The Elephant in the Room

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Not too long ago, you might have seen her under a circus tent at a tawdry sideshow: The Fat Lady. She was a massive woman, more than seven hundred pounds on a five-foot frame. She had not chosen to be on view--in fact, in her early forties, she had confined herself to home because of her size. A fall followed by overwhelming infection led to her emergence. They had to cut a hole in the wall to get her out, the nurses whispered. For The Fat Lady, the hospital was a constant ordeal of exposure. In and out we came, interns and residents and attendings, x-ray technicians, respiratory therapists, nurses, cleaning staff. She had to be turned and cleaned, intravenous lines had to be inserted, urinary catheters placed. Four people were needed to roll her bed down the hall, and six to turn her. One day, as we tried to estimate an appropriate dose of medication for someone of her size, I noted that she weighed as much as our five-person team combined. Nervous laughter followed. Yet it was critical to discuss her weight--her obesity defined her illness and limited our ability to help her. She could not fit into the CT scan machine, so the abdominal infection causing her sepsis could not be easily localized. She could not breathe lying in bed, so she needed a breathing machine. Her veins were nearly impossible to find, so intravenous medications were harder to provide. Although the weight was killing her, it seemed absurd and cruel to talk to her about it, like telling someone who was suffering from incurable lung cancer that they really should quit smoking sometime soon. There were, of course, the inevitable whispers outside her room: How could she let herself get that way? Her family must have some major issues. I've never seen anything like it. Even if she gets better, how will we get her out of that bed? The medical care a seven-hundred-pound woman receives in an intensive care unit at the end of her life may seem to have little to do with our obligations to the average overweight patient. Yet whether we are sitting in an ICU or a clinic, we are unwilling to meet the question face-to-face. Surveys suggest that doctors don't discuss obesity, even though we know well that it is a major cause of chronic illness and death. So why don't physicians bring it up? And what should my patients expect from me? If we consider obesity purely in medical terms, every patient should be weighed and measured and informed of health risks, treatments available, and followup required. …