The Damage That Doctors Do

[BearBones]

While there are certainly problems with how our culture perceives the role of medical practitioners, it is disingenuous to not hold practitioners equally (or more) responsible for the state of the culture.

Like financial advisors, doctors don't make money by saying "there is nothing I can do for you".

I will post only once, since I don't think that I am going to change anyone's opinion here. There are a lot of valid complaints posted in this discussion, but there is also a ton of overgeneralization and misrepresentation of medical data.

It should come as no surprise that not all health care practitioners are equally competent. We have the same variability and inherent limitations as all humans. And among the majority of doctors who are competent, some styles fit well with some patients and don't fit well with others. Shop around. Most of us on this site tend to be intelligent, curious, and motivated, so naturally we want someone who is humble, takes time to explain, who discusses "alternative" therapies, and who leaves us feeling empowered. But unfortunately this is not how a large proportion of the patients who most heavily utilize the nation's health care resources feel, in my experience. Many are not given the same level of intelligence, motivation, self control, or self love/respect that it takes to heal themselves. They are out of control, and they desperately want to be fixed. Do any of you have habits that you have trouble correcting, even if it interferes with your well-being? Then why do you think that the 350 pound patient just needs to be told that they need to stop ingesting so many calories? They know that. They just can't stop eating! Similar for the patient about to undergo their third coronary stent who needs to quit smoking. The clinically depressed who would benefit from 45 minutes of meditation daily. The diabetic that has retinopathy because they don't want to take their disease seriously.

The bottom line, as a health care provider, I agree with a lot of your sentiments. There are definitely some bad apples out there, and the system is imperfect.  It is unfortunate in many ways that medicine has become suffused by capitalism. But this discussion has become rather one sided and narrow minded, IMO. If you feel otherwise, remember your posts when you or someone in your family suffers from multiple trauma, develops severe lupus vasculitis or acute leukemia, or loses vision from a surgically repairable retinal detachment. Modern medicine is flawed, but it is also full of miracles if you open your minds and look in the right places.

[AdamA]

If you feel otherwise, remember your posts when you or someone in your family suffers from multiple trauma, develops severe lupus vasculitis or acute leukemia, or loses vision from a surgically repairable retinal detachment. Modern medicine is flawed, but it is also full of miracles if you open your minds and look in the right places.

I agree with you 100% BearBones. 

I just think that the success we have had treating certain illnesses (such as those you mentioned) has created the expectation that there is a pill or procedure for everything.

[MediumTex]

I very much appreciate the feedback from the medical professionals (and everyone else).

I don't mean to suggest at all that there is any generalization that can be drawn about all doctors all of the time.  I have just noticed certain patterns of dysfunctional approaches to diagnosis and treatment that seem to originate in the items I listed in the OP.  Although I wasn't thinking about it when I wrote the OP, I had the unpleasant experience in 2004-2005 of watching my Dad get diagnosed with stage III lung cancer, battle it fiercely, see some successes, and ultimately die.  I share that experience because I spent countless hours during that time getting to know various doctors and I was generally impressed with them.  I did learn from that experience, though, that chemotherapy for advanced lung cancer is probably not worth the trouble.

If I were a doctor I am certain that I would be endlessly frustrated that some of my patients didn't want to get well as much as I wanted them to (or at least weren't as focused on the task as I would be).

If I were to create a health care system from scratch (and money was not a primary consideration) one thing I would do would be to assign each patient with a serious illness a "patient advocate" who would be a retired or active medical professional.  The patient advocate would have to have one of those project manager-type personalities and would basically be there to listen to what the physicians were telling the patient, raise issues, ask questions, explain things to the patient, and generally act as a quality control agent.  I think that sick people with family members who are highly engaged with their medical care (and are acting in a "patient advocate"-type role) probably get much better treatment outcomes than those people who are basically on their own while in the hospital or during the course of their treatment.  I hate to put it this way, but a sick person by himself is much easier to take advantage of (or maybe just provide a little lazier type of care to) than a sick person who has someone looking out for his interests all of the time.

I read an interesting article a couple of years ago about how in cultures that resist labeling mental illness as mental illness tended to see higher recovery rates because people with minor mental illnesses were less likely to be singled out as being crazy or otherwise mentally unfit and thus were more easily assimilated back into society when they recovered.

I haven't heard much defense of antidepressant medications.  I really think that many of those medications make people worse off, and the people often don't have a clue about what is happening to them.  I am sure they do help some people, though.

