Tuesday, January 29, 2013

Blaming the Patient

"Discrimination against heavy people, by the general public and medical professionals, might be a greater health and social problem than any extra pounds they may be carrying" argues UCLA Professor Abigal Saguy, PhD, in a provocative essay in the Washington Post.  "Despite the fact that body weight is largely determined by an individual’s biology, genetics and social environment, medical providers often blame patients for their weight and blame their weight for any health problems they have" she writes, comparing such "size profiling" to "racial profiling." 

"Both types of profiling" she continues "lead to false positives (people wrongfully accused or medically overtreated) and false negatives (people who get away or are medically undertreated)."

I think comparing "size profiling" to the horrible continued legacy of racism is a stretch, but Dr. Saguy has a point--some clinicians seem quick to blame their patients for being overweight.  And also for smoking, for abusing drugs and alcohol, for eating unhealthful diets, for not exercising enough, for not taking their prescribed medications and for not following their physician's advice.  I have heard some internists rail against patients who are "not taking responsibility" for their own health, demanding to know what the ACP is doing to make people accept more responsibility.

I can sympathize with physicians who are doing everything they can to help their patients improve their health, only to encounter patients who continue to do bad things to their health.  Especially, if the physician is subjected to performance measures that penalize them when their patients don't have the desired outcomes.  No one wants to be blamed for things outside of their own control!

But this is true of patients as well.

 The "blame the patient" attitude assumes that how much we weigh or how sick or well we are is mostly a matter of will power. Sure, there are things that each of us can do (and don't do) that can help make us less or more healthy.  But many of these things--eating better, exercising more, not smoking, not drinking to excess--may be very difficult or even impossible for some people to achieve because of genetics (family history of alcoholism and other substance abuse), culture and community (the diet your grew up with, the food choices available to you in your community, exposure to crime and violence), stress, literacy, physical and emotional abuse, how you were raised by your parents, the quality of your schools--the list goes on and on.  And even if you do everything right, it may not work--eating well and exercising does not guarantee that someone won't be overweight.  And being overweight doesn't guarantee you will get sick.

The "blame the patient" philosophy also shows up in public policy proposals: high deductible health plans that by definition mean that the sick will pay more out-of-pocket (because they need and use more health services) than the well (because they need and use fewer health care services); higher co-payments for receiving non-emergency care in emergency rooms (which disproportionately affect poor people in poor health who may not have good access to community-based primary care); and proposed regulations that allow employers to charge higher health insurance premiums or impose other rewards and penalties to employees based on how well they achieve improvements in their own health status. 

Yesterday, House Democrats sent a letter to the Obama administration, objecting to a proposed rule that allows employers to establish "health-contingent wellness programs" that "allow differential rewards based on health status factors, including a person's cholesterol, blood pressure, weight or body mass index."   The lawmakers argued that such programs would undermine the ACA's prohibition on discrimination against persons with pre-existing conditions, and would disproportionately harm "certain population groups, including racial and ethnic minorities, such as  Hispanics, African-Americans, and some Asian groups [with] a higher proportion of known genetic predisposition for certain illnesses that are screened through biometric measurement such as cholesterol or blood sugar levels."  

ACP, in a comment letter on the same proposed rule, similarly stated "that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals." 

And ACP's ethics policy, developed by its Committee on Ethics, Professionalism and Human Rights, states that "Incentives to promote behavior change should be designed to allocate health care resources fairly without discriminating against a class or category of people. The incentive structure must not penalize individuals by withholding benefits for behaviors or actions that may be beyond their control. Incentives to encourage healthy behaviors should be appropriate for the target population. The American College of Physicians supports the use of positive incentives for patients such as programs and services that effectively and justly promote physical and mental health and well-being."

Objecting to stigmatizing and punishing patients because of their body weight, health status, genetics, and personal choices is not the same as arguing that patients shouldn't be engaged in, and responsible for, making contributions to their own health.  Physicians can and should engage patients in shared decision-making about their health.  They should engage patients in helping them understand their risk factors and how they might help reduce their risks.  They should help them succeed and also support them if they fail. 

Physicians can also advocate for public policies to engage and empower patients in healthcare decision-making--such as for reimbursement changes to allow physicians to spend the time required for effective shared decision-making and creating positive incentives to help people access effective weight-loss or other wellness programs. While advocating against policies to stigmatize and punish people for their health status.

As my mother might say, no one likes a scold.  Let's stop scolding people for supposedly not doing enough to stay healthy.  And instead, lets start helping them be as healthy as they can and make sure they are cared for when they are sick, no matter what they did or didn't do when it comes to taking care of their own health or the genes they inherited from their parents.

