The XX Factor

At the Doctor’s Office, Size Does Matter

The basic physical examination no longer fits the one-third of the U.S. population that’s obese. Blood pressure cuffs are too small; it’s hard for a doctor to hear the heart and lungs through layers of fat; heavy flaps of tissue block access to certain body parts. And so the authors of a recent Journal of the American Medical Association article called “Reexamining the Physical Examination for Obese Patients” recommend extra-large gowns, high chairs without arms, heavy-duty scales, and specific maneuvers for the physical exam. But I worried, when I first read all this, that redefining the physical might make obesity the new norm.

Here’s why I worried: There’s nothing like a difficult exam of an obese patient to make me, as a primary care doctor, focus on weight for the rest of the visit. If we refashion the exam as our population plumps, will doctors stop thinking about obesity so much? Shouldn’t we devote more resources to battling obesity-creating more healthy food choices, redesigning towns and cities to encourage walking and bicycling, providing insurance coverage for weight-reduction surgery, and increasing access to comprehensive weight-reduction programs? Surely this is better than widening airline seats, installing hydraulic lifts in ambulances, or buying larger exam tables.

But as I thought about it, I realized the absurdity of my thinking. We desperately need both-sound weight loss approaches and respectful ways to help obese people function in society. I can’t say to my patient: “Sorry, I don’t have a cuff that’s large enough for your arm, so we’ll skip the blood pressure today. But please look at this pamphlet on weight loss.”

Obese people deserve at least as good a physical exam as everybody else, if not better. With the extra fat tissue, the usual challenge of hunting for important abnormalities is kicked up a notch. With some parts of the physical, a shoddy exam can have potentially deadly consequences-some of them of special concern to women.

Take the breast exam: Obese women have a higher incidence of breast cancer, they’re diagnosed later, and they have a higher mortality than nonobese women. Sadly, this may in part be because their breast exams are difficult. Large breasts aren’t easy to examine, so a small lump is easier to miss, and ultrasounds and mammograms are bad at getting through fat.

Obese women also have a higher risk for endometrial cancer, and possibly ovarian and cervical cancer. But the problem of reaching the cervix is only the beginning: One study found that some extremely obese women say that they are embarrassed to be weighed, that they are treated without respect, that they sense a negative attitude about their weight from their doctors, and that they don’t like unsolicited weight loss advice.

So, yes, it’s great that doctors are re-examining the physical exam for obese patients, but equipping the office with longer speculums and bigger gowns is only the beginning. If the doctor can’t connect with the patient, it doesn’t matter how wide the table is. Obese people-and obese women in particular-already suffer substantially. The doctor’s office should not add to that suffering.