Early in my career, I was a junior doctor at a clinic where one of the senior doctors would go on smoke breaks with his patients. He had the look of a lifelong smoker - lots of wrinkles, hoarse voice and yellowed fingers. I would leave the building where we both worked and there he'd be, a little distance from the door, mid-smoke. At the time, I was still working out my own take on the responsibilities doctors have to act like role models for their patients. The sight of a senior physician engaging in health-harmful behaviour, and with a patient, no less, provoked all sorts of questions for me.
Should doctors smoke with their patients? More to the point, what responsibilities does a doctor have to act as a role model? To what extent does a physician's personal behaviour affect the care that physician provides? Such questions sprang to mind again when I saw the study published earlier this year in Obesity by researchers at the Johns Hopkins Bloomberg School of Public Health. The study authors claimed it was the first to examine whether a physician's weight affected the doc's care of obese patients.
As the study noted, remarkable parallels exist between academic studies conducted years ago on smoking physicians, and more contemporary work on obese physicians. Older studies on smoking physicians suggest that a doctor's personal behaviour does affect the medical care that doctor provides. For example, studies suggest that MDs who smoked were less likely to raise smoking as a health issue with their patients. They were also less likely to encourage patients to quit smoking, and less likely to make stopping smoking a high priority for patients.
Such findings bring to mind a British Medical Journal editorial from 1995, which wondered whether medical students who smoked should be channelled away from working as general practitioners. "An apocryphal tale in public health, said to have originated from a candid tobacco industry executive, is that each doctor who smokes is worth hundreds of thousands of dollars to the [tobacco] industry," went an opening line in the editorial by Simon Chapman, then an associate professor at the University of Sydney.
If overeating is today's equivalent to smoking as an epidemic behaviour that poses severe and underacknowledged health risks, then should we be asking whether overweight medical students should also be channelled away from primary care?
A physician's weight is an attribute that is both a part of an MD's appearance, and a suggestion of his or her behaviour. The issue of doctor appearance is something that's been studied a lot by academia. For example, numerous studies suggest that a work uniform of a white lab coat and formal attire "may favourably influence trust and confidence-building in the medical encounter." At the clinic where I manage the medical team, we encourage our doctors to dress professionally with lab coats - and I tend to wear a tie and white lab coat when meeting with patients.
However, we don't have any guidelines concerning the weight of our physicians. Which brings us back to that study from the Johns Hopkins Bloomberg School of Public Health. A U.S.-wide survey of the behaviour of 500 primarycare physicians revealed tendencies that were similar to the older smoking studies. Obese doctors were less likely to diagnose for obesity, for example, and heavier doctors also were less likely to bring up obesity as a health issue for their patients. Meanwhile, normal-weighted physicians were a lot more likely to believe that MDs had a responsibility to act as role models for patients by maintaining a healthy weight and exercising regularly.
Nevertheless, I agree with the study authors when they counsel against "isolating heavier physicians for intervention" because it "may increase obesity stigma." As a profession we all have a duty to combat obesity - regardless of our weight, or any other attributes. To really combat the growing health problem of obesity, we should train all doctors on the risks, regardless of their own weights, and encourage doctors to engage in regular exercise and healthy eating habits. At my own clinic, employees are offered fitness boot camps and discounts for personal training appointments. They also receive newsletters on healthy nutrition. Among our physicians are serious runners and cyclists, and many recreational athletes who work out regularly at the gym.
So, should a patient avoid overweight doctors, doctors who smoke, or any medical professionals who engage in health-harmful behaviour? Not necessarily. People seeking a primary care practitioner who is a perfect role model for healthy behaviour would find themselves selecting from a very short list. Medical professionals are as flawed as anyone else. The doctor-patient relationship must include rapport and trust. While many of us may prefer our physicians to be trim and professionally dressed, others may prefer a doctor who is as flawed and as human as they are. The bottom line? The MD should always encourage healthy behaviour regardless of personal biases - but action speaks louder than words.
Dr. James Aw is the medical director of the Medcan Clinic, a leading private health clinic in Toronto.
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