lifestyle? Not trying to sound offensive but I feel like patients would be more willing to take medical advice if their physician practiced what they preached. In your opinion, why do so many physicians smoke and live lives that lead to obesity if they are aware of the risks?

You are wrong. In fact, when the doctor looks like the patient, the patents is more likely to open up tot he doctor, and feel more comfortable with them. I have a clinician colleague who was a resident during the start of the AIDS epidemic. He has a noticeable strawberry birthmark on his face, and he found that AIDS patients with Kaposi sarcoma (go look it up) were more comfortable with him, because they thought he was one of them.

You’re right. I definitely feel this way because I have stigmatized obesity. I guess I feel this way because it’s a disease that can be controlled with good habits (I mean, it’s all about calories right?). I need to reevaluate how I feel about certain diseases and their etiologies. As a physician, it will be my job to treat and not judge, while offering realistic advice at the same time. Thanks for pointing out the flaw in my way of thinking; I learned a valuable lesson!

And when it comes to writing down that the patient is obese, you're not a doctor and you don't get to make that call...the doctor does.

 

[RedBear3005]

You are wrong. In fact, when the doctor looks like the patient, the patents is more likely to open up tot he doctor, and feel more comfortable with them. I have a clinician colleague who was a resident during the start of the AIDS epidemic. He has a noticeable strawberry birthmark on his face, and he found that AIDS patients with Kaposi sarcoma (go look it up) were more comfortable with him, because they thought he was one of them.

And when it comes to writing down that the patient is obese, you're not a doctor and you don't get to make that call...the doctor does.

While I generally disagree with many of the OPs observations in this thread, they might not be wrong in that their perspective may represent the perspective of a significant portion of the population.

My father is significantly overweight and has diabetes. His physician, of more than twenty years, is always telling him to lose weight. His physician is also a very, very heavy man and significantly younger than my father. My father doesn't take his advice to lose weight seriously. And do you know what my father's rationale is? "Well, my physician is as overweight as I am. He is an educated person. He understands all of the potential risk posed by obesity. If he understands those risk and yet he continues to be overweight, then the risk posed by obesity can't be that bad."

Is this logic flawed? Incredibly. It assumes that all choices and actions result from the ability to "reason" alone and that our choices are not equally impacted by our emotions and experiences. However, it is my father's logic and it is somewhat in line with what the OP is suggesting. I am not saying that the observation that @Goro made isn't also the case...(I mean, it's the reason I have a "female" OB/GYN)...I'm just saying that the OP isn't totally off the mark.

 

[JMilo]

While I generally disagree with all of the OPs observations in this thread, they might not be wrong in that their perspective may represent the perspective of a significant portion of the population.

My father is significantly overweight and has diabetes. His physician, of more than twenty years, is always telling him to lose weight. His physician is also a very, very heavy man and significantly younger than my father. My father doesn't take his advice to lose weight seriously. And do you know what my father's rationale is? "Well, my physician is as overweight as I am. He is an educated person. He understands all of the potential risk posed by obesity. If he understands those risk and yet he continues to be overweight, then the risk posed by obesity can't be that bad."

Is this logic flawed? Incredibly. It assumes that all choices and actions result from the ability to "reason" alone and that our choices are not equally impacted by our emotions and experiences. However, it is my father's logic and it is somewhat in line with what the OP is suggesting. I am not saying that the observation that @Goro made isn't also the case...(I mean, it's the reason I have a "female" OB/GYN)...I'm just saying that the OP isn't totally off the mark.

Yes. He is an educated person, understands the risks of obesity, and told you that you have to lose weight...blatantly ignoring this advice, for any reason, is deeply flawed. Your father is looking for an excuse...if your doctor was skinny, your father would find another excuse not to try and lose weight.

 

[JonathanHusky]

While I generally disagree with many of the OPs observations in this thread, they might not be wrong in that their perspective may represent the perspective of a significant portion of the population.

My father is significantly overweight and has diabetes. His physician, of more than twenty years, is always telling him to lose weight. His physician is also a very, very heavy man and significantly younger than my father. My father doesn't take his advice to lose weight seriously. And do you know what my father's rationale is? "Well, my physician is as overweight as I am. He is an educated person. He understands all of the potential risk posed by obesity. If he understands those risk and yet he continues to be overweight, then the risk posed by obesity can't be that bad."

Is this logic flawed? Incredibly. It assumes that all choices and actions result from the ability to "reason" alone and that our choices are not equally impacted by our emotions and experiences. However, it is my father's logic and it is somewhat in line with what the OP is suggesting. I am not saying that the observation that @Goro made isn't also the case...(I mean, it's the reason I have a "female" OB/GYN)...I'm just saying that the OP isn't totally off the mark.

so basically it varies from pt to pt... some find it easier to open up if their physicians are going through similar health problems while others use it as an excuse to not follow through with the physicians orders

going back to OP's question, aren't you supposed to write down what the physician tells you to write down? never scribed but it seems unlikely that you'd be expected to make the final call on whether or not "obesity" should go in the pt's chart

 

[RedBear3005]

Yes. He is an educated person, understands the risks of obesity, and told you that you have to lose weight...blatantly ignoring this advice, for any reason, is deeply flawed. Your father is looking for an excuse...if your doctor was skinny, your father would find another excuse not to try and lose weight.

