WhiteCoat

Refusing to Treat Obese Patients

I discussed whether or not ambulances should be required to add equipment costing $12,000 in order to be able to transport 850 pound patients in a previous post, so I won’t belabor the point here. Providing medical care to morbidly obese patients presents multiple challenges.

Then I read an article in the Florida Sun Sentinel about how some obstetrician/gynecologists in South Florida are refusing to provide medical care to obese women. Fifteen out of 105 Ob/Gyns refuse to treat patients based upon either weight or BMI. Some won’t take any patients who weigh more than 200 lbs.

In the article, other obstetricians without such a policy state that “no doctor should be unable to treat patients just because they are heavy.”

The “ability” to treat patients is only one of the issues involved, though.

Morbidly obese patients are more likely to develop surgical and post-op complications.  One of the physicians in the article mentioned that ultrasounds are more difficult to perform and interpret in obese patients. If a physician misses a critical finding on ultrasound due to a patient’s obesity, a plaintiff’s attorney will argue that the patient should have been referred to someone with more experience under those circumstances.

Malpractice insurance costs in Florida are some of the highest in the country. In fact, the costs are so high that the article states that half of Florida obstetricians go without malpractice insurance.

If physicians want to decrease their risk in managing patients by excluding patients who are at higher risk for complications, shouldn’t they be able to do so?

Many commenters to the article have harsh words for doctors who are unwilling to treat obese patients. The article itself cites physician groups, medical ethics experts and advocates for the obese, all of whom said that refusing to treat patients based on obesity would “violate the spirit of the medical profession.”

Insurers can refuse to provide insurance based upon pre-existing conditions (at least for a few more years) or can jack up premiums so high that the insurance is unaffordable. Good luck getting life insurance or disability insurance if you have a history of cancer. Airlines can refuse to transport people that are deemed an excessive “risk.” Banks can put limitations on those who enter their premises. Try walking inside a bank wearing a ski mask some day. Lawyers can reject any potential client for any reason. I don’t understand why people find it morally reprehensible if some doctors want to try to limit their liability by refusing to care for patients who are a higher risk for adverse outcomes.

This whole situation is a perfect example of the “perfect care” or “available care” paradigm.

The more that physicians who care for higher-risk patients are sued for less than perfect outcomes, the less that those physicians will be willing to treat higher-risk patients.

30 Responses to “Refusing to Treat Obese Patients”

  1. Gene says:

    I disagree with the “number” as a cut-off. As someone who is almost 6′ myself, 200 pounds is a couple dozen away from my current HEALTHY BMI. But I can understand the reasons for turning away someone who is morbidly obese (and the complications that often follow her).

  2. tish says:

    This totally makes sense. I mean where else can someone be forced to provide service for people? Those that are obese also have a duty to try and loose the weight…it sickens me to think that someone would want to sue a doctor because they missed something or didn’t get the right diagnosis because of THEIR weight. That is crazy. I sympathize with the best of them, but you also have to be rational here…

    • Ed says:

      I don’t know. It seems kinda strange to say “you have to be more healthy than you are now to see a doctor.”

      Don’t get me wrong, I can see their point. I just don’t think that this is the right way to address it.

      Sadly, no, I do not know a better way.

  3. KT says:

    I’d say specialists like bariatric obstetricians are not far away! (if we don’t have them already)

  4. Matt says:

    “This whole situation is a perfect example of the “perfect care” or “available care” paradigm.”

    If this is the premise for your post, it’s false. Why? Couple of reasons.

    1. Unless you’re asking for immunity from suit from all obese people, then who cares? You’ve already gotten your damage caps in Florida, which is the usual remedy you tout for high malpractice premiums.

    2. If they’re wealthy, they’ll get care. The availability of physicians is tied to wealth of the community, not malpractice premiums.

    3. You’re treading a slippery slope here because you’re implying if you get some unnamed favor (immunity or whatever), there will be available care. If you continue to say such things, you’re inviting mandatory universal care when you don’t deliver. You’ve often argued healthcare is not a right, but then you undercut your argument here.

    4. Our society as a whole has never demanded perfect care from physicians. And it never will.

    Now, as to this paragraph:

    “Insurers can refuse to provide insurance based upon pre-existing conditions (at least for a few more years) or can jack up premiums so high that the insurance is unaffordable. Good luck getting life insurance or disability insurance if you have a history of cancer. Airlines can refuse to transport people that are deemed an excessive “risk.” Banks can put limitations on those who enter their premises. Try walking inside a bank wearing a ski mask some day. Lawyers can reject any potential client for any reason.

