Obesity could affect diagnoses, Pitt experts say

A high body mass index could indicate more than just obesity. In a new report, a pair of Pitt… A high body mass index could indicate more than just obesity. In a new report, a pair of Pitt researchers question if people with higher BMIs receive thorough medical examinations and whether obesity could hinder doctors from spotting symptoms of disease.

The two researchers — Dr. Ann Silk and Dr. Kathleen McTigue — published a report in the Journal of the American Medical Association last month claiming that medical students are not being trained to properly diagnose obese patients, news which sparked harsh reactions from national advocacy organizations.

The article  said that formal medical training does not provide instruction on adapting examinations to fit heavier patients, putting those who are considered obese — with a BMI above 30 — at risk for misdiagnosis.

Silk, a third-year resident at UPMC who worked on the report, initially hoped the commentary would be more of a research project geared toward how to best maximize hospital visits for obese patients.

After conducting her research, though, Silk found that there was a “tremendous” lack of information pertaining to examinations of the obese.

Silk said that the findings by her and her colleague, McTigue, apply to medical training at all schools, not just at Pitt.

“Pitt’s overall scope of the problem is not enough. Within medical training there should be more of a specialization,” Silk said.

The National Association to Advance Fat Acceptance, a national nonprofit advocacy group for overweight Americans, acknowledges this problem as a serious issue.

Peggy Howell, the director of public relations for NAAFA, said the biggest issue is that some doctors maintain a prejudice toward overweight patients.

“Very often, doctors immediately just say, ‘You need to lose weight,’ and pass over the current health issue by not administering proper treatment,” Howell said. “Physicians should ask the same questions and do the same examinations as they do for regular-sized patients.”

Examinations for obese patients, however, require different techniques and skills, Silk said.

“As a physician who sees obese patients daily, I know that it is tremendously difficult to find abnormalities below the thick layer of soft tissue found on obese patients,” Silk said. “Without an adaptive physical exam designed for these patients, I myself feel dissatisfied and less confident with the examination.”

Second year Pitt medical student Colby Croft said that the focus of most of his education addressed how to treat healthy-sized patients.

“I cannot recall any instances in our formal curriculum in which we have learned how treating, examining or interviewing obese patients is different from caring for adults of a healthy weight,” Croft said. “Even our textbooks fail to offer and provide images of obese patients.”

UPMC intern Kelly Ross graduated from Pitt’s School of Medicine last year. She said that although treatment of obese patients was not a huge focus in medical school, she attended seminars concerning how to speak to patients about their weight while in her residency at UPMC.

Pitt medical professor Jason Rosenstock acknowledged that the statements made in the researchers’ article were “probably true.”

“Our program does not teach about obesity well enough. However, we are putting a lot of efforts towards improving that,” Rosenstock said.

Those in charge of the medical school’s curriculum disagree, however, with the published commentary.

“Like so many other things, treating those who are overnourished is integrated into the regular curriculum. As is other dimensions of physical examination,” said Dr. John Mahoney, the associate dean of medical education for Pitt’s School of Medicine. “Just because we do not have a course titled ‘Examination of an Obese Patient’ does not mean that the subject is not adequately addressed.”

Mahoney felt confident in the training Pitt provides, but like all education, he said, there could always be more.

“The key is to achieve balance in our curriculum,” Mahoney said.

In 2007, the American Medical Association recognized the University of Pittsburgh School of Medicine as one institution working toward bettering its instruction of treating obese patients.

Regardless of training availability, Silk thinks the examination of obese patients presents a number of difficulties.

“Extra tissue just makes it harder to palpate abnormalities. The only way to get around this limitation is to do a careful and thorough physical exam and pay attention to collateral information from the patient’s history,” Silk said.

Rosenstock agreed.

“A close calculation of BMI, documentation of family history and consideration of cultural implications all need to be involved in the process,” Rosenstock said. “It’s such a large problem that a multidisciplinary approach needs to be taken.”

Rosenstock’s class, primarily focused on behavioral medicine, contributes several hours of class time per term to instructing students on how to communicate with their patients on lifestyle changes, with a concentration on preventive medicine.

“The reason we wrote the commentary,” Silk said, “is to … spark debate, collaboration and research in medical education about the accuracy of the physical exam in an obese patient.”