Study on physicians’ (dis)respect of fat patients

BRIEF REPORT
Physician Respect for Patients with Obesity
Mary Margaret Huizinga, MD, MPH1,3, Lisa A. Cooper, MD, MPH1,2,3, Sara N. Bleich, PhD2,
Jeanne M. Clark, MD, MPH1,3,4, and Mary Catherine Beach, MD, MPH1,3
1Division of General InternalMedicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore,MD, USA; 2Department of
Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 3Welch Center for Prevention,
Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; 4Department of Epidemiology, Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD, USA.

INTRODUCTION: Obesity stigma is common in our
society, and a general stigma towards obesity has also
been documented in physicians. We hypothesized that
physician respect for patients would be lower in
patients with higher body mass index (BMI).
METHODS: We analyzed data from the baseline visit of 40
physicians and 238 patients enrolled in a randomized
controlled trial of patient-physician communication. The
independent variable was BMI, and the outcome was
physician respect for the patient. We performed Poisson
regression analyses with robust variance estimates,
accounting for clustering of patients within physicians,
to examine the association between BMI and physician
ratings of respect for particular patients.

RESULTS: The mean (SD) BMI of the patients was 32.9
(8.1) kg/m2. Physicians had low respect for 39% of the
participants. Higher BMI was significantly and negatively
associated with respect [prevalence ratio (PrR)
0.83, 95% CI: 0.73–0.95; p=0.006; per 10 kg/m2
increase in BMI]. BMI remained significantly associated
with respect after adjustment for patient age and
gender (PrR 0.86, 95%CI: 0.74–1.00; p=0.049).
CONCLUSION: We found that higher patient BMI was
associated with lower physician respect. Further research
is needed to understand if lower physician respect for
patients with higher BMI adversely affects the quality of
care.

KEY WORDS: obesity stigma; physician respect and body mass index.
J Gen Intern Med 24(11):1236–9
DOI: 10.1007/s11606-009-1104-8
© Society of General Internal Medicine 2009

