When Melissa Boughton complained to her OB-GYN about dull pelvic pain, the doctor responded by asking about her diet and exercise habits.
The question seemed irrelevant, given what kind of pain she was in, as Boughton thought at the time. But it wasn’t strange coming from this doctor. “Every time I was there, she was talking about diet and exercise,” said Boughton, who is 34 and lives in Durham, North Carolina.
On this occasion, three years ago, OB-GYN told Boughton that losing weight would likely solve pelvic pain. The doctor introduces diet and exercise at least twice during the appointment. The doctor said she requested an ultrasound to calm Boughton’s mind.
Ultrasound revealed the source of the pain: a 7-centimeter tumor filled with fluid on Bogton’s left ovary.
“I hate that doctor for the way she treated me – like my pain wasn’t a big deal,” Boughton said. “It looks like she made a decision about me based on a very quick look.”
Research has long shown that physicians are less likely to respect patients who are overweight or obese, with nearly three-quarters of adults in the United States now falling into one of these categories. Obesity, which characterizes patients with a body mass index of 30 or higher, is prevalent in the South and Midwest, according to the Centers for Disease Control and Prevention. The state with the highest rate is Mississippi, where 4 in 10 adults qualifies as obese.
Obesity is a common, treatable condition that is linked to a long list of health risks, including type 2 diabetes, heart disease, and some types of cancer. Although obesity is common, it carries a unique stigma.
This is almost like misbehaving.
Scott Butch, Cleveland Clinic Obesity and Metabolic Institute
Physicians often treat the practice of medicine with a bias against fats and struggle to connect with patients who weigh more than what is considered normal. Some obesity experts blame a lack of focus on the topic in medical schools. Others blame a lack of empathy.
To counter this, the Association of American Medical Colleges plans to introduce new standards for diversity, equality, and inclusion in June aimed at teaching clinicians, among other things, the respectful treatment of people diagnosed as being overweight or obese.
That doesn’t happen for many patients, said Dr. Scott Butch, MD, director of obesity medicine at the Cleveland Clinic Obesity and Metabolic Institute. “This is almost like misbehaving. You have these doctors or doctors — whoever they are — linking everything to a patient’s obesity without investigation,” Butch said. “Stereotypes and misconceptions about this disease bleed into clinical practice.”
Butch argued that the problem is that little attention is paid to obesity in medical school. Butch said that when he trained and taught at Harvard Medical School for several years, students received no more than nine hours of obesity education spread over three days in four years.
In 2013, the American Medical Association voted to recognize obesity as a disease. But Butch said doctors often approach it on a one-size-fits-all scale. He said “Eat less, move more” doesn’t work for everyone.
Psychologists warn that parents and medical providers need to take special care when talking to children diagnosed with obesity about their weight. The way parents and caregivers talk to children about their weight can have lifelong consequences and in some cases lead to unhealthy eating habits. For children who are obese, obesity experts agree that losing weight is not always the goal.
“There are many different forms of obesity, but we treat it like we give the same chemotherapy for all cancers,” Butch said.
Things I never learned in medical school
All but four of the country’s 128 awarding medical schools reported covering content related to obesity and bariatric medicine in the 2020-21 academic year, according to curricular data submitted to KHN by the Association of American Medical Colleges, which does not represent osteopathic schools.
However, research indicates that many clinicians are not adequately trained to address weight issues with patients and that education about obesity in medical schools around the world is “too neglectful”. A survey of leaders from 40 US medical schools found that only 10 percent felt their students were “very prepared” to deal with obese patients.
Meanwhile, the authors of a 2020 journal article describing the survey results wrote that “half of the medical schools surveyed reported that expanding education on obesity was a low or no priority.”
Butch wants Congress to pass a resolution insisting that medical schools incorporate substantive training in nutrition, diet and obesity. However, he acknowledged that medical school curricula are already full of topics that are essential to cover them.
Dr. David Cole, president of the Medical University of South Carolina, said a lot of topics should be covered more comprehensively in medical school but they are not.
“There’s this huge book – it’s about that big,” Cole said, raising his hand off the top of a conference table in Charleston. “The point is: Things I didn’t learn in medical school.”
The larger issue, he said, is that medicine has historically been taught to emphasize preservation and failed to emphasize culturally competent care. “That was true 100 years ago, if it were to be the source of all knowledge,” Cole said. “This is not valid anymore.”
The Association of American Medical Colleges is trying to tackle the problem in two ways.
First, he developed a professional readiness test for aspiring medical students, called PREview, which is designed to assess an applicant’s cultural competence, social and listening skills, as well as their ability to think about situations they might encounter in medical school and clinical settings. “We call them softer skills, but they are really harder to learn,” said Lisa Hawley, an educational psychologist and senior director of strategic initiatives at the association. More than a dozen medical schools now recommend or require applicants to submit their PREview scores along with their Medical School Admissions Test scores.
Second, the College of Medicine Association will roll out new competency standards for medical students, residents, and existing physicians regarding diversity, equity, and inclusion in June. These standards will address racism, implicit bias, and gender equality and will aim to teach clinicians how to talk to people who are overweight.
“The bias towards these individuals is very high,” Hawley said. “We have a lot of work to do in this area.”
After discovering the source of Melissa Boughton’s pelvic pain, an obstetrician-gynecologist who recommended diet and exercise to relieve her symptoms, told Boughton that the lump wasn’t a big deal.
“I just acted like it was the most normal thing in the world,” Boughton said.
Boughton asked for a second opinion from a female doctor who marketed her practice as a “healthy at every size” office. This doctor referred Boughton to a surgical oncologist, who removed the tumor, her left ovary, and part of her fallopian tube. The tumor was large, but not cancerous. And although surgery to remove it was successful, Boughton has since been having trouble conceiving and is undergoing fertility treatment as she tries to have a baby.
“It’s an emotional rollercoaster,” she said. “I feel too young at 34 to have this.”
Boughton – who describes herself as someone who “doesn’t fit a BMI” – said the experience taught her to choose her doctors differently.
“You can ask me if I’m dieting and exercising all at once,” she said. Any more than that, and start shopping for a different doctor.
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