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Med Students Unaware of Their Bias Against Obese Patients
An anonymous reader sends news of a study which found that "two out of five medical students have an unconscious bias against obese people." The study, published in the Journal of Academic Medicine (abstract) examined med students from many different cultural and geographical backgrounds.
"The researchers used a computer program called the Weight Implicit Association Test (IAT) to measures students’ unconscious preferences for 'fat' or 'thin' individuals. Students also answered a survey assessing their conscious weight-related preferences. The authors determined if the students were aware of their bias by seeing if their IAT results matched their stated preferences. Overall, 39 percent of medical students had a moderate to strong unconscious anti-fat bias as compared to 17 percent who had a moderate to strong anti-thin bias. Less than 25 percent of students were aware of their biases. 'Because anti-fat stigma is so prevalent and a significant barrier to the treatment of obesity, teaching medical students to recognize and mitigate this bias is crucial to improving the care for the two-thirds of American adults who are now overweight or obese,' Miller said. 'Medical schools should address weight bias as part of a comprehensive obesity curriculum.'"
Fat hatred and blaming people for being fat is so universal and so conscious that it's hard to take any methodolgy seriously that finds that people are "unconscious" of their hatred of obese people.
Want to get at the real socially redeeming value of this journal entry? Study the methodolgy, understand where it went wrong, and above all never, ever use it.
I'm not unaware. I know exactly what I think about fat people and It's not good.
but I couldn't eat a whole one
I got to the chocolate box before you, that's why the hard ones have teeth marks.
than doctors having a bias against smokers, recreational drug abusers, sex addicts with lots of partners, etc? Each of these groups are doing things that is typically detrimental to one's health, so there seems to be an issue of self control there.
Compassion is supposed to be a hallmark trait of the medical profession. Any doctor who lets his personal beliefs get in the way of his practicing medicine in the best possible way to ANY patient - be s/he fat, thin, muslim, atheist, black, green, prisoner, retarded, or just an average joe - is a bad doctor. If a patient is obese then yes, it poses a serious health risk and a problem. My job as a doctor is not to lecture that patient or make fun of them, but to try to help them as much as I can with the tools I have at my disposal. The same for alcoholics, drug addicts, and anyone else. Because at the end of the day said behavior is usually just a symptom of a different, underlying problem.
Seven puppies were harmed during the making of this post.
For those not familiar with implicit association tests, they are based on measuring your reaction times when matching certain types of data according to different specified criteria. For example a gender association test might measure time for matching gender with staying at home raising children versus working outside the home.
Harvard has plenty of sample tests.
Having taken some of the tests I can say that the results can be quite surprising and point out biases that you are unaware of. I definitely found that some associations were much easier for me than others. (Happy to say that the gender example above was not a problem for me.)
"anti-fat stigma is so prevalent and a significant barrier to the treatment of obesity"
Being fat-positive would help with the treatment of obesity?
"Doctors are more likely to assume that obese individuals won’t follow treatment plans"
The primary goal of our treatment plan is often to get them to lose weight to cure their hypertension and type 2 diabetes. It's not a bias if you see the same patient in clinic every few months for years and they continue to gain weight and ignore your recommendations.
**** ********* M.D. , PGY-4 Resident
You're ignoring the part about the implicit association test. See my post above.
I agree that what someone admits to doesn't say anything about unconscious feelings. But an IAT can demonstrate feelings that you're not even aware of.
were obese? When my wife was in med school about half the class was obese, a few morbidly so.
Are you unaware that "Less than 25 percent of students were aware of their biases" means that 75% were unaware of their biases?
Sounds as though that is a pretty apt title.
Sure, it is biases against "various weights" not just "overweight & obese", but the point still stands.
Thirty four characters live here.
Actually, it's even worse - 25% of students were aware of the bias, and 39% were biased against obese people, so it's really only 30%.
Other reasons this study is stupid:
* half as many students instead have an anti-thin bias
* about 40% of med students never even graduate and become doctors anyway
* it was done at a single "Southeastern university"
* one of the assumptions they were worried about was that they "are more likely to assume that obese individuals won’t follow treatment plans." Given the number one thing an obese person can do to improve their health is exercise, eat less, and subsequently lose weight (all achievable goals for the majority of obese people, who honestly already knew those things anyway) they probably have a reason to worry about that, and it's therefore medically significant to their treatment recommendations!
