The Gatekeeper

July 8, 2016: The day of my first doctor’s appointment at the weight loss clinic began by pulling on my favorite Bob’s Burgers black t-shirt and a pair of comfortable jeans, believing somehow these articles of clothing would protect me or give me comfort.

I was anxious. I was afraid they would find something wrong with me, and I would not be able to have surgery and be stuck in my body size the rest of my life. After the education session, I firmly believed the only answer to weight loss was surgery.

Sidenote: Every day I am vigilant to rail against the surgery brainwashing. At the education session, and during the months of preparation for the surgery, I was told over and over again about how surgery is the only answer to “real, long lasting weight loss.” Since I became more mobile after the second month post surgery, I have become the type of person I feared — A person who looks at others as potential weight loss surgery candidates. The brainwashing was so innate and severe that when I see an overweight person, my first thought is: “I wonder if they have thought about surgery.”

Fortunately, therapy has helped me become acutely self-aware. When that first thought becomes conscious, I admonish myself. I make myself recognize how beautiful, amazing and strong that person is. They are outside the house, moving around, in yoga classes, at the coffee shop living their lives. They are doing things I found impossible due to fear of people or due to the pain walking caused. I send them positive thoughts and strength for them to love themselves and find a place to exist in this world that does not make a place for overweight people to fit. End Sidenote.

Returning to the same hospital where we attended the information session, my husband found the closest parking ramp to the weight loss clinic’s office. I was wearing the same sandals I wore the night of the information session, and the walk from the parking lot to the clinic burned my feet. My sharp back pain forced me to sit down halfway between the parking ramp and the office.

Breathless, I stepped to the front desk to speak with a thin, older woman. The woman stood up and said “Hello” with a look of recognition and  through an obviously fake smile. She expressed a familiarity with me that made me uncomfortable. She asked me, “Who might you be?”

Seriously? “Who might you be?” This phrase is uttered by adults to children or animals with their hands on their knees while they bend over to look at the child or the animal.

I told her my name, and she squinted her eyes, looking at me skeptically, as if I wasn’t who I said I was. Then after several awkward silent moments, she turned around and picked up a piece of paper off a table behind her. She placed the paper on the counter between us and looked over her glasses at me. The paper was a print out of all of my information, and she slowly, very slowly went down each box reading my name, my address, my insurance etc. She used a pen to point at each of the boxes to make sure the information was correct. Aside from the obvious violation of HIPAA as my information was laying completely printed and out in the open AND her reading my information loud enough to the entire waiting room, each answer I gave  was met with that same skeptical look.

The look made me feel like she thought I was lying or confused. I felt like I was a child lost in a store and telling the security guard my mom’s information, but he doesn’t believe me when I say I’m lost. Finally she released me and told me to sit in the waiting room. This was my first day at the clinic. I was ashamed, anxious and embarrassed because I was there to ask for help. What I expected and wanted to see from the first person representing the clinic that day was empathy, compassion and kindness. Instead, I was treated like a child and a suspicious liar at the same time.  

As far as the actual appointment, that will be covered in future posts. But for now, you will be sticking to the gatekeeper.

GATEKEEPERS

After the appointment finished, I had to speak to her again with a green slip of paper the nutritionist handed to me to schedule the next appointment. This was another excruciating encounter, as she awkwardly fiddled with the schedule much longer than a person should. The appointment was over and all I wanted to do was get to the car before the tears started flowing. Instead, she became a roadblock; a way for the weight loss clinic to make sure I would return.

Once I finally had an appointment, using the same pen she used earlier, she slowly wrote in large, grandiose cursive writing the date and time of the next appointment  as if she was making a beautiful piece of calligraphy art.

Again, I thought this just must be the way she behaves at the first appointment. Nope. This is how she behaves at EVERY appointment. She asks for my information in the exact same way EVERY time.

She doesn’t behave this way with just me. No, this is her behavior with all of the bariatric surgery patients. Her behavior reinforces the stereotypes that fat people are lazy and stupid. Before the surgery, her behavior reinforced the treatment I received in the world. After the surgery, her behavior is a reminder that no matter how much weight I lose, I will still be overweight and stuck facing these stereotypes.

Now, I work every day to not allow people to make me feel like a lazy, stupid child. Some days are easy, other days suck. Weight loss clinic appointment days are one of the latter. I have hope that one day they will be the former.

