I’m sometimes not sure whom I make madder: some kids, some parents, or some insurance companies!
Making kids mad:
Me: “Jill, help me understand why your weight would be way down this week?”
Jill (shrugging): “I don’t know. I actually exercised less and ate exactly what I was supposed to.”
Me: “OK. I guess your body is just telling us you need more food.”
Jill: “What!!?? No way! I refuse to have more food.”
Me: “Well…. unless you can think of something that didn’t go quite the way it was supposed to, we’re left with the inescapable conclusion that you need more fuel.”
Jill: “No I can’t”. Turning angrily to her mother “I warned you, mother. I will never accept more food. There’s 250 calories in a yogurt (guessing this would be my suggestion) and I will not add 250 calories to my day. I don’t need it! You can’t make me!”
A discussion about balancing intake and energy output fell on deaf ears and Jill stormed out the door. Mom waited behind.
“I think she is just sick of yogurt, doctor,” Mom said.
Me: “No, Nancy, it’s not that she is sick of yogurt. She told us what she doesn’t want: she doesn’t want ‘another 250 calories’.”
Nancy: “But maybe if she was offered other things….”
Me: “She could, of course, have other things, provided they contained the same quality and quantity of calories and the balance of fat, protein and carbs. But she won’t accept them either. Look at her food journal: she eats exactly the same thing every day, by her own choice. It’s not about which food we suggest, she just doesn’t want more calories.”
Making parents mad:
Me: “Looking at these food journals, Will and Petra, I wonder which of you eats with Tom for breakfast and dinner?”
They look at each other. Petra replies, “Well…. we’re both around. We put Tom’s breakfast on the table and he eats it while we are getting everyone else ready for the morning.”
Me: “But what do you eat?”
Petra: “I have black coffee. I’ve never been a breakfast person”.
Me: “But Petra, think of the message. You are in charge of Tom’s food and he has to eat what his treatment team has decided he needs. But if you fast while he eats, he will never believe that it’s ok to eat.”
Petra: “Well, doctor, I am telling you right now that I won’t eat breakfast because I never have and because I don’t want to gain weight myself….”
Me: “So let’s talk about family dinners, then. As you know, Kartini parents commit to family dinners. Will, you said you could be home at 6:30 every night, and Petra you said you could have dinner on the table at 7. It seemed like a good plan. But I notice on the food journal that this is not happening and Tom told me about how angry he got when he ate at 8 PM one night and 5:30, on his own, the next.”
Will: “Yeah, but when do I get to work out? I used to use the dinner time for my work outs. I have a high stress job. I need to exercise.”
Me: “well, if you work out instead of eating dinner with the family, think how it will make Tom feel. Also, your wife will have gone to the effort of putting dinner on the table….”
Will: “Well, not exactly. She makes dinner, but everyone eats separately because of our schedules. Mostly, the kids eat on the couch in front of the TV….”
*Sigh* Mom is already mad that she can’t restrict meals according to her old routine and dad that he can’t use the dinner hour to go to the gym. Family dinners are perfunctory, strained, and need the television to keep people in the same room. Where to start?
Making insurance doctors mad:
My medical assistant: “It’s Dr. Marvel from the insurance company for Adrienne, doctor.”
Me: “Hello Dr. Marvel, I understand that you’ve decided to recommend that PatientsFirst Insurance stop paying for the intensive outpatient level of care for Adrienne.”
Dr. Marvel: “That’s right. This kid weighs enough, in my opinion, and doesn’t need this level of care anymore.”
Me: “But Dr. Marvel, she has been sick for four years and in intensive outpatient for three weeks. Who gets well in three weeks? She is still substantially below her premorbid weight and has no period. Furthermore she is wracked with eating disorder thoughts and guilt. She has just opened up in group about processing these feelings.”
Dr. Marvel: “Right. But she weighed too much in the first place. According to insurance tables, she should weigh even less than she does now.”
Me: “Well how do you explain her amenorrhea?”
Dr. Marvel: “just give her a year. Maybe it will come back. Besides, we don’t see that your family therapist is focusing on the real issues. For example, why does the kid choose this eating disorder as a way of expressing her distress in the first place? What role have her parents played in this? I see that they went through a separation a few years ago. Why isn’t that be focused on in family therapy? How is their dysfunction maintaining her eating disorder?
Me: “Dr. Marvel, parents don’t cause eating disorders. I would be very unhappy if our family therapists did ‘work’ with the parents that suggested that they did’”.
Dr Marvel: “That’s just your opinion. Anyway, she is weight restored and so I can’t authorize this level of care.”
Me: “No one can tell how severe an eating disorder is just by looking at insurance chart weights. This child is suffering terrible eating disorder thoughts and the family is just learning how to support her. If you won’t authorize more treatment, I guess you will have to recommend according to your conscience.”
Dr Marvel: “What do you mean my conscience? I don’t appreciate you saying that. What does that have to do with it?”
Now, actually, in this case I guess it’s more about them making me mad…..