This chapter will address the following American College of Graduate Medical Education competencies: interpersonal and communication skills and professionalism.

Interpersonal and Communication Skills: This chapter will help the pediatric health care provider enhance effective exchange of information and collaboration with patients and families as well as with other health professionals to accomplish advocacy goals.

Professionalism: Professionalism is important in advocacy just as it is in clinical care. This chapter will help the pediatric health care provider understand and counter weight bias as a component of commitment to professional responsibilities, acting on ethical principles, and sensitivity to diversity and values of respect.

Imagine what it would be like to unfairly be poorly treated for a characteristic that is visible 100% of the time. How would you feel, what would you think, and if this characteristic were something you could change, would this poor treatment motivate you to do so? Weight-based stigma refers to negative weight–related attitudes and beliefs that result in a wide range of negative assumptions about, and victimizing behaviors toward, individuals who have overweight or obesity. These negative assumptions, stereotypes, biases, and prejudices can be evidenced verbally (eg, bullying, derogatory remarks, names, and/or pejorative labels), physically (eg, hitting, grabbing, or other acts of aggression and violations of personal space), or by relational aggression (eg, intentional social exclusion, spreading of rumors). The National Child Traumatic Stress Network (NCTSN) deems bullying and victimization as a form of trauma, akin to abuse and neglect.¹ In its more severe forms, weight-based victimization can be considered discrimination.^2,3 For adolescents, the rates of weight-based discrimination are comparable to rates of discrimination due to perceived sexual orientation, and more frequent than rates of discrimination due to race, religion, or disability.^4,5

Children and adolescents can experience stigma and victimization across many environments, including school (eg, teachers and coaches), home (eg, family members), and social (eg, peers). Both children and adults can also experience stigma within the health care environment. Negative weight–related attitudes and beliefs toward adult patients with obesity have been evidenced by physicians, nurses, psychologists, dietitians, and medical students, including providers who specialize in obesity.⁶

These beliefs maintain that adult patients with obesity are lazy, nonadherent to recommendations, undisciplined, unsuccessful, unpleasant, and have little willpower.⁷ One study of British health care providers revealed beliefs that adults were overweight primarily due to physical inactivity, overeating, food addiction, and personality characteristics. These providers also perceived adults with overweight as having reduced self-esteem, reduced sexual attractiveness, and reduced health.⁸ Another study of general practitioners in France indicated 60% believe adult patient’s lack of motivation is the most common barrier in medical weight management.⁹ Research from the United Kingdom compared attributed causes of obesity identified by both general practitioners and adult patients. The providers indicated more blame-based beliefs, viewing the individual as the primary cause and solution to weight management. The patients were more likely to attribute obesity to medical causes or poverty.¹⁰ Another study compared motivation to change self-reported by patients to motivation of the patients as perceived by providers. There was a significant difference between the two, with patients reporting higher levels of wanting to make changes than the physicians attributed to them.¹¹

An experimental study designed to assess how an adult patient’s body weight influences primary care provider attitudes utilized responses to 6 adult patient vignettes that were identical, except for gender and body mass index (BMI). As the otherwise identical patients increased in BMI, physicians considered them less disciplined, poorer at self-care, and less healthy. Further, with the heavier patients, physicians reported lower job satisfaction, less patience for these patients whom they described as more annoying, and a decreased desire to provide care for these individuals, believing it to be a poorer use of time with likely little benefit or impact upon predicted medical nonadherence.¹² These examples from the literature indicate the infiltration of weight stigma into the medical environment. Productive, supportive, and ultimately beneficial communication between provider and patient may be impaired if the provider views a patient as unmotivated, at sole fault for his or her weight status, and not worth the effort to provide care for. Further, there is less likelihood that a patient will return to a provider by whom he or she feels judged and poorly valued, subsequently limiting the provision of care to an individual who has medical necessity.^13,14

