Harvard medical students in training at BIDMC are asked to keep a journal about aspects of their training. This excerpt from one, who had a clerkship with our bariatric surgery group, is indicative of the type of transition that occurs as they follow a patient over an extended period of time and learn about the progression of his or her medical condition.
Before
Like most people, I think that obesity is a lifestyle issue -- it is a reflection of our society with gluttony of unhealthy food and paucity of exercise. And like most people, I feel uneasy about "fixing" obesity by reducing the size of the stomach to give the "artificial" feeling of safety and/or to curb the caloric intake by shortening the length of the digested food transit. Is this an appropriate and responsible medical approach? Is obesity a condition indicating for surgical procedure? What kind of people would allow, or even demand, to have one's body altered in such unnatural ways to escape from obesity?
After
Having spent almost one year with my patient, I am beginning to realize some answers.... Health care for obese patients has been hindered by the traditional misconception that weight is not a physiologically regulated variable, but rather determined by gluttonous food habits and hedonistic desires. Indeed, much of our US population considers morbidly obese individuals weak-willed, awkward, self-indulgent, and immoral. This prejudice cuts across age, sex, religion, and socioeconomic status, and often precipitates psychological distress in the obese. [Citing recent studies:] Of the weight loss treatment options presented, extensive research has shown that such options alone have not effectively achieved medically significant sustained weight loss in morbidly obese patients. Even combined with pharmacotherapy, results have been less than promising.....
In contrast to the disappointing results for non-operative treatments for obesity, bariatric surgery was presented as a much more effective alternative.... Surgery effectively "reset" energy equilibrium and defeated the powerful mechanisms for defense against starvation that are inappropriately overactive in obesity. Patients experienced decreased appetite, increased energy expenditure, and a decreased stress response after undergoing surgical intervention, while patients on weight loss diets experienced just the opposite.
[After many conversations with the patient:] Through rich, candid narrative, Z has taught me to relinquish assumptions, to empathize, and above all, to never forget to listen to my patients so that I can offer them what they really need.
