“I could never be a primary care doctor,” my friend and fellow medical student says as she pops a french fry into her mouth.
There are five or six of us sitting around a hospital cafeteria table, grabbing a quick lunch between our morning and afternoon lectures. “I mean, seeing fat people with diabetes and heart disease all day. It would just be so frustrating, because they did it to themselves, you know?”
My friend is not alone in her attitude towards fat patients. Most experts agree that genetic, socioeconomic and environmental factors all contribute to obesity, many of which are out of patients’ control. Still, the belief that obesity can be reduced to an issue of willpower pervades. Unfortunately, blaming fat patients for their state of health is only one manifestation of a much deeper problem in medicine: anti-fat bias. A recent study of nearly 5,000 first-year medical students in the United States found that 59% of surveyed students exhibited moderate-to-strong bias against fat people. Medical students demonstrated more negative explicit attitudes toward obese people than toward racial minorities, gay and lesbian people and poor people. Nearly one in six students agreed with the statement, “I don’t like fat people very much.”
Sadly, anti-fat attitudes do not disappear upon medical school graduation. Research has shown that physicians exhibit both strong implicit and explicit anti-fat bias on Weight Implicit Association tests; that physicians are less likely to build emotional rapport with overweight and obese patients; that physicians’ level of respect for patients actually goes down as patient weight goes up; that patient size negatively impacts the amount of time a physician spends with a patient; and that even health professionals who specialize in obesity exhibit high levels of anti-fat bias, including endorsement of stereotypes that fat people are “lazy,” “stupid” and “worthless.” The numbers are disturbing, but not surprising.
At my medical school, I find that obesity is frequently regarded as a punchline rather than a category of discrimination. When we learned that obesity exacerbates arthritis due to increased weight burden on the joints, our lecture hall erupted into giggles. Our teachers and mentors are no better. One of my professors actually showed us a slide with two stick figures, one fat and one skinny. He drew a check mark above the skinny one, an “X” above the fat one. More laughter. It is not difficult to extrapolate how our bias as providers hurts our patients.
The effect of anti-fat bias on public health has been particularly well documented in the realm of preventive health care and screening. For example, a 2004 study of nearly 53,000 adults showed that morbidly obese women are significantly less likely than non-obese women to get screened for colorectal cancer, even when controlling for confounding factors. Obese women are also less likely to access cervical and breast cancer screening than their non-obese counterparts. In a 2006 study published in the International Journal of Obesity, obese women who were asked to report the reasons they avoided getting Pap smears most commonly reported “disrespectful treatment [by health care providers]” and “negative attitudes of providers.” These data support the argument that eradicating anti-fat bias among health professionals is critical for providing adequate preventive health care to obese patients.
Yet I think that the crux of weight stigma in medicine extends even beyond the barriers to care that it creates. I do not mean to diminish the importance of invaluable screening evaluations that have doubtlessly saved countless lives. I only mean to say that as medical students, as doctors, as people who have chosen to enter a field in which our primary duty is to serve other humans regardless of their creed, background or color, the fact that our respect for patients has been shown to decrease as the size of their bodies increases is deeply shameful in and of itself. I am talking about the research, yes, but I am also talking about the daily interactions I have with my classmates and preceptors. I am talking about the attending physician who laughs as he tells us that when he donated his own bone marrow, he had to undergo plasmapheresis for six hours instead of four because his recipient was such a “large lady.” I am talking about my friends who say they never want to take care of patients with type II diabetes because those patients “did it to themselves.” I am talking about the giggles that ensue when the issue arises as to whether or not a patient will “even fit into the CT scanner.” The thing is — and I cannot believe I even have to write this — fat people are people, too. This is about more than the prevention services we provide, more than the number of women who are screened for cervical cancer, more than statistics and data. This is about being human. I can already hear the voices of my critics: “But isn’t fat unhealthy? Aren’t fat people choosing to be fat?” Not necessarily. All too frequently in medicine, the terms “fat” and “unhealthy” are mistakenly collapsed. In fact, there is a growing body of evidence to suggest that the relationship between body weight and overall health status is not so clear (to read more from folks beginning to challenge this paradigm, check out here and here). Yes, obesity is a risk factor for many diseases. So are age, race, gender and family history. It is unclear whether and to what extent we can choose our body size any more than we can choose those characteristics. Still, even if being fat were entirely a matter of willpower and even if fat definitively meant unhealthy, would that give us an excuse to treat fat patients poorly? When has hostility ever been conducive to taking care of a patient? Creating a clinical environment so antagonistic that fat patients are afraid to access care is not helping anybody.
Obviously many paradigm shifts need to take place in order to reduce anti-fat bias. One place to start is in medical schools. Despite its pervasiveness, anti-fat bias has never been mentioned — much less formally addressed — in my medical education. As trainees of the medical profession, we will inevitably take care of thousands of overweight and obese patients in our careers. Yet we receive no formal training in sensitivity to weight issues. As we build our medical curricula to include cultural competence training in race, gender and sexual orientation, we should include body size. We need mentors to guide us in critically examining the assumptions we make about fat patients (and people). We need to learn to challenge the implicit and explicit biases we hold. We need to reiterate, over and over, that fat patients cannot be written off because they “do it to themselves.” Our future patients deserve better.