Why are doctors so mean to fat people?
A question that blew me away.
Welcome to Chief Complaint! I’m so happy you’re here. For those of you who are new, this newsletter features intermittent musings about medicine, gender, parenting, and body liberation — all from your friendly neighborhood primary care doc. Thanks for joining me.
Why are doctors so bad at being nice to fat people?
This was a question posed to me by a therapist named Cassie Krajewski who invited me on to her (fabulous!) podcast to talk about size-inclusive medicine.
I was floored by the question, then floored that I was floored. In all of the work I’ve been doing over the last year, going on my roadshow about fatphobia in health care, I had never been asked this question before. It was so obvious, and so smart.
Why do doctors suck so much at this basic — and I would argue, not too difficult — thing?
As Cassie pointed out, doctors do really hard things. We take difficult exams. We make decisions under pressure. Some doctors do literal brain surgery. (Not I, but that’s probably for the best.)
Yet many neurosurgeons, known for having the hardest possible job in the world, are not known for these fundamental skills: Make fat people feel welcome. Make them feel comfortable. Don’t make them dread coming to see you. Don’t make them feel overwhelmed with self-loathing at the mere idea of being in your presence.
They’re skills I’m teaching my three-year-old: Be gentle. Treat others as you’d like to be treated. Are those things really harder than brain surgery? Unfortunately, it seems like they might be.
Study after study shows that doctors and nurses are some of the worst offenders when it comes to making people in bigger bodies feel stigmatized and unwelcome.
What is going on? I’ve been mulling over Cassie’s question over the last few days, and posed it to a few fat-friendly physician friends. Collectively, we’ve come up with a few ideas about why this is so difficult for doctors.
Here are a few theories:
Doctors are humans, products of the culture in which we live. Although we like to think of ourselves as scientists — and some of us are! — doctors are human beings, living in a culture of our own creation. We imagine that we’re rational and objective, guided by data every step of the way. But if that were the case, we’d all have long-abandoned fatphobia, because the data are pretty clear: it doesn’t help people get healthier. (And helping people be healthy is our job.) This explanation is both as simple and as complex as it gets. Our culture is fatphobic, and doctors are humans living in it. Fatphobia so deeply ingrained that it’s hard to even see it, unless you look closely. As an anthropologist friend likes to say, “Culture is everything!”
They think perpetuating stigma helps make their patients healthier. Thankfully, I think this is a very small minority of health care providers, but they can be loud. This is the medicalized version of trolls who post “stop glorifying ob*sity” on the social media accounts of fat people… living. A vocal minority of doctors think it’s good to stigmatize bigger bodies. For example, some (prominent!) bioethicists writing in (prominent!) medical journals have gone so far as to argue that “parents [of children with weight above a certain percentile on the growth charts] should be dealt with directly and with feeling but also delicately and with some finesse, much like a diplomat dealing with a recalcitrant political regime up to no good but also sometimes prickly to talk with.” (His tone… Vomit emoji. He’s clearly never, ever counseled a family at a well-child visit.)
Doctors think they’re helping people lose weight, and they think that’s a good thing. Luckily, I think perspectives like Daniel Callahan’s, above, are quite rare. The majority of fatphobic doctors, I think, are doing something harder to pin down. They don’t think of themselves as discriminatory — who does? — but they think instead they’re tackling the “disease” of ob*sity head on. They think they’re helping people lose weight. And they think helping people lose weight is always, unequivocally good. I was recently interviewed by the Washington Post, and my segment on their daily podcast was preceded by a story from a Post reporter who went to see the doctor with a broken wrist, and was told, “Hey, have you thought about trying Ozempic?” Every fat person has one of these stories. Although that anecdote is particularly egregious, I have to imagine the doctor thought he was offering up a helpful factoid. I have to imagine he thought he was being compassionate.
Weight is easy to observe, so commenting on it gives doctors the illusion of insight. I was chatting with a friend the other day about his experiences with weight stigma as an “underweight” teen, while he was in the process of being diagnosed with Crohn’s disease. While his doctors were struggling to figure out how to help him, they’d return again and again to his weight: “You need to eat more,” they’d say. It struck me as a clear example of doctors who clearly had no idea what was going on, but they were trained to “fix” a “problem.” They couldn’t identify the problem or the solution, so they turned his weight into a problem, and turned “eating more” into the solution. Doctors have a hard time with uncertainty and ambiguity. It’s antithetical to the way we’re trained, where there’s always a right answer to the multiple-choice question.
Fatphobia helps doctors ignore our own mortality. In so much of my experience in health care, the culture of medicine works hard to create a false dichotomy between physician and patient. We talk about illness and wellness as if they’re opposite phenomena without overlap, and we talk about physician and patient as if they’re separate categories — as if we aren’t all patients, too. We talk about “healthy” behaviors and “noncompliant” patients all as part of an elaborate mythology to convince ourselves that preventing disease is under our control, not an existential interplay between genetics and fate. Fatphobia fits nicely into this unspoken worldview: by blaming our bigger-bodied patients for their health problems, we retain a vision of control. We are shielded from confronting our own mortality, from the randomness of it all.