    Are insurers and airlines what you really want to evoke when comparing your own industry? And no, not all lawyers can reject any potential client for any reason. That’s patently false.

    “I don’t understand why people find it morally reprehensible if some doctors want to try to limit their liability by refusing to care for patients who are a higher risk for adverse outcomes.”

    You can’t have it both ways. You can’t argue “perfect/available” and then say “we’re independent professionals and ought to be able to accept or take whoever we want.” You want all the upside of the free market with none of the downside.

    • DefendUSA says:

      “Our society as a whole has never demanded perfect care from physicians. And it never will.”

      That is pure BS and you know it. This is why you have ambulance chasers in your field, is it not, Matt?

      Case and point: The phen-phen diet was supposed to be the miracle weight loss drug. Docs prescribe it and some people died and some by their own stupidity of taking the drug in excess. But their families sue the “imperfect” doctor AND the pharmacuetical companies because it wasn’t “perfect”!! Who walks away saying “I knew the risks”? and does NOT sue? Not many and you you know it.

      If doctors tell someone who is obese that perhaps they should get closer to an ideal body weight to lower the risks associated with pregnancy, you can almost bet that someone will sue for discrimination, as opposed to understanding the advice in in the best interest of the patient.

      You cannot have it both ways, either. And despite that wealthy people have money and the poor do not, each demands perfection in their care, because otherwise no one would sue at all, would they? Would you or would you not agree that most doctors are not in the habit of being grossly negligent, yet they are forced to go against what they define as “smart practice” because some protocol says they must. I don’t believe this is ever taken into account.

      And the analogies that WC provides are valid to prove the point. A doctor does not have to take the risk if he knows better. I see nothing wrong with that. And if the patient chooses to doc shop to get someone to do what another won’t? Fine. At least if I were that denier doc, I would be able to sleep at night. Why can other industries do it, and yet a physician is held to a different standard? It doesn’t wash with me.

      • Anon Doc says:

        “If doctors tell someone who is obese that perhaps they should get closer to an ideal body weight to lower the risks associated with pregnancy, you can almost bet that someone will sue for discrimination, as opposed to understanding the advice in in the best interest of the patient.”

        That wound sound utterly ridiculous until one remembers that FL is also the state with the law against pediatricians being able to talk to gun owners about securing guns in the home.

    • WhiteCoat says:

      Classic Mattuendo …
      1. I’m not “asking” for anything. I’m merely showing that there is a correlation between liability and availability. You keep trying to make it look as if I approve of $250k damage caps. I don’t. There should be some limit on jackpot awards, but $250k isn’t that tipping point.
      2. You’re right. Wealthy patients have more likelihood of getting care than indigent patients. From the article, it doesn’t seem as if the doctors are asking about one’s socioeconomic status before refusing care to the patients. That’s when the free market kicks in. If the docs don’t have enough patients, then they change their policies.
      3. Creating innuendos. I’m only showing the correlation between liability and availability. Look at vaccine manufacturers or malpractice insurers in certain high-risk markets if you want other examples.
      4. If society doesn’t demand perfect care, why is it that you repeatedly refuse to give me even one example of a physician’s mistake that shouldn’t be subject to a lawsuit? Until you do that, you’re blowing smoke (and not doing a very good job at it, either).

      “not all lawyers can reject any potential client for any reason. That’s patently false.”
      Public defenders – probably correct. They can’t reject every client.
      Lawyers running private offices – I call bullshit. Show me the law that says lawyers must take each and every patient that shows up at their office seeking legal care.

      “You want all the upside of the free market with none of the downside.”
      Again, not true at all. I am showing correlations. Some Florida patients are starting to see the downside of the free market. That’s the whole point of the post – medical care isn’t a right and if you treat providers poorly enough, you’ll gradually see the availability of services wane.

      • Matt says:

        WC, I figured out where we are getting crossways. It’s here:

        “I’m merely showing that there is a correlation between liability and availability.”

        The thing is, you’re not. You’re just guessing. You don’t cite any stats on the availability of Florida physicians v. any other place. You don’t list how many claims there are in Florida and whether that’s gone up or down and whether it’s changed the availability factor. Your article only says 15 out of 105 in that loose survey reject them.

