Walton-Ball E and Vered M. Weight-stigma: a barrier likely to persist in future physicians and what we can do to intervene. Harvard Public Health Review. 2021; 28.
Individuals affected by obesity are a commonly stigmatized group in the United States, with physicians being amongst those who carry negative views toward these individuals. As patients, individuals with obesity experience stigma in medical settings through substandard clinical interactions and have reported avoiding seeking healthcare due to this stigma. The current review elicits the perceptions of patients with obesity in medical students and the effects of these perceptions on medical students’ abilities to manage patients with obesity. Finally, this review considers the use of a variety of educational interventions for decreasing stigmatization of patients with obesity in medical students.
Individuals with obesity have been long-time victims of weight-stigma, a phenomenon that includes negative attitudes, discrimination, stereotyping and bias toward a person based on their weight (The Lancet Public Health, 2019; Emmer et al., 2019). This stigma has been reported in numerous countries around the world (Brewis et al., 2011; Brewis et al., 2018), with the USA being one of many nations in which weight-stigma is widely prevalent (Prunty at al., 2020; Puhl et al., 2018). Despite over one third of the American population being affected by obesity (Fang et al., 2019), individuals with increased weight still experience this stigma in numerous ways and environments. Specifically, weight-stigma commonly manifests through stereotypes, otherwise described as unreasoned judgements (Emmer et al., 2020), of laziness, unintelligence and lack of willpower (Puhl et al, 2009; Puhl et al, 2015; Taylor et al., 2006). Furthermore, individuals with obesity have been found to elicit the negative emotions of disgust, dislike, anger and blame in other people toward the individuals with obesity (Vartanian, 2010). Individuals with obesity experience this stigma in various aspects of their life, including popular media, school, and notably, employment settings (Puhl & Brownell, 2001). In fact, weight based discrimination has been shown to influence many aspects of employment, including both hiring practices (Klesges et al., 1990), salary (Register & Williams, 1990), and promotions (Boridieri, et al., 1997). As such, in addition to reporting low quality of life (Markowitz, 1998; Myers & Rosen, 1999), it is likely no surprise that stigmatized individuals are at greater risk for experiencing depression (Li et al., 2009, Phelan et al., 2013) and other negative mental health effects (Sarwer & Polonsky, 2016).
Despite countless studies demonstrating the importance of hereditary and genetic factors in determining which individuals are at increased likelihood of developing obesity (Maes et al., 1997; Sørensen et al., 1989; Stunkard et al., 1986), this stigma persists. In fact, weight-stigma manifests not only in the general population, but also amongst health care providers (Foster et al., 2003; Glauser et al., 2015), a group of professionals arguably amongst the most up-to-date and educated on the multifactorial nature of chronic disease. Specifically, primary care providers have been found to perceive patients with obesity as awkward, ugly and noncompliant (Foster et al., 2003), with about half believing that obesity is related to a lack of self-control (Glauser et al., 2015). Moreover, these negative views exist even in physicians who specialize in treating patients with obesity (Schwartz et al., 2003).
The stigma faced by patients with obesity is reflected in clinical practice through substandard healthcare. It has been found that primary care providers prefer to spend less time with patients with obesity (Hebl & Xu, 2001) and that they spend less time educating these patients about their health (Bertakis & Azari, 2005). This stigma has become a serious issue for patients with obesity, as many report feeling disrespected by their physicians, that they will not be taken seriously during appointments (Anderson & Wadden, 2004; Brown et al., 2006), and furthermore, that this stigma is a barrier to obtaining healthcare (Amy et al., 2006). In fact, patients with obesity have reported delaying seeking healthcare because of their weight (Amy et al., 2006; Puhl & Heuer, 2010). Evidently, the stigmatization of patients with obesity in healthcare likely perpetuates pre-existing health disparities even further (Puhl & Heuer, 2010).
With the weight-stigma toward individuals with obesity extending beyond just general society to practicing clinicians, a question dawns as to whether this stigma will continue to persist in future healthcare providers, or more specifically, by current medical students. This review aims to unveil answers to three main questions: 1) do medical students demonstrate stigmatization (including stereotypes, negative attitudes or biases) toward patients with obesity? 2) do medical students’ views on individuals with obesity affect their clinical performance when managing these individuals as patients?, and 3) what educational interventions are useful in diminishing stigma toward patients with obesity in medical students?
