Recognizing and Countering Anti-Fat Bias in Healthcare

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizanno:

Hello, welcome to today's episode of MedEd Thread, an education podcast exploring anti-fat bias in healthcare. I'm your host, Dr. Tony Tizzano, director of Student and Learner Health here at Cleveland Clinic in Cleveland, Ohio. Today I am very pleased to have Dr. Alison Reiheld, PhD, professor of philosophy at Southern Illinois University, Edwardsville, here to join us. Dr. Reiheld specializes in ethics and value theory with a focus on medical ethics and feminist philosophy. Alison, welcome to today's podcast.

Dr. Alison Reiheld:

Thank you Dr. Tizzano. I'm pleased to be here.

Dr. Tony Tizanno:

And Tony, please.

Dr. Alison Reiheld:

Okay, thank you, Tony.

Dr. Tony Tizanno:

To get us started, please tell us a little bit about yourself, your educational background, your role at the university, and how you got connected with Cleveland Clinic's MedEd Thread.

Dr. Alison Reiheld:

Yeah, sure. So I, you know, I actually began thinking about medical ethics as a transition from biology, which is what my undergrad degree is in. And I kept being interested in these like really deep questions like why is it okay to do the research that we were doing with animal mouse models? Right? And as I explored these questions more, I really found my calling in medical ethics, bringing together the fact that we really need science to think through human problems and solve human needs with the sort of unavoidable questions about the nature of science and its uses that are fundamental to medical ethics. And I think that has followed through as a thread in all of my work in medical ethics.

At the university, I have just become chair of my department. I am a professor of philosophy and was previously director of women's studies, and I'm really glad to be able to bring the skills that I have to these other roles.

Dr. Tony Tizanno:

So just to frame this a bit further for our audience, you know, the majority of US adults have been labeled as overweight or obese according to CDC guidelines. You know, this is perhaps part of a larger endeavor to identify drivers and outcomes associated with obesity across the United States and abroad. However, it's generated an arguably skewed perception that weight is an accurate indicator of health, and accordingly, a harmful bias towards people with larger bodies.

So in today's segment, the hope is that we can explore how these biases impact healthcare and contribute to negative attitudes, stereotypes and discrimination that may occur towards individuals based on their body size. So Alison, if you could help frame this a bit further for our listeners and some context around how today's topic can manifest and impact the delivery of healthcare.

Dr. Alison Reiheld:

Yeah, there's a couple of things that we probably need to start by getting clear on, and that's distinctions between talking about weight, talking about obesity, talking about fatness, for instance. So I use the term fat and what I hope is a non derogatory way simply to describe people who have a lot of adipose tissue, and that's not at all the same as weight.

So very famously, Arnold Schwarzenegger's body weight when he was doing his bodybuilding was sufficient to classify him as obese. But that's not really what we're talking about when we're talking about obesity. What we're really talking about is fatness, right? Because nobody's concerned that Arnold Schwartzenegger isn't healthy and his BMI is too high, right? What we are concerned about when we are concerned about obesity is really fatness. And I think it's important to talk about fatness in a matter of fact way, and to acknowledge there are larger bodied people with higher amounts of adipose tissue who still deserve to have healthcare in the bodies that they have.

Dr. Tony Tizanno:

Absolutely. So what are some of the stereotypes that you think about?

Dr. Alison Reiheld:

Well, so there are a lot of stereotypes that come up in surveys of clinicians. So I'm thinking here, surveys of nutritionists and dieticians, nurses and physicians indicate that they share certain kinds of attitudes about fat folks. They assume that fat folks are fat because they eat poorly and don't exercise. And this contributes to stereotypes that fat folks are lazy and non-compliant.

So if you look at surveys of clinicians, a majority of them will say yes, they think that fat folks are lazy and non-compliant. This has huge issues if you are trying to interact with patients around changing lifestyle factors, or if you are trying to interact with their bodies as, say, thinking about whether fatness should be a non-modifiable risk condition, or whether it's something that we should blame people for as a risk condition and a body status.

Dr. Tony Tizanno:

What sparked your interest in this particular area?

Dr. Alison Reiheld:

So it's a combination of personal and statistical, right? It just simply is the case that more and more people are fat, as you mentioned, and that when fat people go to the clinic for healthcare, they often receive weight loss advice instead of, or as a displacement of treatment for their primary complaint. And knowing that just set off every single sort of spider sense that I have about medical ethics over my years of experience, right? It struck me that what is happening there is that people are coming into the clinic already vulnerable in some ways, but then their clinical encounters are actually rendering them more vulnerable than they were before they walked in the door.

So if you go in for a complaint of asthma difficulty, and what you get is weight loss advice and not an adjustment on your inhaler, that's a serious issue, right? And I think that because we think of obesity, of fatness, as a major health issue, it's really easy for clinicians to think their job when they see a fat person should be to help them become less fat. And that can hijack the clinical encounter away from these other things that patients need from their clinicians.

