more_vert
DURING my undergraduate degree I was acutely unwell with a bad cold. I needed a medical certificate to get an extension on an assessment that was due so I could recover through rest. I couldn’t get into my regular GP, so I went to one nearer the campus.
As I was a new patient, the doctor wanted to take a slightly broader history, which made sense to start with as that gave her some more contextual information. But I was surprised when she decided to explore something in more detail: “Let’s talk about your weight”.
Part of that surprise was because at the start I had explained that this was a one-off visit to the clinic and that I’d follow up with my regular doctor if I had ongoing symptoms. It was also because it really seemed out of the blue for a consultation about a cold.
I didn’t think about this incident much until just last year when a friend of mine went to see a GP about a lump in her breast. She decided it would be worth seeing someone that had a good reputation specifically in this aspect of women’s health. It was her second ever visit to this doctor and the first for this concern.
After a very brief examination, the doctor declared: “I’m not concerned about your breast, but you are very overweight”. This was followed by my friend being put on an extremely restrictive diet so that she could lose weight quickly, without so much as a discussion as to her general medical history or lifestyle or mental health.
In news that is unlikely to surprise you, neither of us lost much weight after these encounters. It is also not an uncommon experience for overweight people, and particularly women, to have our weight be front and centre in consultations. The fatness can often be the first problem source considered for symptoms, which can result in missed diagnoses along with a reluctance to seek further care in environments where fat patients can be treated with less respect, resulting in lower trust.
Health behaviour change strategies such as motivational interviewing are being more frequently recommended as a good approach to all sorts of lifestyle concerns. These kinds of patient-centred strategies have reasonable outcomes within study environments, but how does talking about weight work in the wild? In practice, talking about weight is hard for a variety of reasons, including difficulties in even broaching the topic and the awkwardness of such conversation.
When considering raising weight, some research has shown that one of the more effective strategies is to ensure it is linked to the patient’s presenting problem. Rather than raising weight as an additional concern, highlighting the clinical relevance of weight opportunistically can allow for more positively received brief interventions.
This needs to be done carefully because there is some evidence that it may be met with resistance, particularly if the link was not clear to the patient. This may be due to the larger social issues at play – the ongoing issues of stigma and moral accountability for weight can make starting conversations difficult. If weight is raised in ways that are not sensitive to these issues, it may delegitimise the patient’s request for medical attention.
No matter the approach used, listening to the patient’s response is crucial. Recent research into referrals to weight management services in the UK showed that simple affirmative responses from patients, such as a “yes” or “yeah”, are often interpreted as positive uptake by the GP. But, in reality, these were not associated with engagement with the service. Instead, patients who gave more enthusiastic affirmative responses, such as “oh yes” or “lovely”, were more likely to take up the suggestion.
Equally, when a patient seems resistant, pursuit of positive uptake is not helpful. Resistance is not something that needs to be overcome. Instead, it can be a window into the personal and social barriers for the patient in taking on lifestyle advice and offers an opportunity for the doctor to modify that advice rather than simply repeating it.
These studies have found that providing positive advice and foregrounding general principles of being healthy regardless of weight were more likely to get uptake from a patient. The mixed evidence on how to do this highlights that more research is needed to identify the more effective approaches in different clinical and cultural contexts. For now, carefully listening to how patients respond while checking for your own possible bias toward fat patients and their concerns will make these conversations easier.
Special thanks to A/Prof Maria Stubbe and Dr Charlotte Albury who provided advice on this article. All errors remain my own.
Dr Sarah J White is a Senior Lecturer in the Faculty of Medicine, Health and Human Sciences at Macquarie University. Dr White is the current Australian National Representative for the International Association for Communication in Healthcare.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Loading ...
The current Cochrane position statement is interesting. The most successful means of weight loss is bariatric surgery, with the more radical procedures (e.g. gastric sleeve) being more effective than the less (e.g. gastric banding). Many otherwise EBM-believing doctors go weak at the knees with this evidence. They hide this inconvenient truth from their patients.