Today's questions:  Do you agree with Dr. Saguy that many in the medical profession stigmatize patients for being overweight and other aspects of their health?  How do you feel about programs that would penalize people for not achieving measurable improvements in their health?


Jennifer said...

ABSOLUTELY the medical profession stigmatizes patients for their body size. As a former medical professional, I was privy to some hateful judgmental discussions about cases of fat patients. What stands out most in my mind was the recurring "suggestion" that we recommend wiring jaws shut to "help" fat patients eat less. Even if these words never reach the patient's ears, it clearly demonstrates a bias against fat patients and a blame placed upon them for their size. Research supports these observations: many doctors think of fat patients as lazy, noncompliant, non-hygienic, stupid. Again, even if a doctor doesn't call a patient "stupid" to their face, to have these thoughts in their mind, how can the medicine practiced be fair and unbiased?

What I wish every doctor would consider is this: Remove weight from the equation. If a thin patient entered the office with low back pain, how would you treat it? If a fat patient does the same, do you treat differently?

And today as a fat patient who has been heavily abused by medical professionals, I can speak firsthand about the biases held tightly by these professionals. I was given a diagnosis of "fat" over and over again. Even when requesting the same treatment as thinner patients, it generally fell on deaf ears. Once I finally received adequate care, I discovered my conditions were easy to treat, and had precisely zero bearing on my weight, as they affect thin and fat people alike.

Programs that penalize anyone for not changing things that are beyond their control will result in doing harm. Patients who cannot lose weight will continue to be marginalized and stigmatized. There is no way to know all of the factors involved in someone's weight, and therefore it will be impossible to be able to differentiate which fat patients are naturally fat, and which are just gross lazy slobs.

I'm all for teaching about healthy lifestyle choices (if only medical schools taught by the Health At Every Size philosophy!), but this is not size-dependent. Do thin patients get a free pass because they "look" healthy (read: thin)? If a fat patient has good cholesterol, BP, glucose, etc, but is still fat, why is weight loss still prescribed? Even if a person has metabolic factors to consider, weight loss in and of itself does not reduce risk. HAES works for all people of all sizes. The fact that we're dividing up patient populations by "ideal" and "not ideal" aesthetics does a disservice to everyone of all sizes and on both sides of the prescription pad.

Nancy Lebovitz said...

I strongly agree that doctors stigmatize patients for their weight. In particular, I've heard all too many accounts of doctors who won't look at fat people's symptoms-- they just say "lose weight".

And unusually thin people are sometimes just told to gain weight.

I think programs which penalize patients for not showing improvements in their health are a very bad idea. What if the diagnosis and/or treatment are wrong?

Nancy Lebovitz said...

I strongly agree that doctors stigmatize patients for their weight. In particular, I've heard all too many accounts of doctors who won't look at fat people's symptoms-- they just say "lose weight".

And unusually thin people are sometimes just told to gain weight.

I think programs which penalize patients for not showing improvements in their health are a very bad idea. What if the diagnosis and/or treatment are wrong?

Brad F said...

When I saw the congressional letter, I was not sure of the purpose--a warning shot perhaps?

The statutory language can be gamed with effort, but the wording is not so ambiguous as to render overseers powerless.

Three minutes to read whole link, with key excerpt below:


"The NPRM is consistent with the majority of HIPAA provisions regarding wellness programs and re-iterates the two categories of wellness programs, participatory and health contingent. However, in response to stakeholder comments to HIPAA regulations and to remain consistent with the ACA, the proposed regulations modify and clarify four of the five additional non-discriminatory standards that the health contingent programs are required to follow.[10]"


Steve Lucas said...

This is a very real issue as I am a life long weight lifter and have a BMI above 20. I have been told by more than one doctor that I am not only obese but morbidly obese, and that my wife finds me disgusting, remembering that when I look down I see my belt buckle. My BMI runs in the 23 to 24 range.

I have also been told that since I cannot control my eating I need to start on multiple statins prior to any test.

Smoking is bad and I do not smoke, but if doctors truly believed that smoking is an addiction they would understand a person just cannot stop.

Ultimately one doctor was honest when blocking the door and telling me I was taking food from his children he stated that with my insurance and income I had an obligation to see hem every 90 days in order to support his practice. This same doctor wanted to put me on fen-phen, but I did not need to worry since unlike other doctors he was not afraid of raising the dose to get the desired results.

Doctors do have a weight and smoking bias made worse by the modern practice model of seeing too many patients and ordering too many test. One doctor was honest when he told me seeing patients only slowed down his system since everything he needed to know was in the paperwork.

Back in the early 70’s an economics professor explained that many of society’s health problems were found in the lower economic strata of our society due to income limitations. Weight is a function of diet and carbs and starches make up a large part of this groups diet due to cost.

