Real-Life Decision Making
Sarah walks into your clinic and leans on your desk. She's wheezing slightly. "I'm a bit of an asthmatic," she says. "But I love to exercise, and I heard you people can help me exercise more."
"Well, we can probably help you find a fitness program that will suit you," you say.
You talk with Sarah about her medical history. You find out she is more than a bit asthmatic and is extremely fitness-conscious. She tells you she wants to be able to do exercise twice a day for at least two or three hours.
This is a lot of physical activity. "I've been doing that much already," Sarah says. "I have to keep trim." But as she pushes up the intensity of her exercise, she has been having more and more difficulty breathing.
You perform some tests. One is called the oxygen-consumption test. Your findings show that she is quite asthmatic when she exercises, so you devise a program you think she will be able to handle. It involves much less exercise than she has been doing in the past.
Sarah comes back in a few weeks, looking gaunter and still wheezing. You're horrified to see her in such poor condition. Obviously, the exercise program you prescribed was wrong or she's been doing too much work.
After talking to her, you find that she has been doing far more exercise than you prescribed, and obviously far more than her body can handle. You ask her about her significant drop in weight.
Sarah tells you that if she can't breathe well enough to exercise, she'll have to stop eating so much in order to stay trim. Alarm bells go off in your head. You talk to her about proper nutrition and advise her to stick to the exercise program you've designed for her.
Sarah comes back in another few weeks, and she is even thinner and is still wheezing. She still isn't following your advice.
You want to help her and you want to do it yourself. You've consulted dietitians for advice in other cases, but you've never referred anyone for psychiatric help before. "We get people in who have all kinds of problems, such as compulsive exercisers and those that have eating disorders," says Jennifer McCrae, a kinesiologist in Illinois. "And we work out a program that will help them."
This suggestion to seek psychiatric help may drive away your patient altogether, and it may not be necessary. What do you decide to do?