To eliminate prejudice, doctors are training to look beyond obesity
When Melissa Boughton complained to her OB-GYN of dull pelvic pain, the doctor responded by asking about her diet and exercise habits.
The question seemed out of place, given the kind of pain she was feeling, Boughton thought at the time. But that wasn’t unusual coming from this doctor. “Every time I was there she would talk about diet and exercise,” said Boughton, who is 34 and lives in Durham, North Carolina.
On that occasion, three years ago, the OB-GYN told Boughton that losing weight would likely solve the pelvic pain. The doctor brought up diet and exercise at least twice more during the appointment. The doctor said she would order an ultrasound to reassure Boughton.
The ultrasound revealed the source of her pain: a 7-centimeter fluid-filled tumor on Boughton’s left ovary.
“I hate this doctor for the way she treated me – like my pain wasn’t serious,” Boughton said. “She seemed to make a decision about me based on a very superficial look.”
Research has long shown that doctors are less likely to respect overweight or obese patients, even as nearly three-quarters of adults in the United States now fall into one of those categories. Obesity, which characterizes patients with a body mass index of 30 or higher, is pervasive in the South and Midwest, according to the Centers for Disease Control and Prevention. The state with the highest rate is Mississippi, where 4 in 10 adults are considered obese.
Obesity is a common and treatable disease linked to a long list of health risks, including type 2 diabetes, heart disease and certain cancers. Despite the prevalence of obesity, it carries a unique stigma.
Physicians often approach the practice of medicine with an anti-fat bias and find it difficult to communicate with patients whose weight exceeds what is considered the normal range. Some obesity experts blame the lack of focus on the subject in medical schools. Others blame a lack of empathy.
To counter this, the Association of American Medical Colleges plans to roll out new diversity, equity and inclusion standards in June aimed at teaching physicians about, among other things, the respectful treatment of those diagnosed as overweight or obese.
That doesn’t happen for many patients, said Dr. Scott Butsch, director of obesity medicine at the Cleveland Clinic’s Bariatric and Metabolic Institute. “It’s almost like malpractice. You’ve got these doctors or clinicians — whoever they are — regarding anything about the patient’s obesity without investigation,” Butsch said. “The stereotypes and misperceptions around this disease have implications for clinical practice.”
The problem, Butsch says, is that too little attention is paid to obesity in medical school. When he trained and taught at Harvard Medical School for several years, Butsch said, students received no more than nine hours of obesity education spread over three days in four years.
In 2013, the American Medical Association voted to recognize obesity as a disease. But, Butsch said, doctors often approach it with a one-size-fits-all approach. “Eat less, move more” doesn’t work for everyone, he said.
Parents and caregivers should be especially careful when talking about their weight to children who have been diagnosed with obesity, psychologists have warned. The way parents and caregivers talk to children about their weight can have lifelong consequences and, in some cases, trigger poor eating habits. For obese children, obesity experts agree that weight loss isn’t always the goal.
“There are many different forms of obesity, but we treat them as if we were giving the same chemotherapy to all types of cancer,” Butsch said.
All but four of the country’s 128 medical schools reported covering content related to obesity and bariatric medicine in the 2020-21 academic year, according to program data provided to KHN by the Association. of American Medical Colleges, which does not represent osteopathic schools. .
Even so, the research suggests that many physicians have not been sufficiently trained to deal with weight issues with patients and that obesity education in medical schools around the world is “grossly neglected”. A survey of leaders at 40 US medical schools found that only 10% felt their students were “very prepared” to manage obese patients.
Meanwhile, “half of the medical schools surveyed said expanding obesity education was a low or no priority,” wrote the authors of a 2020 journal article that describes the results of the investigation.
Butsch wants Congress to pass a resolution urging medical schools to incorporate substantive education on nutrition, diet and obesity. He acknowledged, however, that the medical school curriculum is already filled with material deemed necessary to cover.
Dr. David Cole, president of the Medical University of South Carolina, said many topics should be covered more thoroughly in medical school, but aren’t. “There’s this massive tome — it’s about that big,” Cole said, raising his hand about a foot from the top of a conference table in Charleston. “The subject is: things I never learned in medical school.”
The biggest problem, he said, is that medicine has always been taught to emphasize memorization and has not emphasized culturally competent care. “It was valid 100 years ago, if you were supposed to be the source of all knowledge,” Cole said. “It’s just not valid anymore.”
The Association of American Medical Colleges is trying to address the problem in two ways.
First, he developed a career readiness exam for prospective medical students, called PREview, designed to assess a candidate’s cultural competency, social skills, and listening skills, as well as their ability to reflect. situations he may encounter in medical school and in the clinical setting. . “We call them softer skills, but they’re really the hardest to learn,” said Lisa Howley, an educational psychologist and the association’s senior director of strategic initiatives. More than a dozen medical schools now recommend or require applicants to submit their PREview test scores along with their Medical College Admissions test scores.
Second, the association of medical schools will roll out new competency standards for medical students, residents, and existing physicians in June on diversity, equity, and inclusion. These standards will address racism, implicit bias and gender equality and aim to teach doctors how to talk to people who are overweight.
“The bias toward these people is way too high,” Howley said. “We still have a lot of work to do in this space.”
After the source of Melissa Boughton’s pelvic pain was discovered, the OB-GYN who had recommended diet and exercise to relieve her symptoms told Boughton that the tumor was not serious. “She acted like it was the most normal thing in the world,” Boughton said.
Boughton sought a second opinion from a doctor who marketed his practice as a “Healthy at All Sizes” office. That doctor referred Boughton to a surgical oncologist, who removed the tumor, her left ovary, and part of a fallopian tube. The tumor was big, but it wasn’t cancerous. And although the surgery to remove it was deemed a success, Boughton has since struggled to conceive and is undergoing fertility treatment as she tries to have a baby.
“It’s an emotional rollercoaster,” she said. “I feel very young at 34 to experience this.”
Boughton – who describes himself as someone who “doesn’t fit into the BMI box” – said the experience has taught him to choose his doctors differently.
“You can ask me if I’m dieting and exercising like once,” she said. Any more than that, and she starts shopping for another doctor.
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