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goes wrong and someone sues you, the question may be asked: What have you done to address this." Training doesn't have to be elaborate, he says. "When you sit everyone down in the morning with coffee and bagels, you can have someone talk to them for 45 minutes. It can be something online, or something to talk about when things are slow. If you're going to take care of large patients routinely, it probably should be a focus. It's a low-cost, high-yield initia- tive." And insensitivity is pervasive. "Even a Miss Universe gets accused of being a fat slob," says Dr. Sinha. "If Donald Trump had had some sen- sitivity training, he might not have said that." Ms. Waters agrees that empathy is key. "I've discussed this with my staff and I try to lead by example," she says. "Often, very heavy patients are very self-conscious and their self-esteem is low. They're very introverted. It's almost disheartening. They'll say things like, 'Thank you, and I'm sorry I weigh so much.' I make it a point to say: 'That's OK. You would do the same for me, wouldn't you?' They're usually taken aback at first. But they say, 'Yeah, I would.' That helps break down barriers and lets them know they're no different than me, my neighbor, or anybody else. We all come in different shapes and sizes and should be treated as equals." Many factors "In the last 30 years, the average American has gotten about 21 pounds heavier," says Dr. Sinha, who has studied the phenomenon extensively. Ask 5 people why, and you may get 5 different answers. "Our por- tion control in this country is way out of control," says Ms. Dynderski. "The average meal here in any restaurant could feed 2 people. It's the way we're raised. We live to eat. In other countries, they eat to live." 5 6 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 6