Seeing a doctor may not be fun, but it's not supposed to be fear-inducing. For many heavier patients, though, interacting with the health care system (and the ever-present scale) can be downright daunting, according to internist Kimberly Gudzune, MD, MPH, an assistant professor of medicine at the Johns Hopkins School of Medicine in Baltimore.
Physicians often hold negative attitudes, both explicit and implicit, about people with excess weight, said Dr. Gudzune, whose research focuses on how obesity influences patients' health care experiences. This weight bias can lead to delays in care and other downstream health consequences, she said.
Research shows that clinicians treat patients differently based on visible factors (e.g., great respect for older patients; lower positive affect and more verbal dominance with black vs. white patients), Dr. Gudzune said. “Weight, similar to age and race, is another visible trait. As soon as a provider walks in the door, we're automatically making judgments about who you are as a person,” she said.
During her talk in November 2016 at ObesityWeek in New Orleans, Dr. Gudzune discussed the effects of weight bias in the clinical setting and how clinicians can begin to mitigate the impact.
The ugly evidence
Much research has shown that clinicians have biases related to overweight and obesity, conditions that affect more than two-thirds of U.S. adults, Dr. Gudzune said. “[With] the magnitude of the effect of obesity in our country, a substantial number of people are experiencing health care disparities as a result,” she said.
Studies have consistently shown that physicians associate obesity with such negative attributes as poor hygiene, nonadherence, hostility, and dishonesty, Dr. Gudzune said. “These types of attitudes are pervasive. It's not just in the U.S. . . . [but] physicians across the world as well: Australian, Israeli, European physicians. . . . These attitudes have been documented as far back as 1969, and they continue to persist up until today,” she said.
In surveys of primary care physicians, more than 50% view patients with obesity as awkward, unattractive, and ugly, Dr. Gudzune said. “They have less respect for patients with obesity. They also believe that heavier patients are less likely to follow medical advice, benefit from counseling, or adhere to medications, which are some of the things that are really critical in thinking about managing obesity,” she said. She added that these attitudes may extend to other health professionals, such as medical students, nurses, and nutritionists.
In her own research, Dr. Gudzune recorded patient-physician visits to analyze the domains of communication in primary care: biomedical (e.g., prescriptions, medical information), psychosocial/lifestyle (e.g., exercise, smoking), and rapport-building (e.g., positive, emotional, social). There were no significant differences between patients with normal weight and those with excess weight or obesity in the biomedical or psychosocial/lifestyle domains, she said.
But with patients who are overweight or obese, physicians engage in significantly less rapport-building, especially of an emotional nature (e.g., empathy, concern, reassurance, partnership, self-disclosure), Dr. Gudzune said. “So this is really suggesting to me that we're not really making that emotional connection, which has actually been shown to make our counseling more effective,” she said. And patients who are overweight or obese may actually need more biomedical counseling, so the nonsignificant change in that domain might not be equitable, she added.
Some studies have looked at whether these differences in communication affect how physicians interpret clinical symptoms or make decisions, Dr. Gudzune said. “First, providers will say that they have technical difficulties performing examinations or do not have the equipment to accommodate all patients,” she said. “Rather than seeing that as a need to potentially fix, they just avoid performing those exams. Also, the suggested diagnostic plans may differ by patient weight, where the physicians tend to prescribe more tests but spend less time with the patient.”
Avoiding or delaying seeking medical care is very common in this patient population, Dr. Gudzune said. “In surveys, 55% of patients with obesity have reported canceling an appointment because they're anxious about being weighed,” she said. People with obesity also report delays in cancer screening tests because of perceived barriers, such as disrespectful treatment or the embarrassment of being weighed, Dr. Gudzune said, noting that they also point to such issues as inadequate medical equipment or unsolicited weight loss advice.
In her work on “doctor shopping,” she found that patients with obesity are 37% more likely to see three or more primary care clinicians in a 24-month period. “These doctor shoppers actually have. . . high use of the ED without increased risk of hospitalization, which is really saying to me that this lack of continuity of care is actually having real impacts—that people are using the emergency room for services that could potentially be remedied if they had a good primary care relationship,” Dr. Gudzune said.
In a follow-up survey of doctor shoppers, she found that some are motivated to switch physicians because they experienced weight-stigmatizing encounters in the clinical setting, and they tend to have shorter relationship durations with their current clinician, she said.
“The trust didn't seem to be affected in their current provider, but what I found very interesting is that they're more likely to perceive. . . that they're still being judged about their weight,” Dr. Gudzune said. “So I think those negative experiences are actually still carrying on through the health care system and that we're creating a very sensitive patient population that's having their guard up and not really receptive to care.”
