Kris Schwacha, DO

Approach to care

• What does it look like for you to provide care to patients in larger bodies? How is, or isn’t, your approach different from how you care for patients in smaller bodies? If you work with children, how is or isn’t your approach different when working with children?

  I am more frequent to screen for disordered eating patterns or history when someone in a larger body is talking about overall health and wellness concerns.
  I ask patients of all sizes during check ups what they are doing to move their bodies, and how they are nourishing their bodies.
  I do work with kids, and I ask those above questions as well. I also ask more specifically about kinds of intake for kids of all sizes - veggies, fruits, meat, variety, processed foods, sweets, sugary drinks, skipping meals. It is standard work in my clinic to screen all adolescents for disordered eating.

• What is your perspective on how weight is or is not related to health?

  Sometimes it's relevant to health, and sometimes it isn't, just like any other vital sign (heart rate, BP, etc.). People can live in larger bodies and be healthy, people can live in smaller bodies and be unhealthy. Health can mean different things for different people, and regardless of health status all people deserve to be treated with respect and kindness.

• Finish this sentence: “Fat people are…” 

  just regular people who want to get on with their lives!

• How do you, your clinic, and the healthcare system you work in use BMI (i.e BMI cutoffs for accessing certain services, BMI on charts and printouts, etc)? Is this flexible?

  I have no way to automatically get BMI off charts and printouts (I've tried). If a patient doesn't want to see it on their printout, I cover it with stickers.
  I usually use BMI if it helps get someone access to a treatment they are interested in, or in an area where I am required to document BMI (physicals, prenatal visits). Many of my colleagues, however, do routinely practice weight-negative medicine and use "ob*sity"-centered language in their care, regardless if it is relevant to the visit.

• If a patient declines to be weighed, how do you and/or your staff proceed?

  My staff has usually been trained to allow patients to decline being weighed without issue, however working at a residency program means there is a large variety of support staff that I work with and some variance in how they may respond to things. I will only comment or discuss further about a weight declination IF it is something relevant to the care being provided at that visit/something I think is very medically important (ie, monitoring weight gain in a pregnancy to monitor fetal growth, as a measure of fluid retention in heart failure patients, etc.).

• If a patient declines to discuss weight loss, nutrition, and/or exercise, how do you proceed?

  I respect their wishes and move on.

• What does the physical accessibility of your office space look like? What kinds of accommodations are present for people in larger bodies? Are there things you wish were in place that are currently not? 

  The clinic is fully wheelchair accessible and has wide hallways for access. The bathrooms are large single person bathrooms, making it easy for people with mobility devices or who have someone to assist them present for toileting. There are wider seats in waiting areas without armrests available for patients of various sizes. There are a select few exam room tables that have an electric lever to operate, allowing folks with mobility issues to easily transfer onto or get onto the table. There are a variety of BP cuff sizes (though still not perfect).
  There is a lab, Xray department, MRI, and pharmacy within the clinic. I think the MRI is a closed MRI.

• What do you do to allow fat people to feel comfortable and welcome in your office? 

  I only talk about weight when it's medically relevant (rarely), and when I do I first get patient consent to talk about it. I don't advise weight loss, but I explore the conversation of weight loss if the patient expresses that as a wish. I don't use the diagnosis "ob*sity" unless it helps my patient access care that they want, and only do so with express consent.

• If you’d like to use this space to talk about any identities (gender, race, size, sexuality, etc.) you hold and how this relates to your care, please do so. 

  I am a medical provider in a fat body, and this definitely shapes my practice. I am white, queer (though I may pass as a cisgender woman), which all also influence the way I interface with the world.
  I practice in a clinic with an incredibly wide diversity of backgrounds - not just of patients, but of providers and support staff. As such, there is a massive diversity of how providers at my clinic approach weight, and so while I try to practice weight-neutral medicine, that is not true of all my colleagues. They and I strive to provide excellent care to all our patients, but this is a point of disagreement between myself and some of my colleagues.