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.

Thou Shalt Never

Once I was sold a weight loss surgery, the information session continued on and on. Two women who didn’t understand the concept of presentations – the presenter talks and only the presenter talks – provided constant commentary on each slide, and they also fell into the category of heckling like Statler and Waldorf from the Muppet Show

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when the doctor was discussing how the surgeries are performed.

The doctor explained the 3 surgeries the weight loss clinic will provide in high school health book detail. Then he moved on to the list of activities we could never do again if we chose surgery. According to the presentation,

WE CAN NEVER:

  • Drink Soda or any other “fizzy” drinks
  • Use a Straw
  • Chew Gum
  • Drink Caffeine
  • Drink Alcohol
  • Eat Hard Candies
  • Eat Coconut
  • Smoke
  • Snack between the 3 meals per day
  • Drink less than 64 ounces of fluid per day
  • Drink less than a ½ hour before a meal and after a meal
  • Skip Vitamins
  • Drink Very Cold Fluids

This list took a very long time for the doctor to explain due to the confusion from the crowd. One woman asked, “What do you mean I have to give up Diet Coke?” And the doctor’s response was, “Some of the fattest people I know drink Diet Coke.” Well, now that’s an answer.  Why didn’t he treat her like an adult and explain that the carbonation in Diet Coke will cause her pain once the surgery is performed? Another woman asked about the no alcohol, and the doctor backed off on this rule. He said, “It’s something you can enjoy occasionally. Like champagne at a wedding.” This seemed to satisfy most people in the audience, including me. However, at my first nutritionist visit, she said she wished the doctors would stop using that example because champagne is “fizzy” so technically we couldn’t have that type of alcohol anyway.

The presentation continued with more rules. A bariatric surgery patient has to meet guidelines before they can be considered for the surgery. These include having strong, healthy teeth and the ability to walk unassisted for 5 minutes. Another guideline the doctor informed us about was that we will have to lose a certain amount of weight before our surgery because it helps to reduce the risk of complications during the surgery. Losing weight makes the liver smaller which makes it easier for the doctor to move it out of the way to perform the operation. He stressed to the group that if we don’t lose the weight, we will not be cleared for the procedure. We were also told we would be weighed on the day of operation to make sure that we hadn’t gained any weight from being cleared for surgery to the actual surgery date. He said that if we are even 1 pound over our required weight loss on surgery day, he would cancel it. “I’ve done it before, and I won’t hesitate to do it again.” This statement haunted me as I tried to lose my required weigh throughout the gastric sleeve preparation process. Every time I stood on a scale at home that didn’t say what I needed it to, I imagined myself standing in a blue surgical gown on a scale and refused the surgery. But his threat threaded its way into the lobes of my brain to become the first fear I would visit when my mind was quiet. It fueled my depression.

The entire process for this clinic usually takes AT LEAST 4 months to get the surgery. Like a fool, I took comfort in this time frame. I thought it was going to take 4 months or less to get approved and onto that operating room table. That time would be filled with so many hoops, it will take another blog post to properly list them. For now though, it’s important to note all these hoops had financial repercussions as well.

We hit our out-of-pocket insurance requirements for the year in August, and my goal was to complete the surgery before the end of 2016 so the surgery would be free. My husband tried and tried to convince me that it would be ok to have it in 2017, but I just couldn’t figure out how the bills would work out with our 2017 budget. I was determined to get it done before New Year’s.

But, no matter how many times I went to the clinic, or how far I came in the process with the checklists, when I asked the question “When do you think we can schedule the surgery?” The answer was, ALWAYS, “We’ll have to see.” So, each hoop I jumped through, there were no encouraging words, no estimate of a possible surgery date, no indications as to when the hoops would come to an end, or even if I could get through all of them and have the doctor turn me away for some random hoop they never mentioned. Instead, I was always greeted with the “We’ll have to see” and the vision of me cowering, cold and vulnerable on a scale to be turned away at the very last second became clearer and clearer in my mind. The hoops, the uncertainty, the self-consciousness about my body, the pain to move, the desperate attempt to lose the required amount of weight, kept me up at night and sent me spiraling.

SIDE NOTE

I was diagnosed with depression when I was a freshman in college. I should have been diagnosed much, much earlier, but that isn’t how my family worked.  All my family members had untreated mental illnesses of their own when I was younger.  It was too difficult to see outside their world to see mine. Interestingly enough, once I began my treatment for depression, many of my family members followed suit. It was like I was giving them permission to get help. I do not know a lot about how depression works in other people, but for me, it ebbs and flows. It seems to heighten in intensity for a period of time, usually a month or two at a time, but I think the intensity helps me recognize that I need to focus a bit more on self-care. In this heightened intensity stage, you know, logically, that eventually the sea of depression will subside. For me, incredibly difficult, stressful circumstances push me into the depression sea to drown. I’m dropped into the “Pit of Despair.” My depression moves me into darkness where I don’t have a hope or a belief that the depression will ever subside. I look back at times I was in that pit, and I was surviving, but I do not remember how I functioned. I think about those times and all I see is life shaded black. It’s like depression redacted whole months of my life at a time.

Those months when I was hoop jumping for the weight loss clinic and for my insurance company is a portion of my life when I was drowning in the sea of depression or the pit. I can’t remember day to day, ordinary activities through the black marker redaction.  And it all started with this info session.

Once the presentation concluded there was time for questions. While I sat in a trancelike state, unable to focus on the doctor, women or my husband, the women launched questions at him that only sounded like a quiet buzzing in my ears. I wanted to leave, I wanted to never lay eyes on the doctor or these women ever again, and I wanted to run to the car and hide. After the women rushed the doctor to ask him questions, my husband and I made our way out. Even though the car was in the farthest possible parking lot, I managed to make it to the car. Once inside the car, the emotions stuffed into my chest exploded. I cried, I yelled, I screamed. But I knew there was no choice for me but the surgery. This was the path I had to take because nothing else was working.

When we got home, I shoved my shame into ice cream and planned to make an appointment at the clinic the next day.

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.