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Journal of Clinical Gynecology & Obstetrics

Original Article

Volume 13, Number 2, June 2024, pages 25-34

Female Perspectives Regarding Quality of Care and Weight-Related Communication in Obstetrics-Gynecology and Family Practices

Within the period of a decade, Americans have demonstrated flexibility in their beliefs and attitudes regarding sexual orientation and race, approaching neutrality [1]. However, in regard with weight bias, studies have shown that both implicit and explicit weight bias is persistent among general public and in medical communities [1, 2]. This is despite the rapidly increasing rates of obesity. Over the past two decades, adult obesity prevalence increased from 30.5% in 1999 - 2000 to 41.9% in 2019 - 2020 [3, 4]. With the rising prevalence of obesity, the disease burden is also increasing and is associated with higher rates of diabetes, hypertension, hyperlipidemia, stroke, surgical complications, and malignancies [5-7]. A predominant effect of the obesity epidemic in the field of obstetrics is the increasing rates of polycystic ovarian syndrome, anovulation resulting in infertility, and endometrial cancer in women [8].

Obesity is a complex disease that requires both system- and individual-level interventions and the need for long-term investment and trust from both the provider and the patient. The patient-physician relationship is essential in the care of obesity. Physicians are a critical component to educating patients, including providing support, counseling, and treatment options [9]. For women, primary care settings, including obstetrics-gynecology (OBGYN) and family practices (FP) play pivotal roles in influencing the care that women with obesity receive given the intimate nature of the history and physical examinations. Importantly, there are limited studies that look specifically at the female perspective. Hurst et al reported patients with elevated body mass index (BMI) > 40 kg/m² undergoing prenatal care experienced weight discrimination and offered preferred terminology regarding weight including “high BMI” and “weight” rather than “obesity” or “large size” [10].

Literature suggests that lack of awareness and obesity bias can play an important role in reduced quality and frequency of provided clinical care for patients in particular preventive gynecological care, and more recently described in those with obesity who have a higher prevalence of an overactive bladder [11, 12]. This issue is still prevailing that healthcare providers feel inadequately qualified to effectively counsel patients with obesity [2]. Despite efforts in medical education to reduce weight bias, there remain ingrained physicians’ biases that can negatively affect patients’ perceptions of provider’s credibility, level of trust, and inclination to follow medical advice. From patient perspective, patients have reported weight stigma during their interaction with healthcare providers [13]. Patients perceive of being disrespected and feel that their providers have a lack of understanding on situations that could potentially lead to embarrassment including being weighed in public areas and being offered unsolicited advice to lose weight [5, 14]. These negative patient perspectives against healthcare providers lower expectations for treatment which can result in avoidance of care, poor adherence to treatment, and lack of preventative care such as mammography or Papanicolaou testing irrespective of providers’ effort and intentions [15, 16].

Due to the reported obesity bias in women’s health care in relation to obesity, we examined female patient’s perspective of potential physical and emotional barriers that may affect the experiences of patients with elevated BMI in two different primary care settings: OBGYN and FP. We assessed female patients’ perspectives regarding the quality of care, communication, and the clinical office environment provided by healthcare providers in the primary care outpatient setting.

Patients of two Midwest outpatient academic practices, one OBGYN and one FP clinic, were surveyed from December 2017 to January 2018, and all adult female patients with BMI ≥ 25 kg/m² were invited to participate in a 20-question survey during their regularly scheduled clinic appointment. Included were females to control for the potential confounding effect of sex on comparisons of differences by practice type. Participants who were invited to participate were identified based on the patient’s most recent BMI obtained from the clinical site’s electronic medical record by front desk personnel. Excluded from the study were females with a BMI < 25 kg/m² and pregnant patients. Surveys were distributed upon clinic check-in. Patients were asked to complete the survey after their visit, and to either return the survey to a folder in the clinic or to mail it in a pre-stamped envelope to the researcher (SL). Approximately 6.6% (n = 346/5,242) of all invited female patients from two outpatient academic practices participated in this study. Patients originally identified with a BMI ≥ 25 kg/m² with a healthy weight (BMI < 25) at the time of distribution of the survey (n = 8) or with missing information on weight status (n = 8) were excluded from the analysis. A total of 330 patients were included in the final analysis. No identifying information was collected in the patient survey. Patient survey data were entered and managed using REDCap electronic data capture tools hosted at Wright State University. This cross-sectional survey study based on a convenient sampling of females was approved by the Wright State University Institutional Review Board (SC #6007).

