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.