Training Doctors to Discuss Weight: A Telehealth Tool for Better Obesity Care

Table of Contents

• Key Points
• Background: Why Better Obesity Training Is Needed
• How the Study Was Designed
• Who Participated in the Study
• Inside the Telehealth Exam
• Reliability: Did the Checklists Work Consistently?
• Resident Performance: What the Scores Showed
• What Residents Thought About the Telehealth Format
• What This Means for Patients
• Study Limitations
• Recommendations and Next Steps
• Frequently Asked Questions
• Source Information

Key Points

• A 15-minute telehealth exam with actors reliably assessed residents' obesity history-taking, communication, and professionalism.
• Only 15% of residents asked about highest and lowest weights, showing important gaps in obesity training.
• 92% of residents found the telehealth format acceptable, and many found it realistic.
• Residents with over 5 prior telehealth encounters scored higher on obesity history-taking.
• This pilot study suggests telehealth OSCEs can help teach and assess obesity care skills.

Background: Why Better Obesity Training Is Needed

Obesity — medically defined as a body mass index (BMI) of 30 kg per meter squared or greater — is one of the most serious public health problems in the United States today. It now affects more than 40% of American adults, and that number continues to rise. This excess weight significantly increases the risk of diabetes, coronary heart disease (narrowing of the blood vessels that supply the heart), stroke, high blood pressure, anxiety, depression, and even death from any cause.

Several major national organizations — including the American Heart Association, The Obesity Society, and the United States Preventive Services Task Force — recommend that physicians actively screen patients for obesity and help them achieve and maintain weight loss through counseling and structured behavioral programs. Despite these clear recommendations, doctors incorporate weight management counseling into only about 20% of patient appointments.

Why such a gap between recommendation and practice? One major reason is inadequate training. The researchers behind this study point out that up to one-fifth of internal medicine training programs — the programs responsible for training the primary care physicians who are on the front lines of obesity care — provide very little instruction on physical activity and nutrition. More than one-third offer little or no training at all in the psychosocial and behavioral components of obesity, including weight stigma (negative attitudes and stereotypes about people with obesity) and discrimination.

A national survey of primary care physicians in the United States found that approximately 90% of doctors identified additional training in nutrition and physical activity counseling as a key strategy to improve obesity-related care. The evidence supports this: physicians who learn "good obesity practices" during medical school and residency are more likely to recommend weight loss, discuss diet and exercise with their patients, and refer patients to specialized weight-related services. Research also shows that obesity-related educational interventions can actually help patients lose weight and reduce bias against people with obesity among practitioners.

How the Study Was Designed

This study, conducted by researchers at Northwestern University Feinberg School of Medicine, set out to create and test a telehealth-based educational tool called an objective structured clinical examination (OSCE). An OSCE is a widely used teaching and assessment method in medical education. During an OSCE, a medical trainee interacts with a standardized patient (SP) — a trained actor who portrays a patient with a specific medical concern — while being evaluated on their clinical skills. Traditionally, these encounters happen in person, but the COVID-19 pandemic accelerated the shift to virtual platforms.

Specifically, the researchers aimed to develop a 15-minute telehealth OSCE with reliable checklists to assess whether residents (physicians in training) could take a patient-centered, obesity-focused medical history. The checklists were designed to evaluate three key areas:

• History-taking skills (14 Yes/No items assessing whether residents asked important obesity-related questions)
• Communication skills (9 items scored on a 5-point scale)
• Professionalism (6 items scored on a 5-point scale)

For the communication and professionalism checklists, a score of 1 represented unacceptable or offensive behavior, 2 was subpar but not offensive, 3 was acceptable, 4 was above average, and 5 was excellent.

All checklist items were based on the Obesity Medicine Education Collaborative's published obesity competencies for medical education. Before the study began, the checklists were reviewed by several experts in medical education and assessment, including a national leader in medical education, and adjustments to content and structure were made based on their feedback.