Dr. Tony Tizanno:

Boy, I think that is so well said. And you know, how many times do we find ourselves getting ready to head into a room and the person who roomed them would say, and by the way, they weigh 382 pounds. Like, that should be the piece of information I need before I step through the door. So you're suggesting that the experience in the office relates to a patient's sense of being discriminated that is going to impact the remainder of the visit and untoward reactions and the quality of that entire encounter.

So expand on that a little more, because I think that's really important for any person who deals with individuals to know. And you point out very clearly that just because you're overweight doesn't mean you can't have that primary medical problem that you came in with dealt with.

Dr. Alison Reiheld:

Absolutely. And in fact, you know, it is very difficult to lose weight. So if what we focus on is weight loss before treating other medical conditions, the patient may be presenting with even an effective weight loss will take months or years, but that person has healthcare needs right now that have nothing to do with their weight or that are comorbid with weight in some really interesting ways. But if we can condition treatment for that on weight loss, that is at best a delay of care. And of course, as we know, long-term delays of care turn out to be defacto denials of care. And I really do not believe that clinicians want that to happen. But I think that excessive and primary focus on weight loss for fat people does routinely cause that to happen.

Dr. Tony Tizanno:

Yeah, I can certainly see that. So are there ways in which fat bias might be even more harmful than the presence of that weight itself?

Dr. Alison Reiheld:

I, there certainly are. There are some studies that have shown that persons who are fat show on autopsy more undiagnosed conditions that needed medical treatment at the time of their death than people who had a, quote, normal sized body, unquote, than skinny people. What that means is that those conditions were missed in addition to delay of care.

Fat patients end up not getting the care that they need and deserve in the bodies that they have now. And if I can add one more thing, it would be that not only in this specific encounter where say, you know, Dr. Jones is going to be interacting with a fat patient, would the rest of that encounter be shaped in ways that are medically ethically problematic, <laugh> by anti-fat bias, but also that patient will leave that day wondering whether the next time they try to go to a different doctor, their healthcare needs will be met.

And so we can end up having patients delay seeking care because their experience in the past has been that then when they go in for care for their fat bodies, what they get is weight loss recommendations, not care for their fat bodies. [Right.] So why wouldn't they be suspicious about making another appointment, trying again? How many times do we expect people to keep making additional more appointments until they can find a physician who will treat them with the care that they need in the bodies that they have?

Dr. Tony Tizanno:

Yeah. So well said. I ran across a healthcare provider who related her experience after having gastric bypass surgery, and having lost a significant amount of weight, that her family treated her differently. Her partner treated her differently, her patients treated her differently, she was considered more believable. There is so much that goes into it. So this is the person who's providing the care. And yet, you know, very tuned into all of this. So clearly we need to do better at recognizing and addressing and countering anti-fat bias.

How do we get started in a way that captures the attention and changes the attitudes of health professionals and systems?

Dr. Alison Reiheld:

Part of it, I think, is stories like the one that you just told Tony, because we know that while statistics are powerful, narrative is also powerful. And so if we can have stories that are believable from people who are believable, either because they know how clinical medicine works, like the clinician you were talking about just now, or because we have rich stories that people can look at and evaluate on their own 'cause the narratives are deep and full. I think that that can get us somewhere.

But also we have to keep in mind that we have certain kinds of scripts that clinicians rely on routinely for interacting with patients. Some of these are actually built into the electronic medical record with prompts, so therefore, the quality of your software will determine the quality of your interaction, right? But some of them are also just from our training.

So classic examples of scripts that I think unfortunately contribute to anti-fat bias and interactions with patients include things like you need to lose weight, exercise more and eat better. And I can't tell you how many times I have heard this from my clinicians without them having figured out how I eat or how much I exercise. And I ride 50 to a hundred miles a week on my bike and I do body weight exercises, and I still get advice to exercise more. And I'm like, okay, how many more hours per week in addition to the many, many hours that I exercise, would you like me to exercise? Right?

So I think we have to watch out for these scripts that are based in assumptions about fat people, right? If you haven't determined how people exercise and how they eat, telling them to eat better and exercise more is going to not be very helpful <laugh>. And you also can't just give these kinds of straight out scripts when there are social determinants of health that will affect whether and how people can comply.

Dr. Tony Tizanno:

So it sounds like we're not asking the right questions or we're not listening.

Dr. Alison Reiheld:

I think there's some of this to both. I think that many doctors think that they're already doing a kind of listening when they look at the fat patient's body. [Yeah.] I think they already think they're hearing what they need to hear in order to know which script to deploy and how to go forward from there. And I would respectfully disagree with that.

