The Weight Behind the Scale

For the last 3 years, I have had the privilege of participating in the primary care of a middle-aged Cuban woman at our hospital’s charity clinic. The office is located in the heart of a small urban city where an estimated 40% of the population lives in poverty. Medical students, residents, and attending physicians at the clinic care for patients who are uninsured and underresourced. As one might expect, the financial resources and physical space in this setting are limited.

My patient, given the pseudonym “Ms Hernandez,” carries the clinical label of obesity. The care we provide her is not unlike that of many adult patients nationwide: treatment for insulin-dependent diabetes, hypertension, and hypercholesterolemia. Formerly an elementary school teacher in her home country, she migrated to the United States during early adulthood.

I can vividly recall her first appointment 3 years ago. Although she exhibited a subtle uneasiness, I assumed it was nothing more than that which accompanies any first-time visit. Slowly progressing through the encounter, Ms Hernandez hesitantly informed me of worsening postmenopausal vaginal bleeding. Perceptible in her trepidation to discuss it—let alone to a male provider—she explained that I was the first person to whom she had disclosed this information. Following subsequent workup, Ms Hernandez was unfortunately diagnosed with advanced endometrial cancer.

In the 3 years since then, her disease has remained quiescent. While continuing to manage her other conditions, I have built a fond rapport with Ms Hernandez—one that mirrors what, as a medical student, I imagined the traditional patient-doctor relationship to be: exchanging stories of our families, bringing her young grandchildren to visits, and sharing the occasional laughter over current events. By overcoming the many barriers to her care, my team was able to support her well-being while never sacrificing the personal aspects of medicine. In my mind, we were attaining the ideal connection that every student envisions before entering medical school.

At the conclusion of a recent appointment, she quietly pulled me aside and asked for a minute of my time. As the remainder of the team hurried away to tend the patients in the overflowing waiting room, I stayed behind despite already shifting my focus to the overwhelming tasks that lay ahead. When the door closed, Ms Hernandez spoke to me in a soft voice. With a shamed demeanor, she described the first time she ever came to the clinic. Unbeknownst to me, she had been there before. In fact, the story she shared was considerably different than the one I had imagined for 3 years.

She recounted timidly entering the waiting room, unfamiliar with the foreign setting, and standing just beyond the doorway. Instantly, she noticed a weight scale situated directly adjacent to the short hallway leading to the exam rooms. She turned around and left the office immediately. Three months later, she returned only to repeat these same actions. In total, she had visited the clinic twice before ever working up the courage to see a provider.

Faced with this surprising confession, I gently asked her to explain why she chose to leave the clinic each time. After a short pause, Ms. Hernandez exposed a lifelong struggle with her weight. She referenced painful memories of her adolescence and the resultant shame she still carried. With tears filling her eyes, she revealed that she became overwhelmed by the scrutiny she expected to face when she would inevitably have to step on that scale—scrutiny not only from the medical providers, or herself, but from the judging eyes in the waiting room. The open view of the scale provoked memories of overweight children in her own elementary classes; fearful, vulnerable, and embarrassed during annual school exams. It was only when the fear of her bleeding finally outweighed the fear of her embarrassment that she resolved to stay.

After I apologized for the discomfort the clinic had caused her, she implored me not to feel remorseful because our team had saved her life. Rather, she shared this experience because she had observed another obese patient sitting in the waiting room earlier, eyes fixed on the scale.

When Ms Hernandez left, I remained in the room to collect my thoughts. It was painfully remarkable how a simple overlooked detail, such as the position of a scale within an office space, could potentiate factors that had a significant impact on my patient’s health. Despite priding ourselves on maintaining a personalized approach, my colleagues and I never once recognized her discomfort when performing a routine task customary to almost every medical encounter. The paradox behind this situation was strikingly uncomfortable: an instrument essential in the monitoring of insulin-dependent diabetes was the same apparatus that deterred my patient from seeking care. Indirectly, the scale had delayed the time-sensitive treatment of her cancer.

Observing this stoic, independent woman reduced to tears reminded me to not let the details that impact the interpersonal health of my patients escape my conscious forefront in this ever-changing culture of medicine. Like many, I allowed extrinsic pressures to misguide my attention to detail. I routinely overlooked something that would make any person uncomfortable, unconsciously citing limitations in physical space and overwhelming patient numbers as justification.

Almost poetically, the current sight of any weight scale is a reminder for me to take a step back from the endless demands of this profession. Although it may not be a tangible hard stop built into my everyday workflow, this experience serves as a psychosocial hard stop whenever my daily tasks begin to feel overwhelming. I try to remember that as a clinician, a patient’s weight may simply be another vital sign, another routine measurement, or a random number on a chart. But to a patient, it may be the weight anchoring them down from seeking the care they so desperately need.

Three months later, Ms Hernandez was scheduled for a follow up. As the clinic opened, I sat behind the registration window and watched as she walked in. This time, she was greeted by the sight of a stand-alone curtain surrounding the scale. Without saying a word, she subtly nodded her head and smiled as she approached the desk.