Who Participated in the Study

The study involved 26 internal medicine residents (post-graduate year 2 and 3) at an academic medical center, as well as two standardized patients recruited through the university's Clinical Education Center. First-year residents (PGY-1) were excluded because of their limited experience with ambulatory (outpatient) care and scheduling constraints.

Here is a breakdown of the resident participants:

• Gender: 42.3% identified as male (11 residents)
• Training level: 69.2% were PGY-2 residents (18 residents) and 30.8% were PGY-3 (8 residents)
• Race/ethnicity: 52.0% non-Hispanic White (13 residents), 32.0% Asian/Pacific Islander (8 residents), 4.0% non-Hispanic Black (1 resident), and 12.0% identified as other (3 residents). One resident did not respond to this question.
• Prior telehealth experience: 64% of residents had conducted fewer than 5 telehealth encounters before the study. Specifically, 12.0% had none, 52.0% had 1 to 5, 24.0% had 6 to 10, and 12.0% had 11 or more.

All 26 residents provided written, online consent to participate. Of these, 23 also agreed to have their sessions recorded for later review by the study investigators and standardized patients. The standardized patients received hourly monetary compensation from a grant funded by the Healthy Patient Initiative.

Inside the Telehealth Exam: How the OSCE Worked

The OSCE scenario was adapted from a script previously used to assess medical students' obesity competencies at the university. The script centered on a patient whose chief complaint was weight gain, with an opening statement to the doctor of: "I am beside myself - I have gained so much weight - I want to get control over it." The script included detailed responses to potential resident questions about the patient's obesity history, dietary patterns, physical activity, weight concerns, and past medical history.

The researchers made deliberate modifications to the script to reflect real-world challenges and current events. For example, the script included standardized patient statements designed to challenge the residents, such as "I am so frustrated I cannot keep off the weight... Is there something wrong with me?" They also adapted the scenario for pandemic-era life, adding a line like "I work from home." These changes were discussed with faculty at the Clinical Education Center who have extensive experience conducting OSCEs.

Prior to the study, the standardized patients attended a 1-hour virtual training session where they reviewed the script and learned how to use key video platform features — changing their display name to the patient's name, adjusting the screen to show the resident, and verifying that sound and video worked properly.

Each OSCE followed a structured format:

1. A study team member moderated the virtual session and reviewed key video platform features with the resident.
2. The moderator displayed an instruction sheet outlining the goal ("elicit an obesity-focused history"), the chief complaint, and basic medical history. Notably, residents were not expected to perform a physical exam or provide weight-loss counseling.
3. The participating standardized patient "entered the room" by turning on their camera and microphone to begin the 15-minute clinical encounter.
4. Meanwhile, the second standardized patient and the moderator observed the encounter with their sound and video turned off.
5. At the end, the participating standardized patient gave the resident approximately 5 minutes of verbal feedback.

Both the participating and observing standardized patients independently completed the checklists for each resident using a secure, virtual survey platform. Residents also completed modified versions of the same checklists as a self-assessment, so their scores could be compared to the standardized patients' ratings.

After the first 10 resident encounters, the researchers met with the standardized patients for a mid-OSCE feedback session, and several clarifying statements and examples were added to the checklists. After all sessions were completed, the standardized patients individually re-watched the 23 recorded encounters and re-evaluated residents using the final checklists. This iterative process was designed to resolve any discrepancies in scoring.

Reliability: Did the Checklists Work Consistently?

A key question in any assessment tool is reliability — that is, would two different evaluators watching the same encounter give the same scores? The researchers measured this by calculating the percent agreement between the two standardized patients and the kappa statistic (κ), a statistical measure of inter-rater reliability that accounts for agreement occurring by chance. In general, a kappa of 0.41–0.60 is considered "moderate" agreement, 0.61–0.80 is "substantial," and 0.81–1.00 is "almost perfect" to "perfect."