I enjoyed reading that article that came out a few weeks ago about how physicians are far less likely to pursue every imaginable treatment option when faced with a life threatening illness, even thought they suggest and/or provide the same treatments to their patients every day.  That didn't surprise me at all. 

[stone]

TripleB

25% of medical problems have cures that are worse than the disease (i.e. chemotherapy)

I think it is well worth taking chemotherapy in many cases. I took CHOP for non-Hodgkins Lymphoma and eight years later I'm still fine. Thanks to Texas where CHOP was developed . http://en.wikipedia.org/wiki/CHOP
In no way would I say that the cure was worse than the disease. Most of the time during therapy I felt less unwell than I did from the symptoms of the cancer before starting therapy. I don't think anyone ever used to survive aggressive non-Hodgkins Lymphoma before chemotherapy.

[stone]

Medium Tex, I know that at the hospital where I was treated, every patient's lymphoma treatment plan is decided by a meeting of all the lymphoma consultants together and all lymphoma pathology gets a second opinion by a pathology review. I'd rather have my treatment decided by a group of front line medical people than it being influenced by an advocate. I think an advocate is a very awkward concept. Surely every doctor should be an advocate too. If doctors fail, then why wouldn't advocates fail too? It seems a bit like the investment adviser conundrum. Do you think you would solve the problem of getting duff investment advice if you always had a retired investment adviser with you as an advocate whenever you saw your investment adviser?

I suppose my lymphoma treatment didn't involve anything like the same dilemmas as often crop up with say lung cancer. My cancer had a good chance of curative treatment so choosing that was a no-brainer. Things get more complex where their is an awkward trade off between what is the optimal treatment from a palliative point of view and what is the optimal treatment for extending life. That is especially true when things are probabilistic. So if there is a 10% chance that a very unpleasant three month treatment will extend life by two years, is that worthwhile? Perhaps advocates could play a useful role as people who tried to gather what each patient's personal choice was for such complex situations.

[AdamA]

I'd rather have my treatment decided by a group of front line medical people than it being influenced by an advocate. I think an advocate is a very awkward concept. Surely every doctor should be an advocate too... I suppose my lymphoma treatment didn't involve anything like the same dilemmas as often crop up with say lung cancer.

Surely doctors should be advocates, but no matter how well-intentioned a physician is, there are always biases and conflicts of interest. 

I think part of his point is that it may have been helpful to have had someone around who could have helped him tease out the difference between lymphoma and lung cancer prognosis-wise.  His Oncologist may have steered him toward a more aggressive treatment than he might have opted for, had he clearly understood the likely outcome. 

[MediumTex]

I'd rather have my treatment decided by a group of front line medical people than it being influenced by an advocate. I think an advocate is a very awkward concept. Surely every doctor should be an advocate too... I suppose my lymphoma treatment didn't involve anything like the same dilemmas as often crop up with say lung cancer.

Surely doctors should be advocates, but no matter how well-intentioned a physician is, there are always biases and conflicts of interest.  

I think part of his point is that it may have been helpful to have had someone around who could have helped him tease out the difference between lymphoma and lung cancer prognosis-wise.  His Oncologist may have steered him toward a more aggressive treatment than he might have opted for, had he clearly understood the likely outcome.  

In health care settings it has been my experience that the squeaky wheel often gets the most grease, and it's hard to make the right kind of squeaks when you are facing death.  If, however, you are a loved one of the patient, you can make strategic squeaks that can result in a much higher level of overall engagement from the medical professionals.

Here is a very typical example: my Dad saw many new specialists and each time I would go with him to meet the new doctor and go over what we were going to try to do.  During these meetings I would go over the whole history of the disease diagnosis and treatment, along with how he had responded so far (including the many different setbacks he had experienced).  During these meetings I almost always felt like I pointed something out to the new doctor that didn't necessarily leap off the chart, but which I considered very important.  

Another thing I encountered frequently was nurses who needed to be reminded of the way things were supposed to be done.  It was helpful that my aunt (Dad's sister) is an ER nurse and was around much of the time.  Sometimes it was just reminding them that a bandage was supposed to be adjusted every four hours, rather than six hours.  Other times it was making sure they were gentle when moving him from one place to another.

One thing I found in dealing with his medical team is that it seemed like the doctors appreciated having someone in the patient's family who understood where we were headed and who could help smooth over the inevitable bad news that they were probably going to have to deliver.  If I were a doctor it would break my heart to have to tell a family that a patient was going to die and have them react as if they hadn't seriously considered that possibility before.

