Obesity is pandemic in the United States. Based on a body mass index (BMI) of 25 kg/m2 to 29.9 kg/m2, about 35 percent of U.S. adults are overweight; 26 percent are obese, based on a BMI of 30 kg/m2 or more.1 Several studies indicate that obesity is even more prevalent among those seeking primary care services than it is among the general population2,3 because of the increased morbidity brought on by obesity.
Unfortunately, obese patients often feel unwelcome in medical settings, where they encounter negative attitudes, discriminatory behavior and a challenging physical environment. These negative experiences explain, at least in part, why obese patients are more likely to delay seeking clinical breast exams, gynecological exams and Pap smears, delays which account for some of the increased health risks of obesity.4,5 If the obese, who represent an ever-increasing portion of our primary care patients, are to receive adequate preventive services and adequate diagnosis and treatment of comorbid conditions, we must change the way we care for them. This article will show you how to make improvements in your practice to help obese patients feel welcomed and well treated.
Obesity affects 22 percent of U.S. adults and is even more prevalent among those seeking primary care services due to the increased morbidity associated with the condition.
For many obese patients, the primary care visit is a negative experience due to discriminatory behavior and a challenging physical environment.
Physicians may do better to address weight loss with obese patients after establishing a trusting relationship and tackling smaller health care goals first.
Ms. Jones is a 57-year-old woman who weighs 315 pounds. As she stands at the receptionist window waiting to check in, her knees and back hurt. After signing in, she looks for a comfortable chair in the waiting area, but the only chair available is too narrow and has armrests. She is aware of the stares of other patients as she squeezes into the available chair.
She picks up a magazine to distract herself while waiting. It is replete with photos of thin, attractive and young women and articles about food. When she needs to use the rest room, she finds it small and unaccommodating. She finds it difficult to adequately attend to her personal hygiene in the limited space. At last a nurse calls her and takes her through a narrow door to a scale in a hallway. She feels exposed, aware that others will be able to see her weigh in. She feels embarrassed and hesitates to get on it. The nurse asks her if she is above 300 pounds. When she says yes, the nurse declares, “You are too heavy for this scale.” The nurse looks exasperated as she notes a weight of “300+” in the medical chart.
The nurse takes Ms. Jones to the triage room where she looks for a large blood pressure cuff. When she can’t find one, she calls to a medical assistant across the corridor, “Have you seen the large cuff?” When she finally measures Ms. Jones’ blood pressure, it is 190/105. As the nurse goes to tell the doctor about this reading, the patient thinks she knows why her blood pressure is high; she has come in today for the “female” examination she has been avoiding for years. Her doctor has told her how important it is for her to have regular preventive examinations, but she remembers the pain, discomfort and embarrassment of her last exam. She bathed well today but does not know if it was good enough. She worries, not wanting the physician whom she likes to have an unpleasant experience examining her. She starts feeling nauseous and shares this with the nurse who writes “nausea” as a complaint in her chart.
Once in the examination room, she is told to change into a gown, which appears to her to be two small pieces of paper. She puts on the one with sleeve holes, but it barely covers her; she feels exposed. The second piece is just a paper sheet that she puts on her lap. After 15 minutes of sitting in this gown, she is chilled and uncomfortable. The doctor comes in with the nurse. He remarks that he is pleased she has come for a well-woman examination after all his encouragement. He talks briefly about her blood pressure and asks her about her symptoms. He then asks her to lie down on the examining table. Although the step to the table is narrow, she manages to climb up, but as she lies down, the paper gown breaks apart. The nurse lays another paper sheet on top of her. She feels wobbly and uncomfortable on top of the narrow examination table.
The doctor starts examining her breasts. She wonders whether he knows where to start or end this breast exam. He asks if she does monthly self-examinations. She says no and feels ashamed. She does not know how to examine her large breasts. The doctor talks to her about how to do a self-examination of her breasts, but she is too nervous and nauseous thinking about the pelvic examination to take it in. The doctor then moves down to the end of the table and asks the nurse to help the patient put her feet in the stirrups. Ms. Jones is asked to slide down to the edge of the table, and she struggles to assume the required posture. At last she is in the correct position, and the doctor begins the pelvic examination. The doctor asks for a larger speculum. She can tell the doctor is having difficulty finding her cervix. She is uncomfortable but bears the procedure. She notices the doctor wiping perspiration from his forehead after he completes the exam. She too has sweated through the entire experience. He reassures her that everything looked good, discusses the importance of a screening mammogram, and assures her that he will call her if there is any problem with the Pap test.
