Things to Stop Saying/Doing To Fat Patients At The Start Of Their Appointments
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Higher-weight patients can face tremendous weight stigma, including intrinsic, extrinsic, and structural stigma, within the healthcare system, with those at the highest weights and those who are multiply marginalized being the most impacted. Some of that isn’t something that can be solved by individual providers, but some of it is.
The part of the appointment from the time we enter the office to the time when we see the healthcare provider has the potential for a lot of occurrences of weight stigma. Here are some things the healthcare workers who see patients during this time can do (or stop doing) right now to improve fat* patients’ experiences.
I do want to point out that many of these things are done by healthcare workers who are under pressure from those who are higher up the hierarchy and/or the facility. It can be difficult to push back. I would suggest that you do whatever you possibly can with any power/privilege/leverage that you have, and then work to create allies so that you can work together to push for larger change.
Just as a note, if you find that you are doing some/all of the things mentioned here, know that you aren’t alone and that you can use any guilt/shame/embarrassment/defensiveness you might feel as a catalyst to do things differently moving forward, to share this information with others, and to advocate for change.
In situations that are a structural failure to accommodate the fat patient, I definitely recommend apologizing. Even if it’s not your fault, acknowledging that this patient’s healthcare is being compromised – that they aren’t receiving the same experience that a thinner person would – and apologizing for that can help the patient not to blame themselves for systemic failure and to feel cared for, which can be the difference between them coming back or disengaging in care.
You are too big for…
If a fat patient is not accommodated by a chair, a blood pressure cuff, an MRI machine or anything else, it’s not that the patient is too big, it’s that the equipment is too small. When you tell a fat patient that they are too big for something, you add insult to the (very real) injury of not being accommodated in a healthcare setting, with all the harm that can stem from that.
Just wear two gowns
It’s bad enough to find that a facility hasn’t bothered to purchase gowns that fit you, but this is often followed by a suggestion that you wear two gowns. If you aren’t sure why this isn’t a good idea, go find two shirts that are too small and try to wear them both at once. It can be uncomfortable, othering, embarrassing, and it’s pretty unlikely to cover you effectively. The best solution would obviously be to order gowns in all sizes, including the largest possible, proactively. Failing that, can the patient wear their own clothes? I’ve had them bring in the big paper sheet which is definitely a subpar experience but, at least for me, better than trying to wrestle my way into two too-small gowns.
You should cut down on the snacks…
Many fat patients, myself included, have found ourselves on the receiving end of unsolicited food and/or movement advice from the person who was in charge of taking our vitals prior to our appointment. This is not appropriate and it can often be harmful. Typically, this advice is based on stereotypes and the person doling it out has little to no information about the patient’s possible history of disordered eating, request for weight-neutral care etc. let alone specialized training to back up their recommendations. Weight loss advice is never an ethical, evidence-based treatment option, but it’s even worse when it’s not just unsolicited, but unexpectedly coming from someone who the patient has a reasonable understanding is tasked with taking their vitals, not providing medical advice.
Let me tell you about my diet…
While we’re on the subject, if you are pursuing intentional weight loss or if you have internalized fatphobia, don’t share that with your patients. In fact, don’t engage in diet or weight loss talk within earshot of patients. You don’t know if you will be triggering disordered eating/eating disorders or creating unnecessary stress for patients (not to mention co-workers! Imagine being a fat(ter) person who is subjected all day to the diet talk of coworkers who are explaining how desperate they are not to look like you.) People are allowed to do what they want with their bodies, including attempting weight loss (regardless of the risks and how unlikely it is to succeed,) but those choices don’t happen in a vacuum and conversations about it are not appropriate for every situation.
You are required to submit to routine weigh-in
This one just isn’t true. Besides the fact that the patient’s right to informed consent and refusal is absolute, there is no reason to require a routine weigh-in. If the weigh-in is literally medically necessary (for anesthesia, dosing of meds, monitoring fluid retention etc.) then explain why. If it’s not medically necessary and the patient says no, say “no problem” and move on. While you’re at it, consider ending the practice of routine weigh-ins.
The weigh-in can be a point of significant historical and/or current trauma (and a reason that patients avoid care/don’t come back) so if you don’t really need to know, then there is no need to ask them why they don’t want to weigh-in. They may not want to have to disclose the harm that has been done to them during routine weigh-ins. They may not want to have to disclose that they a weigh-in could trigger an eating disorder relapse at their podiatry appointment. Asking them why can also carry the connotation that their answer might not be good enough which is, again, not true.
Don’t tell them that their insurance requires it unless you know for a fact that it does. Sometimes patients not weighing in can impact practitioner compensation, but insurance offering the practitioner less compensation if patients don’t weigh in is NOT the same thing as the insurance requiring the patient to weigh-in, and it should not be presented as such. (I wrote here about the misconception that Medicare requires weigh-in.)