Articles were identified using PubMed and Web of Science. To identify articles on medical students’ attitudes toward patients with obesity, keywords included, ‘medical student’, ‘physicians in training’, ‘attitude’, ‘stigma’, ‘stereotypes’, ‘bias’, ‘weight’, ‘obesity’, ‘overweight’, ‘attitudes’, ‘performance’, and ‘clinical skills’. To identify articles on educational interventions for medical students, additional keywords included, ‘intervention’, ‘stigma reduction’, ‘bias reduction’, and ‘educational intervention’. Abstracts were screened for relevance. Studies were included if the participant population were university-level students in a healthcare field, with a preference given to studies with participants in medical school. Studies were excluded if full-texts could not be obtained, and interventional studies were excluded if they were not original research. Additional studies were identified through reference lists of studies identified in the initial search.
Numerous studies have investigated the attitudes of future physicians toward patients with obesity, with a handful of these scrutinizing whether these student perspectives are reflected through clinical interaction skills. A study conducted by Miller et al. (2013) found that 1/3 of the medical students surveyed had an implicit negative bias toward patients with obesity and that 2/3 of those with the implicit bias were unaware of it. Furthermore, 73% actually had an explicit preference for ‘thin’ individuals to ‘fat’ individuals. Medical students have been found to view patients affected by obesity (particularly those that are Caucasian) as sloppy, lazy, unattractive, ugly and noncompliant (Andrade et al., 2012). Although both of the aforementioned studies were conducted in recent years, similar views in medical students have been documented for many decades (Blumberg & Mellis, 1985).
Studies investigating the effect of medical students’ views on caring for patients with obesity have found significant (Fang et al., 2019; Pantenburg et al., 2012), yet not unanimous (Wigton & McGaghie, 2001) evidence suggesting that these views are reflected in clinical care abilities. Firstly, Fang et al. (2019) investigated the knowledge of NYU medical students on contributing factors to obesity and found that students rated controllable factors (unhealthy diet, physical inactivity and overeating) as more important than genetic/biological factors in predicting weight. When students were assessed in an OSCE format, maintaining the assumption that controllable factors were more important was associated with poorer counselling skills, whereas believing obesity is to a greater extent related to uncontrollable factors was associated with superior counselling abilities. Similar findings were reported by Pantenburg et al. (2012), who determined that holding the belief that obesity was under patient control corresponded to decreased professionalism and poorer overall performance in counselling patients with obesity. On the other hand, in a study where students were randomly assigned to interact with a virtual patient (either obese, or non-obese), Persky & Eccleston, (2011) found that although students harboured negative stereotypes and predicted less patient adherence in the patient with obesity, there were no significant differences in diagnostic testing recommended by the students. Notably, however, in the interaction with the patient with obesity, students made significantly less eye contact, a nonverbal communication method important for establishing connectedness, conveying empathy and developing overall rapport with patients (Montague et al., 2013). Similarly, another study by Wigton & McGaghie, (2001) found that although students harboured negative views toward patients with obesity, their diagnostic recommendations were unaffected.
When taken together, the aforementioned studies have unanimously suggested that future physicians carry the same stigmatization toward individuals with obesity as the general population, despite likely having increased education on the multifactorial nature of chronic diseases such as obesity. These studies have brought to light potential for these stigmatizing processes to reflect negatively in the clinical practice of our future physicians – with findings suggesting that these views may manifest as decreased eye contact, decreased professionalism and poorer counselling abilities in the clinician-patient interaction.
With continued stigmatization of individuals affected by obesity widely existing in the next generation of physicians, and with these views potentially manifesting as inferior clinical performance, the next question to address is; what can we do to diminish stigma and improve treatment of patients with obesity by future physicians?
To date, various studies have investigated the use of educational interventions for reducing weight-stigma toward patients with obesity amongst medical students, with the majority of short term results demonstrating significant promise. O’brien et al. (2010) randomized students enrolled in a health promotion class to tutorial topics of either genetic & environmental causes of obesity, behavioural causes of obesity, or alcohol consumption in teens. Students participated in four weeks of tutorials, then completed two assignments relevant to their topic. Prior to tutorial implementation, and shortly after, the researchers measured students implicit biases and prejudice toward patients with obesity. Students in the genetic & environmental causes of obesity tutorial group had significant decreases in multiple measures of implicit bias and significant reductions in overall explicit anti-fat bias. Poustchi et al. (2013) took a brief approach with a single-day intervention, where medical students watched a video on the weight-stigma in healthcare followed by an interactive class discussion. After the intervention, the medical students had decreased stereotypical beliefs toward individuals affected by obesity, and attributed greater importance to genetic and environmental factors while placing less of an importance on ‘lack of personal control’ as contributors to obesity.