Also, and I think this a very subtle but important point, if the patient has someone in a patient advocate role that he/she really trusts, it can free up the patient to not worry so much about keeping up with everything.  My Dad knew I was always on top of everything for him and I would be willing to be his advocate for anything he needed and I think it really reduced his stress level (I think it also provided him with the luxury of being able to believe things that comforted him but which deep down he probably knew were not true about his overall situation).  Thus, when he had an issue with a nurse or doctor I could present his concerns with a clear and calm mind (he was often under the influence of various medications) and I almost always felt that this approach was more effective (not unlike the way it's more effective to have an attorney representing you in a legal matter). 

I think that doctors are like many professionals in that they feel a personal and professional responsibility to every patient/client/customer, but in practice some patients get more attention than others, and at the end of the day some patients do get a more attentive form of care than others.

[AdamA]

MT--

Thank you for posting that.  You make some great points, and seem to have very good insight as to how the medical system actually works.

[MediumTex]

MT--

Thank you for posting that.  You make some great points, and seem to have very good insight as to how the medical system actually works.

Here is a question for you or anyone else who wants to take a crack at it:

Do you notice that very obese people sometimes get a different level of engagement from physicians than people who are not obese?

My sister in law passed away a few years ago (about a year after my Dad) and I was very surprised at how obviously different the attitude seemed to be toward her based on her weight.  I was not really involved in her treatment at all, so this impression is based on a few hospital visits, secondhand conversations, and casual chats with her doctors.  Part of it probably was based on reality, since obesity beyond a certain point apparently disqualifies a person from some types of treatment, including certain organ transplants, but part of it seemed like they just didn't want to try as hard because they didn't feel she had taken as good a care of herself as she should have (I hate to say that, but that is my honest opinion).  She was also in a regional hospital that seemed a lot more casual in their overall approach to care, and she was also from a lower socioeconomic background (unfortunately, I think this also sometimes makes a difference).  The whole situation just felt very different from what I had gone through with my Dad.  It was very sad.  The first time I spoke with one of her doctors I had the same attitude I had with my Dad's situation (and he was in a lot worse shape than she was much of the time) and I basically asked the doctor "What's your plan to win?" and the doctor acted like she didn't know what I was talking about.  It was heartbreaking to me to sense that no one seemed to really be intensely interested in her getting better.

Her husband never challenged the doctors, never questioned them aggressively about the overall situation, and just went along with everything they said.  I could sense that he was a little intimidated by the doctors, and I think that he assumed that they were doing everything they could for her, and maybe they were, but her weight definitely seemed to color the way the doctors approached the whole situation.

Has anyone else seen this sort of thing?

[stone]

Medium Tex, was her fatal illness unrelated to her obesity or was she basically dying from obesity? I suppose for people who are dying from obesity, doctors feel hopeless. Is there any merit in viewing obesity as a mental health issue much like gambling addiction but with fatal rather than financial consequences? I suppose doctors are faced with the tragic statistics of just how few morbidly obese people actually succeed at overcoming obesity and maintaining a safe weight.

[MediumTex]

Medium Tex, was her fatal illness unrelated to her obesity or was she basically dying from obesity? I suppose for people who are dying from obesity, doctors feel hopeless. Is there any merit in viewing obesity as a mental health issue much like gambling addiction but with fatal rather than financial consequences? I suppose doctors are faced with the tragic statistics of just how few morbidly obese people actually succeed at overcoming obesity and maintaining a safe weight.

She had hepatitis C and was on chemotherapy for that (I don't recall the name of what she was taking).  She was moving some furniture in her house and injured her neck or back and wound up in the hospital because of the pain.  While there she picked up the staph infection (which I'm sure spread more easily with the weakened immune system from the hep C treatment) and she died a few days later.

Weight was not a factor in the basic health issue, and she was not morbidly obese, just what you might call "thick and solid."

[stone]

Medium Tex, my Dad always gets dressed up very smartly before seeing the doctor and says that it is vital to appear as someone who's life is worth saving . What you are saying makes it sound like he has a point.

[BearBones]

Medium Tex, my Dad always gets dressed up very smartly before seeing the doctor and says that it is vital to appear as someone who's life is worth saving . What you are saying makes it sound like he has a point.

