PictureDr. David Miller, Wake Forest
Less than a month ago, Academic Medicine published a new study of medical students and obesity bias. As Patient Promise signers will recall, one of the major tenets of the oath is to guard oneself from potential biases against their patients. The paper concludes:

"Over one-third of medical students had a significant implicit anti-fat bias; few were aware of that bias. Accordingly, medical schools' obesity curricula should address weight-related biases and their potential impact on care."

We had the opportunity to interview lead author and professor at Wake Forest School of Medicine, Dr. David Miller. This is what he had to say about the study and what it means for the practice of healthcare. 

How did you become interested in the issue of weight stigma in healthcare?

We received a grant from the National Cancer Institute to develop a comprehensive obesity prevention and management curriculum for medical schools.  As part of our efforts, we asked all 3rd year medical students at our institution to take the Weight Implicit Association Test prior to a small group discussion of bias and its impact on the medical encounter.  We noticed many reports of anti-obesity bias in society, so we were very curious to see if medical students shared this bias and if they were aware of it.  If we found that many medical students had an unconscious weight bias, then we would need to address that as part of our curriculum. 

Can you describe the various forms of weight bias (patient to provider, provider to patient, etc), and how much a problem they've posed (statistics)?

In our study, we found that approximately 40% of medical students had a moderate or strong anti-obesity bias, and most were unaware of their bias.  We didn’t specifically examine how this bias affected their clinical encounters, but other researchers have examined that question.  From other published studies, we know that bias affects treatment decisions, differential diagnoses, and patients’ willingness to seek care.

Are there other forms of stigma that we can draw lessons from, e.g. smoking?

It’s hard for me to comment on this question since our study only looked at weight bias.  But you will find several published studies describing the impact of racial bias on medical care.

What are specific steps that healthcare providers can implement to reduce weight stigma in healthcare?

The first step to reducing the effect of bias is to acknowledge its existence and its potential to influence the care we give.  If we (meaning us health professionals) think we are unbiased, then we won’t take any steps to counteract it.  Once we accept the possibility that we could harbor some bias, we can begin to think of ways to minimize its impact.  Unfortunately, actually reducing the impact of bias has proven difficult, and most experts in this area think it takes repeated opportunities for practice.  When we notice we are developing a negative reaction to a patient, that is a good cue to pause and ask ourselves why we are having that reaction and how we can use the situation as a chance to practice our ideals (such as treating all patients equally and with respect).  It may also help to try to understand how obesity has impacted our patients’ daily lives.  Glimpsing their life experience can facilitate empathy. 

What do you think of The Patient Promise as a way to raise awareness/change behavior among clinicians? 

Behavior change is very hard.  Sometimes as physicians we forget that . . . until we try to change something in our own lives.  The demands of medicine can also make it difficult to find time to take care of ourselves.  I’m glad to see the Patient Promise is encouraging physicians to engage in healthy behaviors which will benefit not only us, but our patients as well.

One of the tenets of the Patient Promise is to "identify and guard oneself from potential prejudices against my patient based on unhealthy behaviors, recognizing the often complex origins of these habits." This was based on a growing body of evidence showing that weight bias is growing and adversely affecting the clinician-patient relationship. Recently the New York Times published an article ("When the Doctor is Overweight") that cited research published by Yale's Rudd Center Director of Resarch and Weight Stigma Initiatives and Patient Promise advisor, Dr. Rebecca Puhl. We had the opportunity to catch up with Dr. Puhl and ask her about the issue of weight bias and how we, as clinicians, could become more aware and helpful to our patients. 

How did you become interested in the issue of weight stigma in healthcare?

Weight stigma is pervasive in many different domains of our society, and unfortunately health care is one of them. This is an especially important setting to focus on, because we need to ensure that the two-thirds of Americans who are overweight or obese receive quality health care delivered with the compassion and respect that they, like all patients, deserve from health providers. When we look at the evidence documenting negative consequences that people experience as a result of weight bias, whether it be adverse emotional, social, economic, or physical health outcomes, we need to make sure that health care is not contributing to these disparities.

Can you describe the various forms of weight bias (patient to provider, provider to patient, etc), and how much a problem they've posed in healthcare?

