MRI Access for Higher-Weight Patients

A case study in healthcare inequalities, and what we can do about them

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As I’ve said many times before, when we talk about fat* people’s health outcomes, we cannot blame fat bodies without first accounting for the negative impacts of weight stigma, weight cycling, and healthcare inequalities.

Healthcare inequalities impact fat people in literally every aspect – from accommodation, to research, to tools, best practices, durable medical equipment, and practitioner bias.

Today I’m going to do a deep dive into fat patients’ access to MRI.

Quick background, MRI (Magnetic Resonance Imaging) is an imaging technique that generates detailed images of structures within the body using powerful magnetic fields, magnetic field gradients, and radio waves. An MRI scan can help to diagnose a wide range of conditions and MRI access can be life, and quality-of-life, saving. And all too often, it’s not available for fat patients.

I was giving a talk to a group of medical school students and was discussing MRI access. One of the students shared that at a previous job in an Emergency Department a fat patient had needed and MRI in a life-or-death situation and an MRI that accommodated the patient wasn’t available, so the patient passed away in a situation where a thin person may well have been saved. This is a grim reminder that weight stigma, including lack of access, in healthcare harms and kills fat patients. And when it does, typically the patient’s body size gets the blame.

Let’s start with the basics:

There are two pieces of an MRI machine that can pose access problems. The table that the patient lies on that moves them up and down and in and out of the tube has a weight limit. And then there is  the size of the tube itself, known as “bore width.”

It’s cheaper and easier to increase the weight limit of the table than the size of the bore, and so what some manufacturers did was increase the weight that the table would hold, without increasing the bore size. This created a situation wherein a fat person could lie on the table safely, but would have to be shaped pretty much like a hot dog to actually fit into the MRI

There are wide bore machines. Standard MRI machines typically have a 23.5 inch bore with a weight limit somewhere between 300 and 400 pounds. Wide bore machines are 27.5 inch and typically have a weight limit of 550lbs. High Field Open MRIs are more like a rectangle than a tube and typically have a 36 in width and 18 inch vertical opening. Open Upright MRI machines are a chair with nothing in front of your face and often have weight limits of 500 pounds, but the seat is typically only 18 inches, which is roughly like an economy plane seat (in this case the fat person in question would have to be cube-shaped, rather than hot dog shaped.) There are also open MRIs but in these machines the sides are open but there can still be a clearance issue between the top and the bottom of the machine that varies.

None of these options are large enough to accommodate every patient, which is still a serious problem, but some do accommodate many more patients than the old “standard.”

But wait, there’s more! For many MRIs, the body part being scanned is held in a fixture. With some machines that fixture gets screwed into the table (forcing the person to comport themselves so that their head/shoulder/knee etc. is inside the fixture which cuts into the bore spaces. In other machines the fixture is put on the patient, and then the patient lies down in the machine, this still take up some bore space, but allows more flexibility.

But we’re not done yet, because the “standard” experience is for thin people, and anyone outside of that experience is likely to face barriers at every turn.

A Life-or-Death Game of Hide and Seek

Machines existing that accommodate you is one thing. Actually having access to those machines is another issue entirely.

So, assuming that you live in an area where an accommodating machine is available, and that you can afford a scan on one (either through insurance or self-pay, at least in the US) and that you know all the questions to ask (and those are big assumptions), you still have to find the machines.

Fat patients are often given misinformation, if they can get information at all. I have helped a number of people find accommodating MRIs around the US and believe me when I tell you, it is not easy.

Many times the person who answers the phone hasn’t been trained to understand the questions you are asking, let alone having the answers, and too frequently the promised callbacks never come.

If you can speak with the actual MRI technologist they can often give you the information you need (though not always,) but sometimes they simply don’t take phone calls.

In my experience the most common response is to tell the patient just to come in to “try it.” Or worse, patients are confidently informed that they can be accommodated by someone who, they later find out,  just assumed that “everyone” fits into their MRI.

So that patient will take off work, arrange childcare and transportation, and come to the appointment, often pushing through pain (which is the reason for the MRI) only to find that they don’t fit in the machine, which someone could have and should have told them over the phone.

Then, because fat patients (and our practitioners) are taught to blame our bodies for lack of accommodation, this experience often leads to humiliation, shame and patient disengagement.

The Big Zoo Lie

That medical school student I was talking about in the opening paragraph also brought up another common and horrific myth. When the patient’s death was discussed as part of the morbidity and mortality conference and the question “what could we have done differently” was asked, the suggestion was made that they could have sent the patient to the zoo.

Even if it wasn’t an idea that is, at its core, literally de-humanizing, it’s untrue. The idea that fat patients could use MRI scanners at zoos appears to have roots in a “medical satire” blog that published a deeply fatphobic piece of “satire” on the subject.

This rumor is doubly cruel, because if a fat person is able to overcome the dehumanization of being sent to the zoo, they will soon learn that it was never actually an option to begin with. And they are still a patient who needs an MRI.  We must thoroughly and completely debunk this myth.

What can we do?

Reinforce to your fat patients that this isn’t their fault, that it shouldn’t be happening, that they deserve better.

Create a list. If you are a practitioner who refers patients to MRIs, or who works with fat people who may need MRIs, do the research yourself (or have your staff do it, or hire someone to do it.) Compile a list of facilities that have accommodating options – include information on weight limit, bore size (or vertical and horizontal clearance,) and fixed or free coils. Share this widely with other practitioners in your area.

If a patient can’t be accommodated by an MRI, know what the other diagnostic options are and be ready to discuss them and provide recommendations. (Helpful questions to ask here include “what did we do before we had MRIs?” or “What do they do in places where MRIs aren’t available?”)

If you work at a facility with MRI machines, compile information about MRI options and make sure that information is distributed to those who are patient-facing. While you’re at it, if your facility requires patients to wear gowns, make sure that the largest possible gowns are available. Fat patients’ experiences with your facility should be the same as thin peoples’ experiences.

Standard bore MRIs should become obsolete. Facilities should stop buying them so that they stop manufacturing and selling them. There is no justification to spend a million dollars on a machine that doesn’t work for fat patients. When purchasing and MRI, facilities should purchase the most accommodating machines that exist.

And remember that this is just MRIs. This process needs to be repeated for all other diagnostic tools until fat patients have equality of treatment and experience.

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More Research - For a full bank of research, check out 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’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.