        In short, you’ve established no correlation.

        “Look at vaccine manufacturers or malpractice insurers in certain high-risk markets if you want other examples.”

        Now you’ve changed the discussion, speaking of innuendo. Vaccine manufacturers have almost nothing to do with this. Vaccines are an unprofitable business because you have to redo the product each year and your main buyers are governments buying in bulk. That’s not news. And what do “insurers in high-risk markets” have to do with the discussion? I thought we were talking about availability and perfect care? You’re always chastising me for bringing insurance into the discussion, and here it doesn’t seem relevant at all.

        “Lawyers running private offices – I call bullshit”

        Call it all you want. I can, with one phone call, be appointed by a judge to take a case right now. I can, if I get on a case and the client reneges on his payment promises, be required to complete the case. PS – public defenders are lawyers.

        ” Some Florida patients are starting to see the downside of the free market.”

        Nonsense. That’s not the free market. Nothing about medicine is “free market”, except on the very top end.

    • LawDragon says:

      Okay, another lawyer chiming in here with a different viewpoint. I once handled plaintiff health negligence cases but I haven’t in a while now. I’m not trying to derail WC’s original thread, but some commentary on malpractice is necessary.

      My experience is that patients do expect perfect care and perfect outcomes. I have had numerous inquiries where potential plaintiffs were knocking on the door because of the outcome and were not happy when I explained to them that a adverse outcome is not enough; there needs to be some evidence of medical negligence as well. In any event, in my neck of the woods, medical malpractice suits are not brought without a thorough expert review simply because of the cost of bringing a suit and the unlikliness of recovering costs in the case fails. For what it’s worth, I have never had to actually go to trial on a health negligence case. Every case I’ve had has settled, probably because the cases I took actually had documented negligence. From the various Helth Care Updates, this may not be the case everywhere and that’s a shame. Quite frankly, documented negligence resulting in a adverse outcome should be compensated while an adverse outcome without negligent care should not be compensated.

      Anyway, on to the post. WC is correct iln many ways. A private physician should be able to choose who they want to treat. Bur more important, the issue is why some Florida doc’s won’t treat obese ob/gyn patients. There was a comment about whether we will be seeing bariatric ob/gyns in the near future. What I see is physicians saying I don’t feel comfortable treating these patients. In any profession different people have different skill and knowledge sets. If a physician is not comfortable in their ability to treat obese patients, they shoud not treat them. The patient should be referred to a physician with the appropriate skill and experience to treat them. This is not a slap at physicians; it has to do with a professional’s ability to work within their skill and knowledge base. I decline cases that are within my practice areas if the case invovles issues that I don’t feel comfortable handling. Like WC, my son is a competitive wrestler. A couple of years ago he injured ear cartlege. We went to 3 different ENT docs before we got one that would fix his ear. The first two weren’t comfortable in their ability to do what needed to be done. Why should Florida ob/gyns (or any doc) be any different?

      As a final note, Matt is wrong in his assertion that an attorney cannot refuse clients as they see fit. With the exception of court appointed criminal, dependency, and the like, the Rules of Professional Conduct absolutely allow an attorney to decline a client that they simply are not comfortable in representing.

      Cheers, LawDragon

      • Matt says:

        I agree with almost all of that. Only thing I’d differ on would be the likelihood of being put on a case or allowed to get off because of a lack of comfort. Although that may be a function of being in a small county with few lawyers. More doctors than lawyers, actually.

  5. I think, at least for myself is the slippery slope concern. if you can refuse an obese patient what about refusing a patient with other risks? A particularly complicated series of co-moribidities? cancer? heart condition?

    Also, the decision seems somewhat antithetical, to me, to the idea of doctors? aren’t they supposed to help people who are at high risk? Isn’t the point of GOING to a doctor to keep healthy and avoid the risks?

    Furtheremore there are studies which show that the lower your income, the more likely you are to be obese (and there are a lot of potential reasons why, none of which are important to this conversation) so this offers a sort of classism that once again may put a person of lower-income (who already likely has a lot of restrictions due to insurance or lackthereof) at a higher disadvantage than they already are. So not only are they less likely to get care because of their socio-economic structure, it is now added in that they are even less likely because of their weight.

