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Regular readers may know that while speaking and writing are my primary work, I’m also a Board Certified Patient Advocate and I sometimes work directly with patients, typically in emergency or complex medical situations. Recently I was advocating for a patient at a cardiology appointment (who has given me permission to share this.) I was waiting outside the treatment room while my patient got settled, near the area where the scale that is used for weigh-ins was located. In this practice each cardiologist has a nurse and the nurse is responsible for getting weight as well as actual vital signs. As I was standing there a nurse brought a patient over and asked them to step on the scale. The patient made an “Ugh” noise and the nurse laughed and said “I know, weighing in is the worst. I postponed my last appointment by two weeks so that I could lose five pounds first.”
At that exact moment I was called into my patient’s treatment room and so I switched my focus 100% to the patient but I am reaching out to start a dialog about this at the practice.
I’m sure that this nurse was well-intentioned. I’m sure that she wanted to display empathy, believing that this would make the patient feel more at ease. She is also living in the same messed up, weight-stigma ridden healthcare system/world as the patient is (and all of us are). What she did though, was normalize delaying care to manipulate weight/BMI and that can be dangerous in any type of healthcare but given that this person has need of a cardiologist, the stakes could be even higher.
So, what could be done?
First, let’s talk about if this was a weigh-in that was medically necessary/relevant.
This type of weigh-in is fairly rare, and occurs when the patient's weight is needed for something (for example, dosing medication) or when their weight is being tracked for a legitimate medical reason. In an example relevant to a cardiology office, in patients with Chronic Heart Failure (CHF), sudden changes in weight can indicate a dangerous build up of fluid. This can be an indicator of disease progression. It can also be a trigger for immediate actions to reduce the fluid. At any rate, if a weigh-in is considered medically necessary or relevant, the person conducting the weigh-in can explain the reason for/benefit of the weigh-in, and any possible impact of choosing not to weigh-in (for example, “if we aren’t aware of fluid buildup, it can impact our ability to provide you with the best treatment” or “We won’t be able to perform your surgery because weight is necessary for dosing anesthesia.”) Note that this does not negate the patient's right to informed refusal of a weigh-in. It can also be helpful to say something like “we’re not judging your weight at all, we just need to get an accurate number for [medically necessary reason.]
In can also be helpful in some of these situations to offer a “blind” weigh-in, in which the patient faces away from the scale and is not told the number. Ideally this should be paired with an option for weight/BMI to be removed from aftercare instructions.
If, on the other hand, this is a routine clinical weigh-in (ie: there’s no specific medical reason for it) as I suspect this was since the nurse discussed it so casually, there are more options.
I’ve made the case previously for ending the practice of routine clinical weigh-ins but as long as they are still happening there are some practices that can reduce harm (including things like patients delaying care to try to lose weight manipulate the number on the scale or the problematic BMI calculation that comes after.)
First, we can make clear to patients that they have the right to refuse the weigh-in. Some options for this are stocking more-love.org Don’t Weigh Me cards in the waiting room, having signs by the scale, and/or asking patients “would you like to be weighed today or would you rather skip it?”
This can be supported on the back-end by working with the practice and the Electronic Health Record system, and the healthcare system overall. One incredibly helpful change would be that the percentage of patients whose weight is acquired during routine clinical visits would not be considered an important metric (and perhaps should not be calculated at all) by practices, facilities, EHRs, or insurance companies. For example, currently this number is tied to Medicare’s Merit-Based Incentive Payment System (MIPS), however patients who decline weigh-in are removed from the numerator and denominator of this calculation, thus mitigating any impact on payments. To be clear, even if the provider/practice/facility’s compensation is negatively impacted if they do not acquire patient weights for routine clinical visits, that still does not negate the patients’ right of informed refusal and should never be communicated to the patient as “your insurance requires you to weigh-in.”
If you are a healthcare provider who is being told that you are required to get routine weigh-ins, you can help by asking questions. Exactly who is requiring this? For what reason? What happens if a patient says that they want to decline? Is there a way to change this? Etc. (If you have dealt with this, or are currently navigating it, please feel free to reach out to me (ragen@weightandhealthcare.com) for support and/or if you would like to share your experience.)
If you are a patient who wants to decline weigh-in, I have some information, scripting, and resources to help here.
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More research and resources:
https://haeshealthsheets.com/resources/
*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
Thanks for this timely post. I am fairly confident refusing to be weighed contributed to being discharged by my primary care provider (a nurse practitioner) last month.
In the 18mos or so that I’d been seeing her, I used my wheelchair, and was never asked to weigh in, presumably because her only scale was a small bathroom scale. At my first appt, I was asked if I knew my weight, and when I said no, the assistant said no problem and that only happened one other time (when the NP’s son was filling in and he clearly had zero medical training, but he accepted my “I don’t know” with a raised eyebrow and moved on).
At my last appt, I walked instead of wheeling because I got close parking. A different assistant was there and tried to weigh me. I said “no thank you” and headed to the exam room. She got VISIBLY angry, and said “you have to.” I said “no i do not. Patients always have the right to informed consent and refusal.” She said “[provider] requires all patients to be weighed.” I said “you’ve never asked before, when I used my wheelchair,” and she said “well we can’t accommodate wheelchairs on the scale.” (LOL, nice admission of ADA violations.) anyway, the assistant was like red-faced with anger at this point, so I just said three more times “patients always have the right to informed refusal” and asked what exam room we were going to.
Then she took my actual vitals, but they use an electronic cuff that’s always too small and reads too high. I’ve always asked for manual BP reads, but when I asked this time, she got angry all over again and said the manual cuff is in another room. I tried to be cheerful and say that was fine, I don’t mind waiting, but she said it’s the room with another patient and she can’t interrupt the NP to get it. I said that was fine and I could wait again. The assistant ROLLED HER EYES but took my pulse and blood oxygen readings, and left. (No one took my BP that day.)
I got a certified letter a week later dated the day after that appointment, discharging me for “care and treatment differences.”
I had been planning on leaving for awhile now, it just takes awhile to get back into the community clinic, so I was biding my time. I’ve never been fired by a provider before! I had already lost my trust in her but I feel like she abused her power, and that stress has had a negative impact on my health.
I requested my records from her and found FOUR incorrect diagnostic codes had been added to my chart in a day I didn’t even have an appointment. (Wildly incorrect codes. Like dementia— shit we’ve never discussed ever.) So I had to send her a letter requesting a correction, and I have no idea what kind of impact those diagnostic codes will have on my insurance, or if she’ll even remove them. Which is just adding to my stress.
I am shocked at how many providers do not understand patients’ basic rights.
I literally didn’t go to my OBGYN annual visit last year because I knew my weight had restored after eating significantly less the previous year when grieving the death of my uncle and grandmother in an 18 month period. I finally got it scheduled for next month.
I picked my OB from a referral from my SIL- he was Iranian-American, Duke grad and I liked the rapport he had with both me and my husband. He had a very soothing presence throughout both my high risk pregnancies. But as with any thin medical practitioner I always brace myself for a lecture even though he never really commented on my weight at all.