Reflections
History and humanities Metabolic diseases
Volume 195 - Issue 9

The person inside

Author:  Katrina J R Watson

Med J Aust 2011; 195 (9): 548.
Published online: 7 November 2011
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What can we do to avoid discrimination against the obese?

A few years ago I had the pleasure of tutoring groups of medical students in their communication course. One topic on the syllabus was discrimination — an opportunity for the students to reflect on their own potential biases. During these sessions I discovered that most students could overcome racism, homophobia and religious prejudice quite readily, but had considerable difficulty in being non-judgemental about Australia’s most prevalent health condition: obesity.

In an effort to help my students, I would recount the following anecdote. In the 1980s, I worked in a small endoscopy facility that employed some nurses who were significantly obese. One of these nurses, whom I shall call Janet, was not normally especially friendly to patients. One day I was struck by a particular encounter. A patient was wheeled in, on an extra wide trolley — a patient with morbid obesity. Janet started to stroke the patient’s forehead and call her “dear” and “darling” in the gentlest tone of voice. I had never seen Janet so compassionate before. This made me realise that Janet herself must have experienced negative attitudes from health professionals.

My students have now graduated and will be fine non-judgemental doctors, I hope. But discrimination against obese people in health care settings is still common. Take this example from a blog written by “Midlife Midwife” in the United States:

I have to admit. I have a hard time emotionally with severely overweight people ... I have to really work at not being judgmental of them. I get a sinking feeling in my stomach and frustration bubbles up into my chest when I see a patient’s weight is over 250 pounds. I have to really work to put on my smile and be as kind as possible.1

Midlife Midwife goes on to discuss the technical difficulties of doing a Pap smear, including lack of appropriate specula, in obese women.

The negative attitudes held by Midlife Midwife have been shown to be held by a large percentage of doctors, students, nurses and others.2 Overweight people suffer inferior care, negativity and even ridicule, and they become reluctant to access health care. They are then at risk of further deterioration in health.

Critical attitudes and stigmatisation of obesity do not make weight reduction more likely — in fact the reverse is true. Discrimination has been shown to lead to worsening of unhealthy eating patterns. Conversely, it has been shown that empathy enhances weight reduction.

Overweight people are now claiming the moral high ground. There is a fat acceptance movement, which has spawned various societies, such as the International Size Acceptance Association. However, critics of the fat acceptance movement aver that societal acceptance of obesity will reduce the aspirations of the community to lose weight.

If I were tutoring medical students today, they might ask: what do we do? Do we treat obesity as a disease or simply a physical attribute? If we overcome our prejudices and show empathy, are we normalising obesity?

To help in my answer, I might reflect further on my own practice. Over the years I have seen many patients with non-alcoholic fatty liver disease, and so counselling on weight reduction has become part of my bread and butter (thin scrape only!). I think I have been able to empathise with the patient without normalising obesity — obesity is a chronic medical condition. Fat acts as a huge metabolic organ, producing cytokines that cause symptomatic bad health.

I have learned that if you add a few E-verbs to a good spoonful of Empathy you will help your patient achieve weight loss. The mix should include some Empathising, some Evoking of the patient’s reasons to change, a good helping of Enabling (with simple strategies such as a daily walk), some Educating and some Empowering the patient to take control, all while Enjoying the collaboration. If you work with your patient as a team — acting as an ally and an Equal (the final E-word) — you will have a great recipe for success.

Midlife Midwife may have learned a thing or two from one of the responses to his or her blog:

Maybe speculums should be made to fit the people who need them. And maybe fat people are human enough to KNOW that you don’t like them and that you automatically think less of them, and that’s why many would rather go for years without medical care than subject themselves to a snotty, superior attitude and knowing that they’ll be snickered at behind their backs.

Oh, and my husband has no trouble finding where to put the “speculum” in, and I’m 350 lbs. And I regularly walk 5 miles for the hell of it. Put that in your pipe and smoke it.1

Yes, a daily walk is good for everyone — but the most important walk for doctors is the walk in our patients’ shoes.