Perhaps. But in most cases, it may be your father's attitude rather than his dress that makes a difference. IMO, if you want the best care, do the following:

• Be interested and engaged in your health. Most doctors naturally enjoy treating patients that are involved much more than those that are disinterested and/or do not follow through with appropriate medical advice.
• Bring someone else into the room for discussions, if possible. An involved spouse or family member is often best. Four ears is much better than two, and this also shows multiple levels of interest.
• When discussing interventions, particularly those in which decisions are not straight forward, always ask "What would you do if it were you (or your mom, dad, etc). I find that patients often choose rather aggressive care when they are scared, but when they hear that I would choose something less aggressive, they are able to give up some of their fear or relinquish some of their need to control (i.e., not take risks in an attempt to try to change poor outcomes of disease when very low probability of altering outcome).
• Start with a friendly demeanor and open mind. Doctors are human, and we like to connect with our patients. Most are not ignorant, unethical, or unduly motivated by profit. When verbal or non-verbal feedback shows that you are mistrustful or angry (as many posting here seem to be), a healing relationship becomes very difficult.

[AdamA]

Do you notice that very obese people sometimes get a different level of engagement from physicians than people who are not obese?

I had to think about this for a while.  

I don't think that obesity has an influence on the way I practice medicine in the acute care setting as far as objective evaluation and treatment are concerned.  

But as far as "level of engagement" goes, I'm sure this is affected in some way, not just by obesity, but by any characteristic a patient may have that is unappealing to me.  My body language is probably less friendly, I probably chit chat less, and may hurry a bit more than usual to disposition them.  (For the record, I am very aware of this tendency, and do a few things in my practice to try to make up for it, like always sitting down in the room next to the patient's bed, always introducing myself, and always thanking patients for coming into the department).  

She was moving some furniture in her house and injured her neck or back and wound up in the hospital because of the pain.  While there she picked up the staph infection (which I'm sure spread more easily with the weakened immune system from the hep C treatment) and she died a few days later.

 

That's terrible.  I think this kind of thing happens more than most people are aware.  I'm sure the physician who admitted her had the best of intentions, and probably had no choice if her pain was that bad, but that exact scenario is the reason I try to keep people OUT of the hospital unless it's absolutely necessary.

[MediumTex]

• • Start with a friendly demeanor and open mind. Doctors are human, and we like to connect with our patients. Most are not ignorant, unethical, or unduly motivated by profit. When verbal or non-verbal feedback shows that you are mistrustful or angry (as many posting here seem to be), a healing relationship becomes very difficult.

[/quote]

I can only speak for myself, but I am not mistrustful or angry toward doctors at all (I don't know if my prior posts may have suggested I was).

The OP was aimed at a very specific kind of disservice that I think some doctors can provide when a patient is looking for an answer where there may not be one. 

More generally, the only kinds of doctors that really bug me personally are those who carry a chip on their shoulder and talk to patients and family members like they are guinea pigs in a lab trying to tell the scientists how to perform the experiments.  What percentage of overall doctors would you say fall into this category?  I would say it is maybe 15% or so.  I assume you have encountered such people in your travels.  What's it like to work with people like that?

As I have thought about this topic, I think that there are many parallels between doctors and attorneys, with a small percentage of jackasses messing things up for many of us who are sincerely interested in being helpful to our patients/clients.

Rather than mistrustful and angry, I would describe myself as skeptical but open minded.  My trust is always earn-able, though.

[MediumTex]

On the subject of getting better care if you are in good physical shape to start with, I think that this principle pops up in many settings.  For example, I think that your car gets better treatment at a garage if it is clean when it arrives and appears to have been well cared for.

I think that there is also a socioeconomic and educational component that often pops up in medical care.  It's similar to what happens to defendants in criminal cases.  The more money and education they have the better outcomes they tend to get.  Part of it is I think that the attorneys and jurors tend to see a person who is more like them to be less deserving of harsher punishment.  Another part is obviously that the person with the money and education can buy more effective access to more favorable outcomes (favorable for them, anyway).

Through a strange series of events, I once found myself working a booth at a medical trade show where my job was to pull doctors and their families into the display where they could have their pictures taken with a dragon that represented indigestion (I think).  Seeing hundreds of those people with their families in an environment like that was a really interesting experience.  I felt like an anthropologist doing field work.

[Gosso]

• Start with a friendly demeanor and open mind. Doctors are human, and we like to connect with our patients. Most are not ignorant, unethical, or unduly motivated by profit. When verbal or non-verbal feedback shows that you are mistrustful or angry (as many posting here seem to be), a healing relationship becomes very difficult.

