Well: Overweight Patients Face Bias

Stuart Bradford

Are doctors nicer to patients who aren’t fat?

A provocative new study suggests that they are — that thin patients are treated with more warmth and empathy than those who are overweight or obese.

For the study, published in the medical journal Obesity, researchers at Johns Hopkins obtained permission to record discussions between 39 primary care doctors and more than 200 patients who had high blood pressure.

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Although patients were there to talk about blood pressure, not weight, most fell into the overweight or obese category. Only 28 were of normal weight, meaning they had a body mass index below 25. Of the remaining patients, 120 were obese (B.M.I. of 30 or greater) and 60 were classified as overweight (index of 25 to 30).

For the most part, all of the patients were treated about the same; there were no meaningful differences in the amount of time doctors spent with them or the topics discussed.

But when researchers analyzed transcripts of the visits, there was one striking difference. Doctors seemed just a bit nicer to their normal-weight patients, showing more empathy and warmth in their conversations. Although the study was relatively small, the findings are statistically significant.

“It’s not like the physicians were being overtly negative or harsh,” said the lead author, Dr. Kimberly A. Gudzune, an assistant professor of general internal medicine at the Johns Hopkins School of Medicine. “They were just not engaging patients in that rapport-building or making that emotional connection with the patient.”

In conversations with patients of normal weight, the doctors offered simple comments to show concern — for example, “I’m glad you’re feeling better” to a woman who had experienced hot flashes. When a normal-weight patient had trouble getting an appointment with a specialist, her doctor shared her concerns. “I agree with you,” the doctor said. “That gets extremely frustrating when that happens.”

Another patient lamented a scar on her leg after surgery and the ugly shoes she was forced to wear. “You went through a lot,” the doctor told her, adding compliments to lift her spirits. “You still got great legs. Chunky shoes are still in. Get something pretty, something for spring. That always makes you feel good.”

While such expressions of concern and empathy are not remarkable on their own, what was surprising was how absent they were in conversations with overweight and obese patients.

And statements like these are no small thing. Studies show that patients are far more likely to follow a doctor’s advice and to have a better health outcome when they believe their doctor empathizes with their plight.

“When there is increased empathy by the doctor, patients are more likely to report they are satisfied with their care, and they are more likely to adhere to recommendations of physicians,” Dr. Gudzune said. “There is evidence to show that after visits with more empathy, patients have improved clinical outcomes, so patients with diabetes have better blood sugar control or cholesterol is better controlled.”

Dr. David L. Katz, director of the Yale-Griffin University Prevention Research Center, says that overweight patients often complain to him that doctors appear judgmental about their weight, at the expense of other health concerns.

“You come in with a headache, and the doctors say, ‘You really need to lose weight.’ You have a sore throat, and the doctor says, ‘You really need to lose weight,’ ” he said. “These patients feel like the doctor doesn’t help them and they insult them, and so they stop going.”

In dealing with patients who are overweight, Dr. Katz added, doctors often show the same biases and prejudices as the culture at large. The problem may be compounded by the fact that doctors are trained to deal with immediate medical problems that have specific solutions, like a pill to lower blood pressure or emergency treatment for a heart attack. But obesity is a far more complex problem that isn’t easy to solve, and that can be frustrating to doctors.

“When we can’t fix what is broken we tend to behave badly,” he said.

Dr. Katz said his grandmother, who was obese, was so tired of physicians’ negative comments about her weight that she stopped going to the doctor altogether, even when she developed a breast tumor. When she finally sought treatment, she had advanced-stage breast cancer and died in her 50s.

“Every time she went to the doctor for any reason, they wagged a finger at her and talked about her weight,” Dr. Katz said. “We need to understand that the stakes are very high.”

The solution, he said, is better training so that medical students and doctors understand the complex nature of obesity as well as their own (perhaps subconscious) biases. Yale, for one, offers a continuing education program for doctors on compassionate and effective lifestyle counseling for patients.

“I think a lot of them are compassionate and don’t realize this is going on,” Dr. Katz said. “The antipathy for obesity is really rooted in our culture. We should expect better from doctors and train them better.”

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Well: When the Doctor Is Overweight

Cheryl Graham

Dr. George Fielding, a pioneer of weight loss surgery in Australia, remembers how patients treated him in the late 1990s, when his weight reached 330 pounds on his six-foot frame. He would meet new patients, dressed in Armani suits and feeling on top of the world, and then be abruptly upended.

