Weight, Weight, Don’t Tell Me

As a psychiatrist, I was trained to begin the mental status examination and overall assessment of my patient as soon as I greeted them in the waiting room. Even now, three decades after finishing medical school, I follow almost the same sequence of actions in my day-to-day interactions with my patients that I did as a resident in training. Granted, there are now electronic medical records and I rarely come in contact with a paper chart any more, temperatures are recorded with digital thermometers and blood pressures with self pumping cuffs, but a large part of the basic interaction between psychiatrist and patient has changed little since the days of Freud. 

I greet my patient in the waiting areas of the clinics I work in, usually offering a handshake unless it is obvious to me that the person is painfully shy, obviously paranoid, or just has their hands jammed down into their pockets with no intention of bringing them out. I walk ahead of the patient at first, since I have to swipe a card to let us into the next hallway via an electronic door. After that, I usually offer to let the patient go first so that I may assess station, gait, arm swing, clothing, personal hygiene, balance, coordination, response to directions and a myriad other things that one can assess just by direct observation. It has always been interesting to me just how much I can know about a person before we even enter my office and sit down, before the first questions are even asked. 

Now, I could bore you with a blow by blow of the next thirty minutes of a psychiatric appointment, but I won’t do that. What I do want to tell you about is one of the most fascinating parts of history taking in the psychiatric consultant’s room, something I have begun to pay much more attention to in the last few years. 

“Mrs. Jones, let’s get you up on the scales so I can get your weight today before we sit down.”

Yes, the simple act of my patient stepping on the scales that are prominently positioned in my office before we do anything else is a treasure trove of information. 

Now, watch and listen closely, because after I make that statement (and it is a statement, not a question), information about my patient starts to fly. I try to capture it all, either on paper (the actual height and weight themselves) or in my head (the hesitancy or willingness to get up there in the first place, for example). 

“Should I take my boots off? These are steel-toed boots, and they weigh at least fifteen pounds.”

“Do you want me to take my clothes off?”

“I just weighed myself at home and I weighed…”

“Well, you know I just had a big lunch.”

“Well yeah, I know that’s ten pounds more than last time, but I always weigh myself naked at home first thing in the morning, so…”

“I’m big boned.”

“Aw, man, do I have to?” 

“The nurse just weighed me last year.”

“I think this medication makes me sleep-eat.”

“I will if you will.”

“Wow, this is like going to a real doctor’s office!”

“Can’t you remember to weigh me before the Christmas holidays this year, instead of after?”

And of course, even as these statements are coming, there is the Sacrament of the Emptying of the Pockets, a ritual that virtually everyone I’ve ever weighed must religiously practice. It is second only to The Removal of the Heavy Shoes. What have I seen come out of the pockets of six year old children, adults in their thirties, and octogenarians? 

Money, baseball cards, combs, Gummy Bears, marbles, pills, knives, a gun (once, and that was enough), condoms (that was the octogenarian, by the way), paper, rocks, scissors, cell phones of every size and variety, iPad Minis, paperback books, CD players, bugs (usually in bottles for safe keeping), baseball caps, sunglasses, Tums, aspirin, Motrin, Tylenol, cough syrup, cigarettes, cigars, and chewing tobacco. Once, there was even a brick. Another story for another day. 

Okay, we’re almost on the scales. Can you believe it? Now can you see how much I already know about you? We haven’t even started the formal interview yet!

Yes, there’s more.

If you are the kind of person who wants to show me how good you’ve been with your diet and exercise regimen, you don’t wait for me. You reach up and confidently push the little weights across the bars until they settle at the points you are sure they will settle at, since you weigh yourself five times a day at home. You are happy to show me how much you don’t weigh today. 

If you are grossly overweight, you know it, I know it, and you know I know it, you also reach up and manipulate the mechanism. However, knowing that you weigh over three hundred pounds, you push the bottom marker to 200, and then you inch inch inch inch the top one along until it gets all the way to the end of the beam, hopeful that in the time it took us to reach my office from the waiting room, a metabolic miracle has occurred. The Immaculate Reduction is what you are praying for as you ascend the platform. Only then do you accept the fact that the lower marker must now go to 250, then we inch inch, inch…yeah. Denial is not just a river in Egypt. 

Finally, if you just can’t stand it when I act like a real doctor and demand these ridiculous vital signs of you when I should just stick to being a psychiatrist, after all, you get up on the Perch of Shame, but you face outwards, towards me. This accomplishes two things. First, you may glare at me for putting you through this. Secondly, you don’t want to know. You don’t want to watch. You don’t want me to tell you. 

“Well, Mrs. Jones, it looks like today you weigh…”

“Wait, wait, don’t tell me!” you exclaim, dreading the verdict. 

