written
by a Dr. Edward Thompson. Just the first two lines of it above had me
furious. Not only were they a study in the power of negative metaphors,
but as a fellow physician, they felt all-too familiar. They were the way
I had, on many an occasion, heard patients’ bodies talked about; ways
that I, during my training, had perhaps referred to patients’ bodies.
The simple words felt so easy, so unexamined, and in that very ease was
embedded their violence.
Let’s recap the imagery used. A very
large man is compared to a mountain of flesh. He has a high and
childlike voice. You don’t need to be an MFA in creative writing, or a
sociopolitical genius, to recognize these as metaphors of the grotesque
and infantile. And importantly, the patient’s stomach pain is not a
stated fact, but a complaint, framed by quotes. This makes clear to the
reader that the patient
his stomach hurts. He is
potentially maligning. The implication being that the obese are, well,
complainers. Indeed, although studies show that
,
many of my medical colleagues don’t seem to realize that personal and
institutional violence against fat people (and I use that term in
solidarity with the fat activism and fat studies movements) is a thing. A
real, grotesque and infantile thing. A real, grotesque and infantile
thing that negatively impacts the health care that fat individuals
receive.
essay goes on, describing
the patient in this way: “He spends his days on the sofa at home,
surviving on disability checks related to his back pain.” The
implication being that the man’s weight is what led to his disability
and not the other way around. And we all know what sofa-sitting is code
for: slovenliness and laziness.
So
let’s recap again. We have the grotesque, the infantile, the
complaining, the slovenly and the lazy. The metaphors are piling up.
Yet, wasn’t George H.W. Bush’s signing the
Americans with Disabilities Act supposed
to relegate able-ism to a thing of the past? Weren’t we all supposed to
recognize the rights of our fellow citizens, regardless of appearance,
ability, size, number of limbs or other embodied differences?
Apparently, this memo did not reach most American medical schools. At
least not yet. Because, while a few medical schools have medical
humanities programs, only a fraction of these programs systematically
incorporate
disability studies into their courses, and even fewer acknowledge what’s now known as the activist and academic field of
fat studies.
Interestingly,
size-as-disability is even explicitly brought up by Dr. Thompson’s
patient himself, when he “indignantly” says, “The Americans with
Disabilities Act says that [the paramedics] should have the proper
equipment to handle me, the same as they do for anyone else… I’m
entitled to that. I’ll probably have to sue to get the care I really
need.”
And yet, the ER-physician/writer doesn’t seem to agree: “I don’t quite know how to respond, so I say nothing.”
Instead,
Dr. Thompson’s essay launches into the difficulties of diagnosing the
man’s gallstones, difficulties that are all attributed to his size: the
physical exam which leaves the physician at first “not knowing where to
begin,” and then noting that his “hands look small and insignificant
against the panorama of skin they are kneading.” The author describes
the ultrasound machine that “barely fits” between the oversize bed and
the wall, the technician who declares, “this is impossible,” the chief
of radiology who emerges from the room a half hour later “rings of sweat
under his arms,” and the attendants who must “huff, puff, and grunt” in
order to push the patient down the hall on a gurney. He writes of a
surgical colleagues’ desires to “unload” the patient on a different
hospital due to his size, and the continuous, cutting remarks from the
ER staff: “Don’t put him in a room right over the ER…The floor won’t
support him. He’ll come crashing through and kill us all.”
As a faculty member in the
Master’s Program in Narrative Medicine at
Columbia University, I know about the power of stories: stories told by
physicians, stories told by patients. I know that having health care
students read, write and analyze narratives can deepen their training in
bioethics, medical professionalism, reflective practice, self-care and
patient-centered care. Narrative study can help our students effectively
diagnose, treat, and otherwise attend to the lives of their patients.
Yes,
stories are powerful. But let’s not get too precious about them. Simply
reading any story with a medical student or engaging them in a
narrative writing prompt is not the same as actually educating them in
structural issues of oppression and inequity. Those of us in the medical
humanities professions must teach our students not only to listen to
stories, but to listen to them
critically; asking themselves
questions like “who is speaking?”, “who is being spoken for?”, “what
larger narratives is this story supporting?”, and “what additional
stories are being silenced by this one?” In
a brilliant TED talk,
the writer Chimamanda Ngozi Adichie speaks about the dangers inherent
in a “singular story.” Although Adichie is speaking of singular
narratives about Africa and Africans, the idea can be easily applied to
other issues. Singular stories can ensnare us, make us so accustomed to
one way of thinking that we can no longer imagine there are alternative
narratives possible.