Weight bias takes various forms in the health care setting. From providers, we see that health professionals (e.g., physicians, nurses, dietitians, medical students, psychologists) negatively stereotype obese patients to be sloppy, lazy, lacking in discipline and willpower, and non-compliant with treatment. Experimental research shows that as a patient’s BMI increases, physicians report  having less respect for the patient, less desire to help the patient, and report that patients are less adherent to medications and more annoying than thinner patients. Additional research indicates that compared to appointments with thinner patients, physicians spend less time with obese patients, have less discussion with them, and admit that they don’t intervene as much as they think they should.

Studies show that patients appear to be aware of these biases, and that stigmatizing experiences in the medical setting can negatively affect health care utilization and contribute to avoidance of health care among obese individuals. As an example, among the heaviest women, as many as 68% report delaying health care services because of their weight, and attribute their decisions to previous experiences of disrespectful treatment and negative attitudes from providers, embarrassment about being weighed by medical staff, and that medical equipment was too small for their body size. The percentage of women who reported these bias-related barriers increased with BMI. Two recent national studies by our team found that even the language that a provider uses to discuss excess weight with patients can have concerning consequences. Specifically, we found that 19% of adults and 24% of parents would avoid future medical appointments if they perceived a doctor had used stigmatized language to describe their weight (or their child’s weight). Furthermore, 21% of adults and 35% of parents would switch doctors if this happened to them.

At the same time, some recent research of ours shows that weight bias is not just one-sided in the patient-provider relationship. Patients, too, hold weight biases toward their doctors. We found that people report more mistrust of physicians who are overweight or obese, are less inclined to follow their medical advice, and more likely to change providers if they perceive their physician to be overweight or obese, compared to non-overweight physicians who elicit significantly more favorable reactions. These weight biases remained present regardless of participants’ own body weight. This suggests that both patients and providers may be approaching each other with negative biases and stereotypes that can interfere with the patient-provider relationship and the ability to have productive, positive discussions about weight-related health.

Are there other forms of stigma that we can draw lessons from, e.g. smoking?

Smoking is sometimes raised as an example of where stigmatization was effective in contributing to the decline in smoking rates. However, some important distinctions need to be made in making parallels to obesity. Smoking is a behavior, whereas obesity is a chronic medical condition. In addition, much of the success observed in the decline of smoking rates can be attributed to taxes on cigarettes which substantially raised prices, as well as effective media campaigns (such as the Truth campaign) that targeted the tobacco industry, where the stigmatization was focused on the companies that created the toxic product of cigarettes, rather than the people who smoked who were instead often portrayed as victims of a deceptive industry that heavily marketed to them. In fact, effective campaigns like the Truth campaign made a conscious effort not to stigmatize people who smoke. To draw an accurate parallel would be to stigmatize the food industry and the food products created by the industry, rather than the public who consumes their food products. But this is not what has happened.

There seems to be a public misperception that stigmatizing or shaming individuals who are obese will provide motivation or incentive to improve their health and lose weight. But the considerable science on this issue suggests the opposite is true – that this is not an appropriate or an effective tool to address obesity. When children and adults are stigmatized, shamed, or bullied about their weight, they have an increased risk of depression, anxiety, low self-esteem, poor body image, and suicidal thoughts and behaviors. They are also more likely to engage in unhealthy eating patterns (including binge eating, eating disorder symptoms, and maladaptive weight control behaviors), as well as increased food intake, and avoidance of physical activity – all of which reinforce weight gain and impair weight loss efforts.

So if we want to effectively address obesity, we need to support and empower individuals who are struggling with weight, rather than instill stigma or shame. Stigma has been recognized as a known barrier and enemy throughout our history of public health. For example, in the case of HIV/AIDS, the detrimental role of stigma became so evident that national and international health agendas explicitly identified stigma and discrimination as major barriers to effectively addressing the epidemic. There are many other examples throughout history of stigma imposing suffering on groups vulnerable to disease and impairing efforts to prevent and treat those diseases. Obesity is no different, but unfortunately stigmatization of obesity most often goes ignored and unchallenged.

What are specific steps that healthcare providers can implement to reduce weight stigma in healthcare?

