Obesity training that could help reduce stigma is missing from medical school: Shots

Obesity is associated with many serious health problems in the US, but doctors receive little training in the causes of and treatments for the condition.

wagnerokasaki/Getty Images

Obesity is associated with many serious health problems in the US, but doctors receive little training in the causes of and treatments for the condition.

wagnerokasaki/Getty Images

Tong Yan grew up in a Chinese-American enclave in Los Angeles in a family that revered food but had little regard for those who carried excess weight.

“There was definitely some kind of implicit fattist perspective, like little comments about people’s weight,” says Yan. Obesity didn’t affect him or his family, but a friend – who wasn’t even that heavy – became the butt of jokes. “It was also suggested that obese people are lazy and unmotivated,” he recalls.

It wasn’t until he studied medicine at George Washington University that Yan thought more deeply about weight stigma, which is pervasive in American culture. In the second year, he attended an education summit on obesity organized by one of his professors. As part of the summit, Yan took an implicit bias test that identified his slight preference for thinner people. Patients also shared personal stories about discrimination in exam rooms and how it affected their health and their relationship with doctors.

And he learned how factors other than the exercise of willpower lead to dieting and exercise — things like genetics, brain chemistry, stress level and community design — contribute significantly to the disease.

Yan believes such dedicated obesity training is essential for future physicians.

“I think it’s the beginning of a kind of re-education because whether we talk about it or not, we’re absorbing all the messages about what it means to be called obese, what it means to have a bigger body, since the time we are very small,’ he says.

And yet obesity training in medicine is still relatively uncommon.

“Doctors traditionally don’t learn about obesity, not in medical school or in a residency,” says Dr. Scott Kahan, who teaches at Johns Hopkins and George Washington Universities, and is the medical director of the National Center for Weight and Wellness, a Washington clinic. DC.

“Basically what we’ve learned is just, ‘Obesity is very common and you’ll see it in a lot of your patients. And it’s really important for people to eat less and exercise more’; it’s such a bit,” he says.

Obesity affects so many people – 42% of Americans – and is linked to more than 200 other chronic conditions and leading causes of death, from heart and kidney disease to diabetes. Its impact on patients and their healthcare is difficult to overestimate. And yet, even as scientific knowledge of the disease evolves rapidly, doctors learn very little about the causes of obesity in medical school, much less how to advise or help those who have it.

A 2020 study found that medical schools spend an average of 10 hours on obesity education. Half of the schools indicate that increasing this has a low priority or no priority at all.

That’s not enough, given the far-reaching impact obesity has on the medical profession, says Dr. Robert Kushner, a professor of medicine and medical education at Northwestern University and a co-author of the study.

He says the problem is self-perpetuating, too: “There aren’t many people who are trained in obesity,” he says, and “if you weren’t trained in medical school and you didn’t take it upon yourself to learn about , you won’t be able to be an informed, knowledgeable faculty member.”

Training out of sync with science

As a result of the training deficit, health care providers themselves often perpetuate weight stigma or misconceptions about how best to treat patients who have it.

The standard medical curriculum has also failed to keep pace with obesity research, which has transformed the field in recent decades. It is now seen as a complex disease involving many of the body’s systems. Factors such as genetics, hormones, sleep quality and even stigma can cause weight gain. Treating it therefore often requires more than just restricting or burning calories.

New and promising – albeit very expensive – drugs that act on the parts of the brain that regulate appetite underscore that obesity, like many other diseases, can be treated with drugs, rather than just willpower.

It’s hard to challenge old beliefs about obesity in medical school because classes tend to focus on specific organ-based disciplines, such as cardiology or endocrinology — but obesity cuts across many different categories. It tends to be mentioned for a few minutes here and there, and only in the context of other illnesses, not as an umbrella illness in its own right, says Kushner.

Also, “there’s a prevailing preconception that this is a soft science; this isn’t something we need to teach and people just need to take better care of themselves,” he adds.

The result, he says, is that most doctors are not equipped to help obese patients.

That is something Tong Yan has experienced firsthand. Yan, now in his fourth year of medical school, recalls one of his supervising physicians talking to a patient with pressure headaches that were partly related to complications from obesity. Yan says the doctor was in a hurry – and spoke to the patient through a translator, which took twice as long. He then chided the patient by saying things like, “You need to get out and exercise. You can’t just sit there,” or “Don’t you know this is a problem?”

Yan recoiled from the exchange. He knew that went against what he had learned in training about obesity and bias. But the doctor’s seniority shook both Yan and the patient into silence, without questioning the tone or content of the lecture.

“I’m ashamed to say I didn’t really say much,” admits Yan. “It was just an observation that had a big impact.”

Patients suffer from the doctor’s ignorance

The impact is huge for patients like Patty Nece, who at 64 says she’s never been free from the stigma of living in a big body. She is called after, compared to cows or whales – insults that amplify her own ferocious inner voice.

“I would kind of become my own worst enemy, my own worst bully,” she says. “I’ve won awards as a lawyer and I’ve been active in the community and nothing overcame all the prejudice and stigma I had faced.”

But, she says, the biggest clinical damage comes from doctors themselves, including an orthopedist she consulted several years ago about hip pain.

Almost immediately, without listening to her, examining her, or even touching her, she admittedly began a lecture about her being overweight, attributing her pain to obesity.

“He said, ‘Look, you even cry because of your weight,’ which was so far from the truth; I cried because of him,” says Nece. “I didn’t want to see another doctor in my life.”

When she finally saw someone else for her hip pain, the cause turned out to be a severe curvature in her spine. Nece says health professionals often seem to assume that overweight people don’t know their bodies, even though she thinks about it all the time. She says the orthopedist wasn’t the only one who fired her; she also feels rejected by others because of her weight – dietitians, mammographers, rheumatologists.

That kind of alienation is especially damaging among racial minorities, where care inequalities already pose many challenges. So is the concern for obesity in black and Latino communities, where obesity rates are highest but people are underdiagnosed and undertreated.

Kofi Essel, a pediatrician and nutritionist in Washington DC, says young doctors often don’t have the same background as those who are obese. They don’t understand how things like neighborhood design, food insecurity, and access to fresh produce contribute to obesity.

“Why? Because most of us in medical education come from middle to upper income brackets, so there’s often economic disagreement with many of our patients,” says Essel.

He argues that the solution, again, is to increase education in obesity — not just the science of it, but how to talk to patients with compassion and without stigma. Essel also leads the obesity summit at George Washington University, saying he has changed the way students think about obesity. “Their new awareness, their new knowledge, their new attitude, their new behavior is night and day,” he says.

Student Tong Yan agrees. He plans to become a general practitioner in urban areas where medical care is lagging behind.

“I am particularly motivated to improve these kinds of skills in the future for the benefit of my patients,” he says.

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