The survey collected information on patient and physician demographics, patients’ perceptions of clinical practice, and perceptions of the office environment. Questions utilized in the present study’s questionnaire were from previously published, validated surveys [17, 18]. Patient demographic questions included age range (21 - 30, 31 - 50, and > 50 years), ethnicity (Hispanic vs. non-Hispanic), race (White vs. other), education level (high school degree or lower vs. associate’s degree or higher), perception of their own weight (thin, average, or overweight), and self-reported height and weight, which were used to calculate BMI (kg/m²). Weight status discrepancy was compared between perceived own weight status and CDC weight status (overweight: 25 ≤ BMI < 30; class 1 obesity: 30 ≤ BMI < 35; class 2 obesity: 35 ≤ BMI < 40; class 3 obesity: 40 ≤ BMI) calculated from self-reported weight and height. Discrepancy between patients’ perceptions of own weight status and calculated BMI categories based on self-reported weight and height was recorded: 1) underestimated (e.g., “perceived as thin” vs. overweight, “perceived as average” vs. class 1 and 2 obesity, or “perceived as overweight” vs. class 2 and 3 obesity); and 2) not.

Questions assessing the clinical environment such as the availability and suitability of resources for patients with elevated BMI were measured on a two- to three-point Likert scale. These questions included whether the weight scale was placed in a private setting of the office (0 = no, 1 = did not notice, or 2 = yes), whether the weight scale was large enough to accommodate the patient’s weight (0 = no vs. 1 = yes), and whether the gown utilized during their consultation was the appropriate size (0 = not used, 1 = too small, 2 = too large or 3 = right size). Other questions included whether the blood pressure cuff utilized during their exam was of the appropriate size (0 = too small, 1 = too large or 2 = right size) and if the exam table used during their physical exam was of the appropriate size and height (0 = not used, 1 = too small, 2 = too large or 3 = right size).

Questions regarding patients’ perspectives on clinical practice and the quality of care delivered by their physician were assessed on a four-, five- or seven-point Likert scale with a higher score denoting a higher perceived level of care. These questions included: 1) perceived physician’s level of understanding of what it feels like to be overweight/obese (1 = not at all to 7 = extremely well); 2) the frequency at which their physician treated them with courtesy and respect (1 = never, 2 = sometimes, 3 = usually or 4 = always); 3) perceived level of comfort of their physician in discussing weight-loss or obesity treatment options (1 = very uncomfortable to 7 = very comfortable, or 0 = weight not discussed); 4) perceived whether or not their physician utilized sensitivity when discussing patients’ weight (1 = rarely/never, 2 = sometimes, 3 = about half of the time, 4 = most of the time, 5 = always); and 5) patients’ overall satisfaction with care (1 = very dissatisfied to 7 = very satisfied). Finally, patients were asked if they felt that they were given the same quality of treatment as patients with normal BMI. The four responses were included: yes treated the same, no treated worse than patients who are not overweight/obese, no treated better than patients who are not overweight/obese, or not sure.

Statistical analysis was performed using Windows-based SAS version 9.4 (SAS Institute, Cary, NC). Categorical data were reported as frequencies and percentages, and continuous variables were reported as mean and standard deviation (SD). Group differences between patients’ characteristics and perceptions of clinical practices were compared using the Student’s t-test for continuous variables and the Chi-squared test for categorical variables. Fisher’s exact test was also used to compare those cells’ expected frequencies of less than 5. For those questions on a four or more-point Likert scale, the data were treated as interval data, and the response distribution was examined. Due to the lack of variation and skewness in response to those Likert scale-based questions asking patients’ perspectives, we first used the Wilcoxon two-sample rank sum test to examine the differences in patients’ perspectives on clinical practice between two specialties. Secondly, we used the Chi-squared or Fisher’s exact tests on collapsed responses. For the question (i.e., Do you feel that your doctor treats you the same way as patients who are no overweight?), the Fisher’s exact test was used. Multiple ordinal, multinomial, or binary logistic regression analyses were conducted to test the factors associated with patients’ perspectives and overall satisfaction with care. The specialty practices and covariates such as patient’s demographics (age, race/ethnicity, education level) and weight status were selected in the multiple logistic regression models using the backward selection. Adjusted odds ratio (OR) and 95% confidence intervals (CIs) were displayed. Statistical significance was assessed at P < 0.05.

