One size does not fit all in medical exams

Consumer Reports News: January 14, 2011 09:08 AM

Getting a checkup isn't high on most people's lists of enjoyable activities. But imagine how much less pleasant it would be if you arrived at your appointment to find a medical gown that didn't fit you, a scale that couldn't weigh you, or an exam table that you couldn't easily sit on.

Such inconveniences aren't uncommon for people who are very overweight (obese), reports a recent article in the Journal of the American Medical Association (JAMA). But even more troubling, say the authors, is doctors' frequent lack of knowledge about how to examine their obese patients, which can mean missed diagnoses with potentially serious health consequences.

The number of overweight Americans has soared in recent decades, with 1 in 3 adults now obese. There's been lots of research looking at ways to stem rising obesity rates. However, surprisingly little attention has focused on adapting routine medical care to accommodate people who are very overweight. 

At the root of the problem, say the authors, are gaps in doctors' medical training. Medical schools often give no formal instruction in how to examine obese patients. And medical textbooks and illustrations almost always depict normal-sized people, with obvious "bony landmarks" such as visible rib cages and hip bones.

However, when someone is obese, bones that would usually help guide doctors to the locations of organs and other internal parts are often not apparent because of body fat. Fat can also make tumors and other abnormalities difficult to detect, and muffle heart and breathing sounds. And folds of fat can make routine procedures challenging, including gynecological exams.

This means that an obese person may not get the same level of care as someone who's slender, despite the fact that they have a higher risk of many serious health problems, including heart disease and some cancers. So what to do? The authors recommend, first and foremost, that medical schools place more emphasis on how to examine obese patients.

They also provide several practical suggestions for doctors. Below are a few key points. You can view the complete list here.

  • Make sure furniture, tools, and supplies can accommodate obese patients: This involves stocking extra-large gowns, providing low, reinforced exam tables and roomy chairs, and having scales with a high weight capacity (many scales don't go above 350 pounds).
  • Allow enough time for a thorough exam: Checkups for obese patients often take longer, for a variety of reasons. For example, many overweight people are very out of shape, so it takes a while for their heart rate to go down after they've arrived at their appointment. The authors suggest waiting for 15 minutes before checking their vital signs.
  • Use other tools and approaches: A handheld ultrasound can help doctors check a patient's pulse if this is not possible in the usual way, and a longer speculum can assist with gynecological exams. Positioning patients in different ways can also make a difference. For example, having a female patient lie on her side may help with a breast exam.

What you need to know. One size does not fit all when it comes to medical care. If you feel you're not getting adequate care, it's important to speak up. And if your doctor isn't responsive, consider finding a doctor who is.

Sophie Ramsey, patient editor, BMJ Group has partnered with The BMJ Group to monitor the latest medical research and assess the evidence to help you decide which news you should use.

Aaron Bailey

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