Reckoning with the past: a qualitative analysis of medical students describing their formative experiences with weight bias

Abstract

Introduction

Most healthcare providers exhibit weight bias (i.e., negative assumptions, beliefs, or discriminatory acts toward someone based on their weight/body size) in their interactions with patients with obesity. Such bias can be exacerbated in medical training and may lead to reduced healthcare utilization and worsened patient outcomes. This study explored reflections of pre-clinical medical students on formative experiences they perceived to be related to their newly identified implicit weight bias.

Method

Seven hundred and sixteen second-year medical students completed the Weight Implicit Association Test (IAT) between April 2019-April 2022 and were instructed to write a reflective response based on their results. Of this sample, 212 students described experiences from childhood in their reflections, and these participant quotes were pulled for analysis. Inductive coding techniques were used to identify themes that were generated from medical students’ reflections on formative experiences using the software program Dedoose Version 8.3.35.

Results

The identified themes highlighted medical students’ own struggles with weight management and body dissatisfaction in childhood, a fear of having obesity, the prioritization of a “healthy” (i.e., thin) body and the stigmatization of larger bodies, and the influence of culture of origin on thin-ideal internalization. Results recognize the manifold experiences that these medical students have before entering their formalized medical training.

Discussion

Despite the proven negative impact on patient care caused by clinician weight bias there is a paucity of medical training programs that address weight bias. This research highlights the need for a more intentional educational curriculum to counteract the deeply rooted implicit weight bias existent in some future healthcare providers.

Plain English summary

Weight bias is common in healthcare settings and can lead to patients’ reduced healthcare utilization and worsened health outcomes. Weight bias is developed at a young age and influences how people think about and treat themselves and others, including in healthcare settings. In this article, we examine how medical students perceive their formative experiences as influencing their development of weight bias. We explore how these insights might inform the design of medical curricula that can mitigate weight bias and improve patient experiences and health outcomes.

Approximately 42% of adults have obesity in the United States, with projected estimates reaching as high as 50% by the year 2030 [1, 2]. Worldwide obesity affects 1 in 8 people, including 16% of adults—more than double the rate in 1990—and 20% of adolescents, a figure that has more than quadrupled since then [3]. Obesity is a complex, multifactorial disease influenced by biological, environmental, psychological, and socioeconomic factors [4]. Bias toward individuals with obesity is pervasive, both in the public and among healthcare professionals [5, 6]. This bias, defined as negative attitudes or beliefs about others due to their body size, negatively affects many outcomes of an individual’s health, including psychological and physical health [7, 8]. Bias can be either implicit, which refers to unconscious attitudes that affect a person’s decisions outside of their awareness, or explicit, which refers to consciously held attitudes and behaviors conducted with intent [9]. Weight bias refers to negative attitudes and beliefs toward individuals with obesity, such as attributing their condition to traits like lack of discipline [10]. This bias is pervasive, particularly in healthcare, where it can lead to unsolicited comments about a patient’s weight and an excessive focus on weight issues, even when unrelated to the patient’s primary concern [11].

Though obesity is associated with multiple health risks (e.g., hypertension, diabetes, coronary heart disease), studies have found lower rates of healthcare utilization in patients with higher weight resulting from expected weight bias [12]. Reasons for avoidance of healthcare by patients with obesity include patronizing behavior from providers, providers’ perceived lack of training in obesity, and providers’ attribution of all health issues to weight [12]. This avoidance of healthcare leads to delayed diagnosis of not only obesity-related conditions but other important assessments, including breast and gynecological cancer screenings [13].

Developmental research suggests that biases begin to form early in childhood [14, 15]. According to Bronfenbrenner’s Ecological Model of Human Development [16], children learn about the world through a complex interaction between their immediate surroundings (e.g., family, friends), connections among various elements of their environment (e.g., interactions between parents and teachers), and wider societal factors (e.g., cultural beliefs, social norms). Children collect information from their surrounding world, including their families, communities, and the media; and use this information to construct beliefs about various social categories of significance (e.g., gender, race, body size) [15, 17]. Children as young as three demonstrate implicit weight bias, which refers to unconscious forms of weight bias that occur automatically [18]. Mass media, family, and peers have been identified as key drivers of this bias [19,20,21]. Mass media, including cartoons and programs geared toward children, frequently portrays individuals with obesity in stigmatizing ways [22]. Similarly, parents transmit stereotypical attitudes about individuals with obesity beginning in early childhood onward [19, 23]. Weight-based teasing and bullying are common among children in schools [24], further perpetuating weight bias. Research shows that children can internalize the weight bias they are exposed to and this influences how they feel about their own bodies beyond childhood, with nearly half of preadolescents reporting a wish to be thinner [18, 25, 26]. Thus, children develop weight bias at a young age and this bias continues to influence how they think about and treat themselves and others later in life, including in professional and healthcare settings.

