The stories are as common as they are concerning: The young, overweight woman who visited her doctor complaining of shortness of breath and was told to lose weight. A year later it was discovered she’d had lung cancer all along. The older, overweight woman who’d torn her meniscus at work and when the pain didn’t go away, she was labeled as an addict seeking a workmen’s compensation settlement. Turned out, she had necrosis of a bone in her knee that required surgery to correct. The woman with the rare disease who visited doctor after doctor, searching for an appropriate diagnosis, but was constantly told the problem was psychological and that there was nothing physically wrong with her.
In Courtney Tawresey’s case, she broke her leg while she was in law school. As a younger person, she’d been a competitive swimmer and competed in college, but when the Dallas-based attorney entered law school in the early 2000s she became less active and gained weight. “I broke my leg and they put a rod in my lower leg. It was OK for a little while,” she says, but over time, it became “super painful,” which made walking and keeping her weight under control even harder. “When you can’t walk two or three blocks without being in tears, you’re certainly not going to go to the gym and run on the treadmill.”
For the next four or five years, she says she limped and saw a number of doctors, all of whom ascribed the pain to her weight gain. “I was overweight for sure,” she says, but the simple reply that she should just lose weight to alleviate the pain wasn’t the right answer. “I tried losing weight, but it didn’t make it any better.”
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The pain wore on her as doctor after doctor failed to find the root of the problem. Eventually, Tawresey’s mother, an operating room nurse in Seattle, attended a surgery in which a cancer patient was having a rod inserted into the leg. “She made an offhand comment to this doctor about my rod, not thinking that he would really care, and just explained to him all the trouble I was having. He said, ‘That’s not right. Get her up here,'” so Tawresey flew out the next week. “He did a bunch of tests that nobody had done, and the tests showed that there was some inflammation in the lower leg that didn’t tell him exactly what it was,” she says, but indicated the problem would require more than just a drop in body weight to correct.
“I think I was 35 years old at the time, and I just sat in his office and cried. I told him ‘if we can’t figure this out, I want you to amputate my leg. I can’t live with this anymore,'” she recalls. The surgeon scheduled an exploratory surgery and found that the fracture in her leg had never healed properly. He took out the rod and put in a longer one, which triggered the bone to regrow and heal itself. Within a few years, Tawresey was completing her third Iron-distance triathlon (that’s a 2.4-mile swim, followed by a 112-mile bike ride, topped off with a 26.2-mile run). She’s also completed nine half-Iron-distance triathlons.
She races in the Athena class, a category for women who weigh more than 165 pounds and says, “I have weight to lose and it’s certainly a goal that I continue to strive for. But anytime I go to the doctor, I always get ‘the talk.’ Even after telling them I do Ironman triathlons and it’s on my form that I work out six days a week, 20 hours per week, I always get the lecture.” It doesn’t matter that “all of my blood work is perfect. There’s no cholesterol problem. I’m not anywhere close to being diabetic or prediabetic. I’m not morbidly obese by their standard, but I get the comment, ‘If you could just be a little more active.’ Really? I’m pretty sure that’s not the part of the equation I need to work on, people. That’s not the answer,” she says.
These sorts of stories, while anecdotal, hint at an undercurrent in medicine that is troubling — that in the quest to protect patients from the perils of obesity, which has been associated with several chronic diseases and has been recognized by several major organizations including the American Medical Association as a disease itself, some doctors could be shortchanging patients and causing negative outcomes and increased suffering. More often than not, these patients tend to be female as well as overweight, and by not following up on that persistent cough or difficult-to-pinpoint pain, some doctors may end up providing less care, usually completely unintentionally.
Dr. C. Noel Bairey Merz, medical director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center in Los Angeles, says these experiences in which “women are dismissed or more likely to be misdiagnosed” are “very real,” and in the 1980s and 1990s, it lead to a spike in the number of heart disease deaths among women. Physicians weren’t catching on to female patterns of certain heart conditions and some were brushing off patients. Through continued efforts to raise awareness of women’s cardiovascular disease, Bairey Merz says the death rate has returned to parity, but “before the 1980s, fewer women were dying of heart disease than men, so we think we continue to have residual problems that we’re working to improve.”
One of the ongoing issues is that “we live in a gendered society,” she says, in which historically, men have been leaders in medicine and much of the medical research that has formed our understanding of the human body has been carried out by and on men. This means the body of knowledge may not always translate exactly to women.
In addition, in direct patient-doctor interaction, regardless of how well trained a doctor is, some may still carry an implicit bias and unintentionally negatively judge overweight women. “Women are overly stigmatized about their weight. Men are equally overweight, but we don’t hear a lot of physicians telling men” to just lose weight to fix a problem. “It’s very gendered and it’s very unfair,” she says, but it can also have unintended consequences. In terms of cardiovascular disease, these consequences can be particularly dire, “because half of all heart disease presents the first time as death. You don’t get to go back and ask, ‘Maybe if we do this other test, we’ll find out what’s wrong.'”
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In some instances, paternalism in patient-doctor interactions can also be a problem. Although Bairey Merz says this attitude is changing with the advent of shared decision-making in which doctors and patients are considered to be partners in health, “the doctor is still the expert” who makes a diagnosis and suggests a course of treatment. The average layperson probably doesn’t have the expertise or insight to know if that is an incorrect diagnosis.
