Obese patients say some doctors disrespectful
■ Physicians who specialize in treating obesity say education is key to remedying this bias.
By Christine S. Moyer — Posted Nov. 23, 2009
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Physicians near Harrisburg, Pa., often refer non-compliant obese patients to Jarol Boan, MD, MPH, an internist specializing in obesity management.
In such cases, physicians become frustrated when their patients don't lose weight, or don't lose it as quickly as they would like. So these patients end up at Dr. Boan's practice, where many feel comfortable enough to admit that physicians' comments about their weight have hurt their feelings.
These patients are not alone, according to a study in the November Journal of General Internal Medicine.
The study, which examined data from 40 Baltimore-area physicians and 238 of their patients between 2002 and 2005, found that physicians have lower respect for patients with a higher body mass index.
Doctors who specialize in obesity management weren't surprised by the study's findings. "There's no question that for many physicians, there is a lack of respect for overweight and obese patients. Much of that relates to a lack of understanding of what leads to obesity. It's all too common that physicians assume it's a lack of will power," said Patrick McBride, MD, MPH, a professor of family medicine at the University of Wisconsin School of Medicine and Public Health.
As part of a randomized trial, physicians ranked their level of respect -- high or low -- on a five-point scale after a patient visit. Researchers found that physicians reported having low respect for 39% of patients. These patients were younger and had higher BMI levels than patients the physicians reported respecting.
One root of the problem, experts say, is medical school curriculum, which historically has overlooked lessons on nutrition, causes of obesity and respect for overweight and obese patients.
The Assn. of American Medical Colleges was so concerned about physicians' ability to treat the more than 72 million obese Americans that the organization convened an expert panel to study the issue. The panel's curriculum recommendations, published in 2007, included training future physicians to be sensitive to the ostracism experienced by overweight and obese patients. Medical schools are beginning to respond by incorporating more overweight and obesity issues into curriculum.
At the same time the recommendations were published, Dr. Boan, an AAMC panel member, created a multidisciplinary clinical management of obesity elective for fourth-year medical students at Penn State College of Medicine, where she teaches.
She advises students that the key to addressing an obese patient's weight is finding a hook to begin the conversation. For example, she recently showed an obese patient his lab results, which revealed elevated levels of triglycerides.
"I asked him, 'What do you think you can do to change this, given that this is a risk for cardiovascular disease?' " Dr. Boan said.
The patient admitted he had gained weight lately.
"I try and get a hook, because I never, ever tell the patient, 'I think you're fat and you need to do something about it,' " she said.
Even if physicians confront patients directly about their weight, "fat" is not the most effective term to use, according to a study in the September 2003 issue of Obesity Research, now called Obesity.
The study found that obese men and women considered "excess fat, fatness, heaviness, large size" and "obesity" undesirable terms to describe their weight. Topping the favorable list were "BMI, excess weight" and "weight."
"Personally, I think it can cause more harm than good for a doctor to say, 'You should lose this weight.' without giving the patient any tools," said Mary Margaret Huizinga, MD, MPH, author of the obesity study and assistant professor of medicine and director of the Johns Hopkins Digestive Weight Loss Center at the Johns Hopkins University School of Medicine in Maryland.
Dr. Huizinga suggested that doctors help patients find ways to incorporate a healthy lifestyle into their schedules. Physicians cannot assume that obese patients are ready to change, said William Dietz, MD, PhD, director of the Division of Nutrition, Physical Activity and Obesity at the Centers for Disease Control and Prevention.
"I would ask the patient if they are concerned about their weight ... and begin to understand why they're concerned about it," said Dr. Dietz, who was also on the AAMC expert panel.
Doctors who specialize in treating obesity agree that the key to remedying physician bias toward obese patients is mainly through education.
Dr. McBride, chair of the AAMC expert panel, said at least 40% of obesity is genetically determined. Many other cases are out of patients' control due to their limited income and poor availability of healthy food choices. Even modest changes in a person's weight -- as small as 5% to 7% -- make a significant impact on a person's health, he added.
Quincy Harberger, a fourth-year medical student at Penn State College of Medicine, registered for Dr. Boan's obesity course. He is spending November following Dr. Boan, nutritionists, pediatricians and surgeons who focus on treating overweight and obese patients.
He said he didn't realize the extent of the challenges involved in treating these patients. "Almost all of them don't have time to take care of themselves, and they feel really, really bad about it."