The patient is large. Very large. At more than 600 pounds, he is a mountain of flesh
“My stomach hurts,” he says, his voice surprisingly high and childlike.
THE OTHER DAY, a colleague brought to my attention an essay from The Washington Post called “A morbidly obese patient tests the limits of a doctor’s compassion” written by a Dr. Edward Thompson. Just the first two lines of it above had me furious. Not only were they a study in the power of negative metaphors, but as a fellow physician, they felt all-too familiar. They were the way I had, on many an occasion, heard patients’ bodies talked about; ways that I, during my training, had perhaps referred to patients’ bodies. The simple words felt so easy, so unexamined, and in that very ease was embedded their violence.
Let’s recap the imagery used. A very large man is compared to a mountain of flesh. He has a high and childlike voice. You don’t need to be an MFA in creative writing, or a sociopolitical genius, to recognize these as metaphors of the grotesque and infantile. And importantly, the patient’s stomach pain is not a stated fact, but a complaint, framed by quotes. This makes clear to the reader that the patient claims his stomach hurts. He is potentially malingering. The implication being that the obese are, well, complainers. Indeed, although studies show that physicians are nicer to thinner patients, many of my medical colleagues don’t seem to realize that personal and institutional violence against fat people (and I use that term in solidarity with the fat activism and fat studies movements) is a thing. A real, grotesque and infantile thing. A real, grotesque and infantile thing that negatively impacts the health care that fat individuals receive.
The Washington Post essay goes on, describing the patient in this way: “He spends his days on the sofa at home, surviving on disability checks related to his back pain.” The implication being that the man’s weight is what led to his disability and not the other way around. And we all know what sofa-sitting is code for: slovenliness and laziness.
So let’s recap again. We have the grotesque, the infantile, the complaining, the slovenly and the lazy. The metaphors are piling up.
Yet, wasn’t George H.W. Bush’s signing the Americans with Disabilities Act supposed to relegate able-ism to a thing of the past? Weren’t we all supposed to recognize the rights of our fellow citizens, regardless of appearance, ability, size, number of limbs or other embodied differences? Apparently, this memo did not reach most American medical schools. At least not yet. Because, while a few medical schools have medical humanities programs, only a fraction of these programs systematically incorporate disability studies into their courses, and even fewer acknowledge what’s now known as the activist and academic field of fat studies.
Interestingly, size-as-disability is even explicitly brought up by Dr. Thompson’s patient himself, when he “indignantly” says, “The Americans with Disabilities Act says that [the paramedics] should have the proper equipment to handle me, the same as they do for anyone else… I’m entitled to that. I’ll probably have to sue to get the care I really need.”
And yet, the ER-physician/writer doesn’t seem to agree: “I don’t quite know how to respond, so I say nothing.”
Instead, Dr. Thompson’s essay launches into the difficulties of diagnosing the man’s gallstones, difficulties that are all attributed to his size: the physical exam which leaves the physician at first “not knowing where to begin,” and then noting that his “hands look small and insignificant against the panorama of skin they are kneading.” The author describes the ultrasound machine that “barely fits” between the oversize bed and the wall, the technician who declares, “this is impossible,” the chief of radiology who emerges from the room a half hour later “rings of sweat under his arms,” and the attendants who must “huff, puff, and grunt” in order to push the patient down the hall on a gurney. He writes of a surgical colleagues’ desires to “unload” the patient on a different hospital due to his size, and the continuous, cutting remarks from the ER staff: “Don’t put him in a room right over the ER…The floor won’t support him. He’ll come crashing through and kill us all.”
As a faculty member in the Master’s Program in Narrative Medicine at Columbia University, I know about the power of stories: stories told by physicians, stories told by patients. I know that having health care students read, write and analyze narratives can deepen their training in bioethics, medical professionalism, reflective practice, self-care and patient-centered care. Narrative study can help our students effectively diagnose, treat, and otherwise attend to the lives of their patients.
