A Story I Have to Tell

Fernando Botero's: After Velazquez

On the intake sheet it only said "second opinion" so I had no idea when i walked into the examination room and was greeted by my patient and her mother.  She was a lovely young woman complaining of more than 10 years of back pain with debilitating progression.  This woman was also coping with psychotic schizophrenia (on three controlling medications) and suffering from morbid obesity (5'4" an 310 lbs).  Her exam showed no significant neurological impairment.  However, her MRI revealed a large ruptured disc and also the ravages of degeneration from the extra stress of her body habitus.
I began my usual explanation about ruptured discs and treatment options but had to conclude by informing her I would not consider surgery for a number of reasons all related to her obesity (the high rate of surgical complications, the likelihood of significant residual pain related to the widespread deterioration of her spine, her inability to exercise and adequately mobilize after surgery just a few of many).  I went on guardedly to make sure she understood that it wasn't that I didn't want to help her or that I was prejudiced about her weight and then moved on to my recommendation that she strongly consider surgical treatment for her obesity. I finished, so I thought, on a positive note saying that with the rapid weight loss one could expect, we might be able to consider surgical treatment for her back in less than a year.
I stopped talking after inviting any questions and there was absolute silence.  It took great restraint to let her speak next-the pause was so prolonged.  Her mother took my cue and also waited.
"It won't work," she finally blurted out,"I am a compulsive eater and so I know I will fail any surgical intervention because I don't have any control." Gratefully, her mother took up the conversation with her own story of surgical weight loss and subsequent reversal of the ravages of uncontrolled diabetes.  My patient responded again with a plaintive, "Won't work, I am psychologically impaired and I like to eat too much."
I smiled, it was time for me to end my silence. Gently I offered that many of US were compulsive eaters who loved to eat and that her weight issues were separate fro her other problems.  I realized that she had always linked the two and knew (rightly) that she would never conquer her mental illness, only keep it controlled (mostly with strong medications) for periods of time.  Thus she had come to think of her eating has a fait accompli, too.
I doubt I will see her in my operating room any time soon but I knew by her and her mother's beaming smiles that I had offered them something even better-perhaps a fresh start.  And they had given me something-the intangible gift of a patient helping you to understand something about the world and yourself that otherwise would have remained elusive.