Given pervasive weight bias, medical students are unlikely to present into their training as neutral, unbiased learners. Students bring various attitudes and experiences into their training that influence their work with patients and biases toward them. Research indicates that merely recognizing implicit bias is insufficient to drive behavioral change; rather, it is through deliberate reflection and purposeful action that learners can deliver intentional and equitable patient care [27]. Importantly, biases can be shifted (at least in the short term) through educational strategies such as engagement with others’ perspectives, opportunities for self-reflection, and increased opportunities for contact with minoritized groups [28,29,30], although structural and institutional changes are necessary to maintain improvements over time [31, 32]. Thus, understanding medical students’ formative experiences is important; both in identifying how these experiences lead to the development of weight bias and in designing effective curricula to reduce weight bias in future physicians. Reflection is an important educational strategy in beginning the process of mitigating bias [33]. Our previous qualitative work implicated childhood experiences as being particularly influential in the development of weight bias [34]. Therefore, our specific research aim was to examine how medical students’ perceive their formative experiences, including childhood, as influencing their development of weight bias and to explore how these insights may inform the design of medical curricula to mitigate such biases.

Methods

Participants and procedures

Data were collected from 716 second-year medical students at the George Washington University School of Medicine and Health Science across four cohorts between April of 2019–2022. Participants were instructed to complete the Harvard Implicit Association Test (IAT) for Weight [35], a measure of unconscious attitudes about body size that provides test takers with immediate results designed primarily to raise awareness about participant potential implicit biases. Participants were also instructed to write a mandatory reflection. The exact prompt they received was: “Write a personal reflection (< 500 words) on your reaction to the exercise you just completed (i.e., Implicit Association Test-Weight) and describe your current attitude towards those who are overweight or have obesity.” After completion of the IAT assignment, participants were immediately provided results from the Harvard IAT website along with a comparison graph of others who have completed the test in years past showing test takers typically have a strong preference for thinner body sizes. Participants are also able to explore the website to better understand test validity and origins. Narrative responses and IAT results were not linked to personally identifying information and, prior to collecting responses, students were informed that their responses would be deidentified. For the purposes of this study, we focused on analyzing qualitative statements and IAT results were not a data point of interest. In addition, students were required to complete a small group (8–10 participants/group) experience within one week of completion of the IAT in order to reflect on experiences and crystalize learning. All procedures were approved by the Institutional Review Board of the George Washington University Office of Human Research.

Participants were only included in this study if their reflection response included a mention of their formative, or childhood experiences (defined as prior to undergraduate education). From the original sample of 716 students, 212 (29.6%) mentioned formative experiences in their reflection and were included in this study. The average age of the original sample was 26 years old. Participants in the original sample self-reported their race as Asian (29.8%), Black (9.0%), and White (46%). Approximately 10% reporting being Hispanic. The majority were women (56.6%).

Data analysis

A thematic analysis approach [36, 37] was used to examine the data in Dedoose Version 8.3.35 (SocioCultural Research Consultants LLC, Los Angeles, California). Three members of the team (KG, TY, KE) reviewed every statement from the original sample of 716 participants to identify those that mentioned a “formative experience” such as parents, childhood friends, schooling, or other influences during childhood. Every statement was reviewed by at least two members of the team, to ensure all statements that described a formative experience were included.

Once all reflections that included formative experiences were identified, four members of the research team (EC, KG, TY, and KE) read through this dataset of 212 reflections to become familiar with participant statements. Next, the research team met to generate a list of initial codes, or basic categories used to group related content across participant statements, that were applied to participant data in Dedoose to identify potential patterns in participant statements. The coded data were then examined to identify themes of broader meaning. The process was inductive, such that themes were constructed specifically from the coded data, based on the research team’s analysis of how the codes related to one another across the dataset. The research team met to refine these themes to ensure they were distinct from each other and had adequate supporting data. Each interview was coded by at least two team members and any discrepancies were addressed through a collective review involving all four team members involved in data analysis.

