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Key Feature 1: In patients who appear to be obese, make the diagnosis of obesity using a clear definition (i.e., currently body mass index) and inform them of the diagnosis.
Skill: Clinical Reasoning Phase: Diagnosis Key Feature 2: In all obese patients, assess for treatable co-morbidities such as hypertension, diabetes, coronary artery disease, sleep apnea, and osteoarthritis, as these are more likely to be present. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 3: In patients diagnosed with obesity who have confirmed normal thyroid function, avoid repeated thyroid-stimulating hormone testing. Skill: Clinical Reasoning, Selectivity Phase: Investigation, Treatment Key Feature 4: In obese patients, inquire about the effect of obesity on the patient’s personal and social life to better understand its impact on the patient. Skill: Patient Centered Phase: History Key Feature 5: In a patient diagnosed with obesity, establish the patient’s readiness to make changes necessary to lose weight, as advice will differ, and reassess this readiness periodically. Skill: Patient Centered Phase: History, Follow-up Key Feature 6: Advise the obese patient seeking treatment that effective management will require appropriate diet, adequate exercise, and support (independent of any medical or surgical treatment), and facilitate the patient’s access to these as needed and as possible. Skill: Clinical Reasoning Phase: Treatment Key Feature 8: In managing childhood obesity, challenge parents to make appropriate family-wide changes in diet and exercise, and to avoid counterproductive interventions (ex: berating or singling out the obese child). Skill: Clinical Reasoning, Communication Phase: Treatment In my first year or residency I did a quality improvement project in my clinic, with the hopes of performing an intervention that would lead to increased screening and diagnosis of overweight and obesity. The intervention was having signage in the office encouraging patients to start a conversation about their weight if they were interested. Of the approximately 300 patients who came through the clinic during the intervention period, 1 patient initiated a conversation about their weight, and this patient had a normal BMI. Although my quality improvement project did not increase the ability to screen for overweight and obesity, it did increase my understanding that screening for overweight and obesity is likely not sensitive unless it is physician-directed, or that at least passive that signage as I had put out was not effective in my current patient population. I screen patients with an objective measure of overweight and obesity by assessing their BMI along with other interventions during a periodic health assessment. In adults, I also obtain a measure of central adiposity by assessing what their waist circumference is at any given BMI as some patients with a normal BMI may have a large enough waist circumference that they may be at increased risk for cardiovascular disease. As well, some patients with an elevated BMI may have greater risk for cardiovascular disease than this number alone suggests, as people who are "apples" and carry most of their weight around their abdomen and this increases their risk, as opposed to the "pears" that have a more distributed weight. These measurements are objective, and I believe that doing them with all patients helps alleviate the stigma that persists in Western culture regarding having overweight/obesity. That being said, the stigma and the social and psychological consequences are pervasive, so when patients have overweight or obesity, I also perform an assessment of their mental health. Beyond the negative consequences on mental health, overweight and obesity can occur alongside a slough of comorbidities and an enlist a number of complications. These include hypertension, sleep apnea, polycystic ovarian syndrome, osteoarthritis, gastroesophageal reflux disease, fatty liver disease, a decrease in exercise capacity or ability to perform activities of daily living attributed to excess weight, dyslipidemia, and diabetes mellitus. It is important to assess for and address these other concerns alongside the provision of treatment and management of overweight and obesity. Laboratory investigations are necessary to assess whether of not the weight gain is complicated by new diabetes (fasting blood glucose or hemoglobin A1C), dyslipidemia (lipid panel), or fatty liver disease (ALT), or is a result of hypothyroidism (TSH), which is common enough with a presentation that can be fairly non-specific and so warrants a blood test to be ruled out, in a patient presenting with new-onset overweight/obesity without a previous test of their thyroid function since the onset of overweight/obesity. In terms of the treatment and management of obesity, society has drilled it into us that it is typically a consequence of poor lifestyle choices. That if we only ate less and exercised more, overweight and obesity would not be an issue. The emphasis on personal behaviours neglects the reality of just how complicated the innate pathways wiring our brain and endocrine systems are, encouraging weight gain and fighting efforts to lose weight, and this perspective does not take into account the societal structures that promote and reinforce weight gain. Yes, personal lifestyle choices can make a difference, mostly by improving health and wellbeing rather than necessarily dropping numbers on the scale overly significantly (wide range of results here). It is important for us to encourage one another to adopt healthier behaviours whenever possible without compromising quality of life, with the intent of actually enhancing it. We all have a role in adopting healthy behaviours in families and other community and societal units, while at the same time avoiding behaviours that stigmatise people who have excess weight. The more we see it as a personal consequence, the further from the truth I believe it is, and the less effective will be the call to action. The impact of any given intervention on quality of life is individualistic as well, and the individual has to find proposed behaviour changes tolerable and worth it to be motivated to continue the behaviours long-term. As a family doctor, my role in this matter is to assist the patient in moving from ambivalence to action when it is something they truly want (aka motivational interviewing for healthy lifestyle changes), as well as promoting the best interests of the community. I am a firm believer that we need to strengthen our communities with healthy public policy. Unfortunately, no matter how motivated one is, once an individual has acquired enough weight such that they meet the criteria for overweight or obesity, healthy lifestyle behaviours alone are typically not sufficient to treat overweight and obesity so as to achieve a normal weight. On the flip side, there are medications and surgical treatments that are highly effective. While these treatment modalities do not replace the need for healthy lifestyle behaviours, they do make significant differences in the morbidity and mortality of patients with overweight and obesity. I am of the opinion that many physicians are not offering these treatments to patients frequently enough, probably as a consequence of a lack of discussion about weight with patients altogether. Fortunately, there are people who have started organisations such as Obesity Canada that seek to change this discourse. As the issue continues to be a growing concern as rates of overweight and obesity continue to increase, I suspect that eventually overweight and obesity will be managed much more effectively as the chronic disease process that it is.
