In this study we found increased negative stereotyping, less anticipated patient adherence, worse perceived health, more responsibility attributed for potentially weight-related presenting complaints, and less visual contact directed toward the obese version of a virtual patient than the non-obese version of the patient. This pattern occurred in response to the size of the patient alone, as all other interaction variables and all potential confounders were held constant. Unlike previous studies that used videotaped actors or written vignettes30, 31
, use of an IVE clinical ‘simulation’ allowed us to disentangle the effect of patient weight from other factors while maintaining psychological realism and immersion in the experimental scenario. Previous research has shown that experiences in virtual environments are psychologically compelling37
. Virtual patients generally elicit reactions similar to standardized patients in training scenarios38, 39
. Behavior in these simulations can also translate to behavior in real clinical interactions39, 40
The attitude and belief outcomes reported here are important in their own right and can have substantial impact on patients' experiences of the medical encounter. Furthermore, Epstein and Street41, 42
posit a model through which negative interpersonal interactions in the clinic can contribute to obese individuals' avoidance of preventive care, as demonstrated in the literature13-15
. In the model, factors like clinician-patient rapport and patient satisfaction are considered ‘proximal outcomes’ of the clinical interaction. These proximal outcomes can influence health directly and also influence ‘intermediate outcomes’ such as a patient's commitment to treatment, which impacts health. The current study demonstrated one concrete example of negative interpersonal behavior in that students exhibited decreased visual contact with the obese patient. Visual contact is a proxy for eye contact, a behavior that is linked to empathy expression by providers. Eye contact is part of a constellation of nonverbal behaviors that reflect providers' regard for patients and that are linked to patient satisfaction25
We anticipated that differences in beliefs and attitudes would affect students' clinical recommendations for the obese patient. Although there were some individual clinical recommendations that differed between the obese and non-obese versions of the patient in the current study, we did not find pervasive patterns indicative of bias. Though we found no clear evidence of bias, there were some differences in rates of individual recommendations that are of interest. The differences we found between conditions (e.g., for lifestyle-related treatment recommendations) were not inappropriate when the patient's body weight was used as clinical data in the decision-making process. It is worth noting, however, that some of the individual recommendations that differed between the obese and non-obese patient, weight loss and lipid profile in particular, though medically reasonable, may be less germane to short-term workup or symptom relief. Other recommendation differences (minimizing knee stress, heat and cold application, and bronchodilator prescription) might also indicate weight-related assumptions about factors causing the patient's symptoms. Such recommendations, therefore, may be indicative of an understanding that the obese patient is less healthy, less active, or should lose weight generally. Further research should explore beliefs and assumptions behind these subtle differences in recommendation patterns.
We did not find evidence to support our hypothesis that students would rely on lifestyle recommendations to address the obese patient's potentially weight-related symptoms and would thus be less thorough with respect to symptom management and diagnostics. There are several possible reasons for this. In general, diagnosis, treatment, and management of conditions like knee pain and shortness of breath involve protocols43, 44
that these students are likely to have recently learned. Behaviors that largely depend upon protocol and habit are less likely to be influenced by one's attitudes and beliefs45
. Thus, it may be the case that the particular symptoms examined here did not leave students leeway to express their attitudes. Previous research has similarly shown little influence of patient characteristics on management plans for shortness of breath whereas these characteristics influenced recommendations for a different symptom46
. Alternatively, some students in our sample may not yet have been well-versed in these protocols and thus may have made more recommendations across the board so as not miss anything. More research is warranted to disentangle these issues. Regardless, in this study, the attitudes and beliefs students reported toward obese patients seem to hold more implications for the quality of the clinical encounter than for care recommendations.
In examining these findings it is also of note that participant BMI was not a significant predictor in our analyses. Thus, students who had higher BMIs did not exhibit lower levels of bias. This finding extends the currently mixed literature6
on whether providers' weight impacts their attitudes and/or beliefs about patients who are obese.
The current study has several limitations. This study focused on medical students. Although we chose this sample because students are a clear target for potential interventions, they are still in the midst of their clinical training. Thus, the current findings may be less generalizable to practicing physicians and other clinicians. Furthermore, although we were able to measure and report students' nonverbal visual contact during the clinical interaction, we did not include other measures of interpersonal behavior or interaction quality. This is in part because the communication between the students and the virtual patient was constrained to keep it constant between participants and between conditions. In the future, examining additional verbal and nonverbal behaviors could shed more light on how attitudes and beliefs impact interpersonal behavior during a medical encounter. In addition, several of our measures consisted of a single item. More in depth assessments may increase validity of belief and attitude measurement in future studies.
Another limitation was the fact that we did not include assessments of whether and the extent to which participants perceived the patient as being obese. The virtual patient did appear to have a somewhat smaller body type than would be typical of someone with a BMI of 39.9. Based on the fact that the vast majority of students recommended weight loss for the patient, however, it clear that the patient was generally perceived as being overweight or obese. Finally, we did not allow for a true physical examination or interview during the clinical interaction. We provided students with several pieces of clinical information (e.g., blood pressure, smoking status) and included a visual examination period in which students could take a closer look at the patient. However, students were not able to perform any other type of examination that might have informed their diagnostic and treatment recommendations. For this initial study we opted to keep the interaction simple. In the future, however, making the flow of the interaction more similar to reality may increase external validity.
Further exploration of the patient-provider relationship and how obesity stigma plays out in this complex interaction is warranted. Experimental work focusing on the patients' experiences in the interaction will aid in understanding processes at work when they report negative encounters with providers. In turn, explication of these processes will help to identify points of intervention where we might improve patient-provider interactions for patients who are obese.
The current findings demonstrate that patients who are obese can trigger negative, biased attitudes, beliefs, and differential interpersonal behavior based on their size alone, in the absence of particular interaction styles, health characteristics, or other differences. Even though these attitudes and beliefs did not translate into biases in patient care recommendations, they have important implications in their own right. Negative attitudes and biases can influence the tone of clinical encounters and rapport in the patient-provider relationship, both of which can have important downstream consequences. It is therefore important to develop strategies for mitigating the effects of these reactions to patients who are obese.