I had to be honest—I was uncomfortable with my new patient, a woman in her late thirties, in my office for a general medical check-up. Ms. M. was petite in stature, but wide in girth, a medical condition we’d term “morbid obesity.” Her face was entirely swallowed up in thick fleshy layers of neck and jowl. Her belly was so overgrown and pendulous that it hung like a third appendage between her legs. Her hips and legs were so wide that her gait was impeded.
She struggled onto the exam table with difficulty. The metal table shuddered under her weight. When I lifted her shirt to listen to her lungs, I gained an up-close view of bulbous waves of adipose tissue that spilled over in tiered layers. When I palpated her abdomen, my hands were engulfed in a sea of fat. My job is to be nonjudgmental, but the reflexive discomfort was impossible to deny, and I was upset at my unease.
So when I read a recent study in the Journal of General Internal Medicine that doctors seem to express less respect for obese patients, I wasn’t surprised—but I was dismayed. Why do medical professionals react that way?
No doubt one reason is that obesity—like alcoholism and drug use—is considered to be self-induced, even by doctors who are well aware of genetics and the other confounding factors involved. From the perspective of a group singularly steeped in the discipline and deprivation that got us through medical school and residency, it’s hard to jettison the idea—despite mountains of scientific evidence to the contrary—that these medical conditions could be alleviated by simple personal responsibility.
Perhaps in obese patients we see the feared reflections of ourselves, should we lose our carefully honed discipline. My own adolescent battles with weight and body image—however modest compared with my patient’s—left me with an aversion to junk food and overeating. Maybe Ms. M. represents my worst nightmare, what I would become if I stopped being vigilant and lost control altogether.
Maybe the pure physicality of obesity is the issue. In a society that worships svelte and fit bodies to an unhealthy extreme, even a well-groomed, tidy person like Ms. M. can be perceived as slovenly just because of her weight.
These reactions are entirely irrational, of course; but emotions were never billed as rational, and doctors are as susceptible as anyone else. I don’t want to be the type of doctor who prejudges her patients, and I certainly don’t want to contribute to the very real stigma that obese people face in so many aspects of their lives. Yet I couldn’t help the automatic discomfort I felt.
The more I actually talked with Ms. M, the easier things became. She was soft-spoken and talked forthrightly of the stress of raising three children and tending her to her own medical problems, many of which stemmed from her obesity. She admitted that she had trouble controlling her eating, that stress only caused her to eat more, and that being overweight made her depressed. And she spoke of a family history of obesity, poverty, emotional abuse, and neglect.
After we finished our visit, I thought about my reaction to her. Was it any different than racism, any less repellent? Even if her condition were self-induced, even partly, how could I countenance how I felt?
Over the years, I’ve cared for patients who were potently malodorous. I’ve tugged off socks with lives of their own. I’ve changed dressings on putrid, oozing wounds. I’ve encountered maggots, roaches, and diarrhea during physical examinations. I’ve gagged and felt close to vomiting many times—I’m as squeamish as the next person. I can’t control my physical reactions, as I can’t control some of my emotional ones. But I can control what I do with them; they are internal experiences and can be tamed with my outer behavior.
But is that enough? Even if I hide how I feel about an “undesirable” patient, my feelings still may subtly influence how I respond and interact, in a way that results in poorer medical care. This is a genuine fear of mine. Marginalized groups of all stripes have tended to avoid the health care system. The barriers are many—financial, logistical, language. Studies suggest that the feeling of being disrespected, even covertly, also plays a role.
So how do doctors change our inner landscapes? How do we control our gut feelings? One step is to own up: to be honest about our feelings (in the appropriate forum, of course), however distasteful these feelings may be. Another approach, to borrow a technique from psychology, is to “act as if.” If a doctor can act as if an obese—or smelly, or irritating, or alcoholic—patient doesn’t bother her, perhaps in time it really won’t. More important, her behavior serves as a model to the students, interns, and medical staff around her.
I was relieved recently to read a new study, the largest of its kind, that found that the medical care given to overweight patients is no different than what the general medical population receives. Despite an ingrained societal bias against obesity, one that affects physicians as well, the medical profession seems to able to overcome it and deliver quality treatment.
I’m not sure that suffices, though. Doctors may swallow their gut feelings, hold their noses, and adequately treat patients whom they deem undesirable. But even that approach conflicts with a general tenet of medical professionalism, that we treat all patients with compassion. Compassion can’t be faked, or put on for the moment. It presumes genuine sentiment, within which lies respect.
When we train medical students, we talk a lot about empathy. In its most literal sense, empathy is the attempt to appreciate the emotions of another, to feel the world from their perspective. As I talked more with Ms. M. during her visit, I began to get a sense of what her life was like. I couldn’t presume to actually know how she felt, but I could begin to imagine it and how I might cope with an extra hundred pounds and the attendant stress.
When I saw her in my office recently, I felt a difference in myself. The physical exam was still a little difficult for me—I’m being honest—but I worked to keep Ms. M. in the forefront of my mind. My emotions pulled but felt more manageable.
Maybe that’s what doctors should strive for—to prod our negative feelings out of the shadows, however awkward the process. The truth is, disrespect has no place in the doctor-patient relationship. To provide good medical care, doctors must first ensure that every patient feels comfortable in their presence. If doctors don’t feel comfortable themselves, we must be honest about it; only then will the biases have the chance to dissipate.
Danielle Ofri is a writer and practicing internist at Bellevue Hospital in New York City. She is the editor-in-chief of the Bellevue Literary Review and the author most recently of Medicine in Translation: Journeys with My Patients, published by Beacon Press.