Bariatric Surgery as a Product

A thin, grey haired doctor stood behind a podium in the front of the room holding a remote control for the projector. My husband pulled out his notebook, THE notebook, which continues to go with us on every visit to the weight loss clinic. The doctor awkwardly introduced himself and began a power point presentation he’s espoused hundreds of times. The goal of the presentation is a weeding out process. Those who are “serious” and “qualify” to begin a weight loss journey with the clinic have to sit and listen to this doctor, whose lack of sensitivity towards people who are overweight was apparent in his mannerisms, presentation style and the way he answered questions.

He began by showing us a graph to tell us how many factors go into being overweight: endocrine and metabolic systems are not working properly, environment and genetics. When he reached the genetics part, he felt he needed to provide an example of what genetics mean by observing families in Target. He explained that both of his daughters are thin because his wife and himself are thin. “We have thin genetics.” He continued, “The other day, I saw a family who had fat genetics. Both parents were overweight, so as their heavy son put soda into their cart, I thought those are fat genes.”

WHAT?

I felt so badly for the family he was watching and judging in Target. There was no reason to include the soda detail because he was trying to explain how genetics play a role in obesity, not behavior or environment. The use of the soda detail felt cruel. Plus, of all the factors of being overweight, the one I understood without complete explanation was the genetics one.

He explained that severe clinical obesity is a BMI of equal to or greater than 40. The doctor listed several medical conditions that occur when someone’s BMI is that high:  
High Blood Sugar
High Cholesterol
High Blood Pressure
Heart Disease
Loss of 10-15 years of life

Sitting there, at my heaviest weight, my BMI was 56. I was on 2 medications for my high blood pressure and 1 medication for my high blood sugar. He showed us a chart where my BMI number moved beyond morbidly obese to “super morbidly obese.” I didn’t start crying right away due to the shame I felt; that didn’t start until the car ride home.

Instead, shame came in the form of paranoia. I looked down at my body, and I hated it. I felt naked and that everyone was staring at me. My eyes glazed over as the doctor explained how I will earn more money and get better job opportunities if I have the surgery. “Due to widespread discrimination, obese people, especially morbidly obese people are not hired for jobs they are clearly qualified for. Several studies site statics. Imagine the jobs and doors that will open to you.”

As a reminder, this session took place on June 28th, 2016. I thought about how I began my current job on April 25th. It had only been two months since I had been looking for a job. I thought about the rejections I received before taking my current job. Then I began to spiral; I thought about ALL the rejections I have ever received every time I was job hunting in my entire life. I began to blame my past failures, broken dreams and my inability to find a job that fulfills me, challenges me and gives me a sense that I am a part of something important on being super morbidly obese. I realized that I was the fattest person who works at my current company. At that time, there were only 2 women who could ever be classified as overweight, but only by medical standards, not in actual reality. In person, they are beautiful women who probably don’t have to shop in the plus sizes. I began to worry about why I got the job I have and that the people at work must be so disgusted by me. I thought about how I sit by myself at company meetings and get-togethers. The spiral led to the same thought: How could I have let this happen? How could I have gotten so big and I didn’t even notice?

The presentation pulled me from my thoughts as the power point slide listed all the complications that come from obesity:

Diabetes
High Blood Pressure
Sleep Apnea
Arthritis
Depression
High Cholesterol
Menstrual Irregularity
Cancer, especially uterine

The one that stuck out to me was the menstrual irregularity. I was 36 and my husband and I had no plans to have children. We still have no plans to have biological children. My menstrual irregularity wasn’t distressing because of procreation.  No, I was distressed and worried because the excessive bleeding, and the high risk of uterine cancer terrified me, especially as it has affected my family. In future moments of doubt about doing the surgery before I did the surgery, I would squelch that doubt because of the monthly reminder of the time bomb inside of me.

As if fear, money and pure shame had not convinced me why I should have the surgery, the doctor moved onto statistics. Honestly, at this point in the presentation, I was unable to concentrate on anything outside of my thoughts. But my husband had THE notebook, so he was able to share with me weight loss statistics at a time when I was ready to hear them.

