When it comes to the obesity epidemic, it’s not just patients, but doctors who need an education.
In a perspective published in the New England Journal of Medicine, researchers argue that part of the blame for the obesity epidemic lies with physicians – more specifically, the way doctors are trained.
Current medical education programs aren’t designed to tackle complex, multidisciplinary conditions like obesity, which represents an alchemic mix of everything from genetic contributors to metabolic conditions such as diabetes and hypertension, to psychological and behavioral issues. In addition, the particular combination of these factors that drive obesity are different for each patient, and the standardized, fix-it-with-a-pill approach on which modern medicine is built simply isn’t helping doctors to recognize and treat weight problems properly.
The result is already well known. About one third of U.S. children, and two-thirds of adults are overweight or obese, and by 2030, about half of the U.S. population could be in those categories. The authors of the Perspective, Dr. James Colbert at the Brigham and Women’s Hospital, and Dr. Sushrut Jangi at Beth Israel Deaconess Medical Center, argue that chronic illnesses like obesity are becoming increasingly prominent in doctors’ offices throughout the country, but that “physicians-in-training frequently fail to recognize obesity” and its consequences.
Weight is traditionally not a subject covered extensively in medical school – perhaps it gets some attention in a few nutrition lectures or several sessions on metabolic syndrome. That means that it also isn’t a primary topic of conversation in primary care checkups. So the health dangers of being heavy aren’t a priority for busy physicians, who tend to focus instead on specific ailments, such as joint pain, high blood pressure, sleep issues and other acute symptoms for which patients need immediate relief.
The irony, of course, is that many of the conditions that occupy doctors’ visits are a consequence of obesity. “If patients were to lose weight so they were no longer obese, then some of these problems go away,” says Colbert, an instructor of medicine at Harvard Medical School. “Many of these conditions are absolutely connected to obesity.”
But most physicians are overwhelmed by the prospect of diving deeper into each obese patient’s medical history to determine what’s behind their weight gain – is it genetics due to a family history, stress from a traumatic experience or a high-pressure job, or an environment that promotes an unhealthy and sedentary lifestyle? Often, it’s a combination of all of the above.
“Just seeing a patient walk into the clinic to see me, I can put them on a scale and measure their height and weight and calculate their body mass index and tell whether they are obese,” says Colbert. “But for me to figure out why that person is obese could take hours. And most physicians don’t have that time.
Even if they did, they likely wouldn’t devote the precious 15 to 20 minutes they have for the visit to discussing weight. A 2005 study of doctors-in-training found that only a small percentage even noted obesity in heavy patients’ medical histories, indicating that weight was not a priority in assessing their health.
How can that change? The fact that the American Medical Association recently declared obesity a disease should help draw more attention to weight issues at each doctor’s visit. But more fundamental changes need to occur early on in the medical education process, say Colbert and Jangi. Every doctor – not just the internal medicine physicians who are more likely to provide primary care to patients – should have a strong foundation in recognizing and addressing obesity so they can feel comfortable treating it like any other condition.
The Association of American Medical Colleges has started to lay down such a bedrock. A 2011 report identified, among other things, the need for all doctors to have more experience – and therefore be more comfortable – in tackling the behavioral and social contributors to obesity as well as the biological ones. “It used to be that the typical medical student received about two hours of education in nutrition,” says Dr. David Ludwig, director of the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital. And they got even less training in how to discuss behavior-based changes with their patients. “It’s not enough to tell people what to do,” he says, since studies show these strategies don’t change habits for long.
Now more medical education programs are incorporating what’s called motivational interviewing techniques into their curricula; it helps doctors ask more effective questions to elicit meaningful answers from patients about what factors, whether they are social, family-related or emotional, are contributing to their lifestyle choices. “These skills can be learned, but they need to be emphasized in medical school,” says Ludwig.
Giving medical students early exposure to patients in a more realistic setting can also help. At the University of California San Francisco School of Medicine, first year students are encouraged to teach elementary and high school students about nutrition and physical activity, and educate them about the health consequences of obesity. Professors also bring in patients who are struggling with obesity so the doctors-to-be can begin to hone their interviewing and relationship skills in discussing the delicate issue of weight with their patients, and sussing out what might be driving the weight gain. “We are bringing more social and behavioral science into our curriculum, which had been a gap in our curriculum,” says Susan Masters, associate dean for curriculum at UCSF. “We are working to have students understand the behavioral aspects of disease,” which, she says hasn’t always been a priority in medical education.
At the University of Colorado School of Medicine, the Cultural Competence and Diversity Thread is a curriculum that is embedded in the four-year degree to provide students with a deeper understanding of the social contributors to health, including socioeconomic and ethnic influences, which can be as powerful as genetic and biologic factors in diseases like obesity.
The ultimate goal of such integrated strategies is to better prepare the next generation of doctors to address obesity at the earliest possible stage, and possibly even prevent some of the complications that are so common today – including diabetes, hypertension and heart disease — from occurring in the first place. That means physicians will be taking a more proactive role in talking to patients both about what they eat as well as how to change their diet and exercise habits to maintain their optimal weight. At the Warren Alpert Medical School of Brown University, for example, the 22-hour nutrition course offered to second year students is now threaded throughout the four-year program, so students continue to see and understand how basic principles of nutrition affect the body and can, in the case of over-eating, contribute to disease.
These improvements are encouraging, but Ludwig says they are only one part of the obesity-promoting infrastructure that needs to change. Treating chronic diseases like obesity requires more than a single physician; increasingly, doctors recognize that it takes a team to address all of the complex issues that drive weight gain. Obesity clinics currently do a good job of providing doctors, dieticians, exercise experts and psychologists to help obese patients to achieve a healthy weight, but these centers can only help a small percentage of the 66% of Americans who struggle with weight issues. “We can’t just triple the number of physicians so the ratio of physicians to patients is magically more in favor of doctors who can spend more time with patients,” says Colbert. “But what we can do is help patients to access many different types of healthcare providers who can help them manage their chronic condition and coordinate their care.”
Even a team-based approach and more in-depth doctor-patient conversations about obesity won’t become the norm, however, unless another part of the health care system changes – the reimbursement of medical services. Prevention-based strategies as well as lifestyle and behavioral services have traditionally not been covered by insurers as readily as a discrete operation or a prescription, since documenting the benefits of prevention is more challenging – it’s hard to quantify savings for an illness or complication that doesn’t occur. “Education is critical but that alone is not going to solve the problem,” says Ludwig. But it’s an important step in recognizing that it will take more than just telling patients to eat better and exercise more to reverse the obesity epidemic.