On July 19, 2015, I was part of a two-member panel at the Association for Size Diversity and Health (ASDAH) Conference in Boston discussing motivational interviewing. My specific task was to examine the size-based biases that patients often hold toward their practitioners and how best to respond to them using motivational interviewing techniques.
The audience was largely comprised of other clinicians, and as such I shaped my remarks in the context that I was talking with colleagues. Because this information can be helpful for others as well, I have reworked my main points in the framework of talking directly to you, our patients.
In the year between finishing my nutrition degree and earning my license to practice dietetics, I interned at a Boston hospital where I did everything from work in the transplant unit to chop squash in the cafeteria kitchen. It was an interesting year, indeed.
One of my rotations was in the bariatric surgery clinic where two dietitians worked. Because I shadowed both of them closely, I know they were both excellent at their jobs, had virtually the same approach, and taught the same material, yet patients perceived them differently because of their size. Relative to each other, one of the dietitians was bigger and the other was smaller. Some patients looked at the larger one and made comments along the lines of: “Look how big she is! How can she possibly help me?” Meanwhile, other patients referenced the smaller dietitian and questioned, “Look how small she is! How can she possibly know what it is like to be me?”
As a budding dietitian just about to step out into the field, these comments made me look myself up and down and consider, well, what exactly am I supposed to look like then? That question always stuck with me and planted the seed that eventually grew into this piece you are reading now and its accompanying talk, which I nicknamed “Looking the Part”: Patients’ Size-Based Biases Toward Their Practitioners and How to Handle Them.
Practitioners are patients themselves in other contexts, too, so understand that this is not about judgment or one party versus another. For healthcare to be most effective and for us to give ourselves the best odds of attaining whatever the desired outcome might be, patients and practitioners must work together, not oppose one another. We all have incentive to break down the walls of bias.
First, let us give ourselves some context by realizing that patients judge practitioners for other factors that are seemingly independent of size. For example, one study looked at how physician dress affects patient trust and confidence. The researchers found that white coats elicited greater trust and confidence by far compared to scrubs, formal business attire, or casual business attire. In fact, patients indicated they were much more willing to discuss sensitive issues like their psychological, sexual, and social problems based on the presence of said coat.
In another study, white-coat-wearing doctors were also found to be the preference of parents bringing their children to the emergency room. That is, unless their children were there for surgical emergencies, in which case they preferred doctors wearing scrubs, suggesting that perhaps clothing is interpreted as a sign of experience or perhaps expertise.
Other studies have found similar biases related to factors like hairstyle and even whether or not a practitioner wears a name tag, but of course all of these factors are readily modifiable. In other words, while practitioners can restyle their hair, wear different clothing, or put on a name tag if they so choose, other sources of bias are not so easily changed.
For example, a study found that parents selecting orthodontists for their children had significant biases toward young females. Youth was seen as more up-to-date with modern techniques, while females were seen as better at communicating and expressing empathy. While this might be great news for up-and-coming women working in orthodontics, it is not such good news for their colleagues who happen to be older and/or male.
Just like there is not a whole lot we can easily do about our age or gender, our size (contrary to popular belief) is largely out of our hands as well. Let me share with you three of the studies that looked at patients’ size-based biases.
The first study was conducted at Yale where a team of researchers sought to examine what impact, if any, physician weight has on clinician selection, trust, and willingness to follow medical advice. The subjects were split into three groups with each group receiving the same exact survey except for one difference: the physical description of the doctor, who was listed as either normal weight, overweight, or obese in the different versions.
Their results showed that patients had less trust in overweight and obese doctors, were less likely to follow their medical advice, and were more likely to change to a different provider compared to normal weight doctors. In other words, subjects were so shaken by the doctor’s weight that not only were they less likely to follow said doctor’s advice, but they were more likely to switch to another provider. These weight biases remained present regardless of the subjects’ own body weight.
Anecdotally, we see examples of this. A colleague of ours recently told me a story about an experience she had. “I had a patient who was coming to see me to figure out if she wanted to be abstinent from substances. At the second session, she was crying and couldn’t look at me. [The patient said] ‘I have to talk to you about something . . . Look at the size of you. How could you possibly help me?'”
The second study, done at Johns Hopkins, found a different result. The researchers there looked at the impact that physician body mass index (BMI) has on the trust held by overweight and obese patients. Instead of verbally describing the doctors as normal weight, overweight, or obese, as the Yale study did, these researchers used pictograms to convey the same information.
They found that while the surveyed patients generally trusted their doctors, they more strongly trusted dietary advice dispensed by overweight physicians compared to their normal-weight colleagues. The results for other forms of advice, such as exercise advice, were similar, although not statistically significant.
This finding is probably the opposite of what many of you expected. In their discussion section, the researchers suggested that perhaps a patient and his or her doctor being roughly the same size creates some sort of bond of trust, and that is behind their findings. Of course, that is just a hypothesis that would require further study.