Stigma against persons with obesity is pervasive in our
society.1 Persons with obesity earn less money, face
discrimination from individuals and institutions, and experience
insults on a frequent basis.1 Obesity stigma is harmful
and has been associated with low self-esteem, depression and
eating disorders.2,3 Despite the increasing commonness of
obesity, obesity stigma is increasing even as other disparities
are decreasing or have remained unchanged.4 Persons with
the highest levels of obesity are more likely to experience
weight-related stigma.4
Negative bias towards persons with obesity has been well
documented in health-care providers, including physicians, for
the last 40 years.5–7 In a survey of physicians, obesity was
identified as a characteristic that elicited negative feelings,6
and other studies have found that physicians associate
negative terms, such as ignorant, lazy and incompetent, with
obesity.7 In addition, physicians have reported ambivalence
towards the treatment of obesity.7–8 However, none of these
studies have documented physician attitudes towards specific
patients with obesity. Several studies have documented
health-care avoidance in patients with obesity, and in some
studies, participants cited individual and institutional biases
as the reason for avoidance.9–12 There is also evidence that
obesity is associated with decreased preventive services,
especially cancer screenings.13–15 Few studies have studied
physicians’ attitudes and beliefs towards specific patients,
especially with regards to the patient’s weight.
Respect for all patients, which involves positive regard, is a
core component of professionalism in medicine.16 Physicians
who have more respectful attitudes towards patients share
more medical information and have greater positive affect
during encounters compared to patients for whom they have
less respect.17 In a study of obese females, participants
indicated a desire for a respectful relationship with their
physician and would avoid health-care visits if such a
relationship did not exist.9 While a general bias towards
obesity has been documented in the literature, little is known
about the respect a physician has for a patient with obesity
and how that may impact the patient’s care. In this study, we
examine the relationship between physician respect and
patient obesity. We hypothesized that physicians would have
low respect for patients as body mass index (BMI) increased.
METHODS
Study Design and Setting
Data for this study were obtained from the baseline visit of the
Patient-Physician Partnership Study, a randomized controlled
trial of physician and provider interventions to improve
patient-physician communication.18 Forty physicians and
238 of their patients with height, weight and measure of
physician respect available were included in this analysis.
Physicians were recruited from 14 urban community practices
JGIM
Received March 16, 2009
Revised July 28, 2009
Accepted August 18, 2009
Published online September 18, 2009
1236
in the Baltimore, MD, area from January 2002–January 2003.
Patients of enrolled physicians, aged >18 years and English-speaking,
with hypertension were identified from physician
rosters and enrolled September 2003-August 2005.
Measures
Physicians and patients completed questionnaires about the
visit, their attitudes and their perceptions of one another upon
completion of the encounter. The independent variable of
interest was patient BMI, calculated from measured height
and weight. The primary outcome was physician-reported
respect. Physicians were asked to rank their level of respect
for the patient on a 5-point Likert scale after the patient visit.
Two categories were created [high respect = much more or
more than the average patient (Likert score 4–5); low respect =
average or less than the average patient (Likert score 1–3)].
Physicians and patients were asked to report their gender and
race.Due to small sample size, race was examined as Black or not
Black in multivariate analyses. Gender and race concordance
were defined as the physician and patient having the same
gender or race, respectively.
Statistical Analyses
Analyses were performed using STATA 9.2 (College Park, TX).
Descriptive analyses of all variables were performed. Bivariate
analyses of patient characteristics by physician respect were
performed using the adjusted Wald test or Pearson’s chisquared
test, as appropriate. Poisson regression with robust
variance estimates were performed, including patient age and
gender. Poisson regression with robust variance estimates was
used as low physician respect was a common outcome (>10%),
and Poisson regression with robust variance estimates provides a
more reliable estimate of prevalence risk ratio compared to
standard logistic regression.19 All analyses were adjusted for
clustering by physician.
RESULTS
Patient and provider characteristics are presented in Table 1.
The majority of patients in this study were female (64%), Black
(63%) and high school graduates (68%). The mean BMI
(standard deviation, SD) in the study was 32.9 (8.1) kg/m2.
Patient age and gender were significantly associated with BMI.
Physicians were predominantly female (55%); 30% were Black.
The mean (SD) age of the physicians was 42.5(8.6) years.
Association of respect with patient, physician and relationship
characteristics are shown in Table 1. Physicians had low respect
for 92/238 participants (39%). Patients for whomphysicians had
low respect had higher BMI (34.7 vs. 31.8 kg/m2, p=0.009) and
lower age (58.5 vs. 62.9 years, p=0.015) than patients for
whom they had high respect. There was no association
between physician respect and other patient and physician
characteristics.
The crude prevalence ratio (PrR) of low physician respect by
BMI was 0.83 (95% CI: 0.73, 0.95; p=0.006; per 10 kg/m2
increase in BMI; see Table 2). After adjusting for patient age
and gender, BMI remained significantly associated with physician
respect (PrR 0.86, 95% CI: 0.74–0.99, p=0.039). Further
adjustment for additional patient and physician variables, such
as patient race, and physician age, race and gender, did not
substantively change the results.
DISCUSSION
In this study we found that as patients had higher BMI,
physicians reported lower respect for them. A ten-unit higher
BMI was associated with a 14% higher prevalence of low
physician respect. This association was unchanged after
adjustment for patient and physician demographics.
Table 1. Patient and Physician Characteristics by Level of Physician