According to the doctor, when people diet they lose about 8-12% of their excess body weight. After 5 years, 0 will maintain it. When people are on a weight loss drug they will lose 10% of their excess body weight. After 5 years, 10% maintain it. When people have bariatric surgery they will lose at least 50% of their excess body weight. After 5 years, 100% will maintain it. Now seriously, I do not remember which study he was quoting here, but any time percentages are used, 0% and 100% make me very uncomfortable. There are so many different people and areas of grey that it seems improbable to have such numbers, I think NOW, in retrospect. But, at the time, that 100% made me comfortable. It meant to me that unlike all the diets, the jobs, the dreams, if I had the surgery, I would not fail. And in five years, I would still not be a failure.

I now realize this “information session” about bariatric surgery was also a marketing event for bariatric surgery and the doctor’s weight loss clinic. One of the first steps to selling someone something is to earn their trust. The doctor tried to earn trust by shifting the blame. He used the first graph, which showed why and how we become obese, to say: “You shouldn’t beat yourself up; it’s not your fault.” Somehow I believed he was on my side and understood what it was like when I stepped on the scale to see the highest weight I would ever be.

After I trusted him, he used scare tactics with medical conditions and complications and told me how much his “product” would save me money. He ended with the “weight lost” statistics to prove that I will never lose weight on my own, I will never be able to keep the weight off if I happen to lose weight, so surgery was my only option.  While some of the information the doctor used was factual, it certainly manipulated the audience’s “decision making” in one direction.

The Chairs

According to the weight loss clinic’s flyer, the information session is:

To make sure you have the information you need, we require patients to attend an information session before their first clinic appointment. Sessions are hosted by our surgeons and give you a chance to meet them and ask questions. We’ll guide you through surgery requirements and discuss the risks and benefits of each procedure. You are welcome to bring family or a friend with you.

Looking back, I should have noticed the word: “require.” The weight loss clinic that performed my surgery used the word “require” or “requirement” more than they used the words “gastric sleeve procedure.” I didn’t know, at the time, that the information session would begin the relinquishing of my autonomy to repetitive requirements. I want to believe that someday I will become comfortable enough with my weight loss journey to regain my autonomy.

Anyway, I accepted this hour and a half long “session” at face value: a simple meet and greet with surgeons and a Q&A afterward. However, as I said before, this session began with a heartbreaking bang as I overheard a woman say to her friend, “Wow. You’re not as big as her.”

This comment didn’t shake me right away. Instead, I was more concerned about finding 2 empty chairs next to each other, and NOT in the front row, for my husband and me to sit in. I found two extra-large chairs in the second row.

Looking around, I realized the entire room was full of these extra-large chairs. I don’t understand extra-large chairs. I will admit that a couple reasons on the “pro-surgery” list included eliminating the fear of breaking a chair AND getting on a plane with confidence because I know I only need one seat and no seat belt extender.

However, the only places I have seen extra-large chairs, such as these, have been therapist and doctor’s offices, which already have sturdy regular chairs that I’m not afraid I will break. Plus, when you go back to actually see the doctor or therapist, you are given a couch to sit on by the therapist and an unstable, wobbly plastic chair by the doctor. So, why have these chairs at all?

I think the goal of the chair is to demonstrate that the office which uses them is politically correct and “accepting” of people who are morbidly obese. But, I think it does the opposite. When I am forced to sit in one of these chairs, because it is the last available one in the room, I feel like I have a giant, flashing arrow over my head calling attention to the fat girl, who is so big she needs a giant chair. In a passive aggressive way, the chair is actually fat shaming the person sitting in it. It makes you feel as though you are not “normal” or “good enough” to have a regular chair.

The other issue with the chairs is that they are not engineered to be comfortable in any way. Sitting in the extra-large chair at my heaviest weight, there was still a good 6-8 inches of spare room on the seat, and my husband’s had more. After the verbal fat shaming I received, I wanted to sit close to my husband. The chair had a different idea. The sharp angular wooden arms were at just the right height to bite into my ribs when I leaned over. Even though there was physically more room on the chair, there was less useable room. The structure of the chair confined me, as if my obesity was contagious.

Later on, I would learn that the weight loss clinic had only these types of chairs in their waiting room, in their examination rooms, and this training room that I would return to again and again. I will never avoid these fat shaming prison chairs.