It's not mental illness, it's addiction. Yet, I really don't like that word as it implies a removal of personal responsibility. No, like so many other things, overeating has to do with abuse of our pleasure systems. If we taught people to be self aware enough to recognize when they are engaging in actions that will subvert physiological systems into a habit then they would (hopefully) be able to self limit early on.
On the Oregon Cost born and raised, On the beach is where I spent most of my days
A health care professional can be expected to have a bias regarding healthy vs unhealthy life choices.
No shit. That is not what they mean by bias in this study. RTFA:
“Bias can affect clinical care and the doctor-patient relationship, and even a patient’s willingness or desire to go see their physician, so it is crucial that we try to deal with any bias during medical school,” said David Miller, M.D., associate professor of internal medicine at Wake Forest Baptist and lead author of the study.
“Previous research has shown that on average, physicians have a strong anti-fat bias similar to that of the general population. Doctors are more likely to assume that obese individuals won’t follow treatment plans, and they are less likely to respect obese patients than average weight patients,” Miller said.
Well, you completely missed the point. Doctors who don't recognize their biases are more likely to misdiagnose patients that they're biased against.
Take me, for example. My kidneys failed due to IGA nephropathy, which has absolutely nothing to do with weight. I'm overweight, however, so for the first year of me feeling run down, getting sick often and having other health isuses my doctor insisted that I just needed to lose weight. He never bothered looking for other potential causes because, in his mind, the problem had to be that I was too fat and therefore didn't deserve any further attention.
I explained it in simple terms and offered a real life example and you still can't figure out why a doctor that doesn't recognize his biases is a bad thing?
* about 40% of med students never even graduate and become doctors anyway
Cite?
* it was done at a single "Southeastern university"
Which means a follow on study should cover a broader group, not that the study is invalid. Starting with a small sample and expanding it as time and money allows is common practice.
* one of the assumptions they were worried about was that they "are more likely to assume that obese individuals won’t follow treatment plans." Given the number one thing an obese person can do to improve their health is exercise, eat less, and subsequently lose weight ... they probably have a reason to worry about that, and it's therefore medically significant to their treatment recommendations!
They said "treatment plans", not "treatment plans related to obesity". Treatment plans specifically related to obesity are, as you observed, not necessary except in extreme cases. Dealing with a broken finger or taking the entire course of antibiotics even though you're feeling better also involve treatment plans. Being fat usually means a lack of self-control or excessive self-indulgence in one particular area. The same is true about people who do any number of things, like have unprotected sex with multiple partners. It does not mean they won't follow recommendations in other areas. Your prejudice demonstrates exactly what the study is concerned about.
one thing an obese person can do to improve their health is exercise, eat less
Putting aside that that's two things, there is growing evidence that getting insufficient exercise is worse than being moderately overweight (not fat though). There are plenty of thin people who get little exercise, and exercise is not the biggest factor in loosing weight. However the amount of exercise you get is something that's easy to lie to the doctor about. Additionally a lack of aerobic/cardio exercise is not something that's immediately obvious to people you meet, hence less prejudice.
Second, and by far most intriguing, is the 33% (101/310) of students who openly acknowledged an explicit personal bias. Given that 39% (121/301) were found to have an actual bias on the implicit test, on the surface this result isn't surprising - but the 101 who think they're biased, and the 121 who actually have an implicit bias, don't overlap very closely. Just 40 students who thought they had a bias actually did. The study authors (and the journalists who have summarized their results) decided to frame this in the form of two-thirds of anti-fat students don't know they're biased! It's much more curious, I think, to note that a healthy majority of students who thought they were biased against the obese - 61% (61/101) - actually aren't.
Indeed, it turns out that there wasn't a significant correlation between believing one was biased and actually having a bias. So why do three out of five students who think they have an anti-fat bias hold that belief mistakenly?
~Idarubicin
It's slightly complicated by all the bad advice that's given on how to manage ones weight.
However, when all is said and done, eating less and moving more solves the problem for most people. Sometimes there's a need to fix ones sleep and or stress in order to lose the weight.
But, doctors themselves are a terrible source of information on diet and exercise. Unless it's changed recently, they only get a few weeks of training on diet and none on exercise.
Mostly because fat people live sedentary lives; the guy with a beer gut isn't going to die rock climbing. That doesn't mean they're healthier.
Actually, no, but because the BMI scale is significantly off. Most people who go rock climbing will be considered "obese", or at very least overweight by it, because they have significant muscle mass.
And it's not simply "normal" weight, it's based on actual fitness. Your body can not do as many things if it has lots of fat and little muscle, so you are functionally disabled. You don't see fat people out running because on the odd occasion that they do, they can't keep it up for very long. They can't have sex as long. They can't climb flights of stairs. They can't physically defend themselves.