Meanwhile, we do see examples of patients who show preferences for larger providers. A fellow dietitian told me about an experience she had where a patient refused to let her intern sit in on their session. “When I sat down to do her session, she told me she was sorry that she asked the intern to leave, but she didn’t want another skinny dietitian telling her she can’t eat more than 1,200 calories and must record everything . . . She was relieved when she saw me.”
The third study was done at the University of Gloucester in the United Kingdom where the researchers sought to determine the influence that sports dietitians’ appearance has on selection and perceived performance. They surveyed 100 competitive athletes from 17 different sports in the United Kingdom and showed them computer-generated images of the same woman that were manipulated to feature her at four different sizes designed to represent BMIs ranging from 23 to 38. The athletes were then asked to rank which of these dietitians they would most like to work with and how effective they believed the dietitians to be at their jobs.
The two images of the dietitian as smaller fared best in both questions. In other words, based on nothing more than size, the athletes were significantly more interested in working with smaller dietitians and assumed those women to be better dietitians.
When I was talking with a fellow dietitian about the topic, he had this to say about how his size impacts his work: ” . . . more than anything I’ve really noticed the looks more than the comments. I can see someone look at my stomach as I talk to them and then back at my eyes. For some people, I can see how their body language changes in a negative way when they see what I look like.”
So, back to the question I asked myself as an intern: What am I supposed to look like? The answer, to be quite candid, seems to be: Who knows! Some research suggests that patients prefer smaller practitioners, other research indicates they want larger practitioners, and of course some patients do not care, and they understand that the practitioner’s size has nothing to do with his or her ability to provide quality care.
However, whether the majority of patients prefer me at a particular size, or whether only the minority want me at that size, honestly does not matter too much. The nature of my work is one-on-one counseling, so the only person whose feelings really matter is the individual sitting at the table with me. When I am in an appointment with someone, who knows what feelings or biases he or she might have about my size. Although I need to be cognizant of the likely existence of size-based bias, if I make assumptions about the nature of said bias, then I am being biased myself, and that helps nobody.
If I want to provide the best quality care that I can, then my job is not to try in vain to hit some ever-changing target with my appearance, but rather to create a safe space where we can neutrally and non-judgmentally explore the size-based biases that patients bring into my office. This is where motivational interviewing can be so helpful.
My fellow panelist, Ellen Glovsky, gave a comprehensive overview of what motivational interviewing is and how it works, while I focused on how it applies specifically in the instances of patients’ size-based biases toward their practitioners.
First, let me draw a distinction between two motivational interviewing terms: resistance and discord. Resistance is known as sustain talk, arguments for the status quo, or reasons not to change. For example, a patient talking with his or her doctor about smoking cessation might say, “Smoking is so relaxing; I’d really hate to give that up.”
Discord, on the other hand, is not an issue of changing versus staying the same, but rather an issue in the patient-practitioner relationship. Think of some of the anecdotes I mentioned. If a patient walks into his or her practitioner’s office and says something along the lines of “How can you possibly help me? Look at you!” we know that discord is present.
When I encounter discord, the first point I try to remind myself of is to remain neutral. Although it is human nature to get defensive if we feel we are being attacked, practitioners must remind themselves that in professional relationships, the focus is on helping the patient, not getting into an argument.
Instead, I use techniques common in motivational interviewing, such as open-ended questions, affirmations, reflections, and summaries, to further the conversation in an effort to learn more about where the patient is coming from. Through the course of discussion, educational opportunities often present themselves. For example, the conversation might lead to the topic of social norms that are off base, such as the notion that one need be a certain size or weight to be healthy.
During these conversations, it can be tempting for practitioners to self-disclose further information about ourselves. After all, if my body is already the topic of conversation, why not throw in more information about it? The answer is because doing so typically does more harm than good. Instead of self-disclosure resolving discord, oftentimes it widens the gap between the patient and the practitioner, which is why I say so little about myself during my sessions and save self-disclosure for my blog.
The research confirms what many of us anecdotally already knew: Patients do often judge practitioners for their size. However, the specifics of the bias are inconsistent and instead vary from person to person, so it is important that practitioners like myself continue to treat you like the individual that you are and not make assumptions about what you think about our size.
Similarly, I encourage patients to acknowledge and keep in mind two points: (1) You cannot tell anything about how your practitioner leads his or her life based on his or her size with any degree of accuracy. (2) Your practitioner’s size is independent of his or her ability to help you.
If you do have feelings about your practitioner’s size, I encourage you to say so, as keeping it inside might hinder your work. In contrast, bringing it out into the open is an opportunity to learn. The two of you can then have a neutral, open-minded, and non-judgmental discussion about your feelings and point of view and then move forward together.