This morning at 8 a.m. (because doctors meet really, really early) Sam and I met on the fifth floor of St. Joseph’s hospital to give at talk at Grand Rounds in the Diabetes and Endocrinology Department.
We were invited quite some time ago because our friend, swimmer, and guest blogger Dr. Savita Dhanvantari has taken an interest in our feminist approach to fitness and thought we might have something worthwhile to share with the group.
I ran into Sam in the corridor, both of us looking for the classroom in the Diabetes Education Centre, having parked our bikes at different entrances. The hospital is a bit of a maze but we found our destination with a bit of time to spare, just enough to set up the slides.
About 20 people attended the early-morning presentation. The plan was that we’d talk for about 30 minutes and then have a Q and A.
Here’s what our objectives for the talk were:
1. To consider some of the barriers to women for participating in fitness activities
2. Provide a feminist context for the discussion, focusing on social attitudes, cultural expectations, conflicts between athletic and aesthetic values, assumptions about fitness and fatness.
3. Engage in a discussion about how to perpetuate positive messages that encourage women to get active.
Now, to readers of this blog, all of this is old hat. But most of the people we were addressing aren’t readers of the blog. They’re MDs who don’t usually spend a lot of time in sessions with philosophers, let alone bloggers, as the main speakers. Nevertheless, they were an attentive audience, with lots of nodding as we spoke.
We focused on five specific barriers:
1. Making fitness about weight loss
2. Focus on aesthetics instead of athletics
3. Gender gap in sports and fitness activities that starts in childhood
4. Unjust gendered divisions of work time and play time
5. Feeling excluded from gyms and other fitness spaces because of weight, age, lack of knowledge/skill, gender, clothing (a general perception of not belonging).
Then we gave a bit of a summary about why we consider our approach to be feminist. Apart from a consistent gender analysis, we think of our approach as feminist because:
- we talk about social attitudes that create barriers for women’s participation in physical activities (e.g. boys are encouraged to be more active than girls, women’s fitness focuses on weight loss and thinness, etc.)
- we talk about the social and cultural expectations and values that get in women’s way of pursuing fitness activities (e.g. obligations to put “family first,” gendered division of labor in the home shrinks available time, etc.)
- we shift the focus from fatness to fitness, from the aesthetic of normative femininity to what the body can do
We ended by making a few recommendations for how to shift the conversation in ways that might be more encouraging for people who have never been physically active, ways that might make them feel more open to trying to introduce physical activity into their lives. Here’s what we recommended as positive messages:
- Promote inclusive fitness
- Starting small is okay
- Find things people enjoy
- Make fitness a family thing
- Everyday exercise
- Stop focusing on weight loss as a measure of success
- Use your influence as MDs to shift to a message that works for more people
The Q&A was interesting for us. In addition to the usual sorts of questions about whether we thought things were any better today than, say, 30 years ago, quite a few people shared their experiences as clinicians. We heard the frustration they can experience when working with patients who, for their health, need to get active and yet don’t. But here’s where starting where they are, encouraging small steps, and being sensitive to the sorts of barriers that may stand in the way of people’s willingness to incorporate activity into their lives may make a difference.
My ears perked up when one of the doctors suggested that she was working towards getting rid of the scale in her clinic altogether (not quite there yet, but that it’s even being considered is amazing).
We just scratched the surface in the hour we were with them. There is so much more of a conversation to be had. Nevertheless, we appreciated the opportunity to talk to a group of physicians who work with people whose health is in peril and would improve if they became physically active. We hope our feminist approach made sense to them and gives them a different perspective, while also offering something useful and practical.
Thanks again for doing this! I myself was very impressed by the attitudes of the residents and the kinds of questions they were asking. I think there should be much more of a dialogue between clinicians and philosophers, and I hope that your presentation stimulated some thinking on how to approach the subject of exercise and nutrition within the doctor-patient relationship.
Thanks for the invitation, Savita. We had a lot of fun and the residents had great questions and comments. Most interesting when we have these conversations across disciplines. It’s an opportunity for both “sides” to see things a bit differently.
Its great to hear that these doctors are slowly coming around! You touched on something briefly, asking doctors to be more sensitive to their patients’ difficulties, but I wonder if the doctors had any thoughts about paternalistic, prescriptive doctor-patient relationships and how that affects both treatment and willingness to seek treatment? There’s a lot of repair that needs to be done. So many of us have our entire medical history filled with being told that we’re just doing everything wrong.
This is such a huge issue, isn’t it. Wasn’t it the impetus for the ground-breaking Our Bodies, Ourselves. Doctors do need to listen and interact with their patients in a more sensitive way. There were a few kind of shocking remarks that I chose not to blog about but that we attempted to address from our perspective. Thanks for your insight.
Wow, Wow, Wow! This is so great and your points are exactly like what residents and all providers need to hear. The next audience: insurance company policy makers. On the ground, there are lots of people working in community health centers (Dan among them) who are trying to get (meager) funding for programs to promote exercise and gentle culture shift (the latter being super-important for lots of groups). BUT- it’s really hard to get this funding, as it’s not procedure-centered (the way most healthcare is reimbursed), and the effects are long-term and diffuse. But there is data that they matter a lot.
I’ve been wanting to do something like this for a while, but your blog post is now going to get me going again. Thanks– I hope you both are realizing what widespread and positive effects this blog has on lots of people (I know, you’re blushing, but it’s true…) 🙂
Insurance company policy-makers! That’s a great idea. Let us know where you get with this – something else to blog about.
