Ann Silk, MD, worries about her
overweight patients. But Dr. Silk, an internal-
medicine resident at the University of Pittsburgh
Medical Center, isn't concerned only about their
diets and cholesterol levels.
She also worries that the fatty tissue on their
bodies will obscure other health problems, like
tumors.
Although excess weight is hard on a patient's
body, it's also hard on doctors who are trying to
perform physical exams.
Blood pressure cuffs have to be bigger.
Stethoscopes can't pick up subtle heart
abnormalities and lung sounds muffled by flesh.
And medical scales often max out at 350 pounds
-- making it hard to determine exactly how
overweight the largest patients are.
Moreover, excess body fat can interfere with a
doctor's ability to assess thyroid or liver health or
recognize abnormal growths.
Even with all the high-tech medical tools at their
disposal, doctors still find out some important,
potentially life-saving information by touching
and feeling their patients' bodies. Fat makes that
job much tougher.
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"It's a worry that we're not finding what we need
to find on exams because there is tissue in the
way of our fingers, and in the way of our
stethoscope," says Dr. Silk, who co-authored an
article about this problem in this week's issue of
the Journal of the American Medical Association.
"It leaves us with a little bit of uncertainty --
maybe you would even say insecurity -- whether
we are identifying all the abnormalities on [an]
exam."
In some cases, this uncertainty could lead to
missed tumors or other oversights, Dr. Silk adds.
"For the abdominal and gynecological exam, a
mass would have to be pretty big before you
could find it."
John Simmons, MD, an assistant professor of
family and community medicine at the Texas
A&M Health Science Center, in College Station,
says that doctors can't identify conditions such as
liver problems, hernias, and fluid buildup in the
abdomen through physical exams alone.
Still, he says, abdominal, breast, thyroid, and
genital examinations are particularly difficult in
obese patients.
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For this reason, obese patients should be
especially proactive about making sure they get
regular screening tests, Dr. Simmons says. If
necessary, they should "take it upon [themselves]
to remind the doctor of potentially embarrassing
but critically important screening tests like
mammograms, Pap smears, genital exams, and
colonoscopies."
The impact of obesity on physical examinations is
still a new area of research, Dr. Silk says. To her
knowledge, no studies have been conducted on
whether excess body fat can delay serious
diagnoses, and medical schools and textbooks
appear to be lagging behind the rise in obesity
rates.
More than one in three U.S. adults are obese, and
two out of every three are overweight. The
average American man and woman now weighs
195 pounds and 165 pounds, respectively --
about 18% more than they did in 1960.
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plans
Dr. Silk and her co-author argue that the standard
physical exam needs to be modified as a result.
Here are some of the changes they say doctors
and obese patients should consider during their
next physical:
Longer breast exams. Some data suggests
that a good breast exam takes three minutes per
breast, but even longer in a heavier patient, Dr.
Silk says. Doctors and patients should be
prepared to spend some extra time on breast
exams.
Rest before tests. Obese patients may grow
short of breath after walking even brief distances,
which could throw off readings for heart rate,
blood pressure, and breathing rate. If needed,
doctors should encourage obese patients to sit
quietly for 15 minutes before checking their vital
signs.
More elbow grease. Belly fat can make it
harder for doctors to feel for liver problems or
unhealthy fluid buildup in the abdomen, which
means doctors may need to press extra firmly or
spend more time on this area. "Patients have to
be good sports at tolerating vigorous exams," Dr.
Silk says.
Different instruments. Standard medical
instruments may not be sufficient to examine
heavier people. For instance, doctors may need
to use a handheld imaging device known as a
Doppler (rather than a stethoscope) to measure
heart rate in obese patients, and they may need
to use a longer speculum for gynecological
exams.
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people
These changes aren't likely to address all the
shortcomings of the physical exam, however.
Medical training and textbooks will eventually
need to be updated to reflect the obesity
epidemic, Dr. Silk and her colleague write, and
some doctors may need to invest in new
technology and equipment.
Source: Http://edition.cnn.com/2011/HEALTH/01/14/obese.doctor.overlook/
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