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March 2014
Think all patients are treated equally when it comes to body size?
“I think that if you gave a doctor a choice, they would choose to do a procedure on a skinny patient over a very obese one,” said Arnold Komisar, MD, medical director of the head and neck service for the North Shore-LIJ Healthcare System, a practicing otolaryngologist at Lenox Hill Medical Center, and a clinical professor of otolaryngology at New York University. “It’s totally anecdotal, but I’m absolutely sure it exists.” Dr. Komisar, who has worked in the field for more than 30 years, said that performing surgical procedures on extremely large patients entails “much more work.”
“It’s more time in the OR just to do the same procedure, because of the patient’s size and tissue planes,” he said. “If I go into a neck to take out a thyroid, the thyroid is deeper, and there’s more tugging, surgically. It becomes more work.”
Obese patients, defined as those who have a body mass index of 30 or higher, present issues that can make surgical procedures, both in otolaryngology and in other specialties, more challenging. They include anesthesia concerns as well as potential comorbidities such as type 2 diabetes,
prediabetes, and hypertension. Such factors can help prejudice physicians against larger patients—which can in turn negatively influence the kind of care these patients receive. Ultimately, such bias can worsen the patient experience so much that patients stop seeking care altogether.
Prevalent Attitudes Among All Physicians
Weight biases aren’t unique to the field of otolaryngology, or even to the field of medicine, said Janice A. Sabin, PhD, MSW, a research assistant professor in the biomedical informatics and medical education department at the University of Washington in Seattle. “This is common and prevalent in society. Doctors aren’t different from others.”
Dr. Sabin studies the biases of healthcare providers and how they may affect patient care, using insights collected through a virtual laboratory based at Harvard University, where people can take online tests that uncover bias against weight, race, and other topics. “It’s a rapid-fire process, where people can’t stop and think about what they want to say,” she said. The database has more than 300,000 responses from the general public, and Dr. Sabin has studied the responses of those who self-identify as medical doctors (though medical specialties were not specified). A physician can show explicit bias, openly admitting he or she does not want to treat an obese patient, as well as implicit bias, a prejudice the physician does not realize he or she holds.
“Anecdotally, it’s pretty obvious that overweight or obese is a problem in healthcare,” said Dr. Sabin, who published her findings in 2012 (PLoS One. 2012;7:e48448). (Overweight people are those who have a body mass index number of 25 to 29.) “Looking at the data, physicians recorded very strong thin-versus-fat preferences, a very strong anti-bias. These are attitudes they might not be aware they have. It’s not a surprise, as these attitudes are very prevalent in society.”
In reviewing studies about weight bias, Dr. Sabin said that patients have reported feeling disrespected by health professionals because of their weight and that women have been subjected to inappropriate comments about their weight by their doctors. As a result, she said patients don’t always seek timely care, and tend to avoid seeing a physician. “It’s a real snowball effect,” she added.
Physicians Miss Out, Too
Patients aren’t the only ones who are hurt by weight bias; physicians are, too. Kimberly Gudzune, MD, MPH, an assistant professor of medicine at The Johns Hopkins University School of Medicine in Baltimore, has studied how physicians interact with their patients by reviewing audiotapes of doctor-patient discussions that represent established patients coming in for routine care from their primary care doctors.
In her research, published in 2013, she found three kinds of communication: biomedical (asking questions about medical problems and symptoms and giving advice), psychosocial (asking about how life is going), and rapport building (the doctor expressing empathy or partnership, or disclosing personal details) (Obesity. 2013:21:1328-1334). While biomedical and psychosocial communication was the same among all patients and doctors, regardless of the patient’s weight, “there was significantly less rapport-building between physicians and their overweight or obese patients,” said Dr. Gudzune. “This suggests they are not building the core of the relationship.”
When doctors empathize with their patients, those patients say they are more satisfied with their medical care and are more likely to follow physician recommendations. This is seen by patients’ improved blood glucose or blood pressure readings, said Dr. Gudzune. Also, when physicians engage in rapport building with their patients, they report feeling more satisfied with their jobs and are less likely to suffer from burnout or have lawsuits files against them.
“I believe rapport is related to implicit bias,” she said. “A physician might not be making those emotional connections [that] are beneficial both to the patient and to the practitioner.”