Looking back, the chairs and the “requirements” were the covert dehumanizing treatment that would eventually turn me into only “a super morbidly obese.” The covert dehumanization made traveling from the information session to the surgery to today an act of sheer will and uncovered an unknown fount of resiliency I had no idea I had.

The First Step

When I decided to write this blog, I did a lot of research about what it means to produce “good” writing. The theme of the research was that “good” writing should be both authentic and vulnerable. I’m not sure what that looks like or what that means for me. When I write about my story, it physically hurts. Sometimes the tears from pain, sadness, heart break and even laughter, well up and I can barely see through them, I just keep writing because I want to be authentic and vulnerable. This blog post is the beginning of the “official” bariatric weight loss journey, so the tone is going to change a bit. The first three posts were the multi-path journey that led to the decision to have the surgery.

The first step in having an elective surgery was finding out if our insurance company would approve or cover the procedure. My husband received word, on his birthday of all days, from the insurance company that: “Weight loss surgery including the gastric sleeve procedure is eligible for coverage under your plan.” The letter continues by providing a link to a list of “designated weight loss surgery providers.”

Although the “designated weight loss surgery providers” came directly from our insurance, and we were told that we were covered, still the letter, strangely and a bit unsettling, came with a caveat stating: “Please note that a provider appearing on the list above is not a guarantee that they are in-network for your specific health plan.”  The insurance company says: Yes, the procedure is covered. AND here is a list of people who we want to do your surgery, BUT make sure that the provider is “in-network” for your plan. My question is, we went directly to the insurance company to make sure everything was covered under OUR plan, why would they give us providers who would be “out-of-network?” These logical questions, as well as future ones, I didn’t ask. Once I make a decision, I push forward with that decision against all logic, setbacks or roadblocks. Looking back, jumping in with both feet without looking for sharks, was negligent on our part. But after Chicago, there was no turning back. I was going to do this!

So, we chose one surgery provider out of the 12 listed. We chose our provider because this was the same hospital system where the Physician’s Assistant, who suggested the weight loss surgery in the first place, works. I wish I could say that my husband and I did research on the providers or thought about how this would be a good place because they could share my information with my primary doctor through their software systems. None of this crossed our minds.

I called the “Surgical Weight Loss Clinic” located in one of the stereotypically richest areas in the city. Maybe for some people this would mean quality or extravagance, and in some ways, it did. I have to say, several times we enjoyed the valet parking service the hospital provided.

On my first phone call with the clinic, I was scheduled for an “information session” on June 28, 2016, at 7:00pm. The only question she asked was, “What kind of surgery are you hoping to have?” “Gastric Sleeve” was my response. The person on the phone didn’t ask why I chose this procedure; she just said I was to bring my identification and health insurance card. I thought this was really strange for something called an “information session.” Blindly, I followed their instructions. We were to meet in the Au Fait room. I had never been to this hospital and an intelligent person would have asked directions on how to get to the Au Fait room.

I was nervous on June 28th for this hour long presentation. I dressed in my cutest: black skort, sheerish red tank, and a black, short sleeve, cotton, light weight cover-up jacket. I wore a pendant with a fake red stone in it, and my only pair of sandals. I thought I looked adorable, but I hardly ever looked in the mirror before surgery. Sure, a glance here or there to make sure something was on straight and nothing in my teeth, but I never REALLY looked into a mirror.

My husband and I work about a mile away from each other and often carpool to work, so instead of going home, we went out to dinner at a sushi bar, Nakamori. My husband and I walked in just in time for happy hour. We both had 2 glasses of plum wine and several rolls of sushi. I’m not good with chopsticks, so I dropped a piece or two on my shirt causing some stains. After we finished, we had time for dessert. We shared a Tempura Ice Cream and a Cheese Cake Tempura … basically deep fried ice cream and cheese cake. It was all delicious, and we were in high spirits from the food and the drinks.

I remember every moment of this meal.

This was the last one I ate for pure pleasure.

I wasn’t worried about the consequences; instead, I was in the moment, enjoying each bite.

The sushi place is about 6 blocks from the hospital, and neither of us could find a map of the inside of the hospital. I allowed my husband to just park in the parking ramp he figured would be the closest. Once we were in the parking ramp, I took off my shirt and turned it inside out to hide the soy sauce stains, touched up my makeup and lipstick, and we were off.

