Managing patient fears around bariatric surgery: a qualitative study of communication differences between high- and...

Obesity affects over 40% of U.S. adults, yet bariatric surgery remains underutilized. Patients often hold fears about surgical complications and lack confidence in weight loss durability. Providers face barriers such as limited knowledge, overestimation of surgical risks, and discomfort with obesity management. This qualitative study investigates provider-perceived barriers and facilitators to bariatric surgery referral, focusing on factors contributing to provider decision-making and patient access.

A qualitative content analysis was conducted on semi-structured, virtual interviews with 17 primary care providers from D.C., Maryland, and Virginia. Providers were categorized as high referrers (> 40 referrals) versus low referrers (≤ 40 referrals) based on annual bariatric surgery referral volumes. An interview guide informed by the Health Equity Implementation Framework was used. An initial deductive approach was used to identify barriers and facilitators, followed by an inductive analysis to capture emergent themes related to health inequities within the referral pathway.

Four domains were identified: (1) clinical decision-making, (2) treatment framing, (3) treatment communication, and (4) system factors. Patient-perceived risks were cited as a barrier by 100% of providers. The most divergent finding was treatment framing: 73% of low referrers framed surgery as a last resort after failure of conservative interventions, compared to 0% of high referrers. High referrers presented a full treatment menu early, reframed patient fears of surgery, and positioned referral as exploratory program entry. Low referrers required patient-initiated motivation, validated fear without reframing, and deferred risk discussions to surgeons.

Divergent referral pathways are driven primarily by provider treatment framing and fear management behaviors rather than differences in clinical knowledge. The low-referrer pathway functions as a form of implicit filtering that narrows access along the referral continuum. High-referrer communication strategies represent proactive behaviors that can be integrated into multi-level intervention targets to dismantle communication-driven barriers and advance equitable bariatric surgery access.