How Weight Bias Affects Otolaryngology Patient Care
Among otolaryngologists, excess patient weight plays a role in many medical issues concerning the head and neck region. “We think of ourselves as working with the collarbone and up, but weight affects our disease procedures and how we deal with it from a surgical standpoint,” said Neil Bhattacharyya, MD, professor of otology and laryngology at Harvard Medical School and the associate chief of otolaryngology at Brigham and Women’s Hospital in Boston. “Most of our surgeries are voluntary. I think it’s natural for doctors who want to minimize risks, who might not be as eager or enthusiastic about doing an elective procedure, like a septoplasty” for a larger patient. For patients with an elevated risk like obesity, which can mean higher risks of anesthesia complications or slower wound healing rates—often linked to type 2 diabetes—a physician may be less likely to agree to perform the procedure.
Dr. Bhattacharyya, who has published research in the Laryngoscope linking obesity to higher rates of chronic rhinosinusitis and allergic rhinitis in adults and children, said that obese patients have more difficult airways to manage, because anesthesia is administered in the same airway that otolaryngologists are operating in (2013;123:1840-1844; 2013;123:2360-2363). “It’s not like doing a foot surgery,” he said.
Also, obesity can affect how well a person will heal from a surgical procedure, based on slower wound healing rates associated with diabetes, as well as inflammation factors. “There is mounting evidence that obesity itself is linked to, and can heighten, inflammation. With things like chronic sinusitis, asthma, chronic tonsillitis, and ear infection—all linked to chronic inflammation—an obese individual is probably not going to have as good an outcome, post-surgically, as a thin individual,” he said.
Dr. Bhattacharyya handles many patients with sleep apnea, which can be linked to obesity and treated surgically. He said the question of whether an obese patient should try to lose weight before the procedure or use the operation as a way to jump-start weight loss, becomes “a kind of chicken or egg discussion” among physicians at conferences. “I was more of a believer of doing the surgery before the weight loss, but I’ve seen that largely not be successful,” he said. “People would lose some weight but would gain it back. Now, for people with a body mass index of over 30, I strongly counsel them to lose weight, and [I] make many referrals to see nutritionists and bariatric surgeons. I want to at least explore and fully confront that aspect of their health—not only for obesity’s contribution to sleep apnea but for other health concerns, particularly cardiovascular.”
Larger patients can face additional issues when they have surgery to treat sleep apnea, said Dr. Bhattacharyya, though he questioned whether it would be considered weight bias or simply smart risk assessment to prevent potential problems. Some of these patients will need intensive care unit coverage after apnea surgery, due to the higher airway risks, so they may need to travel farther from home to an area where there is a teaching hospital with residents on call who can assess a situation more quickly, rather than undergo the procedure at a smaller but more local hospital, he said.
Additionally, a patient’s insurance might not cover surgery at a larger facility as it would at a smaller hospital, depending on the policy, he said. Anesthesia is administered based on body weight, so it takes longer for anesthesia to wash out of an obese patient’s system, compared with that of a thinner patient. This all affects the amount of time the patient is cared for as well as how much the patient will pay out of pocket: A sleep apnea procedure can be an outpatient day surgery for a thin patient but can require more inpatient time and care for the obese patient, who is likely to require a longer hospital stay.
Improving the Doctor-Patient Relationship
In the United States, nearly 36% of all adults are obese, and close to another 33% percent are overweight, according to 2009-2010 data published by the Centers for Disease Control and Prevention.
What’s the best way for physicians to better connect with these patients to ensure quality care? Recognizing the potential for both explicit and implicit bias is key. “The first thing is really improving communication skills with all people, especially those who are different from yourself,” said Dr. Sabin, who cited assorted continuing education programs as well as medical school curricula. “That’s really the answer: fine-tuning your skills and knowing you may have prejudice, and overriding it for patient care.”
Seeing obesity as a chronic disease—and not merely as a symbol of eating too much—can also help. “Just like you would for a patient who has diabetes or emphysema—make that part of the discussion,” said Dr. Bhattacharyya. “Use that as a risk factor and a comorbidity that affects surgery, surgical planning, and prognosis. Make it [change] from something you don’t want to speak about to … a medical connotation that needs to be addressed.”
Doing so can only help more patients and strengthen the skills of every physician—including otolaryngologists and other specialists. Patients who are obese and overweight aren’t going away, and the numbers of larger patients are likely to increase in coming years. As a result, “addressing it and becoming comfortable with these patients is critical for all physicians,” said Dr. Gudzune. “We should really be advocates for patients, and see it as an opportunity for people who are seeking and wanting our help.”
Cheryl Alkon is a freelance medical writer based in Massachusetts.
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