Respect
Characteristic* Patients
receiving
lowered
physician
respect (n=92)
Patients not
receiving
lowered
physician
respect (n=146)
p-value †
Patient n=238
Age, years,
mean (SD)
61.2 (11.7) ‡ 58.5 (11.4) 62.9 (11.7) 0.015
Female 64 (152) ‡ 63 (58) 64 (93) 0.82
Black 63 (149) 64 (60) 62 (91) 0.76
High school
graduate
68 (162) 70 (64) 67 (98) 0.67
Annual
income
<$35,000
73 (166) 74 (67) 73 (99) 0.77
No healthcare
insurance
10 (24) 10 (9) 10 (15) 0.97
BMI, kg/m2
mean (SD)
32.9 (8.1) 34.7 (8.8) 31.8 (7.5) 0.009
Physician n=40
Age, years,
mean (SD)
42.5 (8.6) 42.4 (8.4) 42.1 (7.8) 0.82
Female, % (n) 55 (22) 53 (49) 56 (82) 0.76
Black, % (n) 30 (12) 29 (27) 27 (40) 0.84
Relationship
Race
concordance
45 (106) 50 (46) 41 (60) 0.27
Sex
concordance
59 (141) 60 (55) 59 (86) 0.90
BMI, body mass index; SD, standard deviation; *reported as % (number)
unless otherwise stated; †Pearson’s chi-squared or adjusted Wald test,
as appropriate, adjusted for clustering by physician; ‡significantly
associated with BMI by linear regression adjusting for physician cluster
Table 2. Crude and Adjusted Models of Prevalence Ratio of Low
Physician Respect
Prevalence ratio of low physician
respect (95% confidence interval)
p-value*
Unadjusted model
BMI† 0.83 (0.73 – 0.95) 0.006
Adjusted model
BMI† 0.86 (0.74 – 0.99) 0.039
Patient—age‡ 1.11 (1.00 – 1.22) 0.044
Patient—male§ 0.95 (0.79 – 1.13) 0.54
*Poisson regression, with robust variance estimates, clustering for
physician; †per ten-unit increase in BMI; ‡per 10-year increase in age;
§compared to female patients
JGIM Huizinga et al.: Physician Respect for Patients with Obesity 1237
These findings are in agreement with prior studies that
show obesity elicits negative attitudes from physicians.5–7 Our
study adds to this literature and shows that individual
patients are the recipients of lower physician respect related
to higher BMI, independent of other patient and provider
characteristics. This is an important distinction and provides
further evidence that the care for individuals may be affected
by negative attitudes about obesity.
Respect is a central concept to the practice of medicine, yet
the term respect may hold a variety of meanings. Respect
generally refers to “positive regard” and has been further
conceptualized as the “recognition of the unconditional value
of patients as persons,”16 and it therefore has been argued that
this recognition should be independent of personal characteristics
and accorded equally to all.16 Yet we acknowledge that
respect is conceptualized by many as a sort of admiration,
which is dependent upon a subjective assessment of a person’s
worthiness of respect. It is possible that it is this sense of
“admiration respect” that physicians were using when they
rated their levels of respect for patients in our study, especially
because the wording of the question gave physicians permission
to rate people at different levels. Nevertheless, without a
deliberate intention on the part of the physician to disentangle
their own assessments of a person’s admirability, one form of
disrespect can easily lead to another, leading to an injustice in
the amount of value accorded to the lives of individuals based
on their weight.
In addition to the primary injustice of the lower respect with
higher BMI, there may be further consequences of this finding
that should also be explored. Physician respect is associated
with a greater amount of information given by the physician at
the patient encounter.17 Focus groups and surveys have found
that patients desire a respectful relationship with their physician
and may avoid the health-care system if such a relationship does
not exist.9,12We postulate that physician respect may play a role
in patients with obesity avoiding the health-care systems and
receiving less preventive care and less education about their
health documented in other studies, but more studies are needed
to determine specifically what additional consequences may
occur as a result of lower respect.12,14,15,20
Future research should explore the impact of physician
negative attitudes associated with obesity on the health-care
processes and outcomes for patients. In addition, deeper
understanding about the development of this bias in health care
professionals is needed. Negative bias towards obesity has
been documented in medical students,21 yet little is currently
offered in medical education to reduce or compensate for these
negative attitudes. One of the first steps in promoting equity is
to recognize the problem and to help physicians develop
insight into their own biases.
There are several limitations to our study. It is cross-sectional,
and, as such, we cannot comment on the causal
nature of this association. We are also unable to link low
physician respect for patients to health outcomes. However,
this study remains an important first step in describing and
understanding the association between physician respect and
patient BMI. A social desirability bias is possible as physicians
may not want to report low respect for patients. We attempted
to limit this bias by asking physicians to compare the patient
to the “average patient.” It is unlikely that this social desirability
bias would be differential by BMI. There are many
reasons why physicians might have developed a lowered
respect for patients, and we are unable to explore all of the
possibilities in this study leading to residual confounders. In
addition, we are underpowered to explore possible mediators
and moderators of this relationship.
CONCLUSION
Physicians have lower respect for patients with higher BMI.
This finding is independent of other patient, physician and
relationship characteristics. Low respect from physicians may
lead to poorer health outcomes, but further research is needed
to fully understand the implications of this study’s findings.
Acknowledgements: This work was supported, in part, by grants
from the National Heart, Lung and Blood Institute (R01HL069403
and K24HL083113). MMH was supported by the Johns Hopkins
Clinical Research Scholars Program (NCR 5K12RR023266). The
authors would like to acknowledge Kathryn Carson for her assistance
with data management.
Conflict of Interest: None disclosed.
Corresponding Author: Mary Margaret Huizinga, MD, MPH;
Division of General Internal Medicine, Department of Medicine, Johns
Hopkins University School of Medicine, 2024 East Monument Street,
Suite 1-500, Baltimore, MD 21205, USA (e-mail: mhuizin1@jhmi.edu).
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