This study was conducted in compliance with the ethical standards of the responsible institution on human subjects as well as with the Helsinki Declaration.

Patients and physicians’ characteristics are displayed in Table 1. Patients were between 31 and 50 years old (44.5%), had a self-reported average (± SD) BMI of 39.8 ± 8.2 kg/m², and the majority had a high school diploma or less (67.9%). Only 6.7% patients were categorized as having overweight whereas more than 70% of patients had class 2 or 3 obesity based on BMI calculated from self-reported weight and height. However, 45.5% of patients perceived themselves as overweight (45.5%) while another 43% regarded themselves as very overweight, but no one reported that they were either “extremely thin” or “thin”. Approximately 38% of patients underestimated their own weight status. The majority of physicians were between the ages of 21 and 30 (48.6%), males (52.1%), and resident physicians (51.8%). There were significant differences by specialty (OBGYN vs. FP) in following variables: patients’ age groups and race (P < 0.0001), and educational attainment reported by patients (P < 0.0001). There was no significant difference in weight status of patients seen at OBGYN or FP office. The characteristics of two clinical settings were different in age groups and experience of physician (P < 0.001).

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Table 1. Patients and Physicians’ Overall Characteristics and Differences by Clinical Practices

Patients’ responses to clinical environment by two specialties are listed in Table 2. Over half of patients reported favorable clinical environments as measured by questions addressing the availability and appropriateness of medical equipment for patients with elevated BMI. Patients reported the weight scale being located in a private setting of the medical office (67.5%), and the weight scale (98.8%), gown (57.4%), blood pressure cuff (97.5%), and examining table (92.3%) being of an appropriate size. Significant differences by the specialty were noted when reporting the placement of the weight scale (P < 0.001) and the appropriate size of medical gown (P < 0.001). However, among the patients who used the medical gown for physical exam, there was no significant difference for the appropriateness of medical gown between two specialties (P = 0.71).

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Table 2. Patients’ Perspective of Clinical Environment

Patients’ perceptions to their physician’s understanding, attitude, comfort and satisfactions related to overweight or obesity are displayed in Table 3. Most patients felt their physician was understanding of what it felt like to have elevated BMI (“overweight or obese”, 63.1%). Compared with OBGYN patients, FP patients reported a higher score regarding physician understanding of what it feels like to be overweight/obese (P < 0.001). A significantly higher proportion of FP patients felt this way when compared to OBGYN patients (70.1% vs. 54.0%, P < 0.014). A large majority (91.1%) of patients felt their physician treated them with courtesy and respect, with no significant differences by specialty (P = 0.56). Over half of patients (67.7%) perceived their physician to be comfortable in discussing weight-loss treatment with FP patients perceiving higher level of comfort by their physician than OBGYN patients (75.9% vs. 58.4%, P = 0.006). Most patients felt their physician used sensitivity when discussing their weight (85.7%), and that their physician offered the same quality of care as delivered to patients with a normal BMI (76.8%). No differences by specialty were noted when assessing these items. There was significant difference in overall satisfaction score between two specialties (P = 0.012). A higher proportion of OBGYN patients (93.8%) reported feeling satisfied with the quality of care delivered when compared to FP patients (82.9%, P < 0.01).

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Table 3. Patients’ Perspective on Clinical Practice and the Quality of Care

Table 4 reports the factors associated with patients’ overall satisfcation with care. Of all factors including patients’ demographicss, clinical environment perspectives, and practice type, the only significant factor associated with physician understanding of having a higher BMI was the weight scale in a private setting (P < 0.05). For example, for those patients who said that the weight scale was not located in a private setting compared to patients who said it was, the odds of reporting that her physician did not or somewhat understood was 5.64 times higher (95% CI: 3.21 - 9.89) compared to reporting the physician understood.