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By the end of postgraduate training, using a patient-centered approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Learning (Patients) Key Feature 1: As part of the ongoing care of children, ask parents about their children’s functioning in school to identify learning difficulties. Skill: Clinical Reasoning Phase: History Newborn Key Feature 6: In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (ex: hips, heart, hearing). Skill: Clinical Reasoning Phase: Follow-up, Physical Key Feature 7a: When discharging a newborn from hospital: Advise parent(s) of warning signs of serious or impending illness. Skill: Clinical Reasoning, Communication Phase: Treatment, Follow-up Key Feature 7b: When discharging a newborn from hospital: Develop a plan with them to access appropriate care should a concern arise. Skill: Clinical Reasoning, Patient Centered Phase: Follow-up Obesity Key Feature 7: As part of preventing childhood obesity, advise parents of healthy activity levels for their children. Skill: Clinical Reasoning Phase: Treatment Poisoning Key Feature 1: As part of well-child care, discuss preventing and treating poisoning with parents (ex: “child-proofing”, poison control number). Skill: Communication, Clinical Reasoning Phase: Treatment Well-baby Care Key Feature 1: Measure and chart growth parameters, including head circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record. Skill: Clinical Reasoning, Psychomotor, Skills/Procedure Skills Phase: Physical Key Feature 4: At each assessment, provide parents with anticipatory advice on pertinent issues (ex: feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues). Skill: Clinical Reasoning Phase: Treatment Key Feature 5: Ask about family adjustment to the child (ex: sibling interaction, changing roles of both parents, involvement of extended family). Skill: Patient Centered Phase: History Key Feature 8: Even when children are growing and developing appropriately, evaluate their nutritional intake (ex: type, quality, and quantity of foods) to prevent future problems (ex: anemia, tooth decay), especially in at-risk populations (ex: the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations). Skill: Clinical Reasoning Phase: History, Treatment A well baby is always a good thing! And having an easy and trustworthy method of knowing whether a baby is well is a double good thing. In medical school we were taught we needed to memorise the extensive list of childhood developmental milestones and remember just how many ounces of formula per kg of weight infants need. We were taught to always perform a comprehensive physical examination during a well child checkup, but one that included only the relevant manoeuvres, which tended to change as quickly as you went from one preceptor to the next. BUT THERE IS A BETTER, MORE EVIDENCE-INFORMED, MORE EFFICIENT, AND LESS STRESSFUL WAY. The Rourke Baby Record is an evidence-based pediatric flow sheet that assists physicians in assessing and documenting the routine well-child checkup. It is based on age and can be integrated into electronic medical records. It is my friend, and it's got my back with its guide to interpretation of what is considered within normal limits. The website has links to the WHO growth charts as well, if it wasn't already schmoozing me enough. Furthermore, it provides a template* for the entire encounter, prompting information gathering and anticipatory guidance as relevant to the child's age. With handouts for parents and a list of relevant resources for different-age related concerns (including for the initial discharge from hospital after delivery), along with evidence-informed recommendations for all of the anticipatory guidance you could dream of, no wonder these kids as displayed on their website are as happy as I am!  *Being a template for a generic encounter, it is important for the clinician to be astute in modifying the encounter as needed. For example, one of the prompts for information gathering in the first month of life is inquiry into siblings. I consider this to be a prompt to assess how others in the family in general, including but not limited to siblings, are adjusting to the new family member. This may include how parental roles are being affected, and who in the extended family is offering support. The RBR is a stimulus for a conversation, but should not be considered a literal and exhaustive encounter script. And, when it comes to physical exam maneuvers that aren't as enjoyable, like measuring head circumference or length, or assessing hip stability, I perform these opportunistically or else altogether at the end of the visit so that I disturb the child as little as possible. The template ensures you obtain the important clinical information, but I can choose how to acquire the most information and with more rather than less tact.
Once children are older than 5 years old, switch out your RBR for the Greig Health Record and you can continue on your merry way until a child has reached adulthood. |
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