1
In the US, primary care shifted from _______ to _________ late in the 20th century and in the 21st century
largely acute care
preventive and chronic/routine care
How do patients pressure physicians to change their recommendations?
Through social interaction in the clinic, patients convey their preferences, fears, experiences (and priorities) in ways that can pressure physicians.
In chronic care, they can influence a non-prescription
This intrinsic factor (that can interact with the environment) explains only a part of the obesity epidemic
Genes/genetics
Physicians are most likely to talk productively about weight in this context
When there is a clear link between a chronic condition and weight
Speer & McPhilips find that gender clinic physicians bring up weight in one of these three ways
Announcing/telling, asking, and deducing
What are the two key players in causing disease according to the Moldanado book?
The individual (and that person’s attributes and genetics)
The environment (physical, chemical, psychological etc)
Bergen finds that patients are much more likely to accept lifestyle advice from physicians when it is presented in this manner
Treatment-implicative
This California measure on property taxes ended up impacting school cafeterias and PE classes
Proposition 13
This happens when physicians tell patients to lose weight
Patients are more likely to try to lose weight and/or actually lose weight
Doing this while patients are presymptomatic seems to be the best way to talk about weight (hint: mention two things!)
Medicalizing weight and making concrete/personalized recommendations
What are some risks that can and cannot be modified?
Lifestyle & other choices (can modify); Genetic predisposition (cannot)
These are the three intentional bases of patient resistance, and these are the way that physicians respond to each basis
Preference & pressuring; fear & coaxing; experience & accommodating
Title IX, while groundbreaking and transformative, had this effect on physical education in public schools
Reduced youth physical activity in public schools
Unlike our other epidemics, this is the reason why the obesity epidemic comes about
People don’t necessarily want to talk about the problem or a treatment
This is generally inversely related to physical activity, and is especially problematic for children and adolescents
Screen time
What are the 4 stages of disease progression? At which stage do physicians tend to intervene?
Susceptibility (lifestyle risk factors, genetics)
Pre-symptomatic (screening tests can see but not visible otherwise)
Symptomatic (we feel it) -- physicians rarely intervene before stage 3 or 4
Disability (affects our ability to live our life as we wish)
These are unintentional bases of resistance, and this is how physicians can respond to them in general
Forgetting, running out of prescription, incompatible lifestyle. Physicians can work to identify solutions to these to overcome them
Critser implicates these two food additives/ingredients in the obesity epidemic
High fructose corn syrup and palm oil
These are the four themes that Ward et al find in their study with obese African Americans
Study participants (1) do not like the term “obese,” (2) care about the physicians manner and timing in bringing up weight, (3) recognize the importance of a personalized approach, and (4) have mixed feelings on the effectiveness of scare tactics
We consider obesity to be a health crisis rather than a simple change because...
...it plays a role in so many chronic diseases
What is the structure of the chronic care visit? What role do patients play in each phase?
Opening - Patients can focus on how things are going very well or not well to set up a treatment change
Medication/Symptoms/Test Review - Patients can focus on how things are going very well or not well to lobby for or against a treatment change or justify non-adherence
Counseling (treatment changes or no changes) - Patients can resist. In chronic care we see different bases
This best explains the root of the deviant cases found in Stivers & Timmermans’ study of parents who resist treatment recommendations for their children with epilepsy
Physicians perceive the parents/patients to be stepping on their toes/questioning their medical authority
In the studies reviewed in lecture, ______ report willing to talk about weight in primary care visits while _____ believe that the other party is not interested in doing so
Patients; physicians
Note: this doesn’t mean that patients don’t intentionally or unintentionally discourage physicians from talking to them about their weight!
Gray et al conclude this about doctor’s use of structured versus opportunistic strategies when discussing weight with patients
Both can be utilized successfully
These are a few policy changes we can implement to curtail the obesity epidemic
1. Changing diet and increasing exercise at schools would make a big difference
2. Regulating high caloric foods, sugary drinks etc. including taxing empty calories is a way to preserve choice while disincentivizing unhealthy food choices
3. Providing more options for safe sports and exercise for children, particularly in inner city schools
4. Increasing health education about food, exercise, and food preparation