These aren’t excuses, far from it — fatphobia in medicine causes harm, full stop. I’m working hard to undo it.
But before we can start thinking about solutions, we have to better understand the problem. This post is a first stab at trying to understand what continues to perpetuate this widespread and deeply damaging fatphobia in medicine.
I’d be curious to readers’ ideas, too. Why can’t health care providers just get it together when it comes to caring for patients in bigger bodies? Please share your thoughts in the comments.
I was recently interviewed in
’s newsletter, Weight and Healthcare! This was a huge honor, since her work has profoundly influenced the way I practice medicine. I’d be honored if you’d give it a read.A note on terminology. You’ll often hear me use the word “fat.” It can be a jarring term, if you aren’t used to hearing it, since for so long it has been used as an insult. Believe me – I’ve spent many years of my life avoiding it at all costs. I’m well-versed in euphemisms.
Taking my cues from the brave fat activists who came before me, however, I am officially reclaiming the word. I try to use it, as you’ll hear in the fat positive community, as a “neutral descriptor” – a term like “tall,” or “brunette.”
You’ll hear me use the word “fat” to describe bodies in general, and specific bodies of people who have embraced the term. I do not, however, use it with my patients who haven’t first acknowledged that it’s a word they’re comfortable with. To many, it is still an insulting pejorative, and therefore I only use it to describe people who have consented to it.
If you live in a bigger body, I invite you to try out the word “fat” to describe yourself. You might find it freeing. There’s a whole world of body liberation that awaits you.
A major component that is missing from this conversation is racism. I have never had a black doctor and my experience and treatment by doctors as a black woman has been horrific. I have completely normal test results by all measurements except one - I am fat. But at every physical, or when I break a bone or have a rash or just want to check on something, every doctor has to go on and on about my weight. Moreover, you would be shocked at the things doctors say to black women.
When I was pregnant, I had to switch ob/gyn because my first one was downright abusive to me. I gained a total of 15 pounds my entire pregnantcy and this doctor would not stop talking about my weight. She almost ruined what was a completely average, normal uncomplicated pregnancy with her comments. Not to mention her assumptions about my birth control and my lifestyle, that were extremely racist. I'm a lawyer, happily married and it was my first child, but she assumed I was, well you know what she thought.
My point is that the BMI is racist. Fatphobia is racist. We have seen different, negative outcomes for black women with similar conditions as white women due to medical racism. We need doctors to learn more about how their racial bias is affecting their practice of medicine with BOTH black women and fat people.
Thank you for exploring this issue, I'm not at all intending this to be a cudgel or gotcha, I just think race is an important part of this conversation.
Doctors think they are being "scientific" when it really is fat phobia. For several years I lived with a horrible flare of ulcerative colitis. 3 years of undiagnosed and untreated disease, massive blood loss, loss of bowel control, constant diarrhea. But I was fat, so despite my textbook symptoms they were all ignored, no need for diagnostic tests, they decided I couldn't have UC or CD because I was fat. I was 175 at the time. After months of hospitalization, IV prednisone, and a total colectomy my joint pain was blamed on my obesity. That SAME obesity that saved my life during my final UC flare. I'd lost 30 pounds in a month. Ignoring the prednisone use it took months to get a diagnosis of Avascular Necrosis in many joints - all from the IV steroids, the excruciating pain had NOTHING to do with my body size. I was 160 and looked hollowed out. My CKD was blamed on type two diabetes, which was blamed on obesity. Even though I had NO protein in my urine. It took 3 years of testing for me to convince the many doctors that my CKD was from long-term dehydration from 30 years of living with a high output ileostomy. At 224 I was deemed too fat to live and denied a spot on the kidney transplant list until I lost weight. I'm down to 170, and finally got on the list, but I'm still obese and 2 of the 3 transplant programs in my state still won't accept me. The irony is that an underweight person would have no trouble getting listed. Even though they are MUCH less likely to survive dialysis and transplant. Study after study shows people who are overweight and at the low end of obese survive longer with CKD and have better outcomes from both dialysis and transplant. There is NO science showing obese folks would waste a kidney. It's based on bigotry, not science. Especially at my weight. I'm treated the same way someone who is 2000 pounds. Once I got CKD I found an endocrinologist. He was the FIRST Dr. to blame my genetics, my insulin resistance, my metabolism for my T2D. Obesity didn't give me T2D. T2D, especially after starting insulin, made me obese. He openly told me that as a post menopaused, insulin dependent person I would have to get off the insulin and eat less than 800 calories a day to lose weight. He also openly admitted that exercise will not lead to weight loss. I still go to the YMCA 5 nights a week for several hours, but that is more about showing compliance, than actually impacting my weight. The transplant folks demand compliance to stay on the list. Study after study shows obesity doesn't cause T2D. T2D causes obesity. Yet very rarely do Dr. follow the science. They follow the culture. I HATE urgent care. They blame absolutely everything on my weight. Small bowel blockage - must be because you are fat and you must have overeaten. Not because of the 6 abdominal surgeries and multiple adhesions and strictures. I got 2 cavities, must be caused by eating candy all day. HA! 61 years of being fat = 61 years of crappy medical treatment.