The same study found that patients who perceive this weight-related judgment by their primary care physician were more likely to attempt weight loss but not any more likely to achieve a clinically significant weight loss, she said.
“We need to [discuss weight loss] in a way that judgment isn't coming across. It was in that scenario, where people are having the discussion but not coming away feeling judged, that they were actually significantly more likely to achieve that clinically significant weight loss at 10% or more over a year,” Dr. Gudzune said.
In terms of the treatment that patients who are overweight or obese actually receive, she noted that there are disparities in preventive services. For example, as a woman's weight increases to higher classes of obesity, she's significantly less likely to get a Pap smear, Dr. Gudzune said. “This has also been seen with rates of mammography and colonoscopy, and greater obesity tends to have greater disparities,” she said.
To top it off, most physicians report that they don't think weight management really works, Dr. Gudzune said. “They also feel unprepared with respect to training, there's also limited time and reimbursement for services, they consider weight management to be unrewarding or futile, and they're avoiding discussing weight and weight loss entirely,” she said. “That service of weight loss counseling is, as a result of this big picture, not really being delivered.”
How to do better
Few studies have actually tested weight bias-mitigating interventions, and a systematic review published in 2016 identified only 17 such trials, Dr. Gudzune noted. “Only two of them were done in interventions that were delivered to currently practicing health professionals,” she said, noting that studies have primarily focused on students.
A recent study of a large cohort of medical students found that 74% exhibited implicit weight bias, and 67% endorsed explicit weight bias, Dr. Gudzune said. “And these biases were actually higher toward individuals with obesity than racial minorities, gays, lesbians, and the poor,” she said. “It was only IV drug users that were actually perceived more negatively by students than individuals with obesity.”
Most of the bias interventions with students have focused only on short-term outcomes, and the few with longer-term follow-up have suggested that weight bias may persist over time, Dr. Gudzune noted. In two studies of preclinical students, one group was randomized to a curriculum about the uncontrollable reasons for obesity, another to a curriculum about the controllable reasons, she said.
Students who learned about the uncontrollable reasons had a decrease in implicit weight bias, whereas those who were given controllable reasons saw an increase in that bias, Dr. Gudzune said, adding that an approach using single lectures produced similar results. “I think this speaks that we need to think about how we present obesity in general to students because we could actually be propagating stigma even further,” she said.
Another study among health professional students showed that watching films aimed at reducing weight-related stigma improves explicit attitudes and beliefs toward those with obesity immediately after viewing, Dr. Gudzune said. “But if you go back and talk to the students six weeks later. . . all of those benefits have been eliminated, and there was no effect on implicit anti-fat bias,” she said.
Another intervention randomized students to read about genetic and behavioral mechanisms of obesity or a control topic before experiencing a virtual clinic encounter with a patient with obesity, Dr. Gudzune said. “Again, in the immediate postintervention, the genetic [group] had less negative stereotyping than the control,” she said. In another study, medical students were directed to read two articles on communication issues about weight and obesity stigma before a live, standardized patient encounter, where they discussed the patient's perception of his or her weight, took a weight history, and probed about the social and physical effects of weight, Dr. Gudzune said.
Again, reductions in weight bias failed to stick. “Immediately postintervention, we see a decrease in stereotyping, increase in empathy, and an increase in the confidence in their counseling skills,” she said. “One year later, they went back and looked at these students, and they had maintained the improved empathy and counseling, but the stereotyping, again, actually reverted to baseline.”
The two trials in practicing health professionals and office staff tested the effect of bariatric sensitivity training on the challenges that patients with obesity face, Dr. Gudzune said. Immediately after completion, the educational module increased awareness of how participants' attitudes can impact patients but did not improve their actual attitudes or beliefs about the patients, she said. “A lot of the stereotyping still existed despite the training,” Dr. Gudzune said.
She emphasized that bias-reducing interventions among practicing clinicians remain mostly untested. Some suggestions of potential intervention components include education on the myriad factors that contribute to weight gain and loss, a focus on improved health and well-being rather than body weight, and modification of the clinical environment to provide chairs and medical equipment to accommodate any size, Dr. Gudzune said.
“A lot of times, the nonverbal or the physical environment, those things communicate and say so much without actually saying anything, and that really sets the tone,” she said.
Ultimately, she said, there is an urgent need to design and test programs that attempt to mitigate weight bias in the clinical setting. “I think that while trainees are very important and are an easier population to target, [we] also have to figure out a way to address practicing clinicians because they are the role models,” Dr. Gudzune said.