Consider the words of Dr. Thompson as he describes the desperation of his patient,
The
patient lies trapped in his own body, like a prisoner in an enormous,
fleshy castle. And though he must feel wounded by the ER personnel’s
remarks, he seems to find succor in knowing that there’s no comment so
cutting that it can’t be soothed by the balm of 8,000 calories per day…I
know why my colleagues and I are so glad to have this patient out of
the ER and stowed away upstairs: he’s an oversize mirror, reminding us
of our own excesses. It’s easier to look away and joke at his expense
than it is to peer into his eyes and see our own appetites staring back.
As someone whose work in medical humanities is particularly concerned with
narrative, health, and social justice, I
find this paragraph deeply troubling. Although it is gesturing to, as
Dr. Thompson says, “compassion,” the language itself creates a prison
around the reader’s imagination. Referring to another’s body as “an
enormous, felshy castle” and suggesting that food is a “balm,” and
“obesity” necessarily connected to out-of-control “appetites” is a
singular story about fatness, a story oft told, particularly in
medicine. It is a story that leaves no room for, say, the fat person who
practices self-love and
radical self-acceptance, the
Health At Every Size movement, or the politicization of fatness – the assertion that, as author Susie Orbach has said,
“fat is a feminist issue,” or that
race, class and colonialist politics are
written upon fat bodies. The fact that Dr. Thompson’s story ends with
his patient’s death, and emergency crews being required to cut an
enormous hole out of his roof to hoist him out, only adds to this
particular, tragic story about fatness. This is not, of course, to say
that this particular patient’s life story might not have been tragic,
but rather, that this
Washington Post essay reinforces a singular, expected cultural narrative about fatness and fat people.
As Susan Sontag famously argued in her
Illness as Metaphor,
certain bodily conditions have historically been associated with
failings of moral character. In the past, this stereotyping was limited
to diseases from tuberculosis to cancer, but now, this is most seen
regarding those behavior-based characteristics considered high-risk
factors for disease – from smoking to multiple sexual partners to IV
drug use.
Bolstered by Michelle Obama’s
Let’s Move! and
other similar campaigns, the ‘obesity epidemic’ has become a favorite
topic of neoliberal moralization. What this has resulted in is a kind of
permission within the medical profession to engage in
size-ismunder
the guise of encouraging good health. I’m not saying that physicians
might not speak privately and respectfully to patients about weight, or
that exercise and healthy eating are not a good thing. But physicians –
and indeed, science itself – does not exist somehow outside of culture
and sociopolitics. Consider that
medical and public health anti-obesity messages have
plenty of secondary narratives inherent in their images – other stories
they’re telling about race, masculinity and femininity, parenting,
poverty, disability, as well as the ‘right kind’ of (economic and
nutritional) consumption. In addition, these messages dovetail perfectly
with images in fashion magazines, on billboards, in movies and on TV
about thinness, fairness, youth, beauty, and desirability (not to
mention wealth, heteronormativity, able-bodied-ness, cis-gendered self
representations, etc.).
These medical and media messages create a kind
of
‘toxic body culture’ that
permeates all our consciousness (particularly young peoples’), leading
to everything from disordered eating to low self-esteem to bullying to
warped notions of normalcy.
What’s also troubling is that medical
and public health messages focus almost exclusively on individual “shame
and blame,” even asserting that we doctors somehow
should shame our patients, regardless of evidence which shows that
shame about weight is an ineffective motivator in behavior change. Despite assertions like this one on Gawker that
“Your doctor is probably not fat-shaming you,” the
fact, is, sometimes, intentionally or unintentionally, your doctor just
actually might be fat-shaming you. The moral indignation evoked by
fatness among physicians suggests that it satisfies some emotional
function, some opportunity, in this era of health care consumerism and
internet savvy patients, for physicians still to command a sense of
superior power over patients. Consider that even after a study published
in
Pediatrics suggested that physicians no longer use words that are stigmatizing of childhood obesity, one
physician blogger railed at kevinmd, “Political correctness and sensitivity training are interfering with medicine and healthcare.”
