“What number should she be?” a mom asks me when I broach the topic of her daughter’s increasing BMI at the annual well visit. With the question floating in the air, the girl’s demeanor instantly morphs from amiable to tense. I pause, as something tells me that I am treading on tender ground. The mom and daughter both look at me with wide eyes that suggest both concern and shame.
I was in fifth grade the first time I stepped on a scale, with an emerging understanding that the number carried a value beyond simple quantification. Although the scale I stood on was broken and unreliable, I was aware of the fact that the number that popped up was different from the one that my peers had been discussing at school. That number marked the beginning of a long journey of remaining loyal to a very specific and narrow set of numbers, at the expense of paying attention to ways to genuinely thrive. It wasn’t health that I was focusing on, but rather a number that was dictated to me externally. Looking back on it, that number said very little about the healthy foods I was provided, or the hours I spent in dance class and riding my bike up and down the street with friends. That number was a minuscule snapshot. Nonetheless, I allowed it to become an indicator of importance.
I return to the mom and daughter duo sitting before me. What number? How can I address this question with a focus on health, and avoid a hint of inadequacy or the need to change who she is? As Ellyn Satter puts it, how does one help without harming? I smile and nod as I pull up a screen showing the patient’s growth chart. I explain to the mom and daughter that I don’t care about the numbers necessarily, but am rather paying attention to how she is growing and developing along a trajectory curve that is unique to her. “Sometimes,” I explain, “I think it would be better if we reviewed a growth chart, without ever knowing the actual numbers at all.” I continue to inquire about what health means to this patient. I ask what parts of her day-to-day life she considers to be good for her. What is she proud of? What foods are nourishing? What are her favorite activities and hobbies? I also explore parts of her routines that are challenging or possibly not helping her feel strong and healthy. When the visit concludes, I feel that wellness was addressed more authentically by avoiding the numeric value of her weight altogether.
As I walk out of my clinic at the end of the day, I reflect further on the relationship between numbers and health. I’m not implying that quantification isn’t necessary. After all, I learned in my training that without quantifiable data, patterns and outcomes can’t be uncovered and understood. This I agree with from an academic and research-based perspective. But, I somewhat hesitate in applying this same logic to individualized patient care, and balk at the approach of relying on an integer as the fulcrum in my approach to discussing lifestyle.
My reflection on numbers takes me back to a particular day many years ago, when I worked as a hospitalist NP. It was RSV season and the pediatrics floor was slammed with admissions. I was relatively young in my career, exhausted from a long shift, and fatigued by a relentless pager. AlI I wanted to do was wrap things up and go home. At signout, however, I decided to check one last time on an infant who had been admitted earlier in the day. I called down to the nurse who assured me that the pulse ox was “steady” and that the respiratory rate was actually going down. Something tugged at me to go physically look at the patient again. I grabbed my attending physician and insisted we go to the baby’s room together. The baby was tiring out. The “improved” respiratory rate was actually a result of the baby losing energy to keep up her breathing on her own. The “steady pulse ox” reading was being maintained with a higher flow of oxygen. A code was called and the baby went straight to the PICU. The words that came from my attending at the end of that exhausting shift have stayed with me for the entirety of my career: “Never take care of the numbers, take care of the patient. The numbers mean very little outside of the context of how the patient looks and acts in every dimension.”
While the hospitalized infant was in a different setting, I believe the same advice holds true for the preteen sitting in a community clinic asking about the “number” she should be to have the right BMI. The number is a data point, but not a full representation of the health of the patient, or who the patient is as an individual. As clinicians, we owe it to our patients to treat the individual and not a variable that pops up on the screen. In partnering with our patients and their families in health, we must look at a bigger picture and view the patient’s health as a mosaic that not only consists of vital signs and measurements, but of stories, habits, routines, traditions, histories, goals, values and expectations. These are things that cannot be captured by a number, but yet ultimately cannot be ignored when the goal is true health.
What number do you take with a grain of salt for your patients? Share in the comments.
Kyra is a pediatric NP who trained in Denver, CO and now works in a neighborhood community clinic in the Bay Area. She loves having the opportunity to interact with families and their community as a whole. In her free time, Kyra enjoys spending time with her two kids doing anything that requires being outside in nature. Kyra is a 2021–2022 Doximity Op-Med Fellow.
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