Sunday, June 17, 2012

Patient #4: "Obesity"

      What should I say to a patient who is 468 pounds?
     How might a doctor make a difference when 90% of the patients in a medical practice are overweight or obese?
     Does nutritional counseling make sense when the obesity epidemic has delivered up to the medical profession hundreds and thousands of these gentle souls, limping and heaving under the immensity of their problem, self-conscious and sad, helpless, guilty, and afraid to ask for treatment because they cannot tolerate one more negative innuendo?  As if the physical burdens aren't enough for these patients to bear, an inner persecutor adds psychological ones. 
     Are we all in agreement that the most important way to cut medical costs in America these days is to address the twisted back corridors of the universal human drive to nourish and be nourished, in order to discover wherein something might have gone awry?  
     Mr. M. is 468 pounds.  He is overtly cheerful, polite and well-dressed.  He wears heavy gold-plated chains around his neck, and from one of them hangs a large pendant of a dragon.  He sits on the edge of the chair and leans forward, as though by giving a slant to his back he might reduce the ache he feels there most of the time. This is his first visit.
     He does not mention his weight.  
     He would like me to “do shots” for his feet.  They hurt so much he can’t stand all day at his job.  He has tried over-the-counter pain medicines but they don’t work.  He has changed shoes, worn orthotic gel inserts and applied herbal compresses.  Every evening he soaks his feet in Epsom salts.
     I know that he is requesting corticosteroid injections, a very effective but temporary treatment for the pain of plantar fasciitis.  An examination of his feet confirms the diagnosis.  The skin is thick, leathery, chaffed.  His heels are tender when I press down on the small protuberances of bone where fibrous ligaments attach. 
     I also notice that the redundant folds of his legs are red and scaling, evidence of a chronic fungal infection resulting from moisture.  When I sink my thumb into the skin of his ankles a deep indentation remains.  His legs are retaining fluid--the effect of gravity operating against the circulation of venous blood back to the heart.  This condition may in time lead to ulcers and infection, or even necessitate amputation.
     He has other symptoms which I am able to coax out of him.  They are all familiar to me, the pattern of bodily aches and pains that stem from obesity.  His blood pressure is high and his sugar is edging toward diabetes.
     I do not mention his weight either. 
     Why not?  Well, I want him to come back.  I want to win his confidence by “fixing” his presenting problem.  Therefore I thank him for coming in, ask about his family and job, calculate the number of social supports he might have, and draw up the cortisone shots.
     It will be ten more visits before we talk directly about the possibility of reversing his obesity.  Some patients can’t imagine another body.  Others are stymied by the emotional problems that shimmy up from the depths when the mantle of weight is shed, pound by pound.  The vulnerabilty of the inner personality is immeasurable and must be taken into account before its protective cloak is discarded.  Many patients need to feel the doctor’s hope, because theirs dribbled away long ago. 
     This patient’s insurance company might consider it a waste of money for me to wait through ten chargeable visits before talking about such an obvious problem.  Instead, I have talked around it.
       Even worse, the plan we devise--to request gastric bypass surgery--will cost the insurance company mightily, and we can expect a fight.  Mr M. meets all the criteria for surgery and the savings over the course of his lifetime--should he shed half his weight--will be twenty or even thirty times greater than the cost of the surgery.  But the insurance company isn’t interested in long-term savings.  By the time Mr. M. might suffer the serious (and expensive) medical consequences of his obesity he would likely be covered by another insurance carrier, Medicare or Medicaid.  Then his current insurance carrier, Blue Cross,  wouldn't have to bear the cost.  It's a strategy that maximizes profits.
     I make a strong case for surgery and begin the long stream of paperwork petitioning the insurance company to designate the surgery medically necessary.  I must prove to them that Mr. M. already has at least three serious, life-threatening medical consequences of obesity.  
      Mr. M. begins to imagine himself differently.  We do psychological counseling at every visit alongside more directive treatment of his blood pressure, dietary problems, pain.  The exam room contains us, and he trusts me more each time, so that we are able to begin talking about his difficult past, childhood years full of betrayal and deprivation.  If I can stick with him, I think, to hold him through this year, the chances for long-term weight loss are very high and Mr. M.’s quality of life--who is measuring that?--will improve in a way that is nothing short of momentous. 

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