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The head and the heart

Katers, Laura MS, MCHS, PA-C

Journal of the American Academy of PAs: September 2015 - Volume 28 - Issue 9 - p 1–2
doi: 10.1097/01.JAA.0000470446.74144.c5
Mindful Practice

Laura Katers practices primary care at a community clinic for the underserved in Seattle, Wash. The author has disclosed no potential conflicts of interest, financial or otherwise.

Tanya Gregory, PhD, department editor



I first met Leona when she was assigned to our clinic after an ED visit.

Leona was my age, hadn't been to a medical provider in more than 15 years, and was tipping the scales at 370 pounds. I knew nothing about her other than what was on the discharge paperwork from the ED, her subsequent hospital stay, and the fact that she was morbidly obese.

Genetics are a funny thing. My mom's side of the family tends to be heavyset, big breasted, and stocky. On my dad's side, however, everyone is lean, with a more athletic build. As fate would have it, I inherited my father's lean physique.

Before I started practicing medicine, I often wondered how patients would respond to me talking to them about their weight. One of my professors confessed that discussing obesity with a patient was often a waiting game, or “weighting” game. Who would bring it up first? Would the discussion arise only out of genuine concern for progressive back pain, or other more worrisome comorbidities such as heart failure, or a blood clot in the head or heart? Would I discuss obesity only after a patient's life was on the line?

That's how Leona came to me. On a Wednesday afternoon, she experienced sudden chest pain, began gasping for air and told me she felt like an elephant was sitting on her chest. Luckily for her, the pulmonary embolism was caught early; she was hospitalized, stabilized, and put on anticoagulants. As terrifying as the experience had been, it could have been worse—and she knew it.

She confessed that she hadn't exercised in years. She took care of the house but never ventured far from it. Her mobility was becoming limited by worsening osteoarthritis in her knees, but she refused to walk with a cane, declaring, “I'm only 37!” Surprisingly, her laboratory results were normal. No hypertension, diabetes, or high cholesterol. There was, however, 370 pounds to talk about, a good 200 pounds more than her 5'3” frame was designed to handle.

Recent evidence suggests that the main difference between people who become obese and people who maintain a healthful weight isn't so much what they put in their mouths but rather how sedentary they become. As a society, we don't move very well. Or rather, we move frantically in many directions but not in ways that actually improve our cardiovascular fitness. To paraphrase the Sufi poet Rumi: All of life is a frantic running. But, from what? Where had Leona gotten off track? What was her story?

As so often happens in the practice of medicine, investigation is critical and creativity is key. You learn tricks and tips from seasoned providers along the way. You hear the pearls thrown in at the end of lectures. When it is you and a near stranger sitting in a room talking about the fine intricacies of that person's body, however, there are few rules. In my first year of practice, I have become more realistic about goal setting with patients. Their idea of fit and healthy may not be the same as mine. But I've worked around the excuses patients offer that limit their movement and ability to exercise, and they are valid reasons: unsafe neighborhoods, the cost of gyms or classes or a patient's discomfort in attending either, the logistics of transportation. So, I found YouTube videos of yoga stretches patients could do at home in their underwear, for free. I found phone apps to help with fitness tracking. I helped patients use maps to find steep hills to walk up. I reminded patients that jumping rope only required two things: a tiny space, and a rope.

Often the best predictor of whether patients follow through with an exercise plan is if they revisit something they liked to do when they were younger. What I envisioned for Leona was movement. Something that would get her out of a chair or a bed.

We stumbled a bit, hit a crossroad. She had never properly exercised, she admitted. But ... but ... she used to dance. It was something she did with her aunts when she was younger, usually when they were cooking at family gatherings. That was it. I thought back to myself just that morning. With my own roommate recently out of the house, I suddenly had room to do one thing I usually didn't: dance. During the course of several weeks, Michael Franti & Spearhead blared from my own computer speakers. Ozomatli, Metallica, Trampled by Turtles, and the fast-paced strings of bluegrass.

“Dancing! That's it!” I grinned. Leona's eyes lit up, wide as saucers.

“I can dance?” she asked. “That counts?”

Leona left that visit with a treatment plan and a prescription: Dance to one song every day. After 1 week, increase to two songs. She already knew which song she'd start with: a hot single at the time, Meghan Trainor's “All About That Bass.”

Leona moved away with her family several months later. Before she left, she was up to five songs in a row of dancing daily. Fifteen minutes of exercise. A wonderful repercussion of her own movement was that her two young children looked forward to this “dance time” as well.

She stopped by briefly on her way out of town to pick up her medical records. I set her up with a primary care clinic in the town she was moving to.

“You will keep on dancing, right?” I asked.

“You bet,” she said loudly, and proudly, as she walked out the clinic door. “Now, we are on to Bruno Mars.”

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