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Table 4. Factors Related to Patients’ Overall Satisfaction of Clinical Practice by Specialties

Significant factors (P < 0.05) related to the perception of being treated with respect and courtesy included patients’ age and weight scale privacy (Table 4). Patient’s age (31 - 50 years old vs. 21 - 30 years old: adjusted OR = 0.28, 95% CI: 0.10 - 0.77, P = 0.014; 50 years and over vs. 21 - 30 years old: adjusted OR = 0.36, 95% CI: 0.13 - 0.97, P = 0.043) was independently associated with the perception of the physician treating the patient with courtesy and respect. Older patients were significantly less likely to feel like their physician treated them with courtesy and respect. Visiting either practice was not significantly associated with perception of understanding (P = 0.697), being treated with respect and courtesy (P = 0.465).

Concerning whether the physician was comfortable discussing weight-loss and obesity treatment options with them, specialty, education, and weight scale privacy were independently associated. For example, compared with patients who visited FP practices, patients who visited OBGYN reported that they felt the physicians were significantly more uncomfortable (adjusted OR = 1.91, 95% CI: 1.06 - 3.46) than perceiving comfortable or neutral, given patients’ education level and weight scale privacy constant in the model.

There was no significant factor associated with whether patients felt their physician used sensitivity when discussing their weight or whether patients felt that they were treated the same way as patients who were not overweight.

Regarding the patients’ overall satisfaction, specialty was the only significant factor. Patients who visited OBGYN were 3.22 times (95% CI: 1.47 - 7.07, P = 0.004) more likely to report overall satisfaction with care compared those who visited FP.

Results from our study indicated that the majority of patients reported they were treated with both courtesy and respect whether they were seen at an FP or an OBGYN office. However, FP physicians appeared to be more comfortable discussing weight issues and more likely to understand their patients’ weight experience. In contrast, patients cared for by OBGYN practices had significantly worse experiences regarding weight-related communication and clinical environments. The present study revealed that weight bias continues to be an ongoing issue and is significantly more problematic in OBGYN offices.

Prior to this study and for at least the last decade, educational interventions have attempted to target trainee physicians to address weight-based stigma and the pervasive consequences that come with it [19, 20]. While medical schools do not typically explicitly focus on weight bias [21] many schools have education on empathy, implicit bias, and health disparities [22]. This, with the growing body of literature that addresses the obesity crisis and the known harmful effects of weight stigma, should foreshadow a change in provider behavior. Consequently, changes in patient perceptions would be expected to follow as well. However, limited studies have evaluated the success of these educational interventions, and there is little understanding of the impact on patient behavior. In a 2018 study, Johns Hopkins Medical School evaluated weight bias over 6 years. They demonstrated that many students continued to regard obesity negatively and another national survey of medical students reported its etiology as a lack of willpower from the patient [9, 23]. It has been clearly outlined that obesity bias is bidirectional between both physician and patient. Significant work has been implemented to adjust providers’ perceptions of patients with obesity, in order to ensure that patients do not approach their care with the expectation of differential treatment based on their weight. In our study, 95% of patients reported appropriate exam tables, 68% with correctly sized gowns and more than 80% of respondents felt that weight was discussed sensitively, which is substantially different from previous research [9, 19]. Additionally, over 90% of patients felt their physician treated them with courtesy and respect.

This study highlights a positive trend toward eliminating obesity bias in health care. In addition to modifying inherent anti-fat biases, physicians and their teams must be attuned to concerns and sensitivities of their patients with elevated BMI and provide a clinical environment to meet their specific needs. Modifications to accommodate patients with elevated BMI are not simply good practice, but also dictated by American Disabilities Act of 1990, Title III, under the context of obesity as a disability [24]. As such, physical barriers to entering and using existing facilities should be identified, adjusted, or removed. These include examination rooms that are more accommodating for patients with obesity, larger examination tables with a wider base to facilitate ascending to the table, larger specula for female exams, and larger cloth gowns. While the present study showed areas of necessary improvement, it is reassuring that the majority of patients in both specialties received courteous and respectful treatment from their providers.