Again, wrong. Not fat, and fit are very different things. It's possible to be overweight and extremely fit and active, and its very easy to be underweight or "normal" weight, and not at all fit.
Then don't pretend that homosexuality isn't a mental illness, either. Evolution has conditioned us so that the desire to pass on our genes is a strong imperative. If you actively go out of your way to not pass on your genes, to seek partners who are incapable of doing so, then something must be wrong with your mind. On top of that, anal intercourse has a much higher chance of passing on infectious diseases than vaginal intercourse. Regularly having anal sex must be a mental illness then, too.
Does the above paragraph sound like bullshit? Then stop being a fucking hypocrite. Either both obesity and homosexuality are mental illnesses or neither is. Funny how leftists claim they support alternative lifestyles when in reality they refuse to support alternative lifestyles that are common in red states.
I'll tell you the TRUTH: my obesity is a deliberate lifestyle choice. I eat greasy food, sugary sodas, and other unhealthy food because they taste good and I enjoy it. Simple as that. My lifestyle is infinitely more important to me than my health. I would rather die young after living a life of fun and taste than waste a long life living like a monk. Now, I have no problems with homosexuality, because I recognize it as an alternative lifestyle just like my own, but go fuck yourself if you consider one person's unhealthy lifestyle choice fine but another's a mental illness.
Let me ponder this for a minute.
A health care professional can be expected to have a bias regarding healthy vs unhealthy life choices. Being fat indicates that a person has made one HELL of a lot of unhealthy choices. Like - every single day, he eats to much.
Alternately they have hypothyroidism, for example, as a result of Hashimotos. It could also be Prader-Willi syndrome, or Bardet-Biedl syndrome. There are other genetic factors and diseases which can also result in obesity. Candida Albicans infections of the gut have also been implicated. There are also medications which can result in obesity. Prednisone, which is often used to treat very severe allergies, and also as an anti-rejection drug following organ transplantation, or to treat autoimmune disorders, is one. Others include antidepressants, seizure medications, and certain high blood pressure drugs, such as atenolol and metoprolol (both beta blockers).
Hey asswipe monkey brain *I'M* one of the unlucky ones. *I DO* have health reason to be fat. *I DO* have genetic reasons. Oh and there are mental depression reasons too but frankly exercise helps fix those.
I'm not because I fucking well dont want to be a 10 ton lardass. The real, genuine reason for obesity is that person is just simply too fucking lazy to give a shit. *I'M* the exact reason why lard asses should be given a boot up the arse - if I can do it then so can everyone else. No goddamn excuses - if you are 50 kgs overweight it's *YOUR* fault. Most to lose weight dont need to exercise or watch their diet like I do - to keep myself stable I *need* 50 kms of cycling a day. Think about that - if that doesnt' scream I have issues that I need to overcome when almost all of you cant even think about doing that and you woul be losing plenty of weight then I dont know what does.
So don't fucking tell me you have genetic or health issues keeping you the size of a small bus. You just cant be bothered to do anything about it and to make that do something a lifestyle.
Oh I'm sure there's sob stories about no time or no money or whatever. Bullshit. It's excuses. And that's why people are scorned for being fat. It's YOUR CHOICES than made you a land whale. No your health, not your genetics, not your state of wealth or time.
Fat acceptance? Go fuck yourselves. If I can be a normal size, so can you. STFU and do it.