Although the majority of current research is in the adult population, there is evidence of this influence in pediatric weight management. Parents and caregivers play an important role in pediatric weight management; and in one study of 67 children and caregivers, parents reported feeling blamed, criticized, and being held responsible for their child’s weight status.¹⁵ These negative parental feelings are unlikely to promote successful intervention and outcomes for a child’s weight. In another study, 37% of parents indicated they would feel upset and embarrassed if they perceived their child’s physician was stigmatizing the child based on weight. Thirty-five percent of parents also reported they would seek a new provider for their child, and 24% indicated they would avoid future medical appointments.¹⁶

The American Academy of Pediatrics (AAP) has issued a statement formally recognizing the negative impact of bullying on not only individual pediatric health, but also as a public health problem.¹⁷ This statement specifies that pediatricians and other clinicians have a responsibility to address bullying. The most simple and direct method of addressing bullying and weight-based victimization is to not engage in these behaviors on a personal level in medical encounters with children, caregivers, or families.¹⁸ In addition, promotion of prosocial behavior can also combat bullying from a positive perspective. Choosing these behaviors as a standard part of practice during residency is an ideal way to develop these clinical skills and habits, and learn to develop more ideal patient care.

It is important to recognize that each individual comes to his or her professional role with a personal history, set of experiences, and related opinions and biases. Professional and ethical behavior does not allow for these personal factors to harm another human being in any way. To minimize the potential for weight-based victimization toward children with obesity and their families, it is necessary to be aware of what one’s biases are. To become aware of one’s own biases, it is necessary to mindfully explore questions such as:

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  Am I truly comfortable working with patients and families of all sizes? If yes, would an outside observer be able to verify this based on my patient interactions, including my nonverbal behaviors? If I am not comfortable, what might be some reasons why I am not? What would it take for me to increase my comfort level?

  
  
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  Do I make assumptions about a patient’s or parent’s background, character, intelligence, health status, lifestyle behaviors, or ability to be successful based solely on weight? If so, are these assumptions mostly negative? Do I believe that patients with obesity can be successful at implementing lifestyle changes and weight loss?

  
  
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  Am I sensitive and empathic to the unique needs and concerns of patients with obesity and their families? Do I take time to listen openly to, and understand implications of, reported barriers, or do I consider barriers and hardships to be excuses?

  
  
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  Do I give appropriate feedback to encourage healthful behavior change? Do I praise small successes? Do I spend as much time providing care for patients with obesity and their families as I do for patients with different presenting problems?

  
  
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  Am I experiencing burnout and compassion fatigue with treating patients with obesity and their families? Do I find myself avoiding bringing up obesity and weight in encounters because of perceived diminishing returns and futility?¹⁹

It is not uncommon to initially answer these questions quickly and in a socially desirable way, because it can be difficult to confront a personal bias and its potential implications. However, to truly provide the best care for children with obesity and their families, a more thoughtful and truthful exploration is necessary. Meaningful reduction of bias cannot occur if biases are undiscovered. After exploring what biases may be present, creating changes to these beliefs and opinions requires challenging them with new information. Therefore, consider the paragraphs that follow.

Development of obesity is often because of many factors, several of which may be out of the control of not only the child, but the family. This may feel very overwhelming for them.

It is likely that the child’s family, and perhaps also the child, has previously tried to lose weight, was unsuccessful, and may feel defeated about future attempts. Empathic acknowledgement of the difficulty of weight loss can provide support and promote meaningful patient-provider rapport.

A patient’s other presenting problems and comorbidities may not definitively be weight related, so all relevant causes must be ruled out before assuming that a problem is due to weight. This will in part require active listening to what is being reported by the patient and family.

Behavior changes that may seem small to a provider may be a significant accomplishment for a child or family. Small changes can result in health benefits. Praise is rewarding, and taking time to provide praise can promote continuation of the behavior, as well as further develop the patient-provider relationship.