A few studies have investigated whether the immediate benefits of educational intervention on weight-stigma toward patients with obesity in medical students persists into the longer-term. Firstly, Kushner et al. (2014) conducted an intervention with medical students in Chicago to assess whether they could reduce stigma toward patients with obesity and improve student confidence in counselling patients affected by obesity. Their intervention consisted of having medical students participate in an 8 minute counselling session with a self-identifying overweight actor who role-played predetermined scenarios. Students received feedback on their counselling and observed 4-6 other students undergo the counselling step, followed by a 30 minute group reflection. Kushner et al. (2014) found that although the post-intervention immediate follow-up yielded improvement in all outcomes, a year later improvements in students’ attitudes toward patients with obesity had diminished near-to baseline, except for their confidence in counselling patients with obesity, which remained improved. Matharu et al. (2014) randomized medical students to either a standard lecture or a play-reading condition. In the former, students participated in a 1 hour lecture on the medical causes of obesity, whereas in the latter, students read lines (or observed other students read lines) from a script written by women affected by obesity, discussing their weight in terms of personal experience and social discrimination. Four months later, as compared to baseline, both groups of students displayed increased empathy for patients with obesity, whereas only the play-reading group had decreased explicit bias. Finally, Wiese et al. (1992) took a three step approach with first year medical students from the University of Kentucky. Students randomly assigned to the intervention group 1) watched a video of a woman affected by obesity discuss her feelings regarding her persistent efforts to decrease her weight, 2) read a note on the genetic contributions to obesity, and 3) participated in role-playing exercises that had students think about and discuss thoughts and feelings of an imaginary friend with obesity. A year later, the students in the intervention group were more likely to rate genetics as an important factor in obesity and were less likely to place blame on a patient for being obese.
The results of the previous studies should be considered in light of both strengths and limitations. Firstly, strengths of the studies conducted by (O’brien et al., 2010; Matharu et al., 2014; Wiese et al., 1992) include the methodological approach of randomization of students to intervention-type, thus decreasing potential for confounding. Furthermore, while three of these studies (Kushner et al., 2014; Matharu et al., 2014; Wiese et al., 1992) investigate long-term results, only the immediate effects of intervention were elucidated in the studies conducted by Poustchi et al. (2013) and O’brien et al. (2010). Lastly, the body of interventional studies vary widely in both intervention-method and outcomes measured. This can be considered a strength, as having a variety of interventions found to be effective may be appealing to universities who wish to adapt these practices into their own curriculum while not being limited to a single evidenced based approach. However, this may also be interpreted as a weakness, as the lack of standardized outcome measures likely decreases the robustness of the data when considered together as each outcome measure must be considered in light of its own applicability.
Altogether, despite the limitations discussed, these studies demonstrate significant potential for the use of weight-stigma interventions in medical school students. Although immediate post-intervention results were repeatedly more substantial, multiple studies showed promise for long-lasting effects of these interventions (Kushner et al., 2014; Matharu et al., 2014; Wiese et al., 1992),. Further studies should consider determining institutional willingness to adapt these interventions into medical school curriculum and the feasibility of doing so. Lastly, thought should be given to repeated, spaced anti-stigma educational interventions to determine whether long-term effects will be further increased by such.
The stigmatization of individuals affected by obesity has persisted for many years in American society, with practicing physicians included amongst those sharing these stigmatizing views. Unfortunately, this stigma is reflected widely in practice, with patients with obesity reporting that this stigma serves as a barrier to the uptake of healthcare services (Amy et al., 2006). Medical students, our future physicians, often share this stigmatization of patients with obesity (Andrade et al., 2012; Blumberg & Mellis, 1985; Miller et al., 2013), which some studies have found to manifest as reduced overall performance and decreased professionalism when counselling these patients (Fang et al., 2019; Pantenburg et al., 2012; Wigton & McGaghie, 2001). These findings are sufficient to evoke concern that the prejudice faced by patients with obesity will perpetuate into future generations of physicians. Fortunately, the implementation of numerous educational interventions of which vary in both time-commitment and method have shown significant potential to reduce the stigma, through reduction of bias and stereotyping, and increasing empathy toward patients with obesity in medical students (Amy et al., 2006; Kushner et al., 2014; Wiese et al., 1992). Consideration should be given to implementing these anti-stigma interventions into medical school curriculum around the USA in order to improve clinical care for patients with obesity.
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Erin E. Walton-Ball is a Canadian medical student at the Royal College of Surgeons in Ireland (Correspondence regarding this article should be addressed to 33 Blackhall Square, Dublin, Ireland, D07 FP93. Email: email@example.com.)
Michael D. Vered is a third-year Canadian medical student at the Royal College of Surgeons in Ireland.