Too heavy for medical care: Over 40% of specialty clinics turn away patients weighing 465 pounds

(Press-News.org) One in 270 Americans (nearly 1 million adults) has a BMI of 60 or greater More than half of surveyed clinics lacked exam tables, chairs and/or gowns for patients weighing 450 pounds Receptionists made stigmatizing comments: ‘We’ve reached our limit for bariatric patients’ Patients with obesity are less likely to get cancer screenings and preventive care CHICAGO --- Patients weighing 450 pounds or more face barriers and discrimination when scheduling or attending doctor visits at subspecialty practices, reports a new Northwestern Medicine study.

The scientists used a “secret-shopper” method to attempt to schedule an appointment for a hypothetical patient weighing 465 pounds at practices across five subspecialties (dermatology, endocrinology, obstetrics and gynecology, orthopedic surgery and otolaryngology) located in four metropolitan areas (Boston; Cleveland, Ohio; Houston and Portland, Oregon). Every hypothetical patient was able to walk and did not require assistance getting on and off an exam table.

The researchers were attempting to learn if clinics met the basic standards of care for bariatric patients, which they deemed to be the inclusion of an exam table or chair with a high enough weight limit, a waiting-room seating option, sufficiently wide hallways and doorways, and large enough gowns.

Breakdown of the findings: Of the 300 clinics surveyed in the study, 52% lacked basic standards of care and 41% declined to schedule an appointment. Otolaryngologists (ear, nose and throat doctors) were the least likely to schedule a visit with the patient (only 48.3% scheduled visits, compared to 59% overall). This was despite the fact that when requesting the otolaryngology appointment, the researchers provided information that strongly suggested the patient had cancer.

Only 117 practices (39%) were fully accessible, the study found, with endocrinology practices being the most willing to schedule and most likely to meet basic standards of care.

An additional 16% of practices in the study that were willing to schedule the patient had a sub-standard plan of care that involved workarounds for accessibility limitations, such as telling the patient they could come to the clinic but would need to stand during the exam, or they would have to drape themselves with a sheet because they did not have gowns to fit them.

“Patients living with severe obesity are likely already struggling with shame and difficulty navigating the world,” said senior author Dr. Tara Lagu, adjunct lecturer of medicine and medical social sciences at Northwestern University Feinberg School of Medicine. “To tell a patient that they can’t be examined on a table, or can’t wear a gown, or need to stand during an appointment makes what should be a safe place and the experience of seeing a doctor humiliating and degrading. We need to acknowledge, as a profession, that all people deserve better than this.”

The study will be published Sept. 29 in the Annals of Internal Medicine.

“Our numbers likely underestimate the magnitude of the problem,” said corresponding author Dr. Molly Hales, a physician at UChicago Medicine who conducted the research when she was a postdoctoral research fellow at Feinberg. “Likely, very few high-weight patients who are scheduling appointments know to even ask if they can be accommodated based on their weight, and they might be hesitant to ask these questions or advocate for themselves because of the social stigma.”

'We’ve reached our limit for bariatric patients at this site' The study also found many staff members made potentially insensitive weight-related comments, such as, “We’ve reached our limit for bariatric patients at this site,” without providing a reason, or when the caller attempted to schedule an appointment with an orthopedic surgeon, they were told to instead try a bariatric surgeon first.

The findings highlight a clear need for subspecialty clinics to be familiar with the types of accommodations they might need for patients of higher weights and/or understand what accessibility limits they might have. The study authors also said clinics should be providing staff training on inclusive care.

Less likely to get routine screenings, including for cancer Previous research has found patients with obesity are less likely to get routine screenings and preventive care, including cancer screenings. Some participants with obesity in these earlier studies have discussed avoiding doctor visits because of a lack of accessibility and fear of discrimination at clinics, the study authors said.

“We designed some of the questions our callers asked to be red flags for a receptionist to think, ‘I should really schedule this person’ because the questions suggested the patient might have cancer and need an urgent workup,” Hales said.

For instance, when calling to schedule an otolaryngology appointment for the hypothetical patient, the investigators chose a set of symptoms and imaging findings that indicated a high risk of undiagnosed cancer.

“Obesity affects cancer screenings, and failure to screen can result in later cancer detection,” Lagu said. “We’re always attributing worse outcomes in higher-weight patients to weight itself, but more and more studies are now pointing to worse care, lack of care or being care avoidant as possible reasons for these delays.” 

What can be done? The scientists said clinics looking to better accommodate patients with severe obesity could utilize the Clinical Environment Checklist for Accommodating Patients with Obesity in Ambulatory Care Settings, which has not yet been widely adopted.

“They designed the checklist to be used by general outpatient clinics and tested it in both primary care and subspecialty settings, so it’s a good resource for clinics in determining where there are opportunities for improvement,” Hales said.

The study only included major metropolitan areas, but it’s likely even more important that rural clinics be able to accommodate patients with severe obesity, the authors said, since there are so few subspecialty clinics in rural areas, and so patients are not able to seek out alternatives as easily.

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