And we love you too. 🙂
There are also class issues docs and nurses doing health promotion need to be aware of, some of which intersect with gender in ways that really make formal exercise prohibitively costly to the patient. Some things docs and nurses doing health promotion should think about include issues like these:
-do you have a physically demanding job that leaves you sapped for what counts as the kind of exercise that is medically beneficial?
-do you have access to an affordable gym?
-in your community, are there facilities or groups/clubs that allow for exercising with other people?
– if you are a parent, do you have someone to watch your kids while you exercise? If you are a caregiver for an ill or elderly family member, do you have support to watch them while you exercise?
– if someone tells you to just walk more for exercise or to take up running, is your neighborhood safe for doing so at the times when you would be doing so, especially for women?
p.s.-I was sedentary for years at the end of grad school, with 2 kids. I moved for my first job, got a new doc, and we talked about fitness more than about weight loss. I told her I don’t exercise because I feel guilty coming home from work and leaving my stay-at-home-parent husband to go out again to the gym after he has been home with the youngest all day, and shepherded the eldest through getting home from school, etc. She ACTUALLY LISTENED, paused, thought for a minute, and said, “Did you know the local YMCA has drop-in childcare?” She looked up the prices for me: $1/hour/kid. It was the beginning of me getting fit again. No weight loss. But much improved functionality. When doctors REALLY LISTEN to the barriers patients say are in their way, it can lead to actual problem-solving. If it can’t, it can at least lead to more compassionate interpretation of patient non-compliance.
Alison, you are so right. We did talk about poverty and class as a barrier, noting that so much costs money. Doctors often think they can just recommend stuff and that automatically people are in a position to do it. Not so, and class/economic considerations play a huge role.
Slightly off-topic, but I’ve been thinking a lot recently about how many women athletes are clients of so-called complimentary and alternative medicine, even when the resulting therapeutic benefit is no greater than a placebo effect.
Many physicians believe that it it is unethical to recommend such therapies because it is impossible for the patient to give informed consent.
Yet, as G pointed out in another comment, there is a history of medical doctor’s paternalistic attitudes towards their patients.
But if this history is driving women to CAM practitioners, aren’t these women worse off? They have gone from MDs who offer therapies that work and for which they could explain the efficacy (if willing or able to take the time) to CAM practioners who offer placebos and no ability to meaningfully explain any therapeutic benefit. We have gone from “Trust me, I’m a doctor” to “Trust me, I’m a [CAM practioner]”. Don’t women interested in fitness deserve better?
In a word: yes. We do deserve better. Not a fan of CAM. But you’re right that it’s hard to find a medical practitioner in general practice who is very good with the concerns of athletes. I actually have had a lot more beneficial advice from my physiotherapist.
HI Suzanne– I share your concerns about CAM therapies that have little to no evidence-based effectiveness. However, some CAM therapies in some contexts have been shown to be effective on some measures. And re placebo (also a little off-topic here) here’s a link to a short but fascinating article on placebo use in medicine in the July 2 issue of New England Journal of Medicine by Ted Kaptchuck, who heads the Beth Israel-Deaconess Hospital research group on placebo use in all sorts of medical contexts.
http://www.nejm.org/doi/pdf/10.1056/NEJMp1504023
You’re right– women interested in fitness do deserve better from the medical establishment. We’ve all got a lot of work to do!
Catherine: Thank you for the linked article, which was very interesting. There is obviously still a lot of work to do to harness the same power of the mind that manifests in placebo/nocebo effects and still respects the patient’s intelligence and need for honesty.
Yes, i quite agree on one of the emphacy, that influence should be used to shift to a message that that works.
I would like to speak personally to some of the barriers our family has had to physical activities and also to some of the successes. I am a single mother for most of my children’s lives. All are in their teens now. 19 yr old daughter, 17 yrs old son, and my younges who is 15 yrs old and A gendered . Our barriers can be financial, which we overcome by going for walks, playing tennis or babminton together. Singly, we each have very busy lives and at times a very stressful relationship with thier father and his wife. To overcome those issues we always refer back to the basics…sleep, eating well, spending family time together, friends, and most of all physical activity. We live in a small town, we all have bikes, and are health minded. Still we also live in a red neck town, with a lot of barrier towards women, expecially single mom’s like myself and the challenges that brings into our lives. So… for this comment I would say how great to hear that there is a conversation about gender and activityies. I just completed two youth groups where we looked at gender specifically in how each gender has been socialized differently with expectations on ability and propriety in choosing appropriate activities. Our groups were aimed at breaking down those stereotypes for the purpose of helping youth discover thier own dynamic bent toward health, happiness, and being active.
K.
Your groups sound amazing. How wonderful it is to hear about another strong woman doing her part to change attitudes and promote equality. Thanks for your comment and for sharing your own experience, and doing what you can for your family and your community to make active living a regular thing.
Hi, It’s nice to hear from you. I am sorry I have been away for so long. We have just completed our move and are beginning our new life here. I will be on within the next two weeks to update my thoughts and would love to hear from anyone who would like jto comment.
I will be here soon.
Thanks again
K.
Good stuff. Those points are useful to give to every medical intern/physician.
Maybe…get that published in a national public health education journal? 🙂