I must be one of the lucky few people in the U.S. then. I have two doctors who actually cared enough to get to know me as a person and realize why I have the problems that I have. One of those doctors is my E.N.T. He spent a lot of time and energy clearing up a chronic ear infection and has helped me with some other issues related to my health. The other "doctor" is a nurse practitioner who performed a yearly physical and found that I had a HORRIBLY under-active thyroid that lead to me gaining 30 pounds in just over 4 months. I have spent most of the past year on medication, adjusting the dosage to be correct for my needs. I figure between that and my joining a crossfit gym (if you need to know what it is use some Google fu) I will be loosing most of the weight I have gained. I had a coworker state that I am "unhealthy" because of my weight, yet this same person eats Chinese take out crap 6 days a week, and the other day he eats McDonald/taco bell/fast food and sees nothing wrong with this. He also thinks because he is thin he is in good shape. I have also seen some people who are rail thin, but have an astonishing high problem with diabetes, arthritis, high body fat percentage, and other issues. Yet the doctors tend to take one look at them and say oh you are perfect because you fit the model of health we are taught by the school/government. I have a friend who is overweight, and she knows it. She realizes she has a problem and is working on fixing it with medication, diet, exercise, and a support group. She has a medical condition that was found by a doctor, AFTER she demanded the appropriate tests. Her nutritionist and doctor spent a lot of time going round and round with the results from the test, the doctor did not believe it and thought that diet/exercise was the only reason for the problem. The nutritionist realized that it was a metabolism issue and that it would take some medication in addition to the normal move more, eat less regimen. She physically could not get appropriate nutrition from food, and that lead to eating more to get the required nutrition. This cycle lead to a bunch of other issues, the least of which being weight gain. The medical industry in the U.S. is BROKEN and requires a complete reboot. I have a friend who went to college and graduated with two undergrad degrees and had NO debt. This friend then went to medical school and racked up over three hundred thousand dollars in debt due to tuition, fees and expenses. This is after fighting to get a slot in med. school due to the AMA setting up a limit to how many slots can be made in a given year. He will now be spending the REST OF HIS LIFE paying off student loans from medical school. This same "education" taught outdated skills and minimized critical thinking outside of the industry standards. Thankfully he had an amazing bit of training from his grandparents who were doctors in another country, and knows how to fix things without resorting to over-used, over-priced medications. And he knows what it means to be unconsciously biased against as he is an openly gay man.
Genetics isn't magic. It doesn't spontaneously conjure lipid molecules from nothing. Fat is made of matter. Matter that enters a person's body when they eat it. The fact is that every person on the planet is losing weight every time they breathe. Where do you think those carbon atoms in exhaled CO2 come from? All you have to do is eat less and do more and, with few exceptions for certain rare diseases, you will lose weight. No X-men style genes are magic story telling required.
I hate politics,what the fuck does what color state have to do with what he said, the stupid party system show be abolished since no one ever does what they say they will anyway. What I took from the comment is why is it ok to be homosexual and not obese? Most people who are overweight already know its an issue, but most lack the will power to change. Doctors should look at the cause of an underlying condition, instead of taking the easy route of blaming it on the easy thing. Same thing occurs during flu season, 5 years ago I started getting something that is similar to acid reflux too the point where if I didn't closely monitor what I ate I would get sick. The blamed it on the flu for years and if I get a new doctor they try still.I also saw the same things working in technical support, techs that would always blame and issue on either being a bad hard drive or a virus. It was the easy way out and they would try to get them to by a new hard-drive or reload. These people have to stop being lazy and learn how to diagnose properly. You can warn people about the dangers of obesity which most people already know but not making sure that's the issue is dangerous.
*Are* they less likely to follow treatment plans? It stands to reason that someone who won't do what's necessary for his health in one area might be less likely to do so in another area as well.
Studies have shown that the most common assumption is that fat people are lazy, undisciplined, unwilling to work hard, etc. -- not just in terms of health choices. Your comment is playing directly into that bias.
I think this bias, like most, actually does have some relationship to reality -- i.e., a greater percentage of fat people are likely to have these traits than others.
HOWEVER -- pre-judging an individual on the basis of a single characteristic is the very definition of "bias."
Even if 90% of obese people are lazy bastards who won't even try to listen to their doctor's advice (and I don't think the number is that high), that does not excuse a doctor who provides inferior treatment to the other 10% because of assumptions.
If the doctors' assumption is accurate, it's not bias in the sense implied.
That's like saying -- If a black person is driving around a rich neighborhood, he must be looking to steal something -- because "black people are more likely to commit crimes" is an "accurate" statistic.
Even if X is often correlated with Y, it doesn't justify the assumption that X always implies Y. When dealing with healthcare, these sorts of assumptions can literally be deadly, such as when a physician fails to search for secondary contributory causes of obesity in a particular patient because the assumption is just that the patient must be a lazy bastard who can't follow directions.
>> Being fat indicates that a person has made one HELL of a lot of unhealthy choices. Like - every single day, he eats to much.
With respect Runaway, that thinking right there is exactly the problem.
Obese != unhealthy life choices (at least not in all cases)
Take for example the 250lb person who eats right, jogs, and works out every day vs the 145lb person who never exercises, eats cookies, and pounds beer and soda but for some reason never gains a pound. The 250lb person could have a thyroid problem or other hormonal imbalance causing their metabolism to be too slow. Thus they burn less calories and keep weight easier. But they have strong lungs and a good heart. The doctor brow beats them every visit harping on whatever diet and exercise they claim to be doing as not enough, or (if they are bolder) outright lies. This does not help this patient stay healthy.
