More than a-third of all Americans are obese.¹

Morbid obesity, variously defined as either BMI > 40kg/m² or BMI > 35kg/m² with obesity-related health problems² is a modern plague in most industrialized societies. This obesity epidemic presents both practical and ethical challenges to the practicing emergency physician. The ethical challenges come in three basic subtypes: the fair distribution of scarce medical resources, the temptation to judge or blame big patients, and legal issues around an elusive standard of care for the morbidly obese.

Justice/fairness and resource consumption

The bioethical principle of justice dictates that fair access to care should occur equitably, according to need. This is a fundamental tenet of the ACEP Code of Ethics for Emergency Physicians.³ Emergency physicians often experience the morbidly obese as very high resource utilizers who appear to consume more than their fair share of emergency department services and time.

Not only are they harder to transport, transfer and examine, but morbidly obese patients have slower transit times. Routine tasks like drawing blood, starting IVs, getting X-rays, CT scans, or doing emergency department bedside ultrasound, may span the spectrum from slightly challenging to utterly impossible. But in most cases, these routine tasks are much more time consuming when a patient is morbidly obese.^4-6

Practical resource challenges are an economic issue when emergency physicians are reimbursed on an RVU, fee-for-service, patients-per-hour basis. Patients who tie up ancillary and nursing staff for longer periods of time incur significant opportunity costs and detract from the ability of the staff to attend to other patients. An unintended result is compromised attention to new patients, slowing of emergency department flow, and an inability to maximize efficiency.⁵

Beyond the excess consumption of medical resources on an individual level, there are fairness issues at the hospital and population level as well. Pre-hospital services require more vehicles to have enough that remain “in service” when transporting larger patients who may require protracted extrication and transport times. This is in addition to the EMS and emergency department staff who miss work or suffer back pain from lifting such large patients.⁶ As emergency departments are stretched to serve an increasingly obese populace, they must purchase larger beds and larger scanners, and have more staff available to move, transfer, and transport more morbidly obese individuals.⁷

The American Medical Association recently classified obesity itself as a disease state and a treatable medical condition for purposes of both nosology and reimbursement, legitimizing the time physicians spend embattled with this condition.⁸ Despite these efforts and the unequal distribution of hospital and economic resources involved, emergency physicians caring for obese patients would do well to remember that the principles of equity and justice mandate that resources be allocated fairly and equitably, according to need.

It is this last notion, “equitably, according to need” that we may sometimes forget. Morbidly obese patients have legitimate and often greater needs, which, in turn, demand and justify a larger share of available staff time and other resources.

‘See excess patient mass as excess patient pain. Consider the plausibility that the morbidly obese patient overeating before you experiences pain daily on a per kilogram basis.’

Stigmatization and staff contempt

While Rubenesque figures are still prized among some Pacific island peoples, obesity tends to be viewed in the most unflattering terms in the Western world. Fat phobia and contempt for obesity are ubiquitous. As a microcosm of our society, the emergency department is not immune to these biases. Morbidly obese patients may engender in us both ridicule and contempt for their lack of self-control and dietary discipline as the root cause of their emergency department visit. When we allow these biases to frame our thinking, however, we cross the line from a helping to a blaming profession, where we serve as judge and jury rather than healer and helper.

Emergency physicians care for countless smokers who are short of breath, drinkers with bleeding varices, and substance abusers who crash cars. Hence, we see (perhaps more than most) the obvious relationships between human behavior and medical consequences. As our specialty’s Cicero, Dr. Gregory Henry, once proclaimed, “If it wasn’t for human vice and self-inflicted illness, I’d be out of a job!”

It may be argued that consistently generating high levels of compassion and empathy is part of the emergency physician’s job description, a job for which we are handsomely paid. However, something much more important is at stake than income when we work 10-hour shifts resenting those perceived as weak, irresponsible, gluttonous patients: our humanity. It is in our best interest to appreciate our own personal need to “like” our patients as much as possible.

When we secretly blame or ridicule them for their body habitus, appetites or food addictions, we invite apathy, disillusionment, resentment, and ultimately, burnout. While one cannot fail to be impressed with the size of some of our “customers,” patient blaming, fat jokes and staff stigmatization are the kryptonite of emergency physicians and should be avoided at all costs.