Positionality

Prior to data analysis, the members of the research team met to consider ways in which their professional training and personal experiences might influence their perspectives and interpretation of participant statements. Four of the authors are physicians (KE, KG, TY, LD) and two of the authors are psychologists (EC, AD). Two of the authors (KE, LD) hold leadership positions within a medical school and shared their interpretations of the data based on their extensive experiences in training medical students and treating patients with obesity. Two of the authors (KG, TY) were medical residents at the time of data analysis who reflected on the data from their position as post-graduate trainees. EC and AD are PhD-trained psychologists working in academic (EC) and medical center (AD) settings who bring knowledge in the areas of disordered eating and body image concerns. EC and KE received specific training in qualitative research as part of a training grant award.

Results

Four themes and corresponding subthemes were generated from the data. Figure 1 presents a graphic depiction of our results. We provide descriptions and representative quotes for each theme below.

Fig. 1

Themes and subthemes generated from the data. Themes from early formative experiences mapped onto the Bronfenbrenner’s Ecological Systems Model. Theme 1: “I Know What It’s Like” — Childhood Maltreatment in the Microsystem, Theme 2: “Fear of Obesity” Family Influence in the Microsystem, Theme 3: “Body Ideals are Shaped by Cultural Standards” — Cultural Pressures in the Exosystem, and Theme 4: “If I Can Do It, So Can You” — Social Comparison in the Microsystem

Theme 1: I know what it’s like

Medical students’ descriptions of having a larger body size or struggling with weight during their own childhood were common in the data, with these experiences informing students’ empathy for patients today. Examples of medical trainee’s responses can be found in Table 1. Participants discussed knowing what it is like to be mistreated because of body size (“I was bullied until I developed an eating disorder” P207) and described experiencing mistreatment from classmates, friends, family members, and childhood medical providers. Participants frequently mentioned being “harassed,” “teased,” “bullied,” “put down,” “pressured,” and ostracized because of their body size. These memories were described vividly years later and were described as having a profound impact on participants’ lives. Participants described how these experiences affected their sense of self-worth for years to come (and for some even in the present day), making participants believe they were “undeserving of love,” “unhealthy,” and “not valuable” due to their body size. Participants expressed a desire to not contribute to further mistreatment of patients with obesity in medical settings (“I aim to use my awareness…to avoid this at all costs” P153). These personal experiences also informed participants’ understanding of the difficulties of changing one’s lifestyle or managing weight, with one participant describing it as a “constant struggle” (P64). Participants described the need for enormous effort, courage, frustration, and expense in their attempts to reduce their body size, with some relying on commercialized weight management programs, gym memberships, sports teams, or rigid diets. Because of these noted challenges in their formative years, participants developed a better understanding of the complexity of weight management and obesity etiology, leading them to take a more nuanced view in their work with patients beyond personal responsibility. Participants discussed the genetic, metabolic, and biological components of obesity, along with the role of environmental and societal factors in the development of obesity, that would inform their treatment planning with patients. Participants reported that these personal experiences gave them a greater sense of empathy and understanding in their work with patients that would improve their clinical care.

Table 1 Illustrative medical trainee quotes for theme 1: “I know what it’s like”

Theme 2: fear of having obesity

Some participants described learning in their formative years that having a larger body size symbolized a moral failing of oneself. Examples of medical participant’s responses can be found in Table 2. Participants discussed formative experiences that led them to associate larger body sizes with words that have negative connotations (“laziness”, “undisciplined”, “invisible”, “shameful”). Many of these learned associations were due to the influence of trusted adults surrounding them (parents, extended family, athletic coaches). A number of participants described growing up in households that prioritized eating “healthy” and exercising daily, with the caveat being if they did not do these things and gained weight, it would be a poor reflection of themselves (“I needed to be active and healthy, and if not, bad things would happen to me” P108). Participants reflected on how these negative associations currently impact their views on obesity as well as their relationship with their own bodies. Discussions included persistent fears of gaining weight, poor body image, and the ongoing belief that weight is purely a result of self-control. Many expressed the need and desire to make a “conscious effort” to treat all patients the same regardless of their weight. Participants acknowledged that being aware of their weight-related biases is not enough and that it will require continuous effort and reflection to ensure it does not impact their patient care.