Yes, stories are powerful. But let’s not get too precious about them. Simply reading any story with a medical student or engaging them in a narrative writing prompt is not the same as actually educating them in structural issues of oppression and inequity. Those of us in the medical humanities professions must teach our students not only to listen to stories, but to listen to them critically; asking themselves questions like “who is speaking?”, “who is being spoken for?”, “what larger narratives is this story supporting?”, and “what additional stories are being silenced by this one?” In a brilliant TED talk, the writer Chimamanda Ngozi Adichie speaks about the dangers inherent in a “singular story.” Although Adichie is speaking of singular narratives about Africa and Africans, the idea can be easily applied to other issues. Singular stories can ensnare us, make us so accustomed to one way of thinking that we can no longer imagine there are alternative narratives possible.
Consider the words of Dr. Thompson as he describes the desperation of his patient,
The patient lies trapped in his own body, like a prisoner in an enormous, fleshy castle. And though he must feel wounded by the ER personnel’s remarks, he seems to find succor in knowing that there’s no comment so cutting that it can’t be soothed by the balm of 8,000 calories per day…I know why my colleagues and I are so glad to have this patient out of the ER and stowed away upstairs: he’s an oversize mirror, reminding us of our own excesses. It’s easier to look away and joke at his expense than it is to peer into his eyes and see our own appetites staring back.
As someone whose work in medical humanities is particularly concerned with narrative, health, and social justice, I find this paragraph deeply troubling. Although it is gesturing to, as Dr. Thompson says, “compassion,” the language itself creates a prison around the reader’s imagination. Referring to another’s body as “an enormous, fleshy castle” and suggesting that food is a “balm,” and “obesity” necessarily connected to out-of-control “appetites” is a singular story about fatness, a story oft told, particularly in medicine. It is a story that leaves no room for, say, the fat person who practices self-love and radical self-acceptance, the Health At Every Size movement, or the politicization of fatness – the assertion that, as author Susie Orbach has said, “fat is a feminist issue,” or that race, class and colonialist politics are written upon fat bodies. The fact that Dr. Thompson’s story ends with his patient’s death, and emergency crews being required to cut an enormous hole out of his roof to hoist him out, only adds to this particular, tragic story about fatness. This is not, of course, to say that this particular patient’s life story might not have been tragic, but rather, that this Washington Post essay reinforces a singular, expected cultural narrative about fatness and fat people.
As Susan Sontag famously argued in her Illness as Metaphor, certain bodily conditions have historically been associated with failings of moral character. In the past, this stereotyping was limited to diseases from tuberculosis to cancer, but now, this is most seen regarding those behavior-based characteristics considered high-risk factors for disease – from smoking to multiple sexual partners to IV drug use.
Bolstered by Michelle Obama’s Let’s Move! and other similar campaigns, the ‘obesity epidemic’ has become a favorite topic of neoliberal moralization. What this has resulted in is a kind of permission within the medical profession to engage in size-ism under the guise of encouraging good health. I’m not saying that physicians might not speak privately and respectfully to patients about weight, or that exercise and healthy eating are not a good thing. But physicians – and indeed, science itself – does not exist somehow outside of culture and sociopolitics. Consider that medical and public health anti-obesity messages have plenty of secondary narratives inherent in their images – other stories they’re telling about race, masculinity and femininity, parenting, poverty, disability, as well as the ‘right kind’ of (economic and nutritional) consumption. In addition, these messages dovetail perfectly with images in fashion magazines, on billboards, in movies and on TV about thinness, fairness, youth, beauty, and desirability (not to mention wealth, heteronormativity, able-bodied-ness, cis-gendered self representations, etc.). These medical and media messages create a kind of ‘toxic body culture’ that permeates all our consciousness (particularly young peoples’), leading to everything from disordered eating to low self-esteem to bullying to warped notions of normalcy.
What’s also troubling is that medical and public health messages focus almost exclusively on individual “shame and blame,” even asserting that we doctors somehow should shame our patients, regardless of evidence which shows that shame about weight is an ineffective motivator in behavior change. Despite assertions like this one on Gawker that “Your doctor is probably not fat-shaming you,” the fact, is, sometimes, intentionally or unintentionally, your doctor just actually might be fat-shaming you. The moral indignation evoked by fatness among physicians suggests that it satisfies some emotional function, some opportunity, in this era of health care consumerism and internet savvy patients, for physicians still to command a sense of superior power over patients. Consider that even after a study published in Pediatrics suggested that physicians no longer use words that are stigmatizing of childhood obesity, one physician blogger railed at kevinmd, “Political correctness and sensitivity training are interfering with medicine and healthcare.”
