Public Contrition

A Doctor’s Apology to Patients with Obesity

Obesity has emerged as a significant risk factor for poor outcomes in patients infected with COVID-19. Based on how doctors and others in health care have previously treated patients with obesity or overweight conditions, my guess is that many will respond by declaring: “Well, it’s their own fault for being overweight!”

In the spirit of recognizing that people who struggle with weight loss include our family and friends, let me propose a different sentiment.

To those who we have shamed for having excess body weight and/or failing diets: “You were right, and we are sorry. After giving you undoable tasks, we ridiculed you. When you tried to tell us, we labeled you as weak and crazy. Because we didn’t understand what you were experiencing, we looked down on you. We had never felt it ourselves. We did not know. And for that, we apologize.”

Fat Shaming Doesn’t Work

This is just one version of the apology we owe our fellow human beings whom we told to lose weight using diet and exercise. Then, when it didn’t work, we blamed them for our treatment plan failures and smothered their feedback with prejudice and persecution.

As a physician and researcher, I have worked in this space for many years. I have witnessed firsthand the life-altering power of preexisting ideas, judgments, and stereotypes. I have seen how unfounded, negative ideas are woven through virtually every interaction that those struggling with weight loss endure when seeking help.

And there are tens of millions of them. The Centers for Disease Control and Prevention classifies more than 70% of U.S. adults as overweight, and more than 40% as obese. Those numbers continue to climb, and even when some manage to lose weight, they almost always gain it back over time.

Rash Judgments

To illustrate, imagine that I am your doctor. You have a body rash (which represents the condition of being overweight or obese), and you make an appointment with me to discuss a treatment plan.

During your visit, my office staff uses stigmatizing language and nonverbal signals that make it clear we are annoyed at the idea of dealing with another rash person. We invoke a set of assumptions that dictate the tone of our relationship, including the notions that you are lazy or ignorant or both. You will sense my disgust, which will make you uncomfortable.

Unfortunately, health care providers commonly treat patients who struggle with weight loss by assigning stereotypes, snap judgments, and ingrained negative attributes – including laziness, noncompliance, weakness, and dishonesty.

After this uncomfortable exchange, I will prescribe a treatment program for your rash and explain that it’s quite straightforward and easy to use. I will point you to several resources with pictures of smiling people with beautiful skin who never had a rash to emphasize how wonderful your outcome will be. “It’s just a matter of sticking to it,” I will say.

Back at home, you are excited to start treatment. However, you quickly realize that putting on the cream is unbearable. It burns; your arms and legs feel like they’re on fire shortly after you apply the treatment. You shower and wash off the cream.

A Dismal Conversation

After a few days, you try again. Same result. Your body will not accept the cream without intolerable burning and itching. You return to my office, and we have the following conversation:

You: Doctor, I cannot stick to this plan. My body cannot tolerate the cream.

Me: This is exactly why doctors do not want to deal with rash people. I’m giving you the treatment and you won’t stick to it. I put the cream on myself every morning without an issue.

You: But you don’t have a rash! Putting this cream on when you have a rash is different than putting it on clear skin. I do want to get rid of my rash, but I cannot tolerate this cream.

Me: If you don’t want to follow the treatment, that’s up to you. But it’s not the cream that needs changing. It is your attitude toward sticking with it.

This exchange illustrates prejudicial behavior, bias, and a disconnect between a provider’s perceptions and a patient’s experience.

Prejudice and Bias

For someone who wants to lose weight, the experience of a diet and exercise prescription is not the same as for a lean person on the same program. Perceiving another person’s experience as the same as one’s own when circumstances are different fuels prejudice and bias.

That night, though, you can’t help but wonder: “Is something wrong with me? Maybe my genes or thyroid or something? The cream seems so fun and easy for everyone else.”

At this point, the blame unconscionably lands on the patient. Despite an undeniable explosion of this rash, and abysmal treatment adherence rates while we have been touting the cream, we stubbornly maintain it works. If the rash is expanding, and hundreds of millions of people are failing treatment or relapsing every day, well – it’s their own fault!

As time goes on, you feel increasingly discouraged and depressed because of this untenable situation. Frustration wears on your sense of optimism and chips away at your happy moments. You have this rash and you can’t tolerate the treatment plan, but no one believes you. They judge you, and say you choose not to use the cream because you lack willpower and resolve. You overhear their conversations: “It’s her own fault,” they say. “If that were me, I would just use the d#$% cream.”

This is the very definition of prejudice: an opinion, often negative, directed toward someone and related to something that the individual does not control. Although it has been extensively demonstrated that the causes for overweight and obesity are multifactorial, the myth that it’s the patient’s fault is still widely accepted. This perception of controllability leads to the assignment of derogatory stigma.