The
problem is also American medicine’s myopic concentration on individual
behavior over systemic constraints – a focus which is related perhaps to
our cultural ethos of independence, personal control, and
pull-yourself-up-by-the-bootstrap-iness. Perhaps instead of railing
against “sensitivity training,” shaming patients, and yearning for the
‘good old patriarchal days’ of medicine, we physicians might do better
to protest against systems-based issues like the lack of green, safe,
outdoor spaces in many communities, the existence of food deserts, the
prevalence of GMOs or the affordability processed food products over
whole fresh foods.
Perhaps we medical educators should address how
woefully lacking our systems of training are in what my colleagues
Jonathan Metzl and Helena Hansen call
“structural competency,” the notion that social inequities impact health as much as physiology.
Yet, sociopolitics is only part of my problem with Edward Thompson’s
Washington Post essay.
Granted, physicians – particularly ER physicians – often develop a sort
of gallows humor to deal with the emotional and physical pressures of
patient care. But that doesn’t mean we physician writers are exempt from
privacy regulations (ie. HIPAA) or narrative ethics; nor do we need to
publish each and every thing that comes out of our laptops. Over the
years, after I myself published a medical school memoir in 1999 with
quite a few ‘patient stories’ in it, I have come to realize that there
is a big difference between writing privately for our own needs and
writing for a mass audience; and the latter comes with certain
responsibilities, particularly toward vulnerable subjects.
The very
least of these responsibilities is obtaining explicit permission from
patients or their families before sharing their stories publicly. In
this particular case, Dr. Thompson was apparently unable to obtain
permission from the patient because he had already passed away prior to
the writing of the narrative. Whether the author contacted his family to
obtain permission, I cannot be sure.
There is, of course, a tradition of insightful, humble and self-critical confessional stories in medicine such as
William Carlos Williams’ “The use of force,” or
David Hilfiker’s “Mistakes,” tales
of medical brutality and error which serve to implicate their
physician-authors and shed light on the imperfections of the profession.
I actually imagine that Dr. Thompson was seeking to similarly implicate
himself and his colleagues in their size-ist bigotry. The problem is,
the language and metaphor of his narrative actually serves to reinforce
the self-same fat shaming that the essay seemingly seeks to address.
Whatever the author’s intention, the narrative itself supports rather
than undermines fat hatred and in doing so harms far more people than
just the patient described or his family. Indeed, the narrative itself
potentially
“pulls the red handle” for a lot of people who identify or are potentially identified as fat.
As this insightful, and angry, commentary about Dr. Thompson’s piece from the blog
Shakesville points out,
Fat
people! They exist in the world and can hear you! They may even be
entirely aware of your loathing, your disgust, your discomfort, and your
judgment. They may even (probably) take these things into account when
deciding if the acute pain in their side is bad enough to face the
dehumanization, the hatred, the vitriol, and the humiliation of
interacting with medical staff (you know, those compassionate care
givers ostensibly tasked with giving a shit about their well-being and
health and trying to diagnose and help them) or if they should just wait
it out and see if it gets better.
Fat hatred kills
people. Not least of all because sometimes living with pain and not
knowing what it is may just be preferable to being dehumanized, hated,
and sneered at by the people you have to trust in order to access
medical care.
The resource-hogging “obese patient” has become the new version of the
welfare queen in
our popular imaginations. Such stereotypes about any community – that
they are infantile, monstrous, unthinking, lazy, whiney and
resource-wasting – isn’t only emotionally damaging but potentially
physically harmful. As the blogger at
Shakesville asserts: “fat hatred kills.”
Physicians
cannot use concerns over health to legitimize bias. Medicine is not a
moralizing stick with which we can beat our patients into submission.
Medical
narratives are powerful. Let us use them not to ridicule, alienate, or
demonize our fellow human beings, but rather, create a much-needed
change to a more socially just health care.
THE OTHER DAY, a colleague brought to my attention an essay from The Washington Post called “A morbidly obese patient tests the limits of a doctor’s compassion” written
by a Dr. Edward Thompson. Just the first two lines of it above had me
furious. Not only were they a study in the power of negative metaphors,
but as a fellow physician, they felt all-too familiar. They were the way
I had, on many an occasion, heard patients’ bodies talked about; ways
that I, during my training, had perhaps referred to patients’ bodies.
The simple words felt so easy, so unexamined, and in that very ease was
embedded their violence.
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