Kimberly Gudzune, MD, MPH, Assistant Professor of Medicine, The Johns Hopkins University School of Medicine
Unfortunately, I’m not surprised that Miller and colleagues found that medical students possess both explicit and implicit anti-obesity biases. The medical students reflect the current negative attitudes towards obesity that are pervasive among the general public. The question that this study raises is – what do we do about it?
In the discussion, the authors propose a multi-component curriculum that includes students acknowledging their implicit anti-fat bias, learning how it may influence their actions, then implementing personal strategies to mitigate the effects of this bias during patient encounters. The first two components could be easily accomplished. Medical schools across the country could administer the Weight Implicit Association Test (IAT) to all students and provide education on how weight bias may negatively impact patient care. However, these two steps alone are unlikely to result in significant behavior changes.
The challenge will be providing medical students with the ability to minimize the effects of their anti-obesity bias on patient relationships and care. But, what skills should be taught? Communications training including rapport building and empathy show some promise but may not be sufficient. A single session on this topic is unlikely to provide any long lasting change. Educators may need to consider leveraging the four years of medical school as an opportunity for recurrent sessions on obesity that progress over time, as students’ experiences and skills’ needs change. Such a curriculum could address not only anti-obesity bias but also provide students with nutrition and weight counseling skills, such as the 5A’s or motivational interviewing. Practicing physicians have identified weight management as a knowledge deficiency area, so why not better prepare the next generation of physicians to handle the obesity epidemic. Ultimately, more research is needed to identify what skills should be included in such a curriculum and how best to implement it.
While education and training may be an important first step, we also need to take into account how medical students may be affected by the behaviors of resident and attending physician role models. Since prior studies demonstrate that practicing physicians harbor negative attitudes towards patients with obesity, we may presume that medical students observe these attitudes among their role models. In fact, as a medical student I witnessed residents and attendings making negative remarks towards patients with obesity, even referring to one patient as “Shamu.” I felt uncomfortable in this situation but did not feel I could comment about how these negative attitudes may negatively impact the patient and his care. While my experience highlighted for me how I did not want to practice medicine, a similar experience for other students may suggest that such practices are normative or acceptable. For any educational program to successfully change student behavior, I believe that we must also alter the way in which their physician role models behave to reinforce the students’ classroom learning. Perhaps such an effort could help create new attitudinal norms towards patients with obesity.