Still, “I do think that folks, women in particular, often have a pretty good meter. They know what they’re feeling, and if they feel like they’re being patronized or dismissed or if someone is not listening, they know they’re not in a partnership or are being talked down to.” In those instances, she says it’s important to “get a second opinion. Find a doctor who will listen to you.”
She says that female physicians aren’t always a better choice in these instances, “but data do demonstrate that female physicians are better listeners when they track the amount of time the patient talks versus the amount of time the doctor talks. On average, female physicians do more listening than male physicians.” A recent study also noted that women having heart attacks who were treated by male emergency physicians had worse outcomes than women who were tended by female emergency physicians. That study also showed that male emergency physicians who had at least two female colleagues had better outcomes, which Bairey Merz says means “it’s about knowledge and it’s transferrable. It’s not a secret sauce.”
Bairey Merz adds that, by and large, this gender gap and negative attitudes toward heavier people is unintentional. “This isn’t that doctors don’t like women, and it’s not that women don’t value themselves. It’s that we’ve grown up in a gendered society.” She recommends that physicians and patients check their implicit biases by visiting Project Implicit, a nonprofit organization that offers online tests to help people become more aware of biases they may hold.
Still, she says obesity is a problem and one that doctors are rightly trying to address. “We’re not saying it’s OK to be overweight or obese. It’s not healthy to be overweight.” Patients with obesity are harder to treat in certain instances, depending on the problem, but she says there are some health conditions that are weight-responsive or weight-sensitive and some conditions are not. The average American is overweight, meaning that he or she has a body mass index higher than 25. (BMI is a shorthand measurement of metabolic health based on a person’s height and weight. You can calculate your own BMI with this online calculator from the National Heart, Lung and Blood Institute.)
Dr. Louis J. Aronne, an obesity medicine specialist at the Comprehensive Weight Control Center at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, agrees that obesity is a problem, but that it is also a disease and one that needs more treatment than simply telling a patient to “get more active” or “eat better.”
“There has been a kind of therapeutic nihilism,” he says, in which patients are told to slim down without enough guidance and support. “Just telling someone to ‘get more active’ — that’s not going to work. It’s being specific, having specific advice and knowing what to do.”
He says obesity can be classified as a disease in much the same way that high blood pressure or high cholesterol is a disease, because it can cause chronic diseases like diabetes, some kinds of cancer and heart disease. “Hypertension can damage blood vessels, it can cause a stroke. High cholesterol itself doesn’t damage anything, it’s when your arteries develop atherosclerosis. So, from that perspective, obesity is a disease-causing entity. Clearly, it is a problem, and what we’ve discovered in the past five to 10 years is that the reason it’s hard to lose weight (is because) in the process of gaining weight, damage occurs to critical nerves in the weight-regulating pathways” in the brain that confuse the body and hormones about how much weight is being carried and how much to eat. “This creates a vicious cycle where the system gets increasingly biased toward more weight gain.”
This is why some people need surgery and medication to treat obesity. It’s not a matter of willpower or simply exercising more. Often, a very real physical change has occurred in the body that alters how it responds to food. “Something physical happens that makes it very difficult (to lose weight) and for some people it seems virtually impossible to go back. That’s a real disease entity,” he says.
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However, not everyone has gotten this message. “The thing is that many doctors have been known to focus on a patient’s weight, and they’ll correctly tell an obese patient that the problem is related to their weight. But in some cases, they don’t do the diagnostics to look for something else. It’s possible to miss acute or intercurrent illnesses that occur because they’re just focusing on the weight,” he says.
Aronne helped start the American Board of Obesity Medicine about six years ago to help improve the level of knowledge of this area of medicine and how it can impact patient health. “Physicians are beginning to recognize No. 1 that obesity is a big part of what is going on in their patients, and that they can and should treat it. So people who are trained in obesity medicine, they kind of get it. They understand that this is more than just a behavioral or willpower issue. It’s not a disorder of their willpower.”
In the end, no matter your weight, sex or gender, it’s important to advocate for yourself if you believe something is wrong and you’re being brushed off. If you don’t get an answer that makes sense or you think your doctor isn’t hearing you, find another doctor. Keep pushing until you get an answer. Tawresey believes that if she’d been diagnosed appropriately sooner, she’d have more power in her “bad” leg and be able to perform better in her sport. “Even though it’s been four or five years since it got fixed, I’m still dealing with the repercussions of it.” She still has lingering pain and some muscle atrophy that may never improve.
Though she’s thankful for having finally found a doctor who took her complaints seriously — “He took the time to figure out what the answer was instead of having a 20-minute appointment and getting me out the door,” she notes — she’s correct in saying she shouldn’t have had to rely on chance or an offhand comment to the right person for that to happen. “Had somebody taken the time to get to the root of the problem and not just assumed that it was because I was overweight, then it would have been completely different. I wouldn’t have that atrophy on that side.”
Aronne adds that if you are overweight or obese and having health problems, making an appointment with a specialist certified in obesity medicine might offer an additional insight to not only the weight issue, but potentially a better chance of getting the right answer about whatever else is going on beyond it. “People who are board-certified in obesity medicine have taken an exam and taken more education. It doesn’t mean they’re perfect or great doctors — I can’t vouch for everyone who’s board-certified — but at least it’s a place to begin.”
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