She goes home with some suppositories for her nausea. When she tries to use one, she finds it impossible to insert. She feels too shy to call the doctor’s office for an oral alternative pill, but by the end of the day the nausea improves by itself. She starts thinking it was not that bad. This was one of her better visits to a doctor’s office.
Improving your office space and procedures
As the above case illustrates, a practice’s physical environment and office procedures affect the quality of an obese patient’s experience in the primary care setting. To improve in these areas, begin with a simple evaluation of your practice in terms of its user-friendliness to obese patients. Walk through your practice, following the path a patient would take, and consider what changes you might make to both the physical environment and office procedures to enhance comfort and safety. It can be helpful to ask several obese patients about physical aspects of the office and office procedures they find particularly helpful or burdensome because of their weight. You should also take into account the Americans with Disabilities Act (ADA) Title III to ensure your practice is complying with disability rights laws. (You can find an ADA guide from the U.S. Department of Justice at www.usdoj.gov/crt/ada/cguide.htm.)
When assessing whether your office’s physical setup is welcoming and comfortable for larger patients, be comprehensive. Sensitivity to the needs of obese patients may require attention to parking, office entry, furniture, medical equipment, supplies and office reading material. You may even need to work with specialized vendors to address the many needs of this patient population. The initial cost of upgrading your office may be offset by larger dividends in the long run as your office becomes more accommodating to a broader range of clientele. For specific suggestions to improve the physical environment of your office, see the list later in this article.
Attention to the physical requirements of your office should be supplemented with attention to your office procedures. For example, obese patients may find it burdensome to sit down and stand up repeatedly, so any change you can make to minimize the number of “stops” in a visit can decrease their burden. At the same time, it is important to make comfortable seating available at any point where a delay may occur, such as at the check-out desk. Also, many people – particularly those who are obese – are very sensitive about being weighed. Unless weight monitoring is medically indicated (e.g., for infants, children, pregnant women, individuals on weight-loss programs or those who have medical problems such as congestive heart failure for which weight monitoring is essential), consider giving your patients the choice to be weighed or not. And always measure their weight in private. These relatively small changes in procedure can greatly improve the health care experience for your patients.
Improving the interaction
Sensitive office procedures and physical comforts will go a long way toward creating a welcoming environment for obese patients. But above all, regardless of their weight, patients need to feel cared for by their physicians and the rest of the medical team. To accomplish this in your practice, you need to address knowledge and skill deficits as well as negative attitudes and behaviors that may exist among your colleagues and office staff.
Knowledge and skills. Physicians and their medical teams must understand the special needs and concerns of obese patients and be prepared to deal with them in the clinical setting. For example, obese patients can be sensitive about physical examinations, especially pelvic or genitourinary examinations. To make these visits easier, treat your obese patients with the same consideration and respect you would show to any other patient. Encourage obese female patients to get pelvic examinations as often as any other female patient. Be friendly and open, but careful with humor or any comments that could be taken as offensive. Have the correct instruments, such as a large speculum and large blood pressure cuff, easily accessible in the examination room. Take the time to do a thorough clinical breast examination and to teach the patient how to do a self-examination, just as you would do for a non-obese patient. During the pelvic examination, be gentle and do not rush. Remember how embarrassed or vulnerable any patient can feel in this situation, yet take the time to perform a complete examination. It may be necessary to raise the patient’s legs and flex the hip more in order to get a good view of the cervix, so make sure the nurse or medical assistant is prepared to assist the patient if necessary. And finally, avoid any display of frustration or distaste when doing a difficult examination. (A similarly sensitive approach needs to be taken during rectal or prostate examinations.)
Given the cultural pressure to be thin, many obese people feel considerable shame and blame themselves for being overweight. They are likely to be quite aware of the health implications of obesity and to have dieted, lost and regained weight numerous times. They often know more about programs to address weight than their health care providers may know. Given the demonstrated difficulty in taking off weight and maintaining weight loss and the dangers of yo-yo dieting, it is often judicious for physicians to avoid aggressively addressing the need for obese patients to lose weight, especially early in the doctor-patient relationship. It may be more useful to focus first on very modest goals, such as avoiding further weight gain or increasing physical activity, and to address other health issues, such as the need for preventive screening or the treatment of comorbid conditions.
