Wednesday, April 07, 2010

Health Care for the Obese

A new study published today reports that overweight and obese patients get the same or better quality of health care than "normal" weight patients.

Researchers at the University of Pennsylvania say they looked at quality of care across eight performance measures among Medicare and VA patients, and found no difference in the kinds of treatments doctors prescribed for obese and non-obese patients.

According to a s tory on MedPage Today, "Performance measures included diabetes care management (such as lipid and HbA1c monitoring and eye tests), pneumococcal vaccination, influenza vaccination, screening mammography, colorectal cancer screening, and cervical cancer screening." The story goes on to quote one of the researchers commenting that while doctors do "harbor negative attitudes" toward heavier patients, that prejudice doesn't affect the quality of care delivered.

I think this is a pretty grandiose conclusion to draw from such a limited study, and the researchers themselves cautioned against extrapolating these results too broadly. To me, the study raises some interesting questions: Are doctors more tolerant of overweight vets and/or poorer patients? Is "quality of care" strictly a function of which treatments are recommended?

I don't think so. I wonder what the patients would have to say about the quality of care they received--not just the treatment recommendations (which are of course important) but the relationship they had with their docs, and how it affects their long-term care. I wonder whether these two populations typically have long-term relationships with the same doctor, or whether they often see a revolving cast of medical providers, and whether that might make doctors react differently to them than to patients they see regularly.



Anonymous said...

I wonder if this just means that too many people get lousy care.

Harriet said...

Amen sister. Or brother.

Jane said...

What about people who just don't go to the doctor because of past negative experiences?

IrishUp said...

Uh, what a clusterf*ck of circular reasoning.

1. Medicine falsely conflates obesity with poor health.
2. Medicine recommends treating obese pts AS IF they need testing for diabetes and high choleterol, despite some probability that this is not the case.
3. Oh, the FattieFatz complain they get "poor treatment".
4. Let's test that hypothesis.
5. By using whether or not obese patients are tested for diabetes and cholesterol.
6. Oh, Hey, LOOKIT!! "For instance, obese patients with diabetes were more likely to have recommended care on lipid screening (72% versus 65%, OR 1.37, 95% CI 1.09 to 1.73) and hemoglobin A1c testing (74% versus 62%, OR 1.73, 95% CI 1.41 to 2.11) than normal-weight diabetic patients."
7. In other words, medicine is MORE LIKELY to treat for pathology in patients percieved to be suffering from pathology; stated as "Physicians may be acting more aggressively in risk factor modification in obese patients because they perceive these patients to be at higher risk," Chang said."
7. HAH, SEE, we totes told you, you Fattie McFattyFatz, you're getting Teh Good Medicine!


Oh and, way to contradict yourself!

"The study was limited by its inclusion of only eight quality assessment parameters, some self-reported data, and a lack of generalizability to care in younger populations."

"Even though physicians might harbor negative attitudes towards obese patients, it doesn't seem to be borne out in the quality of care they're delivering," Chang said, "so I think both physicians and patients can feel some degree of relief on that front."

Let me translate that: "Our study didn't really find anything, doesn't apply to everyone, and has design issues, but let me tell you, you marginalized people, MEDICINE IS TOTES NOT MARGINALIZING YOU!".

Glad she cleared that up!

I would ALSO like to think that a study looking to quantify the degree to which obesity is a barrier to good health care would:
- look at mis-diagnoses rates & missed diagnoses.
- include how patients rated their interactions with their physicians.
- evaluate responder bias; people being poorly cared for tend NOT to go to their doctors as often!
- NOT conflate more frequent ordering of tests with appropriate ordering of tests.
- NOT describe a study that was NOT designed to find barriers to care as a study that did not find barriers to care.

Just saying.

(Harriet, is this rant long enough? I could look up the original JAMA and get more snarky, if you like ;>)

Harriet said...

Freaking brilliant, Irish. Brilliant.

Harriet said...

And Jane, that's exactly right. For anyone who doubts that this happens, wander on over to the blog First Do No Harm ( and read all about folks who have been marginalized, humiliated, and scorned by medical professionals for being fat. The outcomes are heartbreaking.

Flannery said...