“Love all, serve all” isn’t just a sign for the Hard Rock Café; it should be our emergency department’s sign too. We do well to see morbidly obese patients as worthy, suffering souls who need our humane and sincere concern and compassion, just like any other patients. Having an unconditional positive regard (UPR) for all patients has long been recognized as a cardinal virtue of excellent emergency physicians.⁹

Adopting a positive, non-judgmental, UPR-like attitude and character enhances both our own enjoyment of emergency medical practice and the patient’s perception of quality care. Fewer lawsuits? Perhaps, but more important, our leadership and example in this area create an atmosphere of mutual respect and healing – a win-win for patients and staff.

ACEP’s Code of Ethics for Emergency Physicians states that we care for all patients regardless of their race, creed, color, or outward appearance.³ Of course, it would be patronizing to issue pretentious platitudes like “be compassionate” and pretend that this is a simple matter: If it were easy, everyone would be doing it.

We would like to arm you with at least one other candidate antidote for doctor indifference: See excess patient mass as excess patient pain. Consider the plausibility that the morbidly obese patient overeating before you experiences pain daily on a per kilogram basis.

While not always “true,” consider that comfort foods are their preferred means of coping. Certainly, we want to encourage obese patients to adopt healthier dietary and exercise habits, but we might do this better by appreciating that they wear their burdens for the whole world to see. Perhaps envisioning proportionality between BMI and pain may help us generate more empathy when evaluating the next morbidly obese “belly pain” patient.

Morbid obesity and the standard of xare

Despite our contentions that material resources should be guarded, stewarded, and equitably distributed,³ we submit that caring and compassion should be given generously if not equally in the ideal emergency department setting. However, beyond the very real resource and stigmatization challenges of caring for morbidly obese patients, there is a third ethico-legal challenge: the sliding scale standard of care. While it might be ideal to examine, test, and ultimately treat all patients equally given similar chief complaints, this is not always possible when a patient is morbidly obese. Indeed, the risk/benefit quotient changes when an emergency physician is managing an airway threat using RSI versus noninvasive ventilation; the safety of standard options changes in an ectomorph versus a small-mouthed, short-necked, double-chinned Mallampati IV.

Similarly, an emergency department might have a policy or care pathway mandating IV analgesia for patients in pain; while this “best practice” is an ideal way to titrate and deliver parenteral analgesia, intranasal, subcutaneous, or even suboptimal intramuscular injections might need to be considered.

Empathy is important, not only with patients, but also with our peers when they are managing morbidly obese patients. A spirit of magnanimity should pervade conversations about colleagues who might deviate from a guideline or miss a subtle physical exam finding, for example, after performing a pelvic exam in an obese woman with a large pannus. While lawyers and risk managers might contend, cookie cutters in hand, that all patients with a given complaint should receive identical standard care, a “one-size-fits-all” attitude defies our reality. The standard certainly shifts by body habitus and available resources in many cases.

From a risk management perspective, transparency is key. Emergency physicians should diplomatically discuss obesity with patients, especially when their size limits the diagnostic and treatment options available. Stating honestly that “I cannot adequately evaluate your abdominal and pelvic organs on my exam today, so we may not be able to determine the exact cause of your pain,” is far better than saying “Well, it’s probably just a little constipation.” Sometimes a patient’s obesity must be discussed openly without blame, fault-finding, or contempt. Discharge instructions should also highlight obesity risks, giving patients strict dietary and activity guidelines as well as referrals back to ongoing primary care.

Given the potential hazards of a shifting standard of care, all such discussions of obesity-related risks and diagnostic and treatment limitations should be carefully documented in the patient’s medical record.

Conclusions

As the obesity epidemic escalates, emergency physicians will continue to be challenged in both moral and practical terms. Resource consumption, staff attitudes and a sliding-scale standard of care are three such ethico-legal challenges that thoughtful emergency physicians will meet with fairness, non-judgment, magnanimity, empathy, compassion and an unconditional positive regard for patients and colleagues alike.

References

1. JAMA. Feb 1 2012;307(5):491-7.
2. Br Med Bull 1997; 53(2): 238-252.
3. ACEP Code of Ethics for Emergency Physicians. http://www.acep.org/Clinical—Practice-Management/Code-of-Ethics-for-Emergency-Physicians/. Accessed July 13, 2013.
4. Emerg Med Australas 2010; 22(4): 316-323.
5. Am J Emerg Med 2012; 30(5): 737-740.
6. EMS Mag 2008; 37(4): 67-71 and 37(5): 73-75.
7. The Obese Patient. In: Venkat A, ed. Challenging and Emerging Conditions in Emergency Medicine. West Sussex, United Kingdom: Wiley-Blackwell; 2011:204-27.
8. New York Times, June 19, 2013, B1
9. Acad Emerg Med 2009; 16(1): 51-55.