Table 6.

Representative quotes for the four themes of the qualitative analysis

1. Empathy and resistance

Unexpected emotional responses: (1) At one point I glimpsed myself in the mirror and I could hardly recognize myself. I admit I am ashamed that I felt disgusted at how I looked. (R 31)  (2) While I expected to find the household chores more tiring, I was surprised by how self-conscious I actually started to feel while wearing the empathy suit (even just for a few minutes). I have always been a small person and I almost felt a sense of embarrassment while wearing the suit. (R 4)

Physical aspect: (1) Going through the different activities made me extremely breathless and insecure at every point of the way where I was unable to see my own feet and not knowing where I am stepping. I was extremely scared to even step into the bathtub! Let alone gathering courage to go out to a swimming pool to get some exercise!! (R 52)  (2) After this experience, it is much easier to sympathize with the reluctance to exercise. When every little movement is difficult, painful and requires a significant effort, why would anyone be motivated to do any additional physical activity? (R 35)

Mental aspect: I think the more difficult thing for me to think about was looking in the mirror with the suit on. I felt pretty awful and would hate if I ever ended up with a weight like that. It really determined the superficial aspect of being overweight. (R 15)

Empathy and re-thinking counselling practice: Prior to this eye opening experience, I felt I had some good knowledge about obesity and I am comfortable talking to my patients about their weight, to offer them evidence based weight loss strategies. I felt it was just a matter of setting up goals, keep pushing themselves to stay active and maintain a good diet for the weight loss to occur. It was difficult for me to put myself in their shoes and see the physical limitations they have with their body habitus. It felt like a workout to me just doing activities of daily living in the twenty minutes I was wearing the empathy suit, which only weighted 10lbs. I now start to see how silly some of my recommendations were. I am able to better sympathize with my patients and will think of advice that is more achievable and realistic for them. (R 36)

Resistance: My predominant feeling is one of annoyance and frustration with regards to this experience. (R 13)

2. Reflexivity: weight counselling practice and role identity

Complexity: As now I have realized, obesity is not unlike arthritis or atherosclerosis in that it is often challenging enough to halt its progression. I used to consider it as a will-influenced reversible process, but now I realize obesity is often impossible to modify when there are multiple resistant contributing factors. Without sustained lifestyle modifications, patients often yoyo through weight fluctuations with short term interventions and eventually become fed up with frustration and depression. That is what happened [to the patient they were counselling]. When a different physician preached her each time about simple concepts and empty slogans, without realistic management specifics, she only got reminded of her sufferings so far. (R 61)

Re-thinking assumptions: I can admit I have made assumptions about people living with obesity. One of those assumptions is these individuals had a choice and it was their fault that they have gained weight. However, I have come to realize that the causes for obesity are multifactorial and rather complex. The exercise of wearing the empathy suit certainly reminded me of how obesity is a difficult health condition to live with and it is not as simple as losing some pounds by altering the energy in and energy out eq. (R 39)

Counselling practice: (1) Reflecting on this experience, I don’t think I gave her [the in-clinic patient] the appropriate level of compassion and respect she deserved. Now that I think of it, she was just looking for an answer. An answer to the question, “Why do I weight more than most people when I never used to be this way?” Now that I think of it, if I had been in her position I would have been incredibly frustrated with her situation and the response from the medical system. (R 2) (2) Often, we dismiss the obese or “fat people” and say people should exercise more and eat less. It is difficult to understand how and why people become so obese. Perhaps, I am not as tolerant as I should be. Society and our choices don’t help either, when fast food is cheaper than fresh vegetables? When we are so rushed for time because we have to work fulltime in order to make ends meet? (R 31)

Role identity: How can I support people thought this struggle and health challenge? What is my role? Where do I fit? (R 31)

Critique: Please, there are more important and pressing things that I should be focusing on. (R 20)

3. Utility of the 5As approach and 5AsT tools

Utility of the 5As: (1) This framework of 5As will actually be useful in many settings to set an appropriate discussion. It is a great tool to have as a resource. (R 14) (2) I appreciate the tools provided to us at our session. It may seem intuitive but when I implement it into practice, it can be challenging. (R 22) (3) Being introduced to the approach to weight management via the 5AsT/4 M [4 M’s of obesity assessment] has provided me with a foundation of knowledge and practical tools that can assist me in supporting my patients better. (R29) (4) I am so happy to know [sic: now] have an approach and also one that I can do myself without having to refer the patient away. I know that I have that in my back pocket as extra help if things are not going well with my help alone. (R 15)

The importance of the “Ask”: The most useful learning point for me was to preface any advice or discussion about weight by asking for the patient’s permission. This point really helps to make explicit the respect you have for patient decision making for their health. (R 35)

Self-efficacy: (1) After reflecting on this encounter, I felt like I had a framework for the discussion, and could provide some realistic goals or expectations. The conversation still felt awkward, but I do think I’ll feel more confident in bringing up the issue of weight with patients in the future. (R 58) (2) On the whole, the encounter was encouraging for me as a physician because I feel like I can now at least START [original emphasis] the conversation about weight, even in children despite not always having the answers or solutions. I plan to take the resources I’ve been given and continue to practice having these conversations to become more proficient in obesity management. (R 24)

Mastery: I have since been able to use the 5AsT tools for other patients and each time I feel the patient walks out happier than if I had just told them to eat less and move more. It’s the full discussion about weight and the underlying etiology of it that really helps a patient realize what some of their obstacles are, because honestly many of them are hard to pick out on your own. (R 15) This was a successful visit using the 5AsT tool and I will try to utilize it more in my clinical practice. (R 36)

4. Challenges

I feel like this symbolizes one of the largest challenges to discussing obesity and weight in the family practice; it is seldom that people book their appointments to chat only about weight, despite it being a topic that needs lengthy discussion. (R 6)

We have all dealt with obese patients throughout our training, and experienced the difficulties of treating such patients. Physically it is more difficult to do physical exams, they often have more comorbidities, and we experience personal frustration with being unable to help them manage their obesity. I don’t think it is a bias to dislike treating obese patients because of these issues. […] I would just prefer if they were not obese as that would benefit their health, as well as make my job easier. Just like we become frustrated with patient that do not stop smoking, we also become frustrated with those that have been unsuccessful in controlling their weight. I think this is a natural reaction because we can see that such individuals are at greater risk for a variety of health problems in the future. As physicians this is something we obviously want to avoid. (R 12)

I find weight loss difficult to discuss for two reasons. First, weight loss is challenging for patients. They don’t realize how difficult it is from a biological perspective to lose weight, and therefore their efforts seem to have no effect. Sometimes maintaining their weight can be a victory but patients don’t see it that way. Second, I question the futility of patient counselling regarding weight, I have nothing magical to offer them aside from diet and exercise except in extreme circumstances. (R 5)

Personally, I find that I do have some biases in terms of patients with obesity. I had believed that any single patient could lose weight, as long as they were willing and motivated enough. Thus, when interacting with patients who were not motivated to increase their activity or change their diet, I would often be frustrated and thus become biased towards them. In terms of pure science and numbers, it is possible for every single patient to lose weight. Ensure calories consumed are less than calories expended will definitely lead to weight loss. However, this sort fo view does not consider the patient as a whole, or as a person. After the empathy simulation session, I find that I have become more empathetic to the plight of obese patient [sic]. (R 31)

Legend: (R #) = Resident anonymized participant ID