    Maybe if the doctors said: well, you aren’t right for this practice but let me recommend you to another who will accept you, I’d feel better about this. I think that doctors definitely have the right to manage their risks, but that person has to be able to go SOMEWHERE. And I think that it would be the doctor’s or at least his office’s responsibility to make sure they actually were pointed in the right direction.

    But I’m Canadian and on TOP of being Canadian, acknowledge that I’m even more ideological than most.

    • WhiteCoat says:

      The slippery slope concern is valid, but is already taking place.
      If you had a complicated series of comorbidities and a doctor felt that he or she was in over his or her head in trying to manage it, would you want to force your doctor to continue treating you? If you forced your doctor to continue treating you against his or her will, would you still hold him or her responsible if there was an adverse outcome?
      English teachers must now teach French. And if they screw up, they can be sued for millions of dollars.
      Police officers must now represent clients in court. Both lawyers and police officers know the law, right? If your client has an adverse judgment, you are on the hook for your entire pension.
      Patent lawyers must now represent criminal defendants with the same penalties applying.
      See how the logic leads to poor results?
      Now I admit that doctors may be able to create some excuse why they are “uncomfortable” treating certain patients to hide a discriminatory motive, but how are we going to differentiate between the two?

      Your classism point is also well taken, but again, look at the practical effects of what you are proposing. You want to force a physician to treat a patient when that physician is either not willing or not able to treat the patient. How are we going to enforce that maxim? Imprisonment? Shackles? Levy one’s student loans, er, um, bank accounts?
      Then, if the physician makes an error and the patient suffers a bad outcome, he or she is potentially liable for the next $58 million judgment.

      Creating a responsibility for one doctor to find another doctor willing to treat non-patients is also inappropriate. If it takes a physician several hours to find another doctor willing to accept someone who isn’t even the physician’s patient, how should the referring physician be compensated? That would be like me saying that you don’t have the answers to my questions on your blog, then forcing you to go and find the answers for me — and for every other person coming to your blog to find an answer.
      Not exactly a duty that should be widely imposed, is it?

      • To start out with, one thing I didn’t make clear is that I don’t think doctors should handle what they are not capable of handling. ie – we don’t want a GP doing the work of an oncologist.

        By an extent, we can then posit that if you do not have the experience or the equipment to handle obese patients, then you should not handle obese patients.

        Except when 20% of adult Americans are obese (and it’s climbing) I suppose the question is, when should doctors be educating themselves to handle the risks instead of turning people away? This of course assuming there is a way to do that, since some of the reasoning involves not being capable of handling an obese patient.

        I think it worked out, that according to the article 90% of doctors in FLA still accept obese patients – so this issue isn’t endemic, but I’d probably still say it’s an issue – certainly not for those doctors who are refusing to treat them, but for the patients and perhaps for the mindset of the profession as a whole. You treat the patient in front of you, you know?

        This doesn’t mean that the sue-quick mindset of the United States is not involved in this issue. Heavy liability has been causing, as far as I know, quite a few problems in the US that drives your medical costs up and I’m sure for doctor’s makes their jobs less pleasant. It’s just one thing to order a likely unnecessary test to cover yourself and to … turn a patient away to cover for yourself.

        And while I don’t think they should be shackled or jailed or … something to make them accept the patient! that doesn’t mean I have to think well of them. (grin) Because you know, my good opinion up here in the North is EVER so important to those FLA doctors’ self-esteems.

        Regarding the idea of one doctor finding another doctor willing to treat people they are not willing or able to treat, I am more thinking … the idea of a referral, than research, etc. Less like cold calling and more like some form of support somehow for the patient. The way a doctor might tell a patient: well I can’t handle your aneurysm but there is a doctor ____ who might, I’m going to refer to him. Or the way a GP refers you to a rehabilitation doctor (which would be my most recent experience). I suppose this would really only be tenable in practices or other organizations, but man. I just hate the idea of “No, sorry, you’re too fat.”

        As an aside, if a doctor turned away a pregnant woman, and it turned out she had an issue, or a problem that could have been helped but wasn’t, would the doctor who turned them away be considered liable?

        Loooong comment. No more talking for RP, now.

  6. Retired businessman says:

    Lawyers take cases on risk/reward. What if doctors do the same? It is just good business after all isn’t it? What if a high risk patient agrees to limit or forgo the right to sue before an operation, would that not end the massive damage awards?

