Once upon a time weight was a subject that primary care physicians could deal with using a little bit of diplomacy. No one was very successful at consistently treating obesity throughout their patient population, but you could at least have the option to address the subject delicately, overtly, or with a mixture of skills artistically crafted for each unique patient.
Electronic medical records changed that. Due to coding requirements, HCC scoring, recognizing relative patient complexity, and comorbidity identification issues, we have now dutifully been listing obesity and morbid obesity on our patients’ problem lists, and on the summaries we provide them at each office visit. Subtlety is now gone. Every person with a BMI that is elevated gets a fresh slap in the face every time they visit the doctor’s office. They see it again when they look up their diagnoses on their patient portal. A constant reminder. Direct. It is confrontational even though unintentional, and a continuous source of unease.
The result? Often our patients feel embarrassed and criticized by seeing those diagnoses attached to their names, probably intensified by the fact that so many of them historically have been shamed about their weight. It is their scarlet letter A which never goes away, and awaits the next insensitive critical commentary. Many patients push back and either challenge the diagnosis, request that it be removed from their problem list, or increasingly seek to avoid or participate in any discussions about their weight. Since the electronic medical record has made this a bright light in the middle of medical care delivery, my experience has been that many patients have been increasingly removed from wanting to discuss this diagnosis. They perceive this documentation as identifying their doctor as being judgmental and critical, and that is not a good basis for mindful, sensitive medical interactions.
That is, until now. Suddenly the landscape has changed. It has very recently become a daily occurrence to have patients calling me apparently now happy to be listed as obese by us. Not only that, they want a letter from me documenting they are obese. They could not be happier when I agree and crank out their letters for them. Some people who haven’t been in the office for several years are happy to come in and be weighed so that they can be reestablished as “proud to be obese” members of my practice. They are so eager to have this documented officially that I suspect a few of them with very borderline BMI readings may have loaded up their pockets and found their heaviest clothing and thickest boots to wear in preparation for their expedition to our office scale. However if they make the cut, they definitely want the letter.
No mystery as to why they are doing this. It’s the novel coronavirus pandemic. Fear of COVID-19. As everyone struggles to be vaccinated, New York State came up with a list of medical conditions that allowed people, typically with a note from their doctor, to qualify for vaccines. Even though right now there has been little success in getting those vaccines, the eligible people under age 65 are actively pursuing their notes so they can join the queue. Both obesity and morbid obesity are on the list. I still haven’t figured out why they are both listed as qualifying diagnoses, because everyone who is morbidly obese also qualifies as obese. Perhaps someone is supposed to give them 2 points for this classification, one for obesity and one for morbid obesity, but I haven’t seen any guidance suggesting that yet.
Here’s the good news. People want to be vaccinated. And these individuals may get their vaccine sooner with these letters, and for them that is really good news. The only truly good news we can hear about vaccination will be the day when it is announced that everyone on the planet is vaccinated effectively, but no one is even dreaming of that fantasy scenario.
There is much complexity here. All providers have appropriately been asked to promote equity in the triaging of vaccine distribution. That has become an oft repeated message that we all support. Inequity in healthcare has a long and inglorious history that we have never even partially solved. Nonetheless, our ability to help with equitable vaccine distribution has been compartmentalized and restricted by the guidelines which are attempting achieve equity by fiat.
The Department of Health has published their official list of diagnoses – in almost all cases without any respect for disease severity – that is intended to identify individuals at higher risk of COVID-19 fatality. We were presented with a set of diagnoses – from COPD to hypertension to obesity – which have been identified as representing higher risk individuals who should get the vaccine earlier. But we already know each of these diagnoses have a great degree of variability in their severity. Unfortunately, the devil is in the details. And this lack of risk stratification within each diagnosis has created an unfortunate opportunity to create a new inequitability in vaccine prioritization
We all appreciate that that list is too big, too nonselective, too vague in some cases, and missing important qualifying severity and specificity concerns to be used properly and fairly. Within this group of qualifying people there are folks with diet controlled hypertension, COPD patients who exercise vigorously and use no inhalers, healthy people with BMI’s just over the line, and numerous other patients whom we regard in our clinical practice as truly healthy but who nonetheless still meet the criteria.
Unfortunately many of those borderline people are actively advocating with their physicians to provide them with just such documentation so they can secure an early place in the vaccine line. They are following the letter of the law and advocating on behalf of their own self-interest, which is natural and understandable. Complying with these requests when we truly do not believe that the individuals are at high risk is the antithesis of the spirit of trying to assure and actively promote equitable distribution of vaccine where the sickest people get it first.
This creates a significant moral and ethical dilemma for physicians who have been asked to participate in this rollout. Do we stick up for our patients and become their individual advocates by writing a note for everyone who technically qualifies, even when we think they are healthy? We are supposed to be advocates for our patients, and in this regard our actions would be just. Or do we engage as responsible medical leaders societally and truly comply with the spirit of the law and limit our identification to the qualifying individuals whom we believe are medically at the highest risk, and therefore are intended to be the first ones within this group to be vaccinated? We are all supposed to be stewards of society’s resources and leaders in equitability in care delivery, and in this regard triaging our patients appropriately would also be just.
Many of us are struggling with this dilemma. I don’t have an answer myself. But it’s time for me to go back and write some more letters. And hope I am doing the right thing.