Providers can implement a number of strategies to reduce weight bias in health care. First, it’s important for health providers to reflect on their personal assumptions and beliefs about obesity. Do they make assumptions about a person’s character, abilities, or behaviors based on their weight? How do they feel when they work with patients of different body sizes? What stereotypes do they have about obesity? Becoming aware of one’s own personal assumptions can make it easier to recognize communication that might be interpreted by others as biased, even if it’s unintentional.

Although providers may face challenges in their efforts to effectively prevent or treat obesity, their efforts must begin with a conversation with patients about weight and health. Giving careful consideration to the language that they use about weight can help facilitate a productive dialogue, to make sure that patients don’t feel blamed or judged about their weight. Our research has found that patients perceive neutral weight terminology (e.g., “BMI”, “unhealthy weight”) to be more motivating for weight loss and less stigmatizing than words like “fat” or “morbid obesity” when they are used by a doctor. So providers should be mindful of the language they use, and may even want to ask patients what words or language they would feel most comfortable using when they talk about the patient’s weight.

It is also helpful for providers to recognize that many patients who are obese will have already experienced weight bias in the health setting, and as a result may be reluctant or hesitant to talk about weight. Using motivational interviewing techniques can help empower patients in discussions about weight-related health, as can efforts to help patients set realistic goals for health behavior changes (e.g., reducing consumption of sugar sweetened beverages, or incrementally increasing physical activity) without even talking about how much weight a patient may need to lose.

Providers can also implement strategies to reduce weight bias in the physical medical office environment. For example, many patients feel embarrassed, anxious, and ashamed of being weighed at medical appointments, to the extent that some will even avoid health care appointments to avoid getting on the scale. To address this, providers can implement sensitive weighing procedures: making sure that scales can accommodate patients of large size, that scales are located in a private location, that the medical staff person recording the weight does so silently, free of any judgment or commentary, and that the patient is asked for his/her permission to be weighed before the process begins. The American Medical Association has guidelines for other aspects of the medical setting that are important to attend to, such as providing large, sturdy, armless chairs that can accommodate heavier patients, and ensuring that medical equipment is sufficiently large to be functional for obese individuals.

What do you think of The Patient Promise as a way to raise awareness/change behavior among clinicians? 

There is an ongoing need to raise awareness of weight bias among health care providers, and The Patient Promise can be an important voice in these efforts. The Patient Promise asks providers to make a commitment to support their patients struggling with obesity, identify and guard themselves from weight prejudices, and to respect their patients, regardless of body size. The more providers who make this pledge, the better equipped we can be to help improve the culture of health care for obese patients and decrease stigma.

One of the first lifestyle behaviors that clinicians and students sacrifice during their training is their sleep. This can have both personal and professional consequences. A recent Huffington Post article entitled "Doctors are Human; They Need Sleep" cites evidence that surgical residents are 22% more likely to commit preventable medical errors when fatigued due to sleep-deprivation. Sleep is so important that it was named one of the "20 Great Challenges" in medicine by TEDMED.

Dr. Rachel Salas is an Assistant Professor Neurology and sleep specialist at Johns Hopkins who has made it her mission to improve sleep quality in her patients and the medical students and residents whom she trains. She also is a supporter and signer of The Patient Promise. We had the opportunity to interview her about her background, how she became interested in sleep, and what The Patient Promise means to her.

Can you describe your current role, and the journey you took to get there? 

As the oldest of four and now, the mother of two, I have always been in position as a role model, whether I realized it or not. As a physician, this is also the case, not only for my patients, but for my students and trainees.  My medical career began while I attended Health Careers High School in San Antonio, Texas at which time I confirmed that I wanted to be a doctor. From there, I went to St. Mary's University to stay close to home. I went on to medical school at the University of Texas Medical Branch at Galveston where I stayed to also complete my internship in internal medicine and neurology residency. I was also selected to be the chief resident my last year of neurology residency. I then came to Johns Hopkins to complete a 2-year fellowship in Sleep Medicine.

While my plans were to return to Texas after fellowship (everyone always goes back to Texas), the department of Neurology, and in particular my mentors, inspired me to start my academic career here at Johns Hopkins.  I have been interested in being an academic physician since medical school. I believe that physicians should be teachers and researchers who strive to provide better care for our patients. Currently, I am an assistant professor in the department of neurology at Johns Hopkins. I am also the Co-director for the JH SOM Neurology Clerkship.  