A Setup for Failure

That evening you sit alone. You think there’s not a single person on the planet who believes your body won’t tolerate this treatment. Society believes you brought this on yourself to begin with; there doesn’t seem to be a way out.

We have driven those with overweight and obesity conditions to this place far too many times. We have set them up to take the fall for our failed treatment approaches. When they came to us with the truth about tolerability, we loudly discredited them and said they were mentally weak, noncompliant, or lazy.

So where do we go from here? If we agree to stop stigmatizing, stereotyping, and blaming patients for our treatment failures, and we accept that our current nonsurgical paradigm is ineffective – what takes its place?

For starters, we need a new approach, founded on respect and dignity for patients. A fresh lens of acceptance and suspended judgment will allow us to shift our focus toward treatments for the body, rather than “mind over matter,” which is a concept we use for no other medical condition. A perspective based in objectivity and equality will allow caregivers to escape the antiquated blaming approach and perceive those with overweight or obese conditions in the same light as those with other diseases. Only then will we finally shift the paradigm.


 
This article, by J. David Prologo, was originally published here on The Conversation under a Creative Commons license. Prologo is an Associate Professor at the Emory University School of Medicine in Atlanta, GA.


 
Public Contrition, photograph © David Goehring / flickr

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September 12, 2020

7 Responses to “A Doctor’s Apology to Patients with Obesity”

  1. September 12, 2020 at 10:24 am, Allen Browne said:

    Ted,

    Thank you.

    It’s sad we have to keep saying this but we do. And fresh approaches and voices are great.

    Allen

  2. September 12, 2020 at 11:18 am, Cathy A Arsenault said:

    I would like to thank Dr. Prologo and I did just that publicly on Twitter yesterday for his humble apology. This is where change begins and as a patient that sat in so many physicians offices ( not actually Dr. Prologo’s) and was ignored, blamed and shamed until I just shut down, I accept his apology. I now know better because I have found doctors that understand obesity, I am now educated myself and I thank Dr. Prologo for his sincerity.
    As a Patient Advocate, Bariatric Life Speaker, Bariatric Patient and Family Advisor, I remind all medical personal that your words and jestures speak volumes to the people that come to you for help. Words and Ways. Patients are vulnerable, obesity is a disease , please get the true facts and join Dr. Prologo in a new beginning.

  3. September 12, 2020 at 4:45 pm, Theresa said:

    I believe a different analogy is,
    I go to the Dr. who without looking at my rash or getting a fix on when the rash started or how it affects me says,
    I have a cream. Use it and go away.
    I go home and am excited. I have a solution. It works, I feel and look better. People complement me on my clear skin. Then a couple of weeks later, it just not working, so I put on more cream.

    Eventually my rash is gone, I’m happy and relieved. But then little by little the rash comes back, the cream doesn’t work and now the rash has spread, it’s over more parts of my body and the Dr. and others don’t believe I used the cream or that I didn’t use enough of the cream,

  4. September 13, 2020 at 10:19 am, Faith Martian said:

    Thanks for the apology. What are Emory and other medical schools actually doing to help get rid of the weight bias they are teaching and enabling? Obesity IS NOT A DISEASE. In 2013 the AMA classified it as a disease AGAINST the advice of its own committee. It made it easier to get reimbursed. The diet industry is a 72B yearly $ grab. BMI was created in the 1800’s by Adolph Quetlet, a statistician, and brought back to life by Ancel Keyes-(google him and find out more!) BMI was never meant to be used on individuals but over populations. Those populations studied? White men. It was lowered over night in 1998. Millions of people went to bed in “normal range,” and woke up “overweight.” An apology is great. Actions speak louder than words, and people have been and continue to be harmed by weight stigma and bias.

  5. September 14, 2020 at 4:22 am, Ted said:

    Faith, we’ll have to agree on the problem of weight stigma and disagree on the medical aspects of obesity. What you wrote suggests that weight and size define obesity. But in fact, what defines obesity is the accumulation of fat tissue that harms a person’s health. Obesity is a diseases because normal metabolic regulation of energy storage is not working well to maintain health when a person has obesity.

  6. September 14, 2020 at 8:06 am, Kelsie said:

    Ted,
    When it comes to a diagnosis code, are doctors supposed to be looking at comorbidities before diagnosing obesity based on height and weight (BMI) alone? Your response with Faith is interesting to me and I feel there needs to be more clarification on this topic of calling obesity a disease.
    Thanks,
    Kelsie

  7. September 14, 2020 at 10:41 am, Ted said:

    Probably the best place to go for the latest thinking on diagnosis and care for obesity is the new Canadian guidelines:
    https://conscienhealth.org/2020/08/new-canadian-obesity-guidelines-health-over-weight/