Knowledge of the research and clinical literature on obesity should, of course, drive your approach to the weight concerns of obese patients. For those patients for whom weight reduction is an appropriate focus of treatment, you and your staff should be able to share empirically grounded and realistic advice. For patients for whom weight loss is not realistic, you can direct their attention toward enhancing self-esteem and other health issues.
TIPS FOR IMPROVING YOUR OFFICE SPACE
To make your office space more welcoming and comfortable to obese patients, consider these ideas:
|Parking & office entry|
|Close parking for people with special needs.|
|Ramps and handrails at entrances.|
|Adequately sized doors and hallways.|
|Adequate number of large chairs with armrests or regular chairs without arm-rests; sufficient height to facilitate rising.|
|Magazines that feature healthy lifestyles and positive images of larger people. Patient-education materials that are friendly to obese patients and address relevant health issues.|
|Adequate size and number of rest rooms.|
|High, easy-rise toilets.|
|Adequate space surrounding toilets.|
|Handrails next to toilets.|
|Personal hygiene materials (such as moist towelettes) to facilitate cleansing.|
|Scale with wide base; equipped to weigh patients > 300 pounds. Scale located in private area.|
|Large blood pressure cuffs.|
|Large examination tables; low enough to allow easy access (hydraulic lift tables are ideal); wider base to facilitate getting onto the table.|
|Large specula for female exams.|
|Extra large gowns, preferably cloth.|
|Comfortable and available seating, as in waiting room.|
|Adequate space for mobility.|
Attitudes and behaviors. Misinformation about obesity contributes to negative attitudes toward obese patients. The belief that anyone who wants to lose weight and keep it off can is clearly contradicted by extensive research demonstrating that long-term maintenance of weight loss is extremely difficult. Educating professional staff about obesity and the challenges of weight management may significantly decrease the “blame the victim” mentality that pervades public attitudes about the obese. Professional staff education should address diverse attitudes about obesity, nutrition and beauty relevant to the dominant patient populations served by your practice.
Physicians can play a key role in eliminating discriminatory attitudes and behaviors from among their colleagues and staff by modeling professional behavior. The behaviors that nurture mutually respectful doctor-patient relationships do not fundamentally change when the patient is obese. The physician needs to inquire about and respond to the patient’s concerns, show courtesy and kindness in assisting the patient with physical exams, and balance the patient’s needs for control and agenda-setting with the physician’s need to be medically comprehensive. With obese patients, the physician needs to be careful to attend to health issues not directly related to obesity and to avoid assuming that obesity is the first and foremost issue that needs attention.
This material is not included in the print version of this article.
“Safe and Effective Management of the Obese Patient.” Collazo-Clavell ML. Mayo Clin Proc. 1999:74:1255-1260.
“Dealing With Obesity as a Chronic Disease.” Hill JO. Obesity Res. 1998;6(1):34S-38S.
“Management of Obesity in Primary Care.” Simkin-Silverman LR, Wing RR. Obesity Res. 1997;5(6):603-12.
Management of Obesity. American Family Physician Monograph No. 2. Leawood, Kan: American Academy of Family Physicians; 1999.
The right approach
Sensitive treatment of obese patients involves attending to their needs for comfort, safety and self-esteem in the primary care setting. Obesity is best viewed as one of many chronic health conditions that afflict the populations we serve. The person, not the obesity, should be the focus of treatment. As with any patient with a chronic health condition, an ongoing relationship with a respectful and caring physician forms the bedrock of medical care.
Encouraging compassionate care of obese patients will positively impact the health of this population even if a pound is never lost. This may occur through increased compliance with preventive screening, better attention to comorbid conditions and more regular medical care. Furthermore, it is the foundation for helping patients realistically address weight and exercise concerns when they are ready and the physician believes it is in the patient’s interest to do so. As the number of obese people in the United States continues to increase, the quality of their care becomes a compelling concern. By acting now, family physicians can lead the health care system in improving care for this vulnerable population of patients.