My post on depression likely came off as emotional and ignorant, but it was meant more for the family member to smarten up.  I realize there are other possible causes of depression beyond just lifestyle, which may be out of the patients control.

Having said that, if I place myself in the shoes of a doctor I would likely become numb to the continuous stream of unhealthy and unmotivated people flowing through my office.  Most of these people would be looking for a quick fix, when in reality what is needed is a complete overhaul of their self-image and lifestyle.  I would give them a list of things they can do to improve their lifestyle, and then prescribe some pills to keep them happy.

It seems doctors are expected to correct all the damage our culture inflicts on our bodies and minds -- and that is not right.  Unfortunately shit flows downhill.

I have suffered from anxiety in the past, but I never consulted a doctor or therapist regarding it.  I am very glad I did this since the anxiety acted as a catalyst to search for answers and improve my life.  If I would have been on medication then I would have the same horrible habits that increased the anxiety in the first place.  I am by no means out of the woods yet, and probably never will be, but I personally see the anxiety as a blessing.  I realize that this is a minor aliment compared to what other people are going through, but it may not be wise to so quickly write-off what Mother Nature is telling us.  I also realize most people do not have the will power that I have, and in their cases maybe they need medication just to get through life, but in my eyes that is very sad.

Of course these comments don't apply to cancers, major injuries, surgeries, etc.  In these cases, drug me up, cut me open, and lets fix this thing!

Edit: Spelling

[TripleB]

Do you notice that very obese people sometimes get a different level of engagement from physicians than people who are not obese?

Yes. Obese people get reduced levels of engagement from physicians. Obese students receive reduced levels of engagements from teachers and everyone else they interact with. Obese people earn less money at their jobs. Obese people have higher rates of depression.

Whether we want to admit it or not, people in today's society view obese people as lazy and weak-willed.

Back to the medical discussion, doctors who know a patient's history is filled with alcoholism or substance abuse will provide a reduced level of care.

To the doctors: think about this. Patient presents with altered mental status brought in by police. Patient has a history of 5 DUIs and cirrhosis of the liver. You will probably check blood glucose levels, but is your first thought AMS due to hypoglycemia or is it just another drinking binge?

Everyone has innate biases, including doctors.

[Reub]

When my mom was in intensive care shortly before she died, the doctors used to come into her room on their daily rounds and ask me to leave while they discussed her condition. To this day I felt that I should have been allowed to hear every word of what they were saying and I resent them for it to this day.

[MediumTex]

When my mom was in intensive care shortly before she died, the doctors used to come into her room on their daily rounds and ask me to leave while they discussed her condition. To this day I felt that I should have been allowed to hear every word of what they were saying and I resent them for it to this day.

That's not a very nice thing to do.  It's disrespectful at best.  If there was some specific reason that they needed to talk privately, they should have told you.

As polite and courteous as I try to be, in that situation it would have been hard not to say something like: "You know what, why don't we go ahead and wheel the patient out, too.  I wouldn't want any of us to accidentally overhear anything you're discussing.  We'll just wait out in the hall until you're done."

[BearBones]

My post on depression likely came off as emotional and ignorant, but it was meant more for the family member to smarten up.  I realize there are other possible causes of depression beyond just lifestyle, which may be out of the patients control.

Having said that, if I place myself in the shoes of a doctor I would likely become numb to the continuous stream of unhealthy and unmotivated people flowing through my office.  Most of these people would be looking for a quick fix, when in reality what is needed is a complete overhaul of their self-image and lifestyle.

My comments above were more directed to those who were posting rather blanket statements about such things as chemotherapy and gastric bypass surgery. Stating that gastric bypass surgery "kills people" (or something to that effect) has its own biases toward the obese, IMO. Many people (smart people, wonderful people) have trouble with weight. They try all sorts of things: fad diets, medications, counseling, hypnosis, and everything turns up short. They just cannot do it. I was so skeptical about gastric bypass (and I do not do it), but I have now seen so many people that have had their lives completely turned around because of it. Joy and exhilaration like I have not seen before. It must be like being freed after a long prison sentence.

So I agree with you. The difficult path is often much more healthy and long lasting than the quick fix when it comes to such things as depression, anxiety, and eating disorders. And doctors too often go for the quick fix. But there are times when such things as antidepressants (short term) and gastric bypass can be life savers.