The 145lb person could have the opposite problem with imbalances causing their body to burn too many calories. They could be skinny as a rail with hypertension and be bordering on becoming Type II diabetic. But the doctor doesn't bother to run any tests or take the results too seriously because they are at their "target weight". This does not help this patient stay healthy.
Doctors should diagnose based on full spectrum data collection. Not simply based on what they see and think at first glance. That's like a climatologist looking at a clear blue sky on a good day and saying "look, no smog. Clearly climate change is not caused by man made pollutants!!! No need to look any further into this."
On second though, perhaps a car analogy would work better. Can somebody help me out here? :)
Studies have shown that the most common assumption is that fat people are lazy, undisciplined, unwilling to work hard, etc. -- not just in terms of health choices. Your comment is playing directly into that bias.
Bulls eye!
And did you exchange a walk on part in the war for a lead role in a cage? - Pink Floyd.
The problem here is that the only signal people have for what their body needs energy-wise is mediated by their hormone balance and brain-chemistry. If you have a condition where even too much energy feels like you're starving (a painful condition), it's readily understandable that you are going to eat too much, even with the best intentions. The problem of simply blaming "eating too much" is that it becomes synonymous with gluttony - a vice and failure of virtue. Even though yes, you are simply eating too much in the thermodynamic sense, it rapidly becomes a stigma where the patient is 'at fault', rather than the underlying medical condition. In this way, victimisation of obese patients is counter-productive.
Sure some people simply have no self-control - but is that because they are bad people, or because there is some factor at work that makes it hard for them? The blame game for obesity is a bit like accusing people with a birth mark of being in league with the devil and burning them - we should know better by now.
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People who are overweight and obese grade 1 are usually not so fat their life quality is reduced. They can walk, run and exercise with no or just small discomfort.
An overweight person who is somewhat fit has a *significant* higher life expectancy than any other combination of fitness and weight.
Muscle mass above a certain amount does more harm than good and reduces life expectancy
Excessive exercising over time damages the body and leads to a shorter life expectancy
- Life expectancy both for body builders and competing marathon runners are low
Body fat above a certain amount does harm to the body and reduces life expectancy
Body fat below a certain amount does harm to the body and reduces life expectancy
- The ideal amount of body fat is far more than what we perceive as "normal" weight -- it's much closer to the medieval beauty ideal then the modern one
---- Sig. gone.
Even if X is often correlated with Y, it doesn't justify the assumption that X always implies Y.
While that is true, the safe bet is still going to be that X implies Y.
That is absolutely false. Particularly since in this case we have examples of not-X that have Y, it may in fact be that Y implies X, but only in some cases, or even that there is no causality at all between X and Y.
I personally don't have statistics about the incidence of "laziness" and "failure to attempt to follow doctor's advice" in non-obese patients. Do you? I'm guessing that it is probably higher in obese patients, but I don't know that.
Obesity is easy to spot. Doctors who see obese patients and recommend that they lose weight can easily tell if those patients aren't successful in following their advice (though, whether the patient actually tried and how hard they may have tried is less easy to evaluate).
On the other hand, for non-obese patients, doctors might recommend a better diet and more exercise to lots of them too. Short of major changes in blood indicators or something, how do they actually know if the patients complied?
Thus, it's pretty hard to have good data about compliance for non-obese patients, or the incidence of "laziness" among them in conforming to medical recommendations. Whereas doctors can easily make assumptions about obese patients who don't slim down, thus giving the appearance of greater incidence.
Now, if we had some clear cases where X doesn't lead to Y, for example when Z is present, then we can solve the problem of unfairly expecting Y by also looking for Z. Hunting for Z will probably be more fruitful in the long run than trying to train people to ignore stereotypes that have evidentiary support.
Maybe. Except your reasoning doesn't take into account the possibility of confounding variables. It could be that X doesn't lead to Y at all, and actually Z is the cause of both X and Y.
In the present case, for example, since there are lazy people and people who don't follow medical advice who aren't obese, perhaps we might be better off searching for commonalities between all lazy people, since they are the actual problem for medical treatment -- rather than searching for exceptions to a stereotype. Maybe there are questions that could be asked in a questionnaire or interview that would give greater insight into whether a patient might be likely to listen to a doctor's advice, and perhaps even whether there might be better strategies. I don't know. But that would be a reasonable place to start.
However, one strategy that does NOT seem fruitful is just to continue to assume that the only people who can't hide their inability to comply are the only ones not listening to doctors... and the reason for that is because they're lazy fat bastards.
