Why obese patients often receive worse care

Physicians may not consider possible causes of illness beyond weight

Despite the increasing prevalence of obesity, the U.S. health care system is ill-equipped—and providers are sometimes unwilling—to provide appropriate care for significantly overweight patients, Gina Kolata writes for the New York Times.

Gaps in care for obese patients

About one in three people in the United States is obese, and more than 15 million people have extreme obesity. But health care providers often do not provide appropriate health care to obese patients—a problem stemming at least partly from providers' reluctance to look beyond weight when diagnosing patients who have obesity.

In one case cited by the Times, an urgent care physician attributed an obese patient's shortness of breath to her weight. However, after seeing Scott Kahan, an obesity specialist at Georgetown University, the patient learned that she actually had life-threatening blood clots in her lungs. Another obese patient was told her hip pain stemmed from her weight, when in fact—as she learned later—she had scoliosis, a condition unrelated to weight.

Overall, according to research, providers tend to spend less time with obese patients, are less likely to refer obese patients for diagnostic testing, and are more likely to harbor bias against overweight patients.

Obese patients also must contend with physicians who are unequipped to provide care.  For instance, most readily accessible scales and scanners aren't built to accommodate very heavy people. Scanners large enough to accommodate heavier patients are available, but a 2008 survey found at least 90 percent of EDs did not have them—and neither did four in five community hospitals classified as bariatric surgery centers.

Instead, some obese patients are forced to rely on X-ray exams, rather than more sensitive scans, and "hop[e] for the best," Kolata writes. In extreme cases, some physicians send patients to a zoo for a scan or simply give up.

Problems caring for overweight patients often extend beyond diagnosis and into treatment. For example, Clifford Hudis, CEO of the American Society of Clinical Oncology, explained that not only can obesity worsen cancer, but it can compromise medical care. Drug doses are often based on standard body sizes, and there is little data about appropriate doses for heavier patients.

Meanwhile, some surgeons refuse outright to perform hip and knee replacement procedures unless obese patients lose weight—even though the American Association of Hip and Knee Surgeons concluded that, while overweight patients should be advised to lose weight, they should not be categorically dismissed based on BMI scores.  

Adolph Yates Jr., an orthopedics professor at the University of Pittsburgh School of Medicine, said, "There is a perception among some surgeons that it is more difficult, and certainly some felt it was an added risk," to operate on very obese patients. Further, providers may be hesitant to treat patients out of fear that poor outcomes could decrease their ratings, Yates said, which in turn can lead to financial penalties and lower Medicare reimbursements.

Looking beyond weight

All of these issues sometimes lead obese patients to skip visits to the doctor. Sarai Walker, the author of the novel "Dietland," said, "I have avoided going to a doctor at all. That is very common with fat people. No matter what the problem is, the doctor will blame it on fat and will tell you to lose weight."

So what can obese patients do?

Some initiatives are underway to improve care for obese patients. For example, Louis Aronne, an obesity specialist at Weill Cornell Medicine, helped found the American Board of Obesity Medicine to train doctors in treating obesity. The group also acts as a resource for patients looking for physicians who will look beyond weight when making a diagnosis.

"Physicians need better education, and they need a different attitude toward people who have obesity," Aronne said. "They need to recognize that this is a disease like diabetes or any other disease they are treating people for."

Kahan also called for patient awareness, contending that before patients can advocate for themselves, providers must treat them with respect. "Patients with severe obesity will experience that stigma inside and outside the health care system," he said.

Experts are also outlining how patients with obesity can better vocalize their needs.  

Rebecca Puhl, deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut, said her organization suggests that patients bring along a friend or family member to advocate for them, or prepare a list of questions they want a physician to address before an appointment. "Write down details: when the problem started, how often it appeared, and your own opinion about whether it is related to your weight," Puhl said.

If a physician still circles back to weight, Puhl said patients should "consider telling the doctor [they] feel upset or distressed" and judged. And if a physician won't consider other factors, Puhl said patients should seek a second opinion or consider looking for a new physician.

"There are fundamental rights here for patients," Puhl said. "All people deserve to be treated with dignity and respect" (Kolata [1], New York Times, 9/25; Kolata [2], New York Times, 9/25; Dietsche, Becker's Hospital Review, 9/26).

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