“Okay, okay,” I say, as I pause mid-scribble, writing the figure on my note sheet for the visit. 

“I forgot to take my keys out of my pocket!”

You drop a set of keys that looks like it could open every locked door in the state hospital plus gain access to a few dozen vehicles for good measure. 

“Yeah, I should take off at least a pound for those,” I say, dryly. 

A beaming smile lights up your face.

Our work is cut out for us, but we’ll make progress today, if we both pull our weight. 

“Have a seat. Now, how have you been since I last saw you?”

 

 

 

 

 

 

 

29 thoughts on “Weight, Weight, Don’t Tell Me

  1. That was funny and kind of endearing but even this distant reader tensed up as we approached the cursed scale.

  2. I’m printing this for my internist, who will relate. I’m “only” 20 pounds overweight and have been fighting my weight for more than 50 years. I almost had a meltdown last year at my physical over getting on that scale. She is very kind and understanding, but since I am on med for BP at age 69 (my only med), I feel I should get those 20 pounds off (again) and be a good girl.Maybe I need a psychiatrist to address my perfectionistic attitudes? :-)

  3. Linda,

    Feel free to share with any of your doctors with my compliments.

    I’m the same way, in that I have (in my head) that high school picture of myself at a weight that is most likely not even healthy for me now. I’m in good shape, exercise, and try to eat moderately and not indulge in things that will really hurt me, so I feel pretty healthy.

    For my patients, it is often a more serious matter, as many of the medicines we use to control serious psychiatric symptoms and help give folks a better quality of life do just that, and do it well, but carry a known side effect burden as well. It’s a tightrope we have have to walk together, just as it sounds like you do with your internist.

    Thanks for reading and commenting, and stay the course!

    Greg

  4. I’m at a good weight now and have no anxiety about getting on the scales (though I do take off my heavy shoes), I generally make some kind of comment simply to make conversation. So I suppose that still says something about me, ha! No escape from the diligent observer.

  5. Doc, Great piece, but I’m thinking patients should be weighed on the way out as well, so when someone says, “Gee, I’m glad I got that off my mind” you’ll be able to quantify the result. The government may require this someday, and you’ll be way ahead of the curve!

  6. Rob

    That might sometimes be offset by the piece of MY mind that I give the folks that don’t follow through with homework, taking meds, or making decisions.

    I guess it would be a wash then.

    G

  7. Good point, Doc. Weigh all concerned, just in case. If nothing else, you’ll know when it’s time for a vacation. Hope you’re having a sunny day. Cabin Fever is pandemic up here. Please send us some warm air! Rob

  8. Oh Greg! This is hilarious! And I see it everyday. I call patients back from the waiting room, and like you, I’ve sized them up before they even get into the office. Of course the first thing we do is weigh. Oh Lord!! Same thing happens. Nobody wants to admit they just flat EAT TOO MUCH. Can I take some off for the clothes, the shoes, etc? Then for the vital signs. Most of the BP’s are high. Hmmm. Could it be stress? Hmmm. I’m thinking, could it be all that weight? Goodness gracious! I have to admit though, even I like to take my shoes off. It’s only fair, right?

  9. What a delightful way to deliver truthiness. You’re reminding me that I have to write a blog post about how I greet (new-to-me) doctors and what I ask during initial consultations. And no, the list does not include asking that *everyone* disrobe!

  10. Great blog Greg. I think this is as much a comment on our values as a society than anything else. Tell me though, how do you manage all this in a teleconsult?? How has that changed a mental state examination let alone having weight measured??

  11. Jocelyn,

    Most of the time I’m one of those people who know about what I should weigh. I exercise a lot now, weigh myself twice a day, and have lost twelve pounds in the last year. I feel pretty good about the nasty scales right now. :)

  12. Good for you Greg – as for me, mindful eating has slipped to a very low priority for a few months while we’ve moved – I’ve discovered the limitations of headspace – and man chocolate can be a good friend at times, if not a bit too sticky in the long term. I think I’m feeling a blog about this coming on in the nearish future. I think the lovely thing you have done is uncover the humanity we all share in these issues…

  13. Jocelyn,

    I know you’ll be settling into a more normal routine before long. You already have a good start. I do want to see where the good chocolate shops are when I come to Melbourne, however. :)

    G

  14. Hee hee- I actually enjoyed the octogenarian taking condoms out of his pockets. Due to the typo (but the way) instead of (by the way), I imagined how one might pull condoms out of a pocket that would be shocking to a doctor :). Then I realized it was a typo. Just FYI, at my Ob/Gyn, they ask that we face away from the scale – I am guessing it makes taking vitals much faster :).

  15. I recall three items from past pocket-emptyings that you didn’t list – a bear’s tooth, a rubber chicken, and a dead skunk. I kid you not.

    Fishin’ doc

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