We walked in the closest door to the parking lot and it was a door at the corner of two empty hallways, with the exception of a bench. I promptly sat down on the bench and my husband wandered off to find a map or something. He managed to find a volunteer information person. He asked her where the Au Fait room was and she said she didn’t know. They both looked at the map she had, and the Au Fait room was not marked on the map. Instead, she simply pointed to where it should be: on the far end of the hospital from where I sat on that bench.

My husband offered to go get the car, pick me up and drop me off at the closest door to the room. I thought that was absurd. I knew if we took it slowly, I would make it there. The problem was that I was anxious now because we were going to be late. The bottom of my feet rubbed against the leather of the sandals and began to burn as we walked. My lower back cramped up, and I was forced to sit down every chance I got.

By the time we made it to the Au Fait room, I was hot and out of breath. My feet burned so badly, I was anxious to sit down and take off my shoes. Instead, I stood in a line where a nurse, who I would come to recognize as the only “nice” nurse in their organization, checked my insurance card and ID. I was handed a pale-yellow packet, “Gastric Sleeve Surgery and You,” and was told to sit down for the presentation.

The first thing I noticed as we were finding seats is that every person (but my husband) was a woman and we were all dressed in black. The chairs were extra, extra large, looked a bit like this one:

:chairs

And were incredibly uncomfortable.

As I sat down, I heard a woman whisper, “Wow. You’re not as big as her.”

This was both the end and the beginning for me.

Terrifying Words & Shame

The path to the difficult decision to get a bariatric surgery all started at a Doctor’s Appointment in April 2016. Sadly, all of our doctors at our regular clinic left within months of each other, and we had to find another doctor. Living in an urban area, the choice of doctors becomes so distant, so cold, that if you are lucky enough to have a friend who has a recommendation, that doctor is usually not taking patients. Instead, my husband and I relied on which one didn’t look like a serial killer in her professional photo. So on the new doctor’s table I found myself half naked.

Quick Side Note: In the months between January and April, I needed to get a pelvic exam due to excessive bleeding, and I need to have one done every year because my mother had uterine cancer when she was 40. The first doctor only discussed my vaginal pain and heavy periods and didn’t check any private parts during my yearly physical. They say that you don’t have to have a pap smear every year if you have never had an abnormal one. However, you should have pelvic and breast exams every year, no matter what. I then went to another doctor in the same clinic. This time, she just gave me a pap smear and nothing else. She told me I had to go somewhere else to get a pelvic exam. Note: she also did not check my breasts as well.

Back to Half Naked on the new doctor’s table. Amazingly, she did her job. Who knew it would take 3 doctors to get them to shove their hand up my vagina. I had better luck in grad school with random boys than this. But quite quickly she changed the topic from my concerns about bleeding to how everything was normal to weight loss surgery.

I’ve had a weight problem / been on a diet / hated my body and myself since I was in 2nd grade. At this time, that meant 29 years I have been battling my self worth, trying diets, succeeding on some, overcame anorexia, overcame bulimia, but everything failed. At this point in April, I thought it was the heaviest I would ever be. I read and tried every weight loss book out there. I tried everything.

Returning to vulnerable and half naked, this doctor suggests the gastric sleeve, a new procedure- where they remove all but a banana size section of your stomach. I told her I didn’t trust weight loss surgery, and what about all the extra skin, and she told me the percentages. Less than 10% of people who try to lose 100+ pounds or more do not gain it back. She also spoke about how she attended a conference about women’s reproductive health where they cited a statistic that women with a BMI higher than 35 have a 9x greater chance of having uterine cancer. She handed me a brochure and disappeared to have me clothe myself and get ready for another A1C (a blood sugar test).

I don’t think there are more terrifying words anyone has ever spoken to me. But, my husband and I were in the middle of a strict diet at that point, and thought, we can do this, we can defy the odds. We decided that we’d try to do it on our own until January 2017, and then, if it didn’t work, we would look into weight loss surgery.

Plus, at the time, I wasn’t sure if I could ever stop feeling that weight loss surgery is a shameful thing. That “How could I allow myself to grow so big that I would need weight loss surgery.” But when given the chance to look at others who have had weight loss surgery, I do not feel as though they should be ashamed. I think, in my mind, the shame should only belong to me and me alone.