I squirm when I visit my skinny dietician, yes it’s judgemental, ‘fat-shaming’ etc, but the evidence is that being fat is bad for you. More lethal than Covid, and we would denigrate a doctor who was an anti-vaxxer. Losing weight (by whatever means works for you) is the ‘vaccine’ for diabetes, stroke, cardiac disease etc. Any doctor who doesn’t push this wonder ‘vaccine’ is negligent.
It is all very nice to be sympathetic until an obese patient unreasonably sues us for consented surgical complications of routine surgery due to obesity. Surgery is most unpleasant in obese patients and high risk.
I maintain my aversion to obesity since encountering ghastly abdominal procedures in fat patients as a young doctor. Then I saw a litany of negligence claims against my general surgical colleagues when expected complications arose during routine surgery on an obese patient. The negligence belongs to the pateint for having the risk, not the surgeon.
I disagree. You went to a doctor who was not your usual doctor requesting a sick leave certificate for a cold – and yet you question her audacity for quite gently and legitimately opening up a discussion about weight? Especially your being in the medical profession and knowing fully the health repercussions of obesity. Doctors have a duty of care and yes, this includes discussing issues that may be sensitive such as dying and goals of care and yes, obesity. Patient autonomy includes the right to refuse life saving treatment and also health awareness advice. But to try to shift the blame to a doctor in this case while defending merely using their services apropos a sick-certicate-writing technician is insulting to say the least.
I’ve been a GP for 25 years have learnt that if I refrain from mentioning weight as a health issue the patient will volunteer it as a health concern within the first couple of consultations. When they bring it up it is generally much easier to discuss the implications, and options/assistance I can offer, and their own thoughts on the issue.
Over these many years I have also realised that a huge proportion of very obese people (I too tend to avoid this term with patients) are victims of child sexual abuse by someone close to them who they should have been able to trust. There is evidence of this in the literature. Thus talking about the “obesity epidemic” is often a kind of “victim blaming”.
The term ‘obese’ has become pejorative in modern society, and is best avoided , even in communications which the patient might read. I tended to give the BMI score, or refer to a high BMI . I also agree that bringing up a patient’s excess weight can be tricky and requires a context, eg the effects on diabetes, a heart condition or upcoming surgery.
It also helps greatly if you have already established a relationship of trust with that patient. Often if you start asking about general health the patient will volunteer that they are overweight, which can lead into further discussion.
In my view it would not be appropriate to raise it “out of the blue” in a a new patient attending for an unrelated matter, as described in the above scenario.
These comments are interesting, many reflecting societal beliefs about higher weight rather than current medical consensus.
Both the RACP and RACGP in their recent position statements recognised the negative impact of weight stigma, the low likelihood of sustained weight loss and major problems with gatekeeping health services on the basis of BMI. Both call for an immediate pivot to a ‘health gain’ instead of ‘weight loss’ approach.
For us larger-bodied people who are continually gaslit and condescended in medical encounters, it can’t come soon enough.
I think a large part of the problem is the loss of a long term relationship and rapport with their doctor which allows numerous sensitive subjects to be broached and managed. Pre-existing trust is an important component with sensitive subjects.
Brief encounters for a medical certificate make it very hard to practice good medicine when the patient clearly has a significant health problem, and especially so when the subject is sensitive.
However, are you a good doctor for not mentioning the obvious signs of domestic violence, child abuse, mental health crisis, thyroid tumour, faecal incontinence, scabies, etc. etc., or morbid obesity likely to significantly shorten the patients life because there is a possibility they may be sensitive about it?
The consumer is not always right in medicine or there is no need for doctors. They can just do their own “research” online and order their own dose of hydroxychloroquine or ivermectin for Covid, no harm done, and no need to be harassed about having a vaccine by a self interested doctor is a current example. Patients appear to have similar success with online dietary advice too.
