If you dread going to the doctor because you think you'll be guilted, you’re not alone, and you're not imagining things. A survey of American patients found 50.1 percent had felt shamed by their doctor during an office visit. Weight, sleep, stress, sex, smoking, sitting, seat belts, screen time; few aspects of the modern lifestyle have escaped implication with disease. Everything's up for shaming.

In the same survey, 33 percent of patients thought the shaming motivated positive behavior change. These patients were grateful that their doctors called them out on an unhealthy habit. But another 45 percent of the shamed patients responded by avoiding, lying to, or terminating treatment with their doctor.

Negative feedback is one of the doctor’s most powerful drugs, but it has wildly divergent effects. It really motivates some and really backfires on others. This idiosyncratic potency is the same reason medicine’s newest, most touted tool for the same problem won’t be the lifestyle-transforming success it’s expected to be, either.

The dramatic sway Fitbits held on the already fitness-obsessed made the med-tech world want to disseminate self-monitors in medicine. They have invested heavily in these devices, on the assumption that giving patients more data will make them more motivated to improve. When this was put to the test among diabetic patients, however, a study group randomized to blood glucose reporting eight times a week had no better glucose control at the end of the year — and were more depressed — than those who didn't have to check all the time.

The conclusion drawn by advocates of more data is that patients who avoid feedback on their medical conditions aren’t ready to make a change. The medical community views their patients who were avoiding the doctor’s office, and who are now avoiding their home monitors, as beyond hope. But you’ve seen a very different response to the shame-avoiders if, like most Americans, there are some new gyms cropping up near you.

The gym industry knew their conventional gyms had both a loyal following and members they couldn’t hang on to. There were those who found an elite, super-fit ideal motivating. Comparing themselves to chiseled models on their billboards and chiseled trainers in their buildings made them want to work out every day. But what about the members enrolling in January who, year after year, were gone by March?

To cater to these disenchanted members, “body-positive” gyms were designed, with new goals and new feedback. Instead of explicitly and implicitly pushing for the “perfect beach body by summer,” these gyms challenge patients to table those thoughts for a while. Fixating on their failure attaining that ideal was coaxing them to run away before the hard work even started. 

Body positive trainers reorient goals to those within members’ control, like showing up regularly. In body positive gyms, members learn to find satisfaction in the effort itself, recognizing that wherever they are, perfect or not, it’s a better place than if they had given up already. These alternative gyms have been the fastest growing segment of the gym industry for the last decade with no sign of slowing.

These businesses recognized that plenty of people who threw out their Fitbits still wanted to get fit, and responded by offering them a different style of support and motivation. Rather than only giving feedback on finger stick glucose results, doctors could recognize any increases in home-cooked meals, or new ingredients tried from the grocery store, or even persistence to keep tracking sugars through failure. We could seize every opportunity to congratulate patients for efforts they made and in so doing nurture them to make more. But we don’t. We impose inflexible standards on entire patient populations, focused on outcomes rather than process.

In a pilot program at senior centers in Los Angeles, elderly patients who were coached to see their daily steps as something within their control rather than an inevitable result of aging had a 24 percent (2.5 mile) increase in their mean steps per week. The researchers didn’t delude their patients by telling them they weren’t aging or that aging didn’t impose downsides. They simply reoriented patients towards productive paths forward.

Harsh truths don’t stay away for long. The moment members leave a body positive gym they are barraged with airbrushed impossibilities once again. The cues aren’t only external, they’re internal too: seeking self-improvement cannot be separated from the uncomfortable feeling that we are falling short.

Ultimately, my patients’ perseverance towards their goals will require responding even to shame-inducing feedback with grit. I’m not worried that I won’t get the facts to them. For patients who are downtrodden and about to quit, what is missing, and therefore what I should give them, isn’t more awareness of their shortcomings. It’s more awareness of their control.