[BearBones]

So I'll reiterate: while I certainly agree that there do exist patients who are "anxious wimps" (just like I think there are physicians who are bad apples), I think a large majority are fundamentally not (just like I think most physicians are good people).  However, I also think that those in the medical profession are the only ones who have the power to change how the population at large views them and their role.  It won't be easy, and would take time, and would probably result in less money in their pocket, but it could be done.

Agree. And in some fundamental way, we all do the best that we can do with our lives, given our nature and nurture (or lack thereof). So the "wimps," the anxious, the depressed, the lazy, and the obese deserve as much empathy and care as others (and generally quite a bit more).

[Gosso]

My post on depression likely came off as emotional and ignorant, but it was meant more for the family member to smarten up.  I realize there are other possible causes of depression beyond just lifestyle, which may be out of the patients control.

Having said that, if I place myself in the shoes of a doctor I would likely become numb to the continuous stream of unhealthy and unmotivated people flowing through my office.  Most of these people would be looking for a quick fix, when in reality what is needed is a complete overhaul of their self-image and lifestyle.

My comments above were more directed to those who were posting rather blanket statements about such things as chemotherapy and gastric bypass surgery. Stating that gastric bypass surgery "kills people" (or something to that effect) has its own biases toward the obese, IMO. Many people (smart people, wonderful people) have trouble with weight. They try all sorts of things: fad diets, medications, counseling, hypnosis, and everything turns up short. They just cannot do it. I was so skeptical about gastric bypass (and I do not do it), but I have now seen so many people that have had their lives completely turned around because of it. Joy and exhilaration like I have not seen before. It must be like being freed after a long prison sentence.

So I agree with you. The difficult path is often much more healthy and long lasting than the quick fix when it comes to such things as depression, anxiety, and eating disorders. And doctors too often go for the quick fix. But there are times when such things as antidepressants (short term) and gastric bypass can be life savers.

I agree with a lot of what you said.  But I still think people are looking for the quick fix from a doctor rather than looking at all the factors.  For example, an obese person will look for the fastest solution for eliminating their excess weight.  IMO that is not the right way to look at it, the weight is not simply from eating too many calories but rather a combination of many factors (stress, sleep, exercise, diet, human contact, etc).  If they take the focus off their weight and improved their lives then I assume the weight would take care of itself (no I don’t have any scientific data to back this up).

This path is far more difficult and painful, and most people are unwilling to follow it, but the rewards are far greater.  Unfortunately the doctor is limited in their ability to help the patient with this, and this is something the patient must do for themselves.  In some cases medication will be needed to just help the person cope, but they need to realize that they have not received "the cure."

Okay, the Tony Robbins seminar is over…that’ll be $2,000. 

Actually I just plugged Tony Robbins into Youtube and found this very candid interview with him where he discusses the over medicated population (12:32):

http://youtu.be/etArvM1WUE4

He is a freakin' GIANT!

[stone]

I think obesity is a very very tricky issue. Perhaps it is a mistake to medicalize it. Perhaps for some people it is a choice that they don't consider a problem. Beth Ditto seems content and I guess she has just as much right to be obese as anyone has to ride a motor bike or go wing-suit flying or whatever.
Gastric bypass surgery is genuinely dangerous isn't it? I thought many people managed to "overcome" the surgery by constantly sipping melted chocolate bars etc. I guess a sort of lifestyle transformation is what someone wanting to reverse obesity really needs and perhaps doctors really aren't the people best placed to help with that. Perhaps people who previously were obese could provide more useful guidance and support and no medical training would be needed and actually would simply be wasted and better used for actual "medical" tasks?

[smurff]

Sometimes the drugs prescribed to treat other serious diseases lead to alterations in the persons metabolism, water retention characteristics, brown fat percentage, etc.  The result was iatrogenic overweight or obesity.  The choice for many of the patients  whose bodies react like this is be fat or die (or at least suffer serious misery from the disease).  

As I recall something like this happened early in the days when drug cocktails were prescribed for treating HIV. (I've forgotten what those drus were called.). One side effect that often appeared was a buffalo hump. I think the protocols have changed so this does not happen as much but before the doctors figured it out, the choice for the patients who developed them was buffalo hump or death.

Some people are also marked by genes to store fat efficiently--so efficiently that they become overweight or obese, even with exercise and good diet.  Give them medicines that alter metabolism as a side effect and things can become grim, weightwise.

As for bariatric surgery:  apparently it cures type 2 diabetes so well that doctors are researching the issue and considering it for type 2 diabetics whose weight falls below the traditional Body mass index guidelines for these surgeries (there are several types, some of which are more effective as treatment than others).