Well, I was going to leave a comment somewhere along the lines of WHAT a steaming pile of RANCID BULLSHIT but then IrishUp totally rocked the socks off that one.

So what Irish said.

Knadele said...

All I can say is that I am quite fat. And I have an amazing doctor who treats me, not my fat.

When issues arise they are not automatically attributed to my size.

I feel like I have gotten wonderful care throughout the 18 years I've been her patient... and that extends to the other doctors she's referred me to over the years as needed.

I guess I'm lucky. But perhaps not.

Angela said...

That study definitely doesn't jive with my experience with several doctors and others that I know who have had the exact same negative experiences. All I can say though is that bigotry/prejudice really wouldn't leave a paper trail if their not asking patients themselves about their experiences. The fact that someone is screened for cholesterol or diabetes means nothing if what they went in for was a bacterial infection or a car accident(it's happened!). And plenty of other research has shown that attitudes do affect behaviors.

Meowser said...

I wonder if this just means that too many people get lousy care.

Oh my yes, I think it does.

My mom, who's never been fat for two seconds of her life (outside pregnancy), has told me about some of the utter dolts she has had for health practitioners. She used to be a heavy smoker and quit about a dozen years ago, but has a diagnosis of "emphysema," but it's really early-stage COPD, as she can actually run on a treadmill every day for exercise without getting winded and has an O2 saturation of 99%, which is good for someone her age who has never smoked.

So the last Dr. Dipshit she saw took a look at her chart and saw the word "emphysema" and figured she was about two seconds from dropping dead, even though a person who actually has late-stage COPD/emphysema couldn't possibly hide it (we're talking about needing an oxygen tank and not being able to complete a sentence without getting out of breath). Didn't even bother talking to her to find out what her individual situation was. Just because people can memorize and regurgitate tons of information and stay up for 72 hours at a time doesn't necessarily mean they actually know anything.

alice said...

Jennalynn, any chance you're on the west coast of FL? ;) I'm very glad you've got a good doctor, and I've experienced a few myself, but they've been the exception much more than they've been the rule.

Mostly, Amen to Jane and IrishUp. I am glad that some of the more flagrant mistreatments weren't shown in these populations, and I want to make sure that the limited positive indications aren't ignored, especially the possibility that this study may alter the perception of fat patients as noncompliant.

However, I worry that this study's going to be used to say "see? You're just fat *and* paranoid. There are No Problems Anywhere, so quit yer whinin.'" Also, I'm VERY sad to see that 'quality' of care is conflated with 'quantity' of care. That's a huge red flag for me, though I'm not naïve enough to expect MedPage Today to catch that.

Ivalo said...

I am in nursing school - about to graduate in June. It saddens me to see that people hate the system so much!! I would like to say that I go to school with a group of exceptional nurses who care for the whole person and really like what they do so far (give us a couple year and we will probably be jaded too!) My experience in the hospital has been that weight isn't even mentioned. Only diagnosis, and if there is judgement by my cohorts, it is not shown. I think that a new class or nurses and doctors are being trained to be more accepting of all type of people given the world that we live in.

I am however, experiencing my first clinical teacher who doesn't like fat people I can tell, and it is difficult, but will only last 5 weeks.

Danielle said...

I am feeling overwhelmed by the amount of garbage surrounding this proclamation. It took me FIFTEEN YEARS to get a diagnosis of narcolepsy because the laundry list of doctors I saw were so distracted by my weight that they couldn't think outside of the "obesity related diseases"... So much money, so much depression from the undiagnosed symptoms, so many false diagnoses, harsh and extensive lectures, unneeded medicines and treatments, and that is just the beginning.

Seriously. This is such a tender subject for me...

All I can say is GARBAGE.

ricki said...

I don't know about the study, but I do know I "fired" the internist I was seeing (and haven't gotten another, I really should, but I'm almost scared to, as so many doctors in my part of the country sideline in "bariatrics") after she recommended a weight loss drug to me when I went in for a flu shot.

For the record, at that point in time I was 5' 7" and weighed 180. But even if I had weighed 450, she shouldn't have done that to me. I had never expressed a desire to her about losing was just, she weighed me, and out came the lecture.