Ummm...most definitely. But this isn't really in contention with the claim the OP is making or my example. Even if my dad is just looking for an excuse not to lose weight, which he most certainly is, this doesn't really undermine the idea that some people take their physicians less seriously when their physician advises them to take a course of action that they would appear not to follow themselves. One of my physicians in college smoked and whenever she would tell someone not to smoke she began with the caveat, "Yes, I smoke but you still shouldn't do it for X, Y, and Z." I assume she did this because she knew we could smell it.

Physicians are people and their reasons for making the choices they do are impacted just as much by their experiences and emotions as ours are as patients. And having read your earlier post, I can appreciate that your physician's appearance or behavior may not at all impact how seriously you take their advice. However, like most things, that is not the case for everyone.

 

[LizzyM]

so basically it varies from pt to pt... some find it easier to open up if their physicians are going through similar health problems while others use it as an excuse to not follow through with the physicians orders

going back to OP's question, aren't you supposed to write down what the physician tells you to write down? never scribed but it seems unlikely that you'd be expected to make the final call on whether or not "obesity" should go in the pt's chart

I'm wondering if there is some sort of rule for scribes in this setting such as, If BMI is > 29.9 then record "obesity". This would be so that the coding of the encounter takes into account all the conditions the patient presented with and not just the chief complaint. Then I suspect that the physician reviews what the scribe has recorded and signs off on it.

 

[RedBear3005]

so basically it varies from pt to pt... some find it easier to open up if their physicians are going through similar health problems while others use it as an excuse to not follow through with the physicians orders

going back to OP's question, aren't you supposed to write down what the physician tells you to write down? never scribed but it seems unlikely that you'd be expected to make the final call on whether or not "obesity" should go in the pt's chart

I think like most things, it varies. And I don't want to say that most people use it as an excuse not to do what their physician suggests (I think that seems a bit reductionist to me if we are speaking about a larger group of people and not just my father) I think instead that it gives some folks pause or a reason to question the veracity of this advice. I think that this pause/challenge could be easily overcome if they just read the medical literature that supports what their physician is saying.

 

[LizzyM]

I think that this pause/challenge could be easily overcome if they just read the medical literature that supports what their physician is saying.

Most patients are not capable of reading the medical literature. Like fake news and real news, sometimes what is valid and reliable and worthy of adoption and what was poorly done, or when the findings are not applicable to a specific patient's situation (e.g. not similar to the study population in disease severity, demographic characteristics, co-morbid conditions, etc.) is not easily detected. Even if it is a good study and relevant to the patient, the technical vocabulary is often beyond the patient's comprehension.

There are some patient education materials that are understandable, attractive, and based on the medical literature. Education alone, however, is insufficient but it may get a patient from pre-contemplation (before they even decide to make a change) to a place where they are thinking about changing a behavior and making and carrying out a plan to change and maintaining that change. If education were all it took, few of us would have any bad habits at all!

 

[STcmOCSD]

And when it comes to writing down that the patient is obese, you're not a doctor and you don't get to make that call...the doctor does.

Unfortunately where I work the physicians rarely dictate the physical exam and expect me to know what to put. Obviously if I have a question I can ask, but they wouldn’t expect me to ask if someone is obese every time I see a patient.

 

[Goro]

Unfortunately where I work the physicians rarely dictate the physical exam and expect me to know what to put. Obviously if I have a question I can ask, but they wouldn’t expect me to ask if someone is obese every time I see a patient.

Ok. Then you know what to do. I trust OP does as well now

 

[GoinHardenYaHoe]

I'm wondering if there is some sort of rule for scribes in this setting such as, If BMI is > 29.9 then record "obesity". This would be so that the coding of the encounter takes into account all the conditions the patient presented with and not just the chief complaint. Then I suspect that the physician reviews what the scribe has recorded and signs off on it.

Yup, thats pretty spot on. We routinely scan lab reports and put down "Impaired fasting glucose" even if the FBS is only 100. Physician has to sign off on everything afterward so it's not like we are doing anything wrong as scribes. Plus, it is what I was taught to do by my chief scribe, so there's that.

 

[Microbug]

Unfortunately where I work the physicians rarely dictate the physical exam and expect me to know what to put. Obviously if I have a question I can ask, but they wouldn’t expect me to ask if someone is obese every time I see a patient.

That’s not sketchy at all

 

[1eyedjack]

How are you supposed to know what to put for cardio, pulmonary, ears, etc??

 

[JMilo]

How are you supposed to know what to put for cardio, pulmonary, ears, etc??

Our physicians usually have a template for their exams, and only dictate if it is remarkable.

 

[STcmOCSD]

That’s not sketchy at all

It is slightly sketchy.

Our physicians usually have a template for their exams, and only dictate if it is remarkable.

Same. If they don’t mention it at all, we put normal HR, normal rhythm, breath sounds NL, breath sounds = bilaterally, and no respiratory distress. If they mention something remarkable we adjust accordingly.