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Physician Bias Research

May 16, 2013

The following are studies referenced or useful to the discussion we are having tonight on Huffington Post about physician shaming.

Barriers to routine gynecological cancer screening for White and African-American obese women



Physician Attitudes

Physician Respect for Patients with Obesity

40 physicians and 238 patients

Negative bias towards persons with obesity has been well documented in health-care providers, including physicians, for the last 40 years. In a survey of physicians, obesity was identified as a characteristic that elicited negative feelings, and other studies have found that physicians associate negative terms, such as ignorant, lazy and incompetent, with obesity. In addition, physicians have reported ambivalence towards the treatment of obesity. However, none of these studies have documented physician attitudes towards specific patients with obesity. Several studies have documented health-care avoidance in patients with obesity, and in some studies, participants cited individual and institutional biases as the reason for avoidance. There is also evidence that obesity is associated with decreased preventive services, especially cancer screenings.

The primary outcome was physician-reported respect. Physicians were asked to rank their level of respect for the patient on a 5-point Likert scale after the patient visit.

A ten-unit higher BMI was associated with a 14% higher prevalence of low physician respect.

We found that higher patient BMI was associated with lower physician respect. Further research is needed to understand if lower physician respect for patients with higher BMI adversely affects the quality of care.

Exploring the association between body weight, stigma of obesity, and health care avoidance. (PDF)

The findings show an increase in BMI is associated with an increase in the delay/avoidance of health care. Weight-related reasons for delaying/avoiding health care included having “gained weight since last health care visit,” not wanting to “get weighted on the provider’s scale,” and knowing they would be told to “lose weight.”

Approximately 34% (n=25) of the obese women (n=73) were shown to delay/avoid health care “ever” due to “weight gain since the last health care visit” (Table 3). Of the obese respondents, 26% (n=19) had delayed/avoided health care due to “not wanting to be weighed on the provider’s scale”. Being “told to lose weight” was a deterring factor to utilizing health care for almost one-third (n=22) of the obese subjects. Among the morbidly obese (BMI > 40; n=11) more than one-fourth of the respondents (n=3) reported that “undressing in the provider’s office” was a reason to delay/avoid seeking health care. More than 60% (n=7) of the morbidly obese cited being “told to lose weight” as a deterrent to seeking medical care.

Studies have shown that health care providers will readily attribute many physical maladies to a client’s obesity and perform limited examinations (Young & Powell, 1985; Packer, 1990). Obesity does not preclude the need for a careful and thorough health history and physical examination. It should not be assumed that an obese person’s pathology is due to excessive adiposity.

Overweight women delay medical care.

All female nurses, nursing assistants, health unit coordinators, and general psychiatric assistants who were employed full- or part-time at the community hospital in July 1992. We received 310 (76%) responses from 409 potential respondents.

Overall, 12.7% of respondents reported delaying or canceling a physician appointment because of weight concerns. Another 2.6% kept their appointments but refused to be weighed. Only body mass index was significantly associated with appointment cancellation. The odds ratio of an obese woman (body mass index in excess of 27) delaying medical care was 3.885 (95% confidence interval, 1.509 to 10.274).

Barriers to routine gynecological cancer screening for White and African-American obese women.

Women with BMI > 55 kg/m(2) had a significantly lower rate (68%) of Papanicolaou (Pap) tests compared to others (86%). The lower screening rate was not a result of lack of available health care since more than 90% of the women had health insurance. Women report that barriers related to their weight contribute to delay of health care. These barriers include disrespectful treatment, embarrassment at being weighed, negative attitudes of providers, unsolicited advice to lose weight, and medical equipment that was too small to be functional. The percentage of women who reported these barriers increased as the women’s BMI increased. Women who delay were significantly less likely to have timely pelvic examinations, Pap tests, and mammograms than the comparison group, even though they reported that they were ‘moderately’ or ‘very concerned’ about cancer symptoms. The women who delay care were also more likely to have been on weight-loss programs five or more times

Women with BMI over 55 were less likely to have pap smears, breast exams and mammograms.

Approximately 16% of respondents included specific examples of barriers or listed additional barriers for the ‘other (please specify)’ option of this question. Examples of disrespectful treatment included disparaging comments by providers or office staff, as well as women’s perceptions that their treatment was influenced by their weight, for example, women asked ‘Would you treat me this way if I were thin?’ Women cited examples of health screenings and treatments that were not provided because the women were told they were too large, ‘my doctor told me he was unable to perform a Pap smear on me because of my size’ or that their health concerns were attributed to being overweight, ‘doctors blame all my symptoms on my obesity’. Embarrassment about being weighed was made worse if the woman was weighed in a public place in view of other patients and staff. Some women questioned whether routine weighing was necessary for treatment of routine medical needs. Women commented on the irony of health care providers who were themselves obese giving weight-loss lectures. Women did not appreciate unsolicited advice to have gastric surgery or what they perceived as scare tactics. Medical equipment that was noted to be too small to be functional included blood pressure cuffs, scales, examination tables, examination rooms that could not accommodate a friend or helper, hospital gowns that did not fit, and waiting rooms with only small chairs with arms.

