Prejudice and Discrimination in the Doctor’s Office

I have a friend who is so beautiful you want to suggest that she model. She is also very overweight. She is well aware of her weight problem and it makes her miserable. This, in turn, sets up  an awful feedback loop in which she feels terrible because of her weight, which drives her to eat, which leads to weight gain, which makes her feel terrible.

Last week, she had horrific abdominal pain that kept her in bed for days. Why didn’t she go to the doctor? I asked. Because, she answered, she feared what the doctor would say about her weight and how she’d be treated–like a pariah who didn’t deserve medical care until she loses weight. The doctor will lecture her, look at her in disgust, and treat her disrespectfully, she said. She knows this because that’s how her gynecologist treated her. So she won’t go back which means she won’t receive needed medical care.

Her experience is not unique. Physicians are simply terrible at working with overweight patients. Studies find they often don’t diagnose patients with obesity, don’t understand the medical repercussions of obesity on overall health, attribute their patients’ weight to a lack of discipline, and feel their patients lack the motivation to lose weight. This applies to nurses as well as doctors. You can read two such studies here and here.

In one of those studies, researchers surveyed 259 obese women. They found that although the women reported they were generally satisfied with the care they received, nearly two thirds said their physicians “don’t understand how difficult it is to be overweight,” and about a third said their doctors didn’t believe them when they said they didn’t eat that much.

So why were they so satisfied? The authors speculated that it is because the women blamed themselves for their weight problem, so they didn’t feel they deserved help or support. They are wrong. The very place they should receive help and support is in the doctor’s office.

They don’t.

In a survey of 255 family physicians, the doctors estimated that, on average, nearly 40 percent of their patients were obese (BMI 30 or higher) or severely obese (BMI 40 or higher). Yet the doctors rarely  recommended bariatric surgery and/or weight loss medications for these patients. Just a fourth said they knew about techniques to examine severely obese patients,  with just a fifth saying they were aware of community resources for these patients. Less than half knew much about weight loss medications or bariatric surgery, and only about 60 percent knew much about weight-loss exercise or diets. Half said that treatment for obesity is often ineffective, a perception that is not borne out by scientific evidence.

For the record, numerous studies find that bariatric surgery is the most effective long-term treatment for weight loss, significantly reducing the overall risk of death and, in many instances, curing any preexisting diabetes.

Yet a study of 200 people undergoing bariatric surgery found that 17 percent of patients changed primary care physicians because of a “perceived indifference, lack of concern, or negative attitude toward bariatric surgery.” The authors concluded that “patients undergoing bariatric surgery continue to feel misunderstood and mistreated by medical and non-medical personnel involved in the treatment of their obesity.”

Why the prejudice? Lots of reasons. First, doctors are just displaying the same prejudice towards overweight people that much of society displays. And here I say, “Shame on you.” I think that healthcare providers, more than anyone else, should know more about the root causes and medical consequences of obesity, and should know how to provide the kind of positive counseling studies find is most effective.

Amazingly, many physicians do not even counsel overweight patients with diabetes, hypertension, and cardiovascular about weight loss or, if they do, their counseling is delivered in a negative manner or patients are advised to do the impossible, such as losing 40 pounds.

For the record, telling patients to eat less and exercise more doesn’t work. They’re overweight, not stupid.

There are, however, numerous evidence-based interactions that do work, including motivational interviewing, referring patients to experts in obesity and nutritional counselors, and prescribing medication.

About 65 percent of Americans are overweight, while a third of Americans are obese. They make up the majority of patients primary care clinicians treat. It is just unconscionable that the medical system does not treat these patients with greater respect and provide the level of care that, the evidence shows, can help them become healthier individuals.