Smoking is a way to build self esteem by showing that you have money to burn. It is also a social activity for a group that often has time to fill.

There has been a push to “Make these people pay!” The reality now as then is that the bulk of these people receive some type of government assistance, so there will be no net gain, only an increase in our taxes to support these increased premiums.

We only need to look at the tobacco settlement to see what happens when government gets money for health care. In my state this money was quickly moved into the general fund and little if any was spent on health care and smoking awareness.

We should really focus on why we spend twice as much as other countries on health care with poorer outcomes. People smoke, drink, and weigh too much in other countries. I have to believe that medicine is viewed as a cost to society, not a profit center, and people are not labeled. They are told to live a health life style, but are not tested and medicated to reach an artificial pharma set standard. A standard designed and modified over time to generate the most profit for the drug companies.

Doctors need to come to grips with the fact that over medication is rampant and that a life well lived is better than a life lived in fear and a drug induced fog trying to achieve an impossible standard.

Steve Lucas

Janice said...

This article reminded me of a new approach called "minimally disruptive medicine," which urges clinicians to consider the work a patient must do to manage his or her health. Pioneered by Dr. Victor Montori at Mayo.


Anonymous said...

As once a thin beautiful woman that aged, gained weight, after menapause I became insulin resistant. I had one female doctor accuse me of being an alcoholic. I never drank. She tried to humilate me by making me hold out my hands. She stated"you see you are shaking". No I was not and I told her so. I left her practice and found out that my high liver readings was due to hemochomotosis a blood disease that hits women after they stop their cycles. I was in that age bracket. After being bled for that is all they have for the treatment my liver reading went down. She was a bias, bent, and slanted skinny woman that looked at me and said
"your too fat". I looked back at her and said I have 35 years on you wait till you hit menapause. She countered that with I have old women much older than you losing weight. I counter and said "I bet you do as women age into their 80's they lose weight. I was right these women were that old I was 55. I am now 65 and it does not get better. I have a fat doctor but he berates me every time we meet over my weight. I tell him off and I say "Listen tubs when you lose I will lose" He has suggested everything from 600 calories diet to surgery. He is the best I am going to find because after all these years I know dang well that they are all bias. If health care wants to punish people that are food addicts which I know I am then they should realize I will die quicker than most. I paid for my own health insurance and still do no government handouts. No one is paying for me. The self righteous bigoted professionals try shaming you yet they would never talk to a drug addict like they do a fat person. The new thinking is the liberal mentality that controlling our lives with government nannies will cost them less in the long run. Actually fat people die earlier. I cost no one anything I pay for my own isulin, drugs, etc. So yes I do know they are prejudice and they do misread a patients problems because all they see is fat. I have friends in the same boat. They missed her Galbladder for 12 years telling her she was fat until emergency surgery was performed. They have a saying in the medical world and this is the real war on women .Female, Fat, Forty, that is the code for saying do not believe their complaints their fat clogs their brains. Personally if I could never see a doctor again I would be happy but I have too. So I go in with my weapons my mouth, research, and data. I am taking this in with me in two weeks.

Unknown said...

Hear hear!

Whatintheworld said...

They are worse with drug addicts. Completely ignore any symptoms as "drug seeking"

Whatintheworld said...

They are worse with drug addicts. Completely ignore any symptoms as "drug seeking"

davidk said...

I am a heavy person! I do know how doctors think! Not all doctors graduated at the head of their classes? Some of these doctors are. Number then a box of rock?

I quit smoking around 45 years of age! Started when I was 24 or so! To this day Doctors blame smoking on my health? How stupid? I worked in automotive as a parts man! Cars drove trough the garage and then parked outside! I breathed more carbon monoxide into my lungs, and all the chemicals in the garage, including brake dust, made out of abestos! Nope! It’s because you smoked! So I consider nurses and doctors very stupid until they sit and listen!

Fat, came into my life early! About the age of 50? A lot of the fat was due to medication I was taking? Now, who prescribed Medications? Doctors of course? So, these doctors, did not graduate at the head of their classes as you can see!
I am 73 now! I was on oxygen for 7 years? I took a lot of Prednisone as one of my meds? Weight gained a lot? Just that one med? Other meds did not help? I was blessed! No more oxygen! My type two diabetes got much worst as I got heavier? Finally 1 month ago a pharmacist found a med that did not hurt my legs so bad, that I could not walk the next day! Yes, my sugars readings are getting better each day and, I am finally loosing weight? So, what I am saying, Some Doctors need an attitude adjustment ? Some doctors need to be educated and their degree taken away from them? Unless a doctor sits an listens, I consider them stupid? There are good doctors, who listen to their patient! Those doctors find remedies? Thank you