Table 2 Illustrative medical trainee quotes for theme 2: “fear of having obesity”

Theme 3: body ideals are shaped by cultural standards

Participants also commonly expressed how US culture and media influenced their views on weight in their formative years (“Most of us in Western society were brought up to idealize thinness” P14). Examples of participants’ responses can be found in Table 3. Participants described how the major conduit for these cultural ideals was media, including television, movies, advertisements, magazines, and social media. While ingesting these forms of media at a young age participants noted what they observed, “seeing thin bodies celebrated on TV, movies, and magazines” (P23). Participants discussed how this led them to idolize the bodies of celebrities with a handful of participants admitting to researching the BMIs of celebrities (“I found myself looking up famous actresses’ BMIs and then comparing it to my own” P149). In addition to seeing the idealization of thinness, they also noted the denigration of larger body sizes (“Television and movies tell us that thin people are active, smart, and wealthy while fat people are lazy, dumb, and poor” P14). An extension of this message from the media was the promotion of diets and exercise as a means to achieve this “desirable” body type. Participants described how advertisements on television and in magazines touted promises of transformative weight loss through “ab exercises” or enticing article titles, like “How [celebrity X] lost the baby weight.” (P185). Participants described how their consumption of these ideals through multiple forms of media in their formative years led them to develop an anti-obesity bias, going on to say how it has been “ingrained” and “burned” into their brains. Upon reflection, participants noted the need to actively fight against these ingrained and historical cultural biases when treating patients, “there is no doubt that I have bias towards obese patients that I will have to actively counteract in order to provide the best possible care as a physician” (P26).

Of note, a number of participants discussed how growing up outside of Western culture also impacted their views on body weight. In comparison to the thin idealization prevalent in American media, some respondents described being raised in cultures that valued larger bodies and deemed larger bodies to be more desirable. This dichotomy of the preferred body type between American culture and the individual’s culture of origin led to some participants experiencing criticism from family members growing up. Many of these comments centered around the critique that the individual was too thin, (“Has your mother been feeding you enough?” P37). However, one respondent discussed how even within a culture where being “plump” was viewed as more desirable, individuals with excess weight still received negative comments about their body “[I] would be told that my body was attractive… but would also be laughed at for being overweight” (P71).

Other participants described growing up external to Western culture within cultures that also promoted a thin body as the idealized body. This influence would come in the form of comments from family members telling others that they were not “thin enough” (P11, South Asia) or labeling others with words such as “chubby” (P10, Philippines). Others expressed how their preference for thinness might stem from the fact that in their particular culture, lower body weights were simply more common. A participant who identified as Korean stated it was “rare” to find a person with obesity in Korea (P5). They went on to describe how, “most of the girls are actually thinner than I am, and I am considered a little underweight according to the BMI calculator.” Another participant who identified as Indian described how in her culture the weight that is considered acceptable for a woman is much narrower than in American culture. She reflected on how growing up in a culture “that does not tolerate overweight as much as underweight” still influences her views on obesity to this day (P12). Participants’ formative cultural experiences around weight left an indelible mark on their perceptions of themselves and others and the language they used to describe weight.

Table 3 Illustrative medical trainee quotes for theme 3: “body ideals are shaped by cultural standards”

Theme 4: if I can do it, so can you

Many participants described experiences of their own weight loss growing up and attributed it to the efforts they put forward in participating in athletics, working out, and maintaining a healthy diet. Examples of participants’ responses can be found in Table 4. These participants highlighted their perceived ease in controlling their weight (“I am a firm believer that mindset can control most things, and that this is true with regard to weight” P186). Although some acknowledged that complex barriers exist for weight loss, participants often concluded that people’s inability to lose weight was due to a lack of “long term commitment” (P51) and/or “personal motivation to achieve their goals” (P167) and thus ultimately “a shortcoming of the person themselves” (P15). Participants expressed how the strong impact of their personal “success” in controlling and losing weight made it difficult to believe those who were unable to do so. Because of everything they personally overcame to lose and maintain their weight loss in their formative years, they described an unwillingness and inability to accept that others cannot accomplish what they did. Their personal experiences are a testimony that anybody “can take responsibility for their situation” (P51) if they put their mind to it. Some participants expressed the feeling that to believe otherwise would be to absolve people of their personal “responsibility to change it.”