The overall results for the three checklists were:

• History-taking checklist: 83.2% agreement between standardized patients (κ = 0.63, standard error [SE] 0.06) — considered substantial agreement
• Communication checklist: 99.5% agreement (κ = 0.72, SE 0.47) — substantial agreement
• Professionalism checklist: 97.8% agreement (κ = 0.44, SE 0.37) — moderate agreement

Looking at individual history-taking items, agreement ranged from a low of 60.9% on Item 8 ("Asked about barriers to healthier eating") to a perfect 100.0% on Item 7 ("Asked about prior attempts to change his/her diet"). The kappa statistic was greater than 0.4 for 7 out of 14 items, indicating moderate to perfect agreement. Two items — Item 1 ("Asked when the patient first began struggling with weight") and Item 9 ("Asked about the type of physical activity the patient performs") — had high percent agreement (87.0% and 95.7%, respectively) but a kappa of 0.0, which is a known statistical paradox that can occur when there is very little variation in the ratings.

When the researchers looked more closely at the 5 history-taking items with less than 75% agreement, they found that agreement tended to be higher when one specific standardized patient (SP1) was involved in the encounter. For SP1, agreement on these items ranged from 70.0% (κ = 0.40) to 90.0% (κ = 0.78). For SP2, the same items had agreement ranging from 53.9% (κ = 0.11) to 61.5% (κ = 0.27). However, these differences were not statistically significant (p > 0.05), meaning the observed variation could have occurred by chance.

For communication and professionalism, agreement was very high across individual items, ranging from 95.7% to 100% for every item. The kappa statistic was actually below zero on communication Item 7 ("Asked open-ended questions") and professionalism Item 1 ("Respect") despite 95.7% agreement on both — again, a statistical artifact that happens when one standardized patient almost always gives the same rating.

Resident Performance: What the Scores Showed

Beyond testing whether the checklists were reliable, the study also revealed important information about how well residents conduct obesity-focused visits.

History-taking performance

On average, residents asked 64.8% (SE 1.2%) of the questions on the history-taking checklist. But performance varied dramatically by specific topic:

• Strong areas: 97.8% asked about the type of physical activity; 93.5% asked when the patient first began struggling with weight; 89.1% asked about past weight-loss attempts; 87.0% asked about prior diet changes; 84.8% asked for a 24-hour diet recall; 84.8% asked about the patient's weight concerns
• Weak areas: only 15.2% asked about the patient's highest and lowest weights; 35.6% asked about the amount of physical activity; 47.8% asked about beverage consumption; 47.8% asked why the patient thought they were gaining weight; 47.8% asked about barriers to physical activity; 47.8% asked about family or partner support; 58.7% asked about barriers to healthier eating

In other words, fewer than half of residents received credit on 6 out of the 14 history-taking items. These are meaningful gaps — understanding a patient's weight history (including highest and lowest weights) and the obstacles they face are essential components of compassionate, effective obesity care.

Communication and professionalism scores

Residents scored an average of 3.8 out of 5 on the communication checklist and 3.9 out of 5 on the professionalism checklist. These scores indicate "acceptable" to "above average" skills, but with clear room for improvement.

Self-assessment vs. standardized patient assessment

An interesting pattern emerged when comparing residents' self-assessments with the standardized patients' scores. Residents rated themselves higher than the standardized patients did on the overall history-taking checklist (71.9% vs. 64.8%) and on several individual communication and professionalism items. However, on the 5-point Likert scale, these differences never exceeded 0.5 points, suggesting residents and evaluators were broadly aligned in their perceptions.

Impact of prior telehealth experience

As a secondary analysis, the researchers compared residents with more than 5 prior telehealth encounters to those with fewer. Residents who had conducted more than 5 telehealth encounters scored higher on the history-taking checklist, as rated by both the standardized patients and by their own self-assessments. They also scored higher on the professionalism checklist in their self-assessments. This finding hints that familiarity with video visits may translate into better clinical performance — an important consideration as telehealth becomes a permanent part of healthcare.