    • Sarah G says:

      If the patient dies, the family will sue, and probably successfully, agreement notwithstanding. That’s just based on observation, though.

      This also brings up another slippery slope: what if MDs made ALL patients sign such forms as a condition of treatment?

    • LawDragon says:

      In my states of practice, Washington and Oregon, it is “agaisnt public policy” to prospectively waive negligence. If I recall correctly from law school (some time ago), this is universal in the US.
      Waivers foregiving negligence if it occurs in the future are not allowed.

      Cheers, LawDragon

  7. Anon Doc says:

    I don’t have any solution for this either, but I can certainly forsee obese pts in FL being unable to find docs to provide prenatal care, ending up giving birth w/o having gotten that care, having a bad outcome and suing the unfortunate OB who happened to be on call at the county hospital for the delivery.

  8. ERP says:

    Hmmm. I would say in “private” practise, the MD can refuse to take anyone one that they don’t want – for whatever reason other than race, ethnicity or religious views (as protected by established law). That doesn’t mean I advocate that though. Basically you are tool if you do so.
    However, if they are on call for the ER, they need to deal with everyone who needs their care when called by the ER doc. That’s just basic.

  9. [...] Some Florida ob-gyns turn away seriously overweight patients, who face a greater risk of complications in pregnancy [Sun-Sentinel/Palm Beach Post] More: White Coat. [...]

  10. Ian Random says:

    As someone who is twice the man he should be (360lbs), I support a doctor’s right to refuse treatment. I always laugh when my allergist says reflexively to update him should I be put on high blood pressure medicine. My blood pressure is 125/89 usually and I’m a couch potato (not by choice).

    • rhiles says:

      As someone who is twice the woman she should be (5’9″ 300lbs) I do NOT support this right. I am a healthy individual, I eat right, I exercise daily, and I even have gone so far as to have a personal trainer create a beautifully crafted work out plan for me. My blood pressure is typically 125/72.My husband and I want to have children at some point as I’m only 22. So why is it right, that I, a healthy, “morbidly obese” individual gets denied care, when I have friends who smoke, drink, do drugs, eat nothing but bacon half the time, never work out, and take terrible care of themselves, but weigh in a “normal” limit. I realize I’m in the minority here as everyone decides that fat people are the laziest, but even still, it’s sick that I might be denied care because I can’t get my weight under control.

  11. Pattie, RN says:

    Has anyone here ever been in the delivery room with a morbid obese mom? (although it tends by far to be the OR). I have attended many such births, and the landmarks are obscured, the fundus almost impossible to locate, excessive bleeding is the norm, and nurses get hurt-badly-trying to support the leg of a 450 pounder trying to push.

    Hell yes, I’d love to be able to send them elsewhere, and these docs should be able to. Sadly, the nurses in L&D are stuck with whatever obese/high/no prenatal care/crack addicted patient that wheels in with a baby wanting OUT.

    • Alison says:

      I wish it could work that way, but the problem is — what happens when the other providers start cherry-picking, too? When all the docs start refusing to treat the undesireable patients? Where will that woman get care then?

      • Hueydoc says:

        Maybe they would get serious about losing weight then ?
        If you are turned down for health insurance because you weigh 10 pounds too much, you either lose the weight or find another company.

      • Hueydoc says:

        And if ALL the other companies turn you down, it’s time to lose the damn weight.

  12. Ask me how many times I’ve went into a store that had a sign on the door that read – “No Shoes, No Shirt, No Service”?

    Why are other professions given the benefit of refusal of service, but not healthcare providers?

    There was a ton of outrage in the media when hospitals first decided not to employee smokers, even though smoking is a leading cause of poor health, and other employers/professions had similar restrictions beforehand.

    The same can be said about pharmacists whom refuse to dispense Plan-B based on their personal religious beliefs.

    For some weird reason, our rights are considered to be secondary to anyone else’s rights. The funny part of it all is that the people who bitch the loudest are almost always the ones who could have prevented the problem they’re having in the first place.

  13. Doc Edwards says:

    No one understands the real issue here.

    By law, you lose your Florida license to practice medicine after three malpractice suits.

    And no one gets sued more than the OB docs. Mega-sleeze John Edwards and many other crooked shysters make vast fortunes off the obstetricians.

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