Bariatric Times

APR 2018

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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12 Review Bariatric Times • April 2018 Clinical Practices to Mitigate Weight Bias BY RUCHI S. DOSHI, MD, MPH, and KIMBERLY A. GUDZUNE, MD, MPH Bariatric Times. 2018;15(4):12–16. ABSTRACT This article reviews the evidence for how the attitudes, communication, and behaviors of clinicians differ towards patients with obesity, and examines interventions to reduce weight bias among current and future healthcare professionals. Healthcare professionals and trainees display weight bias and negative attitudes toward patients with obesity, which might adversely impact the quality of care received and contribute to health and healthcare disparities. To date, most weight bias reduction interventions studied have targeted short-term changes among trainees rather than practicing clinicians. Successful interventions among trainees include traditional classroom lectures and multimedia interventions, such as films and role-playing that cover the multiple causes of obesity, stigma awareness, and perspectives of patient with obesity, as well as experiential learning, such as longitudinally working with patients who have undergone bariatric surgery. Future studies should examine whether practicing clinicians could benefit from these types of weight bias reduction interventions. KEYWORDS Obesity, weight bias, bias reduction, health professionals INTRODUCTION The quality of healthcare can be influenced by personal characteristics of the clinicians and patients, as well as the systemic organization of the clinical environment. 1–3 One primary factor in providing quality healthcare, as perceived by both patients and clinicians, is the patient-clinician relationship. 4,5 The perceptions and attitudes of both the clinician and patient can influence their relationship. 6–9 Clinician attitudes toward patients can affect clinician behaviors, ultimately influencing the quality of healthcare. 10–13 Negative clinician attitudes can affect the patient-clinician relationship, contributing to healthcare disparities. 13–15 Multiple factors can affect clinician attitudes, including visible patient characteristics. Past studies have found that age and race can both affect clinician attitudes and behaviors, with physicians respecting older patients 6 and exhibiting a more positive affect and patient centeredness toward white patients compared to African-American patients. 7 Similarly, a patient's weight might also impact the patient-clinician relationship and the quality of care provided. 13,16 Past literature has shown that individuals with obesity are often stigmatized, 17,18 and health professionals have demonstrated biases toward them. 19,20 Indeed, the bias of these health professionals are both implicit 20,21 and explicit. 22,23 Explicit biases are attitudes or beliefs of which a person is conscious and willingly reports, while implicit biases are unconscious and might be inaccessible to control. Currently, over one-third of US adults are obese. 24–26 Therefore, if patient obesity negatively impacts the patient-clinician relationship, a substantial number of patients might have negative healthcare experiences and be subject to diminished quality of care. Given that studies have found that disparities in preventive services increase with increasing severity of obesity, 27,28 including mammography, pap smears, and colonoscopies, 27–33 these results raise concern that weight bias among healthcare professionals might be contributing to healthcare disparities for individuals with obesity. This article explores how the attitudes, communication, and behaviors of clinicians might influence patients. In addition, the article examines interventions to reduce weight bias among current and future healthcare professionals. PART 1. EVIDENCE FOR HEALTH INEQUALITY FOR PATIENTS WITH OBESITY A framework to assess the contributions of healthcare providers to systemic inequality for racial/ethnic minority patients has been previously established. 34 This framework can also be helpful in considering how clinician bias might contribute to lower quality care and healthcare disparities for patients with obesity (Figure 1). We review the available evidence supporting the application of this framework for patients with obesity, focusing primarily on clinician factors. Clinician attitudes toward patients with obesity. Historically, clinicians have displayed negative attitudes toward patients with obesity, and associate obesity with traits such as poor hygiene, non- adherence, and laziness. 17,18 These attitudes are pervasive across several areas, including the United States, Australia, Israel, and Europe. 35–38 They also have been persistent over time, dating as far back as 1969, when physicians viewed patients with obesity as unintelligent, unsuccessful, inactive, and weak- willed. 39 These negative attitudes are not limited to physicians and are found throughout the medical field, including in medical students, nurses, nutrition professionals, and fitness professionals. 17,18 Notably, a recent survey found that the majority of medical students have implicit and explicit weight bias, and overall have more negative attitudes toward people with obesity than racial minorities, differing sexual orientations, and differing socioeconomic statuses. 40 Over 50 percent of primary care providers (PCPs) report that their heavier patients are less likely to follow their medical advice, benefit from weight counseling, or adhere to medications. 41,42 Overall, these perceptions result in clinicians feeling frustrated, 37,41,43 which can be detrimental to the clinician-patient relationship. 44 Clinician communication behaviors with patients with obesity. Patient overweight and obesity also affects clinician communication, in regard to both patient rapport and weight-loss counseling. One study found that physicians spent less time with patients with overweight or obesity. 45 In addition, physicians built less emotional rapport with patients with overweight or obesity compared to their normal weight counterparts. 46 This lack of rapport might weaken the clinician-patient relationship, diminish adherence to clinician recommendations, and overall decrease the effectiveness of behavior change counseling. Clinician decision-making for patients with obesity. Clinician behaviors also differ depending on patient weight status. For example, physicians might order more tests for patients who are overweight or obese, while spending less time with them. 45 Other studies have found clinicians might have technical difficulties when performing physical exams, or might not have the appropriately sized equipment to accommodate all patients, which can result in limited physical examinations. 29,30 With respect to weight-loss counseling, some studies have demonstrated that physicians currently feel unequipped to treat patients with obesity, 47,48 and that their treatments are ineffective. 41 In addition, clinicians reported limited time and lack of reimbursement for weight-loss counseling. 49–52 They also perceived weight management to be unrewarding or futile, 17,37,41,53 which might result in avoiding discussions with weight or weight loss with patients with overweight and obesity entirely. 54,55 Moreover, clinicians do not regularly discuss or refer patients to weight loss programs. 56–58 Patient factors influencing patient-clinician relationships for patients with obesity. Little is known regarding attitudes, preferences, and communication among patients with obesity; however, research has examined patient behaviors. Studies have shown that patients with overweight or obesity are aware of clinician attitudes toward them, including weight- related bias. 13,59,60 Patients with overweight and obesity who perceive that their primary care providers

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