Surveys were mailed to 500 physicians. Eight were returned due to address unknown or unforwardable, and nine were not practicing family medicine (eight pediatricians, one psychiatrist). Of the remaining 483 subjects, 255 completed the survey (response rate 53%). Comparison of responders vs. nonresponders showed no significant differences in gender (P = 0.21) or practice setting (P = 0.96). A greater percentage of NJFMRN members responded (57%) than nonmembers (40%).
summarizes demographic and practice characteristics of respondents, stratified by gender. The average age of physicians was 48 years (s.d. 9.43). Most physicians were white, male, from single-specialty groups, and practiced in community suburban settings. On average, physicians estimated that 62.5% of their patients were white, 82% had commercial or Medicare insurance, 29.4% were obese (BMI ≥ 30), and 8.5% severely obese (BMI ≥ 40). Most physicians (83%) had intentionally attempted weight loss themselves, and 90% were successful. Compared to males, female physicians were younger, in practice for fewer years, spent fewer hours per week in patient care, saw fewer patients per week, were more likely to be normal weight, and to have intentionally tried to lose weight. Compared to NJFMRN member respondents, non-members who responded were older (P = 0.0073), in practice longer (P = 0.0064), saw more patients per week (P = 0.0019), more likely to be in solo and multispecialty groups (P < 0.001), and less likely to be in academic settings (P = 0.0018).
Characteristics of respondents
Self-reported knowledge regarding care of extremely obese patients
A majority of physicians reported knowing much or very much about exercise regimens to lose weight (60%) and weight-loss diets (57%). Fewer knew much or very much about weight-loss medications (49%), surgical interventions (44%), specific helpful techniques in examining severely obese patients (24%), and community resources for severely obese patients (19%). In multivariate analysis, having >7% severely obese patients in the practice was associated with lower knowledge on surgical interventions (OR 0.37, 95% CI 0.22, 0.64), helpful examination techniques (OR 0.47, 95% CI 0.29, 0.77), and community resources to refer extremely obese patients (OR 0.43, 95% CI 0.26, 0.71).
Approaches to weight management
details specific treatment approaches to weight management. Greater knowledge of weight loss drugs and bariatric surgery were associated with more frequent recommendations of weight loss drugs (P < 0.0001) and bariatric surgery, respectively (P < 0.0001). In multivariate analysis, physicians with >100 patients per week were less likely than those with <50 patients per week to prescribe specific diets, such as South Beach (OR 0.33; 95% CI 0.183, 0.64; P = 0.0009), low fat diet (OR 0.32; 95% CI 0.17, 0.60; P = 0.0004), or Weight-Watchers/ commercial weight loss programs (OR 0.36, 95% CI 0.20, 0.67; P = 0.0012). Physicians with >7% of extremely obese patients were less likely than those with <7% to recommend weight loss medications (OR 0.51; 95% CI 0.31, 0.85; P = 0.009) and bariatric surgery (OR 0.38; 95% CI 0.23, 0.62; P = 0.0002).
Frequency of recommendations of weight loss approaches (N = 255)
Attitudes toward managing obesity
Many physicians agreed or strongly agreed to the following: dealing with obesity and weight loss is frustrating (66%), treatment for obesity is often ineffective (51%), there is not enough reimbursement to discuss weight loss (45%), and being pessimistic that patients could be successful in losing weight (34%). Many physicians frequently or almost always encountered the following challenges when discussing weight loss with obese patients: patients lacked discipline to lose weight (78%), patients want an easy way out (71%), patients do not have time to exercise (62%), patients have psychological problems (57%), patients deny having poor eating habits (54%), patient cannot exercise due to their weight (54%), patients are not motivated to lose weight (52%).
Higher self-reported knowledge was associated with fewer negative attitudes. For example, higher knowledge on weight loss diets was associated with less dislike in discussing weight loss (P < 0.0001), lower frustration (P = 0.0001), lower belief that treatment is often ineffective (P < 0.0001), and less pessimism that patients will be successful in losing weight (P = 0.0002). shows the effect of physician characteristics on attitudes regarding extremely obese patients and weight loss. After adjusting for physician age, gender, patient volume, and volume of severely obese patients, higher patient volume, and older age were independently associated with lower odds of having negative attitudes.
Effect of physician characteristics on attitudes toward management of obesity and extremely obese patients
Challenges doing examinations on extremely obese patients
Many physicians frequently or almost always encountered the following difficulties with examining obese patients: palpating masses in abdomen (82%) or on bimanual pelvic exam (77%), separating thighs for pelvic exam (54%), visualizing the cervix on pelvic exam (49%), extra time needed to do breast exams (46%), and palpating lumps on breast exams (42%). Higher knowledge in specific examination techniques was associated with less difficulty in palpating lumps on clinical breast exam, abdominal, and bimanual pelvic exam (P < 0.005).
Female physicians had less difficulty than male physicians with palpating masses on pelvic exams (OR 0.38, 95% CI 0.21, 0.68; P = 0.0011), while physicians with >7% of patients who were extremely obese reported greater difficulty with palpating masses in the abdomen (OR 2.23, 95% CI, 1.37, 3.8; P = 0.0016).
Availability of supplies and equipment to accommodate extremely obese patients
Almost all physicians had extra large blood pressure cuffs (96.8%). Fewer had large speculums for pelvic exams (77.6%), armless waiting room chairs (61.8%), and extra large gowns (53.6%). Less than half of physicians had a scale for patients over 350 lb (41.7%), large size exam tables (32.1%), and large wheelchairs (17.1%). Higher percentage of severely obese patients was independently associated with having large size exam tables (OR 2.21; 95% CI 1.22, 3.98; P = 0.0085) and large wheelchairs (OR 2.29; 95% CI 1.12, 4.72; P = 0.024).
Strategies to improve care of extremely obese patients
details how respondents rated strategies to improve quality of care for extremely obese patients. Providing insurance coverage for obesity treatment, having readily available nutrition and exercise therapists, and having a list of community resources to refer obese patients were most highly rated. Compared with physicians having <50 patients per week, those with >100 patients per week were more likely to rate having a dietician on site (OR 3.16; 95% CI 1.64, 6.06; P = 0.0006) and a case manager to coordinate care (OR 2.48; 95% CI, 1.32, 4.64; P = 0.0047) as more helpful.
Helpful strategies to improve quality of care for extremely obese patients (N = 255)