“They’d say, ‘Mate! You’re sitting there telling me I need it? You need to have your surgery!’ ”

Despite being an internationally recognized expert on lap band and gastric bypass surgeries, Dr. Fielding knew that his appearance was dissuading some patients from using his services. And years of yo-yo dieting and extreme exercise hadn’t helped him keep the weight off.

“People would come for consultations and say they would do it, and then they didn’t come back,” said Dr. Fielding, who now works at New York University’s Langone Medical Center. “I knew they were probably thinking, ‘Wow, he’s fat! Is he any good?’ ”

So Dr. Fielding wasn’t at all surprised by the results of a recent study in the International Journal of Obesity showing that patients secretly — or not so secretly — look with disdain on doctors who are overweight or obese. Just as overweight people are stigmatized in an array of professional and personal settings, overweight doctors are seen as less credible than “normal weight” doctors, and patients are less likely to follow their medical advice, the study found.

The study’s stinging conclusions resonated, too, with Dr. Deep Ramachandran, a pulmonary critical care and sleep doctor at Genesys Regional Medical Center in Grand Blanc, Mich. After administering tests exploring his patients’ breathing irregularities, he often has to tell them a blunt truth: they need to lose weight.

That can be a particularly tough message for this messenger to deliver. Dr. Ramachandran, 42, says he has a body mass index of 38 and should lose at least 60 pounds.

“It’s easy for doctors to assume that once we put on the white coat, patients will listen to what we say,” he said. “But this study says the white coat doesn’t protect you. You have to own your problems and communicate with patients in ways they can understand.”

So he often tells patients that he, too, struggles with weight loss and knows how hard it is.

“How do we deliver a message that may be seen as hypocritical? I don’t know the answer,” Dr. Ramachandran said. “But doctors are human beings first and scientists second. We are subject to the same maladies as the rest of society. It’s an incredibly difficult problem, and a challenge.”

The bias against overweight people is so socially accepted, said Dr. Rebecca M. Puhl, the lead author of the study and the director of research and weight stigma initiatives at Yale University’s Rudd Center for Food Policy and Obesity, that “despite all the doctor’s training and expertise, it can jeopardize the doctor’s ability to have a conversation about health care with the patient.”

Patients seem to hold doctors to a stricter standard: “If you’re a health professional, people think you shouldn’t be struggling with weight,” said Dr. Puhl, who is a clinical psychologist and has conducted extensive research into weight stigma.

For the study, the Yale researchers randomly assigned 358 participants — about 57 percent female and 70 percent Caucasian, with an average age of 37 — to complete one of three online surveys about a hypothetical doctor, responding to questions like whether they would choose the doctor as a provider, follow the doctor’s advice about exercise and losing weight, or consider the doctor credible and trustworthy. The only difference among the versions — indeed, the only identifying characteristic about the gender-neutral doctor — was whether the doctor was “normal weight,” “overweight” or “obese.”

The researchers also included a widely used “fat phobia” list of 14 pairs of adjectives that ranks the respondent’s perceptions on a scale. Typical pairs include “lazy/industrious,” “good self-control/no self-control” and “attractive/unattractive.”

Those who answered the surveys about doctors described as overweight or obese were significantly more likely to change providers than those with doctors described as being of normal weight, regardless of the weight of the patient. The higher respondents’ fat phobia scores, the more likely they were to place their trust in a physician of “normal weight.”

Dr. Fielding, the Australian bariatric surgeon, knows firsthand the change in attitudes that can occur in patients and colleagues when they deal with doctors of different weights. Since having lap band surgery 13 years ago, at age 43, he has maintained his weight at 210 pounds, following a regimen of regular, moderate exercise and 800 calories a day. “I was treated completely differently by patients and doctors,” he said. “They weren’t distracted by the fact that I was fat.”

He acknowledged that the respect now automatically conferred on him sometimes ignited an ancient flicker of resentment. “I’m the same guy, still George,” he said.

Dr. Puhl suggests that medical professionals have a front-line position to change the bias against people who are overweight and should make sure that patients understand the many factors that contribute to excess weight, including genetics, food chemistry and the biology of satiety.

“Then shift the conversation from weight loss to health behaviors that patients can improve, regardless of body weight,” she said. “I’ve met enough people who are thin and unhealthy because of drinking or smoking, or are overweight by the B.M.I. but are very healthy. And that is true for doctors as well as patients.”

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