The study results have provided an updated insight into the perceptions of women with elevated BMI, which will facilitate improved treatment of this population. Patients of OBGYNs reported significantly less weight-friendly experiences. This is a missed opportunity to connect and support patients through weight management. Two areas of improvement for the office environment include scale placement and appropriate gown size. Undressing is often a necessary aspect of seeing an OBGYN provider, which inherently brings attention to body image and can create anxiety for patients with obesity. It is critical to provide the appropriate environment and equipment to minimize anxiety. Further, providers can better harness the power of empathy. Psychiatric and neurologic data support how empathy can enhance patient adherence to care plans, and instructors can integrate this concept into medical training [25]. The discrepancy between the specialties offers an opportunity for OBGYNs to improve their clinical environments and their demeanor when discussing weight in the office. With regards to factors associated with patients’ perception of clinical practice, the difference between two specialties did not significantly contribute to the perception. Patients’ factors such as age, patients’ weight status and their own weight perception, and physician’s experience were significant predictors for different domains of perceptions.

The strengths of our study are that it compared two specialties that were different and critical to the care of women with overweight and obesity. Further, results were drawn directly from patients. Additionally, patients’ BMI was verified through measurements taken by health care staff as opposed to a self-reported measure. The limitations of this study are that the cross-sectional design based on a convenient sampling means only associations can be determined, not causation. It is also limited in that many of the surveys were collected from a residency clinic, which may not truly represent the FP and OBGYN specialties at large. Further, the sample size limits the generalizability of results. Lastly, patients are more frequently required to undress for examination in OBGYN offices, which may impact survey responses.

Literature has extensively documented the prevalence of obesity bias in the current healthcare environment. We demonstrate that patients visiting FP clinics generally had a more positive perspective on the clinical environment, as well as their provider’s ability to discuss weight-loss and obesity options. This provides an important insight into the developments needed for the field of OBGYN related to weight and obesity-related care. Particularly as an increasing amount of work demonstrates the negative effect of obesity on reproduction, menstruation, and overall women’s health. Interestingly, although patients reported lower satisfaction from OBGYN clinics regarding clinical environment (scales in private location and gowns of appropriate size), OBGYN patients reported a higher overall satisfaction with the care provided to overweight/obese patients. This could indicate that patients are prioritizing different concerns when visiting FP versus OBGYN clinics.

Acknowledgments

The authors thank patients and physicians of participating primary practices for their participation in the survey and the data management staff of the Department of Obstetrics and Gynecology, Wright State University Boonshoft School of Medicine.

Financial Disclosure

This research received no specific grant funding.

Conflict of Interest

None to declare.

Informed Consent

Not applicable.

Author Contributions

Elizabeth Culberson: writing - original draft and editing; Lisa Kellar: data curation, writing - review and editing; Rose Maxwell: writing - review and editing; Leah Whigham: writing - review and editing; Miryoung Lee: statistical analysis, writing - review and editing. All authors contributed to the article and approved the submitted version. Steven Lindheim: formulation of study idea, project administration, writing - review and editing.

Data Availability

Any inquiries regarding supporting data availability of this study should be directed to the corresponding author.