Don’t ask the patient if they weigh in at home.
Don’t offer to guess, or ask the patient to guess. This is simply proof that you don’t need their weight since either a number is medically relevant, or it is guessable.
If the patient says no the best thing that you can do is affirm their choice (“no problem,” “sounds good,” “great, right this way…” etc.) and then move on!
Blood pressure mishaps
Taking blood pressure for fat patients can be fraught.
Many fat patients have faced weight stigma, lack of accommodation, and poor treatment at healthcare appointments. Some to the point that their blood pre)ssure is raised just by being at the doctor (this is known as “white coat hypertension.”
If the patient has faced weight stigma or mistreatment as part of this appointment (no chair in the waiting room, drama at the weigh-in etc.), their blood pressure, taken immediately after, may be high. (Personally, if a practitioner pushes back when I decline weight-in, I also decline blood pressure.)
Also, fat patients are often subjected to blood pressure readings that are known to be inaccurate, I wrote about that here.
On the other side of this, if a fat patient has a blood pressure reading that happens to be considered “normal” do not act surprised or take their blood pressure multiple times unless you would do the same thing for a thin patient.
Talking about the patient in front of the patient
Even when it’s well-meaning, having people talk about how to accommodate you in front of you but not with you can be uncomfortable and dehumanizing. Often it’s…less well meaning, or said with a connotation that the fat person is a problem or pain. If you need help, include the patient ie so instead of yelling “WE’RE GONNA NEED THE BIG CUFF” try either leaving the room or saying “This is Maria, we need to get a thigh cuff for her, have you seen it? (If you have the power/privilege/leverage, whenever you find something that thin patients have in every room but, for fat patients, has to be located, – ie thigh cuffs, larger size gowns etc. – see if you can order enough so that fat patients have the same experience as thin patients.
Just try it…
If the patient is worried or asks if a chair, exam table, or any other equipment will accommodate them, or thinks that the blood pressure cuff, or MRI or CT is too small, don’t suggest they “just try.” Even though, in truth, the chair is the problem and not the patient, trying to sit in a chair that isn’t big enough to accommodate you (or sitting in it and getting stuck) can create embarrassment and shame that keeps the patient from coming back. Stuffing themselves into a too-small chair can mean the patient spends the appointment in pain which can create difficulty concentrating on the appointment (and a higher blood pressure reading.) Having a chair or table break under you is dangerous and, again, there is a tendency to inappropriately blame the patient rather than the equipment. Getting situated on the table just to find out that you won’t fit in the MRI or CT is not just embarrassing, but can exacerbate an injury the patient is getting a scan for. Taking blood pressure with a too-small cuff gives an inaccurate reading. If you don’t know the actual weight-rating, bore size etc. either find out, or ask the patient how they want to handle it. Do not pressure them to “just try it.”
Sigh…This is just taking a lot longer
It is possible that it will take longer to situate a higher-weight patient for a scan, if the patient is both higher-weight and disabled, it may take them longer to get around the office. I know that many providers who are charged with getting vitals or getting patients situated are under a time crunch, and that’s something that isn’t fair to those providers or to the patients. Still, that’s not the patient’s fault so avoid loud sighing, impatient looks and gestures, or telling the patient that this is taking longer than normal. It doesn’t help, and it’s something that can make the patient less likely to come back.
When talking to colleagues avoid saying things that are (intentionally or unintentionally) fatphobic. Put you and the patient on the same team. Instead of blaming the patient, talk about how much it sucks that you aren’t given enough time to accommodate all of your patients.
Medical weight stigma can impact fat people in every aspect of healthcare. If you are a healthcare provider you may not be able to solve all fatphobia that a patient might experience, but you can solve some of it and the action you take will make a real difference in the lives and experiences of your patients. So thanks in advance for any action that you take.
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*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.
What always gets me about "let me tell you about my diet" is how little training most medical professionals get in nutrition and the full mechanics of weight regulation. (Especially nutrition, ouch.) Those who are trained know enough that one person's diet is not always right for everyone or anyone else, whether they're chasing after weight loss or just trying to eat "healthier." Even for diabetes, there's no "one size fits all" food plan.
As someone else once said, "Thinking that losing weight makes you an expert in weight and nutrition is like thinking that surviving cancer makes you a cancer expert." Even for doctors and other medical professionals, someone is not an expert just from personal experience. This is just perception bias at play.
Not sure if you remember me but I was the ED of meda when you came to speak there many years ago . I just want to express my gratitude for all you are doing to help people understand fat phobia and lack of access to appropriate services. So.. you are greatly appreciated and respected and I am so glad i I get to read your newsletter