What Residents Thought About the Telehealth Format

The study also collected qualitative feedback through post-OSCE surveys:

• Acceptance was high: 24 out of 26 residents (92.3%) said telehealth was an "acceptable" platform for the obesity OSCE.
• Realism was recognized: All residents who found the format acceptable said the encounter was either "realistic" or "worked well," with 8 residents (33.3%) describing it as "very" or "extremely realistic."
• Some found restraint challenging: Two residents commented that it was difficult not to provide counseling during the encounter, since the scenario was limited to history-taking.
• Technical issues were common but manageable: Nine residents (34.6%) noted technical problems, and 8 of these were related to video freezing — although sound remained intact throughout.

The standardized patients also provided feedback during the mid-OSCE session and post-OSCE debrief. They reported some confusion about certain checklist items, which led the researchers to add clarifying statements and examples to improve the checklists' clarity for future use.

What This Means for Patients

So why should a patient care about checklists and medical education statistics? Because the way doctors are trained directly shapes the care you receive in the exam room.

These results reveal a striking reality: even motivated, well-trained internal medicine residents miss important conversation topics during obesity-related visits. Only about 1 in 7 residents asked about a patient's highest and lowest weights — one of the most basic pieces of information needed to understand a patient's weight journey. Nearly half never asked about the patient's weight-related concerns or whether the patient felt supported by family — both critical elements of patient-centered care. If residents aren't routinely asking these questions during their training, they may not ask them once they're practicing independently.

The good news is that structured assessment tools like this telehealth OSCE can identify these gaps and provide a roadmap for improvement. The study demonstrates that it's possible to assess — and therefore teach — obesity-specific clinical skills in a realistic, standardized way over video. This has significant implications in a healthcare landscape where roughly 20% of patient encounters now happen via telehealth, a dramatic increase driven by the COVID-19 pandemic.

Additionally, the high acceptance rate (92.3%) among residents is encouraging. If doctors in training find telehealth-based assessments acceptable and realistic, this format could be integrated into residency programs nationwide. This, in turn, could lead to physicians who are better prepared to have empathetic, thorough, and effective conversations about weight with their patients — conversations that can genuinely improve health outcomes.

Study Limitations

While these findings are promising, the researchers were careful to acknowledge the study's limitations:

• Small sample size: With only 26 residents and 2 standardized patients, the results may not generalize to all residency programs or to standardized patients with different training backgrounds.
• Post-hoc clarification decisions: The researchers discovered that one standardized patient tended to rate differently than the other on certain items. They addressed this by clarifying the checklists mid-study, but this procedural adjustment itself highlights the difficulty of achieving fully consistent ratings.
• Limited statistical power: The differences in agreement between the two standardized patients were not statistically significant, which may simply be because the study was too small to detect a real difference.
• Single institution: The study was conducted at one academic medical center, and the results may not reflect the diversity of residency programs across the country.
• No measurement of long-term impact: This pilot study assessed whether the OSCE and checklists were reliable in the moment, but it did not measure whether participating residents actually improved their obesity counseling skills over time or whether patient outcomes changed as a result.

It's also worth noting that the OSCE deliberately focused on history-taking only — residents were explicitly told not to provide counseling or perform a physical exam. Real-world obesity care requires these additional skills, so this assessment covers only one piece of the puzzle.

Recommendations and Next Steps

Based on this pilot study, the researchers recommend several next steps for medical education:

1. Integrate obesity OSCEs into residency curricula: The study authors state plainly that "integrating obesity OSCEs and other educational interventions into residency curricula are needed to improve resident ability to take an obesity-focused history." The telehealth format makes this more practical than ever before, since it eliminates the need for physical exam rooms and allows standardized patients to participate remotely.
2. Strengthen checklist items with lower reliability: The history-taking items with lower agreement (such as asking about barriers to healthy eating) need refinement. The researchers suggest using the SP feedback gathered in this study to improve clarity and reduce ambiguity.
3. Expand to other learner groups: The OSCE could be adapted for medical students, nurse practitioner trainees, and practicing physicians for continuing education.
4. Combine assessment with teaching: OSCEs should be paired with didactic instruction and behavior-change counseling curricula to create a comprehensive obesity education program.
5. Continue to build telehealth training: Since residents with more telehealth experience performed better on the history-taking checklist, providing more virtual clinical experiences during training may itself be an educational intervention worth investing in.