Table 4 Illustrative medical trainee quotes for theme 4: “if I can do it, so can you”

Discussion

To our knowledge, this is the first study to explore medical student’s reflections on formative experiences of weight bias and their influence on their own current attitudes and beliefs about obesity. From the data, four important themes emerged. In the first theme, participants reported empathy towards individuals with larger bodies based on their own weight-stigmatizing experiences (I know what it is like). The second theme centered on participant’s perceived consequences of living with a larger body and how these shaped their beliefs about themselves and their worth (fear of having obesity). The third theme revealed medical students’ acknowledgment of the pervasiveness of weight bias from media and cultural ideals, including the inability to achieve societal body standards (body ideals are shaped by cultural standards). Last, the fourth theme focused on beliefs of personal responsibility for overcoming obesity (If I can do it, so can you).

Weight-related teasing is, by far, the most common form of bullying among children [38, 39], and such experiences were reflected in several quotes from the medical students. Weight stigmatization and more serious forms of discrimination can be formative and traumatic, contributing to the beliefs participants hold about themselves and their patients. Whether experienced directly, through bullying, or indirectly through social media, negative messages about body size and weight become ingrained and self-directed which is also known as internalized weight bias. Internalized weight bias is the process of applying negative weight-related beliefs to one’s sense of worth and has consistently been shown to be detrimental to physical and mental health independent of body weight [8, 40].

In some responses, the role of personal responsibility, including dietary and physical changes, was greatly emphasized, with little to no acknowledgment of factors such as genetic contributions, biological mechanisms that encourage weight regain, or the sociocultural environment. These findings are consistent with previous literature, such that providers with limited knowledge about the complexities and biological underpinnings of obesity generally tend to have fewer positive attitudes about patients with obesity [41]. Several medical students discussed the role of television, magazines, and social media in contributing to unrealistic appearance ideals and the negative characterization of people with obesity. Participants also discussed the difficulty of navigating Westernized appearance values in contrast to appearance expectations from their country of origin. The role of media, particularly social media, is likely to grow, indicating that media literacy, including how social media promotes weight bias, is crucial for trainee critical thinking and development.

Implications for education and training

Themes generated indicate that the subset of medical students in this study were generally aware of their weight bias and carrying varying degrees of traumatic stress from weight-related experiences. Reflecting on one’s own lived experiences may help to increase empathy and understanding of a patient’s lived experiences. Taking that into consideration, it is important for schools to recognize that medical students come with their own formative experiences, many of which have caused significant pain, which likely impact their own confidence, sense of worth, and their receptivity to overt and hidden curriculum messages. Drawing on early lived experiences can help medical students cultivate compassion for themselves and others through remembering their own vulnerabilities and emotional experiences surrounding weight bias. Such experiences also help us understand that weight bias is socially constructed, and by creating shifts in our social environment, such as medical training settings, new learning can occur, and biases can be shifted. Reflecting on these experiences and beliefs also has the potential to improve patient care, especially in pediatric and young adult populations. By providing a safe space to discuss weight bias and focus on patients’ needs, medical students as future healthcare providers can make more equitable and compassionate treatment decisions [27].

A trauma-informed care approach [42], which is important for practicing physicians to use with their patients, may also be useful in educating students about obesity and weight bias. This approach positions faculty and educators to recognize that individuals may likely have their own experiences of trauma and uses strategies like creating space for students to share their perspectives free of judgment and creating opportunities for peer support when exploring issues related to obesity-related conditions, obesity pathophysiology, obesity care, and weight bias. Medical students will likely benefit from personal reflections or open dialogues about the role of formative experiences contributing to their current attitudes and beliefs about obesity. Self-reflection in medical training, in addition to other interventions, is common and effective for reducing stigma in other areas, including anti-racism [43] and substance misuse [44]. Strategies to reduce weight bias should also provide education about the complex, multifaceted etiology of obesity, encouraging students to place less blame on the individual for not achieving a lower weight on their own and focusing on how students can advocate for policy, environmental, and global changes that can promote novel therapeutic interventions and equitable access to resources to encourage sustainable healthy behaviors.