I think that you need to have actual patient-centered communication that elicits from patients how they live their lives in order to know what kind of advice to give them and how to help them actualize that advice. Right? There's a couple ways of looking at non-compliance, and one of them is patients can't be bothered. But another one is the recommendations that were given were not actionable in the lives they actually live.

Dr. Tony Tizanno:

Yeah, that is a mouthful. The recommendations given are not actionable in the lives of the... That is so true on so many levels, and it's easy to say, this is what you do for this, but can you really do it?

Dr. Alison Reiheld:

Yeah. I, I wanna acknowledge here that that kind of conversation will take dramatically more time than the scripts we already have in place. And that's tricky. To do better by patients may require that we change the systems within which clinicians practice. [Yeah.] So they have more time.

Dr. Tony Tizanno:

What you bring forward here seems very actionable, and obviously you're eminent in this area. Are these things being implemented to your mind's eye? And to what extent are we making any progress or getting better?

Dr. Alison Reiheld:

Well, so I think some of them are being implemented by some clinicians, but it's not systemic, right? It relies on the clinician, and I am a huge fan of individual clinicians trying to change what they see to be issues and problems and alter their own practice or the practice of their specific clinic. But if we don't have changes in medical education, if we don't have changes in servicing and the kinds of in-servicing that are offered in hospital settings, for instance, we won't get systemic changes.

So I have had some very, very profoundly changed encounters with clinicians in the last, say, five years on this encounter. Both in terms of talking with people in my capacity as a medical ethicist and as a patient myself. But I know also that some of my colleagues who are medical ethicists, including some who have written on this recently have had interactions where they go in for one kind of healthcare and what they get is weight loss recommendations.

I know somebody who went in for obstetrical care recently, and a huge amount of the time in their patient encounter was taken up with a discussion of weight loss and the obstetrician recommended Ozempic and gave recommendations on how to afford Ozempic and get insurance to cover it. And that came out of the encounter time for the reason that patient actually went in. Right. [Wow.] So it's a mixed bag here, even if people aren't fat shaming patients anymore, which I think is, you know, a bar we should aim for <laugh>

Dr. Tony Tizanno:

And pregnancy is not exactly the time to embark upon a major weight loss initiative. I mean, you may need to stop getting bigger or you may need to stabilize things. So as you look at what is ahead of us, [Yeah] what lies on the horizon?

Dr. Alison Reiheld:

I would really like to see clinicians remember one phrase that I think can help them to remember other ways to change their scripts with patients. And that phrase is, fat patients deserve care in the bodies they have. I think it sticks and it helps us remember that if we condition some kinds of healthcare on whether fat patients are able to produce a more ideal body, that causes this delay, and then defacto denial of care, right?

There are all kinds of other questions that you can ask yourself as a clinician so that you have kind of self scripts to, as the kids would once have said, check yourself before you wreck yourself, that can really help with this. And that stem from remembering that fat patients deserve care in the bodies they have. These include asking yourself things like, what would I recommend in terms of diagnostic tests and treatment if this patient had a smaller body? And are those still actually appropriate here, given the complaint they came in with?

Other things like, is weight loss something that I am trained to speak about well to this patient? And if not, maybe I should spend time focusing on what I am trained to speak about well to this patient, which is the thing they came to see me for. This is especially true in specialist cases, for instance.

And so there's all kinds of ways that we can start thinking about how patients come to us with the bodies they have and maybe long-term changes to their risk profile could be made. But the fact is that they need some healthcare now, not after they've produced a more ideal body. And if we keep waiting, if we keep thinking for fat patients or patients with mental health problems, or patients with certain kinds of disabilities, or patients with certain kinds of cardiac risk factor profiles, right? That we need to get them to change those before we do other things? Then they're not getting the care that they need now. People shouldn't have to become healthy to deserve healthcare.

Dr. Tony Tizanno:

Beautifully said. Well, this has been a very intriguing and a very important topic. Are there some thoughts you might have or questions that I didn't pursue that you think are important for our listeners to know?

Dr. Alison Reiheld:

Well, you know, I think the main thing that I would like people to keep in mind is that I'm not asking clinicians to completely change how they do medicine. I'm asking them to remember that fat people are patients with the same kinds of broad spectrum medical needs that all patients have when they come to you as a clinician, right?

And I am not assuming that clinicians who have anti-fat bias are immoral or unethical or have bad character. We live in a society full of anti-fat bias. It is no wonder that we struggle so hard against it. And so when we are trying to do good, when we are trying to do well and be good at the same time, it takes realizing that we will make mistakes, we have made mistakes, and that what we're really responsible for is how we change towards a better way of providing care.

Dr. Tony Tizanno:

I love it. Beautifully said. Well, thank you so much, Alison. This has been a fascinating and wonderfully insightful podcast.

To our listeners, if you would like to suggest a medical education topic to us or comment on an episode, please email us education@ccf.org. Thank you very much for joining, and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic education podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.