Does Obesity Stigma Affect Anesthesia Care?

Anesthesiologists know the health risks of obesity and the added complexity of providing anesthesia care for significantly overweight patients. Everything from the preoperative assessment to anesthesia induction and maintenance and management of a difficult airway to perioperative pain management requires special planning and consideration.

With obesity prevalence rates at 38.3 percent for women, 34.3 percent for men and 17 percent for children in the United States, obesity is a condition anesthesiologists are likely to see often in their patients.

Evidence suggests that among clinicians across specialties, including anesthesiology, seeing beyond a patient's obesity might actually present the larger challenge in some ways. "Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity," write researchers from Mayo Clinic's Division of Healthcare Policy in a 2015 narrative review of the literature regarding obesity stigma in Obesity Reviews. "Such attitudes influence [physicians'] person-perceptions, judgment, interpersonal behavior and decision-making. These attitudes may impact the care they provide" and "reduce the quality of care for patients with obesity despite the best intentions of healthcare providers." (See figure below.)

A conceptual model of hypothesized pathways whereby the associations between obesity and health outcomes are partially mediated by healthcare providers' attitudes and behaviors about obese patients, and patients' response to feeling stigmatized.
Obes Rev. 2015 Apr; 16(4): 319–326.

Widespread Negativity

Overt and subtle forms of obesity stigma, including "fat shaming," are pervasive in contemporary society. One of the more highly publicized examples occurred during the last presidential debate in which Republican nominee Donald J. Trump referred to "somebody sitting on their bed that weighs 400 pounds" in comments regarding the hack of the Democratic National Committee's servers and in which his Democratic opponent brought up the fat shaming of a 1990s Miss Universe.

Recent data shows that clinicians are not immune, either to biases in general, or to the deeply engrained notion that obesity signifies a moral shortcoming, personal weakness or character flaw. Forty percent of physicians surveyed in the Medscape Lifestyle Report 2016: Bias and Burnout reported they believed they had biases toward specific groups of patients. Emergency medicine physicians ranked highest (62 percent). Other specialists leading the list included orthopedists (50 percent), psychiatrists (48 percent), family physicians and obstetrician/gynecologists (47 percent each), and anesthesiologists (44 percent).

Among the physicians who admitted to biases, weight was cited as the second most common trigger (56 and 48 percent among male and female physicians, respectively) after emotional problems (62 percent). Other characteristics triggering biases included intelligence, language differences, insurance coverage, age, income level, race, physical attractiveness and gender. Also mentioned were drug-seeking and abuse, malingering, entitled and noncompliant patients, and—of interest for anesthesiologists and pain specialists—patients with chronic pain.

Negative attitudes toward obesity can translate into a tendency to attribute a patient's health problems solely to their weight, and to overlook other causes. "If doctors have negative feelings toward patients, they're more dismissive, they're less patient and it can cloud their judgment, making them prone to diagnostic errors," says Jerome Groopman, MD of Harvard Medical School in an article on obesity discrimination in USA Today, "The Surprising Reason Why Being Overweight Isn't Healthy."

A recent article in the New York Times, "Why Do Obese Patients Get Worse Care? Many Doctors Don't See Past the Fat" tells the story of a woman whose physician attributed her sudden shortness of breath to weight pressing on her lungs. Eventually, she was found to have several small blood clots on her lungs, a potentially life-threatening condition. Another woman was told by her physician that the pain in her hip was "obesity pain." She was diagnosed later with progressive scoliosis, a condition unrelated to obesity.

Fear of physician bias can lead people with obesity to mistrust their physicians, avoid seeking care and fail to follow through with treatment regimens and recommendations. An analysis of audio recordings of office visits by 208 patients with 39 primary care physicians found that the physicians were 35 percent less likely to show emotional rapport with obese and overweight patients than with normal weight patients. The physicians made fewer expressions of empathy and concern, and were less likely to engage in social conversation (although a patient's weight did not influence the extent of the physicians' medical questions, medical advice, counseling or discussions of treatment regimens).

These relationship-building differences can have important implications for patient care, says lead author, Kimberly A. Gudzune, MD, MPH of Johns Hopkins University. "If you aren't establishing a rapport with your patients, they may be less likely to adhere to your recommendations to change their lifestyles," she comments in a press release. "Some studies have linked those bonding behaviors with patient satisfaction and adherence, while other studies have found that patients were more likely to change their dietary habits, increase exercise and attempt to lose weight when their physicians expressed more empathy. Without that rapport, you could be cheating the patients who need that engagement the most."