The patient’s family may have experienced weight-based victimization with a previous health care provider, so attending a follow-up appointment with a new provider may be challenging and intimidating. For some, this resiliency demonstrates motivation to change. Therefore, the encounter should be used as a new opportunity to reinforce this readiness, as opposed to encouraging negative beliefs about health care for a child and family who has significant medical necessity.¹⁹

Each of these challenging statements encourages evaluating the experience of medically managed weight loss from the patient’s and family’s perspective. Truly trying to understand the complexities of the situation from their viewpoint fosters empathy and promotes development of positive regard by the provider. Increasing positive thoughts and feelings toward individual patients reduces the likelihood of bias and stigma toward them. And most importantly, empathy and positive regard enhances rapport, and a strong patient-provider alliance is well established in behavioral literature as predictive of successful patient behavior change.²⁰ Therefore, providers can deliver better care by striving to hear and understand each individual patient’s and family’s experience of obesity development and processes of change.

In addition to reducing one’s own potential biases, specific methods of communication are also imperative for practicing stigma-free treatment. The topic of weight can be sensitive to bring up with parents and/or children. Health care providers should choose language that is sensitive and nonblaming. A recent study from the Rudd Center for Food Policy and Obesity examined parental perceptions of language used by providers to discuss weight with children. Parents rated the terms “weight,” “unhealthy weight,” and “high BMI,” as the most desirable, and least stigmatizing and blaming terms for providers to use. Those rated as the most undesirable, stigmatizing, blaming, and least motivating terms were “chubby,” “obese,” “extremely obese,” and “fat.” Parents rated “unhealthy weight,” “weight problem,” “overweight,” and “weight” as the most motivating terms to encourage a child to lose weight (Table 18-1). The authors of the study encouraged providers to not only avoid language considered stigmatizing, but to also ask parents and children about what weight-related terms they prefer on a case-by-case basis.¹⁶

The act of weighing a child can also provoke anxiety or embarrassment, and for patients with obesity, fear of facing a scale can be a deterrent to attending appointments. Respectful verbal and nonverbal communication by everyone involved, including nursing or other care staff, during this process is imperative. First, the weight station should be in a private location to protect confidentiality. For each specific appointment, determine the necessity of obtaining a new weight, particularly if weight has recently been recorded. If weight must be measured, ask permission of the patient for weight to be taken. A way to do this might be to ask, “Do I have your permission to weigh you today?” If permission is not granted, this must be honored, and monitoring personal nonverbal reactions to not display any possible frustration or disappointment is necessary. For some patients, it may be beneficial to discuss as part of the appointment why not taking a weight was preferred. If permission is granted, provide the option of taking the weight while facing away from the numbers, or not being made aware of the weight. Document the weight with the same monitoring of personal nonverbal behavior as to not appear surprised, disappointed, or frustrated. At no point during this process should any negative comments about the patient’s weight be made.¹⁹

Further unbiased or nonstigmatizing communication with a patient and family about weight can be facilitated by utilizing motivational interviewing. The basic tenets of this style of communication highlight patient-focused interactions that allow patients and families to determine their own reasons for motivation to make changes and then create change at a pace at which they can be successful. More specific information about motivational interviewing and how to implement it can be found in Chapter 15.

Sometimes when communicating about weight, speaking with either the caregivers or the child individually is beneficial. For example, if there is clearly significant conflict about weight within the family, and caregivers are acting in a negative or bullying way toward the child, it can be quite meaningful for a provider to halt the interaction and indicate that this type of behavior is unhelpful. Separating the child and caregivers can easily be facilitated by inviting one of the parties to momentarily return to the waiting room, or for a younger child, a chair can be placed in the hallway and a toy or activity provided. Speaking to a caregiver and child separately can then allow an opportunity to discuss these concerns openly and honestly without escalating the conflict, or further permitting the potentially bullying behavior.

An additional element to consider when interacting with a patient and family about weight is to recognize that communication errors can occur. Despite all efforts to provide bias-free treatment and use patient-focused language, patients and providers are human, and miscommunication is part of the human condition. As with any other interaction, if an individual is at fault in the miscommunication, an apology may be warranted. One of the tenets of patient-focused communication is that patients and providers are equal experts—the patients are experts on themselves, and providers are experts on the condition. Therefore, it is appropriate for a provider to apologize if he or she becomes aware of something done or said that communicated weight-based stigma, or was victimizing to a patient. This apology may be the difference between a patient successfully continuing medically necessary treatment, or never returning.²¹