Physicians’ attitudes about obesity and their associations with competency and specialty: A cross-sectional study

400 physicians

More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm.

In one study, physicians rated obesity treatment as less effective than therapies for 9 out of 10 chronic conditions, and only 14% agreed that they were usually successful in helping obese patients lose weight. In another study, 31% of internal medicine residents believed that treating obesity is futile and only 44% felt qualified to treat obese patients.

Most obese patients could reach a normal weight (for height) if motivated (38% agree, 61% disagree)

Obesity is primarily caused by behavioral factors (33% agree, 67% disagree)

Obesity is a treatable condition (92% agree, 8% disagree)

Discussing Weight with Obese Primary Care Patients: Physician and Patient Perceptions

Long-term weight loss maintenance in the United States

When the Doctor Is Overweight

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.

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.

overweight doctors are seen as less credible than “normal weight” doctors, and patients are less likely to follow their medical advice, the study found.

Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006.

The prevalence of weight/height discrimination increased from 7% in 1995-1996 to 12% in 2004-2006, affecting all population groups but the elderly. This growth is unlikely to be explained by changes in obesity rates.

Bias, discrimination, and obesity.

24% of nurses said that they are “repulsed” by obese persons;

The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice

[R]espondents report more mistrust of physicians who are overweight or obese, are less inclined to follow their medical advice and are more likely to change providers if their physician appeared overweight or obese, compared to normal-weight physicians who elicit more favorable opinions from respondents. These biases remained present regardless of participants’ own body weight, and were more pronounced among individuals who demonstrated stronger weight bias toward obese persons in general.

Yale Rudd List of studies (PDF)

Weight Stigma Among Providers Decreases the Quality of Care Received by obese Patients (PDF)

4 Comments leave one →
  1. Lindsay permalink
    May 16, 2013 7:11 pm

    Very sad but doesn’t really surprise me. My mom delayed going to doctors appointments for sixteen years (from early 40’s to late 50’s…kind of a pretty important time for checkups) due to embarrassment over her weight/”I’ll go after I get some of the weight off” which never happened. She suspected she had Type 2 diabetes for years before her symptoms got bad enough and sure enough she was diagnosed. I’m just glad it is being managed now and there was nothing else wrong.

    I find it very strange that the majority of physicians do not believe weight is caused by behavioral factors alone or that obese people could reach normal weight, yet 92% believe that obesity is a “treatable condition”…

  2. May 16, 2013 7:30 pm

    I fully believe this is a cause that needs to “go viral” as the saying goes. Fat patients have suffered humiliation and embarrassment for FAR too long. Even if the doctor is sweet as pie, many times the nurses, office staff and technicians can ruin the visit for a fat patient.
    As discussed in other sections of this blog (Let It Out) several of us have stories to tell regarding disappointing experiences at doctors’ offices – all weight related.

  3. May 18, 2013 4:12 am

    Reblogged this on The Cheese Whines and commented:
    When I was in nursing school, the director of the program asked us if there were any certain types of patients that we’d rather not work with. I said pediatrics because I’m not comfortable working with children. I tend to get too many “panicky mommy” types of feelings when working with the wee ones. I was told I needed to “get over it” as in clinicals we have to work with all ages.
    Several of my classmates said they would not want to work with obese people. The program head did not tell these people that they needed to get over their prejudices. She just nodded her head.
    I finally stated that I believed that people found it easy to discriminate against obese people because we’re very visible and people assume that a heavy person has bad habits.
    Many of the instructors in this program had a strong bias against larger people, and they passed those attitudes on to the students.

    • Elizabeth permalink
      May 18, 2013 10:28 am

      Cie, I’m glad you spoke up regarding fat prejudice. My husband was a CNA working as a unit secretary in an ICU and reported a nurse who did not use sterile procedure when inserting a Foley into an obese patient. He was basically ostracized following his report and did not return to the hospital when he got his nursing degree. I’ve asked him about fat prejudice on the hospital floor he currently works on, but two of the nurses are quite large and outspoken, and he hasn’t seen any anti-fat behavior.

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