Should doctors ever turn away obese patients?
■ A report that some Florida ob-gyns are refusing to treat people more than 200 pounds raises the issue of physician acceptance of these patients.
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Many of the adolescents Chicago pediatrician Ruby Roy, MD, treats weigh more than 200 pounds. When they are too heavy for the exam table, she asks them to stand during office visits. If they are too big to fit into a gown, she covers them with bedsheets.
But she never refuses to treat them because they weigh too much.
"These are the patients who actually need us the most. If you turn them away, you lose any opportunity to change their weight problem," Dr. Roy said.
In southern Florida, however, 14 of 105 area ob-gyn practices surveyed by the South Florida Sun-Sentinel either set weight cut-offs for new patients that start at 200 pounds or turn away people whose measurements indicate that they are obese.
An adult who has a body mass index of 30 or higher is considered obese, according to the Centers for Disease Control and Prevention.
Many of the physicians said their equipment, such as exam tables, could not handle people over a certain weight. Another reason given for refusing care was obese people's increased risk of health complications due to their weight. One ob-gyn the newspaper said turns down women weighing more than 250 pounds did not return a phone call from American Medical News for comment. The publication did not identify the other 13 ob-gyns.
Although it's not illegal for doctors to reject overweight patients, physicians who specialize in obesity management say doctors have a responsibility to care for them.
More than one in three American adults -- 72 million people -- is considered obese, the CDC said.
"I feel it's unethical to turn away any patient based on physical attributes," said Patrick McBride, MD, MPH, a professor of family medicine at the University of Wisconsin School of Medicine and Public Health. "We're called to serve all patients who come to us, and it would set a very dangerous precedent. "
Bariatric physicians say primary care physicians regularly treat patients who have an increased risk of health complications, including smokers. If an obese patient needs care that a primary care doctor cannot provide, that physician should refer the individual to a specialist, experts said.
"This is [primary care physicians'] patient population, and [they're] here to serve the patients," said David Bryman, DO, a Phoenix family physician specializing in bariatric medicine and president-elect of the American Society of Bariatric Physicians. "If that requires getting a little extra equipment to accommodate them, it's just part of the practice of medicine."
Bariatric physicians say standard exam tables can hold patients who weigh more than 200 pounds.
Despite the nation's obesity rate, studies show some doctors have biases toward obese patients. For example, a 2009 Journal of General Internal Medicine study of 40 Baltimore-area physicians and 238 of their patients found that doctors have lower respect for patients with a high BMI.
Bariatric physicians say limited education on the causes of obesity often leads to misconceptions among doctors. But even some researchers and health professionals in the field expressed negative opinions about obese patients, according to a study published in the September 2003 issue of the journal Obesity.
Ethicist Gail Geller, ScD, said weight cut-offs implemented by some South Florida ob-gyns are another example of physician bias toward overweight and obese patients.
"It's a form of discrimination," said Geller, of the Johns Hopkins Berman Institute of Bioethics in Baltimore. She added that physicians can refuse to treat patients based on conscientious objections to issues such as abortion. In those cases, doctors should refer patients to another health professional.
The American Medical Association does not have policy on doctors accepting overweight and obese patients. The AMA advises physicians not to refuse new patients due to race, color, religion, national origin, sexual orientation and gender identity.
The American College of Obstetricians and Gynecologists encourages ob-gyns to follow the AMA's guidelines on accepting new patients.
Practical advice for doctors
Dr. Bryman said too many physicians think obesity is simply the result of patients' consuming too many calories or being too weak to change. Specialists note that obesity is a complex disease that involves metabolic abnormalities, psychological issues and environmental factors.
Dr. McBride encourages doctors to remember that 40% of obesity is genetically determined.
"Physicians have to explore some of the underlying factors contributing to the [patients'] obesity to see if they can help" them lose weight and improve their health, said Jarol Boan, MD, MPH, a Hershey, Pa., internist specializing in obesity management.
Dr. Boan urges doctors to be sensitive when discussing patients' weight during office visits. She suggests that physicians ask the patient, "Are you concerned about your weight? Is there anything you would like to do? Is there any way I can help you?"
When overweight patients are not worried about their weight, Dr. Boan tells them about the health risks associated with obesity but does not press them to change their lifestyle. "It's my experience that [these] patients tend to come back at some point with an interest in talking more about it," she said.
When overweight and obese patients are ready to improve their health, physicians should help them set small, feasible goals, such as reducing the amount of soda they drink to one can a day, said Wendy Scinta, MD, a family physician and bariatrician in Manlius, N.Y.
She recommends that primary care physicians purchase chairs without arms for their waiting rooms to accommodate obese patients. She said doctors also should have larger blood pressure cuffs and scales that measure weight above 400 pounds.
Biases toward obese patients are "something we have to get past," Dr. Scinta said. "This is something we have to continue to get education on so we don't see these patients as a burden, but as a healthy challenge."