At a broader level, the study adds to the growing body of evidence that physician education is a critical lever for improving obesity care. The original article notes that doctors who learn good obesity practices in training are more likely to recommend weight loss, discuss diet and exercise, and refer patients to specialized weight services — and that such educational interventions have been shown to help patients actually lose weight and reduce obesity bias among practitioners.

For patients, the takeaway is hopeful: the medical community is actively working on better ways to train doctors to have these important conversations. The more that obesity education is prioritized in medical training, the better prepared your doctor will be to listen, understand, and partner with you on your health journey.

Frequently Asked Questions

What is a telehealth OSCE and how is it used in obesity training?

An OSCE is a teaching and assessment method where a trainee interacts with a trained actor playing a patient. This study tested a 15-minute version conducted over video. It evaluates history-taking, communication, and professionalism on checklists. It helps identify training gaps in obesity care and can be used for teaching.

What did residents miss most when taking an obesity-focused history?

Only 15.2% of residents asked about the patient's highest and lowest weights. Fewer than half asked about barriers to physical activity, beverage consumption, weight concerns, family support, or why the patient thought they were gaining weight. Residents did well asking about physical activity type and diet history.

Did residents find the telehealth format acceptable for this exam?

Yes, 92.3% of the 26 residents found the telehealth format acceptable. All who found it acceptable said the encounter was realistic or worked well, with one-third describing it as very or extremely realistic. Some noted technical video freezing, but sound remained intact.

What does this study mean for patients?

It shows that even trained residents miss important conversations about weight during visits. Using telehealth checklists can identify these gaps and improve doctor training. With more obesity education, doctors may become better at asking about weight history, concerns, and support—leading to more compassionate and effective care.

What were the limitations of this study?

The study was small—26 residents at one institution—so results may not apply widely. Differences between standardized patients were not statistically significant. The exam only tested history-taking, not counseling or physical exam. Long-term impact on doctor skills or patient outcomes was not measured.

What are the next steps recommended by the researchers?

They recommend integrating obesity OSCEs into residency curricula, refining checklist items with lower reliability, expanding to other learner groups like medical students, combining assessment with teaching, and providing more telehealth training. They note that residents with more telehealth experience scored higher on history-taking.

When should a patient with obesity seek a second opinion about their weight care?

A patient with obesity may benefit from a second opinion if their doctor does not take a thorough weight-focused history. In a training study, residents often missed essential questions, including the patient’s highest and lowest weights, weight-related concerns, family support, and barriers to healthier eating. These gaps matter because understanding a patient’s weight journey and obstacles is essential for compassionate, effective obesity care. If a clinician skips these conversations, another expert may provide a more complete assessment. Diagnostic Detectives Network provides independent expert second opinions.

Source Information

Original Article: "Development of a telehealth obesity OSCE and reliable checklist for assessment of resident physicians: a pilot study"

Authors: Natalie A. Cameron and Robert F. Kushner

Journal: BMC Medical Education (2022) 22:630

DOI: https://doi.org/10.1186/s12909-022-03672-5

Funding: This study was funded by the Healthy Patient Initiative. The funding body played no role in the study design, data collection, data analysis, interpretation of data, or writing of the manuscript.

Note: This patient-friendly article is based on peer-reviewed research published in an open-access medical education journal. It has been written to make the study's findings accessible to the general public while preserving all key data, statistics, and conclusions from the original paper.