Although the study didn't focus specifically on chronic pain, anesthesiologists might consider the possibility that similar problems could occur among their chronic pain patients who are obese. Dr. Gudzune urges physicians to be mindful of negative attitudes and to make an effort to bond with overweight and obese patients. "Patients want information and treatment, but they also need the emotional support and attention that can help them through the challenges that accompany weight loss and the establishment of a healthy lifestyle," she says.

A study of "doctor shopping" among 21,000 health plan members found that obese patients were 52 percent likelier to have had visits with five or more primary care physicians during a two-year period than were normal weight patients, indicating that obese patients have a harder time establishing a satisfactory relationship with a physician.

"The overt negative attitudes were not as predominant [in this study]," comments Dr. Gudzune, who also co-authored this study, in an article in American Medical News. "But that lack of emotional connection—that's where I think this implicit bias is coming in." Obese and overweight patients also had significantly higher rates of emergency room visits, leading the authors to suggest that doctor shopping by obese and overweight patients increases healthcare utilization.

A Positive Approach

Practitioners might reflect on the information presented here, examine their personal attitudes toward obesity, and consider how their beliefs, assumptions and biases might inform their behavior toward patients and possibly even influence their care and treatment decisions.

The Obesity Society offers a variety of strategies to help healthcare professionals address their own negative attitudes toward obese patients. The organization suggests that physicians ask themselves the following:

1. Do I make assumptions based only on weight regarding a person's character, intelligence, professional success, health status or lifestyle behaviors?
2. Am I comfortable working with people of all shapes and sizes?
3. Do I give appropriate feedback to encourage healthful behavior change?
4. Am I sensitive to the needs and concerns of obese individuals?
5. Do I treat the individual or only the condition?

The organization recommends that physicians take the following steps to create a more comfortable, welcoming environment for obese and overweight patients:

1. Consider that patients may have had negative experiences with other health professionals regarding their weight, and approach patients with sensitivity.
2. Recognize the complex etiology of obesity and communicate this to colleagues and patients to avoid stereotypes that obesity is attributable to personal willpower.
3. Explore all causes of presenting problems, not just weight.
4. Recognize that many patients have tried to lose weight repeatedly.
5. Emphasize behavior changes rather than just the number on the scale.
6. Offer concrete advice, e.g., start an exercise program, eat at home, etc., rather than simply saying, "You need to lose weight."
7. Acknowledge the difficulty of lifestyle changes.
8. Recognize that small weight losses can result in significant health gains.
9. Create a supportive healthcare environment with large, armless chairs in waiting rooms, appropriately-sized medical equipment and patient gowns, and friendly patient reading material.

Lawsuits on the Rise

Medical malpractice insurer The Doctors Company points to a dramatic increase in obesity-related lawsuits as another compelling reason for clinicians to examine their attitudes and build positive relationships with their obese patients. Obesity-related claims rose by 64 percent between 1992-2002 and 2007-2012, according to an analysis by the company reported in Clinical Endocrinology News. Anesthesiologists were third on the list of specialties most frequently sued, following orthopedists and family physicians. The increase in lawsuits is not surprising considering the increased prevalence of obesity in the US, according to the article.

An article on the company's website provides examples of cases:

• A young male, 5 feet tall, weighing 290 pounds, elected to undergo gastric bypass surgery. Multiple serious postoperative complications with organ failure led to his death two weeks later.
• A woman in her late 30s, weighing more than 325 pounds, with hypertension, diabetes and a 25-year history of smoking, died after a myocardial infarction and pneumonia were missed by the surgeon.
• A patient weighing more than 350 pounds suffered nerve damage due to positioning on a treatment table.
• A 35-year-old patient, 5 feet 4 inches tall and weighing 260 pounds, vomited and aspirated during a manipulation under intravenous sedation without an endotracheal tube in place.
• Spinal surgery on a woman, 5 feet 6 inches tall and weighing 275 pounds, created serious postoperative complications and paralysis.

"Sensitive treatment of obese patients involves attending to their needs for comfort, safety and respect," the article says. "Obesity can be viewed as one of the many chronic health conditions afflicting patients. The person, not the obesity, should be the focus of treatment."