What to do if you can’t accommodate a higher weight patient

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I just had my yearly mammogram. I had to find a new place because the big fancy cancer center I went to last time didn’t have any chairs in the waiting room that accommodated me, and didn’t have any gowns that fit me (for reference I’m a US size 26/28). I asked for a bigger gown and instead they gave me another of the same size. When I pointed this out they told me “that’s the biggest gown they make” (false) and suggested I try to wear two gowns at the same time (one the standard way, and one Snuggie™ style) but they were heavy and hot and it was a bit like wearing a straight-jacket. Today’s appointment was perfection – the chairs were armless, the robes were accommodating, and I didn’t experience any fatphobia from the admin staff or the tech. But in reflecting on the first experience, I thought I would write about options for practitioners who are faced with a situation where they are unable to accommodate a higher weight patient with the resources at their disposal.

I want to start by acknowledging that often the person who is patient-facing at the moment that the lack of accommodation is discovered is not the person who created the lack of accommodation, and often they don’t have the ability/authority to solve the problem. There are still things that people can do.

Perspective

First, let’s talk about perspective and attitude. It’s important that fat patients are never, ever blamed for a failure to accommodate them. Fat people existing in the healthcare system are never the problem – facilities and tools that don’t accommodate patients of all size are the problem. Instead of being frustrated that fat patients exist, try to cultivate some anger that you don’t have the tools you need to give your higher weight patients equitable care. Remember that you are in a position of power and if you can’t accommodate the patient in front of you, whether it’s your fault or not, they are actively being failed by their healthcare provider.

Avoid The Lack of Inclusion

Of course, the best thing would be to avoid the problem in the first place. Do whatever you can to purchase/advocate for things like armless chairs, the largest possible robes, the largest blood pressure cuffs and other equitable treatment (you can find a handy audit tool here!). If you are working with diagnostic tools that have weight/size limits push to have all the information (for example the weight limits and the bore measurements for an MRI machine) easy to find on your website, and make it standard practice to communicate that to all patients when they schedule.  For example: “I have you down for an MRI. We let all of our patients know that our MRI has a weight limit of 500 pounds and a bore opening of 70cm. We know that doesn’t accommodate everyone and we’re very sorry about that. If it won’t work for you let me know and we’ll search for other solutions.” (See below for other solutions.)

When you can’t help the patient in front of you

• Center the patient’s experience

  • This may feel embarrassing for you, it may be surprising (if you live in a thin body, it might not have occurred to you that things aren’t accommodating to larger bodies,)  it may be something you can’t do anything about, and/or it may be disrupting an already busy day in an understaffed situation. All of that definitely sucks, and isn’t fair, and your feelings about that are valid. But your patient’s healthcare is literally being compromised in this moment. They may be (erroneously) blaming themselves or feeling shame. Even if they are aware that it’s not their fault, they are still experiencing size discrimination at your hands (again, even if it’s not your fault, you are their practitioner.) So, they are the most important person in this interaction, and their needs and experience should be centered. When you do work through your feelings, make sure that you are blaming the lack of accommodation and not your patients’ existence.
    

• Apologize, take the blame

  • For example: “I’m so sorry this is happening. This isn’t your fault, it’s our fault, we should have gowns for all of our patients. “
    

• Ask them what they want (give appropriate options) apologize again

  • Example: “How can I help? Would you prefer to wear your street clothes? Or I can bring you a sheet to wrap around? Or you can try wearing two gowns? What sounds best? Again, I’m so sorry you are having to deal with this.“
    

• Reassure

  • If the patient apologizes or seems to be self-blaming, make sure that you reassure them that it’s not their fault. For example “Oh no, you don’t need to apologize, this is not your fault at all, this is on us.”
    

• Explain how you will address it moving forward (if possible) offer to keep them in the loop (if possible)

  • For example “I’m going to talk to our procurement manager and ask them to get larger size gowns, would you like me to keep you posted?”

  • Make sure to follow through on this.

Things to avoid

• Putting the onus on the patient

  • Don’t tell the patient to bring their own gown (or speculum!) Giving things to thin patients but requiring fat patients to bring their own is the definition of discrimination (and puts higher weight patients at a financial disadvantage as well.)

  • However, if the patient suggests bringing their own gown (or blood pressure cuff, or speculum etc.) then you should do everything in your power to make sure that they are allowed to do that. It’s bad enough to tell a fat patient that they can’t have the same treatment as thinner patients, it’s worse to then tell them that not only won’t you (or your facility) solve the problem, but you/your facility won’t allow them to solve it either.

• Blaming the patient

  • I’m just going to say this again. A lack of accommodation is not the patient’s fault. If you wouldn’t be surprised that a thin person would expect to be accommodated, then don’t be surprised when a fat person does (for example, avoid saying things like “Didn’t you ask what size the MRI is?”)

Other Solutions

The goal here should be complete accommodation - so that we’re not creating spaces that only support the health of some people. Where that isn’t possible (at least immediately,) I recommend the following:

In the event that you aren’t able to accommodate people of all size, you should have non-shaming protocols that everyone is aware of. By non-shaming I mean protocols that do not blame fat bodies for not being accommodated, and don’t create shame in the patient in any way.

This starts with being clear in your online presence and when booking appointments. At a minimum the goal should be that nobody ever arrives at your office just to be turned away for lack of accommodation.

Be specific, take responsibility for the lack of accommodation, and make sure it’s clear that the lack of accessibility is the problem - not the body that is not accommodated. Do your own research to refer to accessible practices.

For example:

The doors in our practice are x inches wide. Unfortunately that fails to accommodate some people and mobility devices. We are sorry for the lack of accommodation and working to solve this problem by [doing these things.] In the meantime we’ve created a list of practices that provide accommodation, click here to view that.

Take responsibility for making sure that you are referring clients to diagnostic centers and other practitioners that can accommodate them.

Reach out to other facilities to get accommodation information

Create lists for clients that give specific information (for example, weight limit and bore size for MRIs etc.)

Encourage other facilities to complete similar audits

Note that accommodation isn’t just about the space, it’s also about the experience. Fat patients often find themselves standing by (often in a too-small gown in a high-stress situation) while practitioners discuss how they might be accommodated (ie: “which room has the big table?” or “I’m not sure if this is going to work” “Do you think she’ll fit?” etc.)

That is something we want to avoid. The process should be just as seamless for fat patients as for thin patients and you should talk with patients, not about them while they stand there uncomfortable. If only some of your space is accommodating (for example, only some tables are high-weight rated, only some rooms would accommodate a mobility scooter etc.) make sure that everyone knows which rooms/equipment work for higher-weight patients and that getting people into those spaces is a seamless process for the patient

Finally, remember that the fatphobic nature of our healthcare system does not lend itself to this type of accommodation. Especially if you are part of a larger healthcare system it may be more difficult to make things happen. Be committed, keep working on systemic inequalities, get creative in the meantime, and remember that lives are literally at stake.

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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’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.