Furthermore, the use of narrative approaches in medical training can help to increase compassion, empathy, and a willingness to hear patient’s stories. Through reflection of their formative experiences of weight bias, medical students may be able to connect more closely with their patients’ narratives, and resonate with their patient’s lived experiences. Narrative approaches focus on patient storytelling, active listening, and challenging assumptions about the “causes” of illness, such as the recognition of the role weight bias plays on exacerbating obesity [45, 46]. Importantly, such approaches must also be actively role-modeled by clinicians and supervisors in the field, as medical students are susceptible to repeating the behaviors they observe from their superiors. Similarly, teaching and role modeling person-first language can reduce stigmatizing language, which has been implemented in several other areas of medicine [47, 48]. Saying “patient with obesity” as opposed to “obese patient,” respects the person independent of their condition. Providers should also consider patients’ preferred terms for discussing body weight, as “obesity” is a clinical term and generally not preferred from a patient point of view [49, 50]. Lastly, role-playing among students of hypothetical scenarios in direct patient care offers opportunities to practice these skills [51].

Importantly, strategies to reduce weight bias can only be successful if medical schools also explicitly address the competing tensions that exist within medical training. For example, students with lived experiences of weight bias are also receiving subtle messaging that providers should role model a “healthy” (i.e., thin) body size [52]. Similarly, medical schools project a focus on student well-being, yet aspects of medical training (e.g., lack of quantity/quality sleep, increased stress/anxiety, long work hours) promote impaired metabolic health and increase risk for rapid weight gain [53]. In addition, classroom lectures and clinical experience often hyperfocus on the “othering” of individuals with obesity, because of associated disease risk reflected in the literature. Students might be encouraged to engage in reflection and other activities to reduce weight bias, yet they also might observe their superiors stigmatize patients and fail to acknowledge the complexity of obesity [54]. These competing tensions leave students dealing with a double-standard that may feel difficult to navigate. Strategies to reduce this tension might include implementing policies that prohibit derogatory language about patients with obesity and providing peer support groups for students [52].

Strengths and limitations

This research study’s strengths include a large sample size of medical students, which allowed for an expansive evaluation of formative experiences of weight bias, current obesity-related beliefs, and potential implications for their work with all patients and particularly those with obesity. Furthermore, this study provided a unique opportunity to better understand the harmful experiences and pain medical students and likely many practicing clinicians carry, including internalized weight bias, some of which enhanced their own empathy towards individuals with overweight and obesity, yet was clearly still painful for many students. These findings provide a strong foundation for future research and medical training curriculum development. Limitations of the study include that only a small portion of participants described formative experiences (N = 212/716, 29.6%), and the use of only one writing prompt. It is likely that our sample does not represent the full pool of people for whom childhood experiences have influenced their attitudes about body size. Moreover, our prompt question did not specifically seek information about formative experiences, and it is possible our sample reflects a highly specific group of individuals that were particularly sensitive to this topic. Future research should explore the use of other qualitative research methods, including interviews and focus groups, to achieve a more comprehensive understanding of students’ formative experiences and internalized weight bias. It would also be helpful to gather more information about how students perceive these formative experiences as influencing their current work in healthcare. In addition, this analysis was focused on a group of medical students who took the IAT for weight bias and whose responses were selected for analysis because they contained reference to formative experiences. Students likely perceived the importance of being aware of weight bias through their engagement in this IAT exercise, which, in partnership with social desirability bias, might have created pressure for students to write what they believed faculty would perceive more favorably as opposed to their more genuine thoughts. The generalizability of findings from this cohort to other medical students, trainees, and practicing clinicians is important to explore in future research.

Conclusion

While weight bias has been long documented as harmful to patient care, there is a paucity of research on the impact of internalized weight bias among practicing clinicians, trainees and medical students. Internalized weight bias comes from lived experience, which may help providers better relate to their patients, and is consistent with narrative approaches in medicine. Future research should not only evaluate internalized weight bias among practicing clinicians, trainees, and medical students, through interviews and psychometric established measures, like the Weight Bias Internalization Scale [40], but also ask questions about how internalized weight bias impacts their perception of medical training on obesity, as well as their patient care and their own mental and physical health.

In summary, medical students are not blank slates or a neutral canvas entering their training; they come with their own assumptions and biases about weight influenced by formative experiences, which are proven to ultimately impact patient care. Many individuals have stories about weight bias, whether through direct experience or observation. From the themes generated in this research, it is evident that the medical students examined here have strong presumptions of where their biases may come from, how they are interwoven into present culture, and how they may impact their patient care. It is important to utilize these experiences as learning opportunities for increasing empathy and a better understanding of patient experiences. Devoting time to reflection and discussion, in addition to awareness building, narrative approaches, role-playing, and person-first language, will better prepare medical students in their working alliance with patients with obesity.