The doctor who treats themself has a fool for a patient seems applicable if they can deny themselves the medical advice they would/should dispense to others.
These discussions now seem to include comments from non medical people which makes it sound more like a Facebook discussion than a medical forum.
I was surprised by the doctor who claimed on the recent SBS program that most obesity is genetic. Epigenetics aside, is there anyone here who doesn’t accept that most obesity is a psychological problem, related to depression, unhealthy coping mechanisms in this increasingly stressful existence, and poor self image?
As an obese person I was very ashamed of myself until in 2012 I had a hip replacement. Much of my adult life I was a healthy weight for times. I was 60 kg (9.5 stone) until I began to study & ever so gradually the weight went on. I went from size 12/14 to 16, etc. until many years later I hit 150kg. I began taking mood stabilizing medication for bipolar which is known to effect weight. I was diagnosed whip osteoarthritis which in the end required a replacement. Before surgery I had a preop appointment & one of the people I saw was a physio. She gave us exercises to strengthen our hip which I did religiously at least once a day. I was by this time needing to use a walking frame. The op went well & I was being taken to an ambulance to go to rehab when I was constantly apologising to the paramedic. He asked me if I woke up one day & thought I want to be obese? The answer was no. He then said life & societal events lead to people being obese in just about every case. Since then I am usually comfortable in my skin when out & about. By the way, the hip is doing very well 9 years on. Thanks for reading/listening.
Thanks for this article Sarah. I can confirm this has happened to me, my mother, both of my sisters and a number of close friends… and that’s just what I know of.
It ranged in impact. One sister presented for an ear infection and was told to lose weight (minimal impact, since the infection was treated, she never went back to that doctor) while my mother, presenting with post-menopausal spotting, bloating/discomfort and weight gain was put off by a several doctors including an endocrinologist because she was ‘just fat’ and needed to lose weight… before being diagnosed with a 10kg ovarian cyst (requiring urgent surgical intervention).
Person-centred care (i.e. determining what is concerning the person in front of you) should always be forefront of a consult and while I agree that there is a level of disquiet and discomfort about the medico-legal aspects of ignoring weight issues, the reality is usually exactly as you described – a complete lack of trust in the health professional that raises it in such a way.
Most fat people know we are fat – particularly women who have been conscious of it since the very first time an old relative pinched our chubby cheeks in childhood and told us that boys don’t want to marry big girls (or something equally stupid … it varies). Many of us probably don’t ‘want’ to be fat and would like some help with it… but we also want help with what we are presenting with. Let us set our own health priorities and build our trust. Then when we do trust, we will probably raise it of our own accord.
There is a fine balance between the opportunistic raising of health issues and inappropriate, unsought comments
eg: Opening a file for a new patient routinely requires asking about allergies, past medical history, current medical treatment, alcohol intake and smoking, all of which could be relevant to the management of the presenting symptom. Questions about illicit drug use and sexual orientation are usually best left until a relationship has been established, unless they are directly related to that presenting problem.
In the situation described, raising a new patient’s weight at the first visit could make the patient think, “All they see me as is another fat person – not individual ‘me’.” I doubt if any of us would say to a new patient presenting with an URTI, “By the way, your breasts are very large, have you ever thought of having them made smaller?” Granted most of us would see this as a much more instrusive question than a comment on the patient’s weight, but the patient might not,
The best description of obesity I’ve ever heard is “normal people reacting normally to an abnormal environment”. Even as an eye doctor I deal with the complications of obesity so this subject is still in my territory to touch upon, on occasion. To de-stigmatise obesity as more than a character failing, is a good way to open. What is missing in medical education generally is ongoing, robust, cutting edge science on weight reduction. This space is altering rapidly and the disconnect between the research and the coal-face is a real problem which our entire profession needs to address in order to manage our community’s (arguably) number one medical problem.