The problem is also American medicine’s myopic concentration on individual behavior over systemic constraints – a focus which is related perhaps to our cultural ethos of independence, personal control, and pull-yourself-up-by-the-bootstrap-iness. Perhaps instead of railing against “sensitivity training,” shaming patients, and yearning for the ‘good old patriarchal days’ of medicine, we physicians might do better to protest against systems-based issues like the lack of green, safe, outdoor spaces in many communities, the existence of food deserts, the prevalence of GMOs or the affordability of processed food products over whole fresh foods. Perhaps we medical educators should address how woefully lacking our systems of training are in what my colleagues Jonathan Metzl and Helena Hansen call “structural competency,” the notion that social inequities impact health as much as physiology.
Yet, sociopolitics is only part of my problem with Edward Thompson’s Washington Post essay. Granted, physicians – particularly ER physicians – often develop a sort of gallows humor to deal with the emotional and physical pressures of patient care. But that doesn’t mean we physician writers are exempt from privacy regulations (ie. HIPAA) or narrative ethics; nor do we need to publish each and every thing that comes out of our laptops. Over the years, after I myself published a medical school memoir in 1999 with quite a few ‘patient stories’ in it, I have come to realize that there is a big difference between writing privately for our own needs and writing for a mass audience; and the latter comes with certain responsibilities, particularly toward vulnerable subjects. The very least of these responsibilities is obtaining explicit permission from patients or their families before sharing their stories publicly. In this particular case, Dr. Thompson was apparently unable to obtain permission from the patient because he had already passed away prior to the writing of the narrative. Whether the author contacted his family to obtain permission, I cannot be sure.
There is, of course, a tradition of insightful, humble and self-critical confessional stories in medicine such as William Carlos Williams’ “The use of force,” or David Hilfiker’s “Mistakes,” tales of medical brutality and error which serve to implicate their physician-authors and shed light on the imperfections of the profession. I actually imagine that Dr. Thompson was seeking to similarly implicate himself and his colleagues in their size-ist bigotry. The problem is, the language and metaphor of his narrative actually serves to reinforce the self-same fat shaming that the essay seemingly seeks to address. Whatever the author’s intention, the narrative itself supports rather than undermines fat hatred and in doing so harms far more people than just the patient described or his family. Indeed, the narrative itself potentially “pulls the red handle” for a lot of people who identify or are potentially identified as fat.
As this insightful, and angry, commentary about Dr. Thompson’s piece from the blog Shakesville points out,
Fat people! They exist in the world and can hear you! They may even be entirely aware of your loathing, your disgust, your discomfort, and your judgment. They may even (probably) take these things into account when deciding if the acute pain in their side is bad enough to face the dehumanization, the hatred, the vitriol, and the humiliation of interacting with medical staff (you know, those compassionate care givers ostensibly tasked with giving a shit about their well-being and health and trying to diagnose and help them) or if they should just wait it out and see if it gets better.
Fat hatred kills people. Not least of all because sometimes living with pain and not knowing what it is may just be preferable to being dehumanized, hated, and sneered at by the people you have to trust in order to access medical care.
The resource-hogging “obese patient” has become the new version of the welfare queen in our popular imaginations. Such stereotypes about any community – that they are infantile, monstrous, unthinking, lazy, whiney and resource-wasting – isn’t only emotionally damaging but potentially physically harmful. As the blogger at Shakesville asserts: “fat hatred kills.”
Physicians cannot use concerns over health to legitimize bias. Medicine is not a moralizing stick with which we can beat our patients into submission.
Medical narratives are powerful. Let us use them not to ridicule, alienate, or demonize our fellow human beings, but rather, create a much-needed change to a more socially just health care.
Thank you to my colleague Dr. Daniel Goldberg for bringing both the Washington Post and Shakesville essays to my attention. Thank you to Drs. Tess Jones, Rebecca Garden and others at the ASBH LITMED listserve for their insightful thoughts and comments in the ensuing discussion.