As my career has evolved, I wear different hats depending on the day you catch me on.  One thing that stays constant, however, is that I am a teacher and a learner.  From my experience, I have really held on to the mantra "see one, do one, and teach one," which we are all taught in medical school.  While most may look at this as more of a clinical procedural activity (i.e., performing a lumbar puncture), I believe it extends to all aspects of being a health care provider.  

In my practice of being an academic physician, I have extended "the see one, do one, teach one" approach to patient care, where I have modified it to "Learn one, Practice one, and Teach one".  This has been a valuable "golden rule" for me, as a physician, as a mother, as a peer, as a teacher, as a friend, as a sister, as daughter.  I am not perfect and it has been a slow process, but I have started with what I know...and that is sleep. Sleep is integral to many other facets of life and it is something that many people do have power to improve. So I have started here. It is my mission to teach my students, menthes, trainees, and peers about so that they can improve their sleep quality. I believe that if I can improve their sleep quality, then they can ask their patients about sleep and so on.  Perhaps, a "pay it forward" on sleep...

What motivated you to sign The Patient Promise and practice what you preach?

I believe Health care providers should practice what we preach--it sets us up for providing better patient care--studies show this. 

How are you living one or more of the tenets of The Patient Promise?

I am spreading the word to others--I practice sleep wellness and have implemented several of the strategies I teach to students and patients about sleep. I am not perfect, but I have started on things I know (i.e., sleep) and plan to work on other areas of my health. My promise today is to practice healthy sleep habits and to teach these practices to others.

Have you discussed your commitment with any of your patients?

Not yet, however, I am spreading the word about The Patient Promise in my sleep health workshop to students. My hope is to teach students about sleep health earlier in medical school so that they begin to see the importance of sleep and that they do have control in improving their sleep. My hope is that experiential learning will get them to learn about their own sleep practices and improve these. Then, as studies show, if they have good sleep practices, they will be more comfortable to talk to their patients about sleep.  Over 60 million people meet the criteria for a sleep disorder, but most do not realize that there is something that can be done or that they may actually have a serious sleep disorder that is affecting their morbidity.

Has The Patient Promise influenced the frequency with which you discuss healthy lifestyle behaviors with your patients?

Yes, I think patients hear their doctor better--when their doctor says "it worked for me or I practice this too". Many people know that physicians, in particular, often are "the worst patients" and often "don't practice what they preach". This needs to change.

Do you feel like practicing healthy behaviors helps you partner with patients in their own journey?


Do you have any advice for clinicians who may be considering signing The Patient Promise?

Start one step at a time. So with what you know. Learn about it first..."Learn one, Practice One, Then Teach One".  For me, it was "Learn about Sleep Health, Practice Sleep Health, Then Teach Sleep Health". It is a process...I am on step three now.


Do you have any questions, comments? Leave them below, or e-mail info@thepatientpromise.org. 

The award-winning Sundance documentary ESCAPE FIRE: The Fight to Rescue American Healthcare, directed by Matthew Heineman and Oscar-Nominee Susan Froemke, tackles one of the most pressing issues of our time: what can be done to save our broken medical system? ESCAPE FIRE will be broadcast on Saturday, March 16th at 8pm & 11pm ET on CNN. Pledge to watch the film at EscapeFireMovie.com/CNN  

In an unprecedented professional education opportunity, watching the film will qualify for two (2) Prescribed CME credits from the American Academy of Family Physicians (AAFP), which can translate via reciprocity into American Medical Association (AMA) Category 1 credits. This is a unique chance for healthcare providers from around the country to join the millions tuning in to elevate and deepen the national dialogue about our healthcare system and our role in leading it out of crisis. A 1/2 hour roundtable discussion led by Dr. Sanjay Gupta, centered around the main themes in the film, will start immediately following the film’s broadcast.  Learn more at EscapeFireMovie.com/CME. You can view the film's trailer here
Check out the Patient Promise and Escape Fire Poster below! Make the Patient Promise your New Year's resolution by signing the promise now. Then lead by example by posting this on your Facebook wall, Twitter feed, or even print and hang in your waiting room! The downloadable file is below.
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