1. Charlesworth TES, Banaji MR. Patterns of implicit and explicit attitudes: I. long-term change and stability from 2007 to 2016. Psychol Sci. 2019;30(2):174-192.
   doi pubmed
2. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring). 2009;17(5):941-964.
   doi pubmed
3. Fryar CD, Carroll MD, Afful J. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960-1962 through 2017-2018. NCHS Health E-Stats. 2020.
4. Ogden CL, Fryar CD, Martin CB, Freedman DS, Carroll MD, Gu Q, Hales CM. Trends in obesity prevalence by race and hispanic origin-1999-2000 to 2017-2018. JAMA. 2020;324(12):1208-1210.
   doi pubmed pmc
5. Hruby A, Hu FB. The epidemiology of obesity: a big picture. Pharmacoeconomics. 2015;33(7):673-689.
   doi pubmed pmc
6. Powell-Wiley TM, Poirier P, Burke LE, Despres JP, Gordon-Larsen P, Lavie CJ, Lear SA, et al. Obesity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2021;143(21):e984-e1010.
   doi pubmed pmc
7. G. B. D. O. Collaborators, Afshin A, Forouzanfar MH, Reitsma MB, Sur P, Estep K, Lee A, et al. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med. 2017;377(1):13-27.
   doi pubmed pmc
8. Palomba S, Santagni S, Falbo A, La Sala GB. Complications and challenges associated with polycystic ovary syndrome: current perspectives. Int J Womens Health. 2015;7:745-763.
   doi pubmed pmc
9. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319-326.
   doi pubmed pmc
10. Hurst DJ, Schmuhl NB, Voils CI, Antony KM. Prenatal care experiences among pregnant women with obesity in Wisconsin, United States: a qualitative quality improvement assessment. BMC Pregnancy Childbirth. 2021;21(1):139.
    doi pubmed pmc
11. Alsannan B, Lagana AS, Alhermi J, Almansoor S, Ayed A, Venezia R, Etrusco A. Prevalence of overactive bladder among overweight and obese women: A prospective cross-sectional cohort study. Eur J Obstet Gynecol Reprod Biol. 2024;295:59-64.
    doi pubmed
12. Telo GH, Friedrich Fontoura L, Avila GO, Gheno V, Bertuzzo Brum MA, Teixeira JB, Erthal IN, et al. Obesity bias: How can this underestimated problem affect medical decisions in healthcare? A systematic review. Obes Rev. 2024;25(4):e13696.
    doi pubmed
13. Ryan L, Coyne R, Heary C, Birney S, Crotty M, Dunne R, Conlan O, et al. Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis. Obes Rev. 2023;24(10):e13606.
    doi pubmed
14. Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007-2008 to 2015-2016. JAMA. 2018;319(16):1723-1725.
    doi pubmed pmc
15. Phelan SM, Burgess DJ, Burke SE, Przedworski JM, Dovidio JF, Hardeman R, Morris M, et al. Beliefs about the causes of obesity in a national sample of 4th year medical students. Patient Educ Couns. 2015;98(11):1446-1449.
    doi pubmed pmc
16. Wee CC, McCarthy EP, Davis RB, Phillips RS. Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care? Ann Intern Med. 2000;132(9):697-704.
    doi pubmed
17. Hebl MR, Mannix LM. The weight of obesity in evaluating others: a mere proximity effect. Pers Soc Psychol Bull. 2003;29(1):28-38.
    doi pubmed
18. Tomiyama AJ, Finch LE, Belsky AC, Buss J, Finley C, Schwartz MB, Daubenmier J. Weight bias in 2001 versus 2013: contradictory attitudes among obesity researchers and health professionals. Obesity (Silver Spring). 2015;23(1):46-53.
    doi pubmed
19. Swift JA, Hanlon S, El-Redy L, Puhl RM, Glazebrook C. Weight bias among UK trainee dietitians, doctors, nurses and nutritionists. J Hum Nutr Diet. 2013;26(4):395-402.
    doi pubmed
20. O'Brien KS, Puhl RM, Latner JD, Mir AS, Hunter JA. Reducing anti-fat prejudice in preservice health students: a randomized trial. Obesity (Silver Spring). 2010;18(11):2138-2144.
    doi pubmed
21. Adams KM, Lindell KC, Kohlmeier M, Zeisel SH. Status of nutrition education in medical schools. Am J Clin Nutr. 2006;83(4):941S-944S.
    doi pubmed pmc
22. Stone J, Moskowitz GB. Non-conscious bias in medical decision making: what can be done to reduce it? Med Educ. 2011;45(8):768-776.
    doi pubmed
23. Geller G, Watkins PA. Addressing medical students' negative bias toward patients with obesity through ethics education. AMA J Ethics. 2018;20(10):E948-959.
    doi pubmed
24. Harkin ST. Americans with disabilities act of 1990, in 101-336, S.-L.a.H. Resources. Editor. 1990.
25. Moudatsou M, Stavropoulou A, Philalithis A, Koukouli S. The role of empathy in health and social care professionals. Healthcare (Basel). 2020;8(1):26.
    doi pubmed pmc

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