Stigma, prejudice and bias have been themes in the news. Recently, commentators speculated about the Supreme Court decisions about affirmative action and gay marriage – policies that seek to assure equal treatment under the law. But biases cannot be legislated or outlawed – they are, after all, how we feel.
One group that suffers greatly from bias and discrimination is fat people. By the way, I would normally not call a large person "fat" because it sounds pejorative, but I am told by my fat friends that they prefer the term "fat" to medical terms like obese, or to euphemisms like large-size, overweight, chubby or "of great proportions." People assume, often incorrectly, that fat people simply lack will power: If they wanted to lose weight they surely could.
It turns out that with regard to biases, health professionals are no different from others, often describing fat people as unattractive, awkward and unwilling to follow medical treatments. Under the guise of "prevention" counseling, doctors often fail to advise but rather ostracize fat people. Not surprisingly, fat people notice these negative biases and claim such comments and digs make a trusting relationship with the doctor nearly impossible.
Medical students report that while it is uncommon for more senior members of the medical team to make fun of a person's race or religion, derogatory comments about a person's large size are common. A study just released looks at medical students' attitudes toward fat people.
The authors point out that people have two types of bias, implicit and explicit. Implicit biases function automatically at an unconscious level and are formed by past experiences and cultural norms. Implicit biases are what drive our first impression or reaction. Explicit biases are conscious, so we can override a bias and opt for a specific behavior.
The majority of medical students reported a preference for thin patients rather than fat ones. Only 1 percent of students reported a preference for fat patients. Implicit biases were stronger than explicit biases. What I found most interesting was that 75 percent of students who exhibited a weight bias did not consider themselves biased.
What remains unanswered is where these biases come from. They are likely formed early and reinforced often by physical education teachers, coaches, clerks at clothing stores, and others.
I recall a study done years ago in which researchers went into a kindergarten class with two identical dolls – except one was fat and the other thin. The children were asked to complete some simple chores. As a reward for completing the chores they could select one of the two dolls. Everyone selected the thin doll. The children were then asked why they made that choice and these little people spoke of the fat doll being ugly, lazy, and always eating. So these biases seem to form very early.
A report recently release from Penn State suggests that doctors are counseling patients less about weight. Perhaps this is due to time pressures, reimbursement rates, or other reasons, but it also could be that doctors just don't like talking to fat people – at least about weight. The first step in changing a bias is to recognize and admit to its existence.
Doctors also need to admit that biases can lead to counterproductive doctor-patient relationships. Without recognition there is no chance for change. The last step is the hardest in that it calls for an attitude change, and this requires more than a lecture in medical schools. It often requires discussions, open discussions with fat people around their feelings, and it requires videotaping doctors with patients so we can point out their actual biased words and behaviors.
Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality. Reach him at firstname.lastname@example.org.