No such condition can result in obesity. All they affect is feeling of hunger. Ie, it's somewhat harder to control yourself but it physically can't make you fat.
There were no obese people at Auschwitz, hormones or not. Uncle Adolf's diet went to the other side, by being nutritionally deficient, but you can't deny it prevented being fat. Limit food intake, and you will not get obese, period.
The creatures outside looked from Alt-Right to Antifa; but already it was impossible to say which was which.
There are objective tests. Doctors with a bias won't give them. I went and got hydro-statically weighed. I know that my lean body mass is 169 lbs. My height is 5'11" and at my last physical I was 212 lbs. That put my body fat percentage at 21%. This is at the high end of "ideal". On the other hand, the BMI put me at the high end of "over weight" and only 3 lbs shy of "obese". According to the BMI I should not weigh more than 178 lbs. That would be 5% body fat. This is the point that you start eating into your essential body fat. So, according to the BMI my body fat should be between 5% and -30% body fat. That is right. The BMI says I should be between sick and dead.
At this physical, my doctor is telling me that I need to lose weight because 212 is "a lot of weight". He didn't car that my body fat % was fine. He just kept pointing out that BMI is "the best indicator of healthy weight". He has a bias against fat people. Even worse, his definition of "fat" is completely twisted and dangerous.
Even worse is that I have been 5 lbs over weight. 5 lbs overweight isn't even close to obese. It also isn't "some buff slav". But, what I hear is from dumbasses saying "Your not Mr. Universe, so the BMI is correct."
True story to back this up -- I was 140 lbs at 6'5 in highschool with very bad joints and asthma I sadly seem to have inherited. Both limit my exercise immensely, as does my job in computers.
Having subsequently moved and having a different doctor now than then and weighing substantially more, I have no new health problems than then but my new doctor upon hearing of my breathing and joint issues blamed my weight and told me to lose it, which obviously won't help, as I had the same problems when clinically under-weight.
Bias is wrong -- and leads to poor assumptions.
- Michael T. Babcock (Yes, I blog)
If I lost the weight my doctor recommended, I would die. Not figuratively. Literally. My doctor recommended that I achieve the weight shown by the BMI chart for my height. That would put my body fat % between 5% (dangerous) and -30% (long dead). EMEL is bumper sticker medicine along with the BMI that goes with it.
You have no idea what you're talking about. Many rock climbers are very, very muscular. Mostly boulderers, but bouldering is probably the most popular type of rock climbing currently.
And even your other sports don't check out. Lebron James, for example is 6'8" 250 lbs. That's a BMI of 27.5 - overweight. Mike Trout (baseball player) is 6'2" 230 lbs. - 29.5 - borderline obese.
What's the most popular fitness activity in the US? Weightlifting. BMI was developed almost 200 years ago, when bloodletting was still standard medical procedure. We should be using body fat percentages if we do population-wide statistics, and not demonizing mass. Mass isn't the issue.
Doctors should diagnose based on full spectrum data collection. Not simply based on what they see and think at first glance.
I had this discussion a dozen times with my brother who is a medical student and the tl;dr is "nobody has the time or money for that".
A doctor will always assume the most likely cause for any given combination of symptoms (even if they don't match 100%) and only start thinking about less likely alternatives if his treatment doesn't lead to improvements. Yes, sucks to be someone with a rare disease (that will only be diagnosed correctly very late if at all) but symptoms are often so unspecific and a thorough examination would be so expensive (let's do a blood screen every time you catch a cold because you might have some ultra-rare disease?) that this is the only practicable way.
Hormonal causes for obesity are possible but pretty rare - a much larger share of obese patients claims to suffer from e.g. thyroid issues than statistically possible. "Just eat less" is the right answer for the vast majority of obese patients and as they will lie to you about their food intake and exercise (admittedly often unconsciously, but then they don't tend to cooperate well when you ask them to keep a diary of every single thing they eat to make the more self-conscious) you never know if your original attempt at treatment did work or not. The share of patients who will lie into your face about having tried everything is probably still much larger than the share of patients who have actually followed your advice and it didn't help because they have some underlying physical issue.
The standard medical procedure of most likely diagnosis -> treatment -> in-depth examination if treatment doesn't show results just breaks down as the doctor has no way of knowing whether the treatment ever took place or not.
The problem in this case that if the patient has X but complains of Z, the doctor will only discuss Y. Same if the patient has A, B, or C, none of which are ever due to Y.