She came in for a cold, or something like that. And then the real complaining started.
"I'm so fat," she said. "I just can't get the weight off."
Maria was in her mid forties. She had birthed five children (gravida 5, I wrote in her chart), which certainly had something to do with the excess weight. She was a bronze skinned, brown-eyed Hispanic. Her accent was strong, but her English was so easy it left no doubt she had lived in America for many years.
("My children taught me English," she had told me quite some time ago. "They went to school and learned it the way Americans know it. If you closed your eyes and listened to them, you would not know they were Hispanic. I talked to them in Spanish, they answered me in English. Before long, I knew English almost as well as they did.")
She shifted on the exam table, and repeated herself just to make sure I heard her. "I'm fat, you know?"
Well, now that you mention it, yes, I did know. Maria was barely five feet tall, and weighed 170 pounds. Her BMI was 33. Yeah, fat.
"What have you done to try to get the weight off? Diet? Exercise?"
"Oh, doctor, I don't exercise. I'm not going to do that. I have never exercised in my entire life. I just know I won't do it."
I had to give her credit for honesty. It wasn't what I wanted to hear, but it was better than a lie. I told her that.
"I believe in living within myself. If I can't do something, I can't do it, that's all. It doesn't do me any good pretend I will do what I know I will not."
"Well, if exercise is out, what about diet?"
"I have tried every diet in the world. High fat, low fat, protein, liquid, all fruit, all vegetable, all nuts and berries. I haven't lost a pound. So what can you do about it?"
This is not the position I relish being in. I can't do anything, so what are you going to do for me? If there were a medical cure for obesity, I would be retired and living in Paris by now. There is nothing, not really. Stimulants help a little, but they have a mild addiction potential and can cause heart problems if they are used for too long. Xenical causes diarrhea. Meridia works sometimes but is ridiculously expensive. Moreover, none of them work in the long term. They are great for losing a few pounds over a short period of time, but usually, as soon as the pills are stopped the weight starts coming back on. The only people I have ever seen permanently lose weight did so with lifestyle changes. Or by contracting a horrible disease.
I gathered myself for the answer. Evasively I said, "There are a few medications that might help, but the truth is that nothing works well without diet and exercise."
"What about surgery?"
I looked her over again. Yes, she was overweight, but she was not morbidly obese. Generally, surgeons are reluctant to cut on a patient with a BMI of less than 40. She was not a good candidate.
"I don't think that is an option," I responded. "To qualify for weight loss surgery you have to have a documented medical reason for surgery. You have to have a health problem — diabetes, for example — that is aggravated by the excess weight and would be improved with weight loss. And usually, for someone your size, they would expect you to be at least 100 pounds overweight."
"I'm 70 pounds overweight at least. That's not enough?"
"No, I don't think they would consider you as a candidate."
She sat there quietly, thinking. I sensed there was trouble coming.
"So, what you're saying is that all I have to do is gain 30 pounds and I can get the surgery."
Wait a minute. "No, I most certainly did not say that. Ms. Santos, that is no way to handle this problem."
"Of course it is, dear." Dear. "Sometimes you have to do what you have to do."
"What you have to do is something besides gain 30 pounds. There is no guarantee that even if you were 100 pounds overweight that the surgeon would take you. It is like you said —you have to work within yourself to lose weight. Understand what you can and cannot do. Surgery is not an option at this stage, and it would be better if you accept that."
"But I am working within myself. I know I can't diet and I know I can't exercise. You just told me medication does not work so well either. So what can I do? I can eat! I know how to do that. Like you said, it's the 'Living Within Yourself Diet.' I am doing what I know I can do. I gain enough weight, I get the surgery, and it all comes off. I love it!"
I bowed my head in a gesture of defeat, knowing I had lost control of the situation. I briefly restated my opinion for one last time. She nodded yes, but I could tell she was planning out a menu of chocolate fudge sundaes and french fries. She turned her face to me and her eyes smiled. She had a new purpose in life.
I heard her say it once again: "The 'Living Within Yourself Diet.' I love it! Thanks, Dr. Hébert!" And she whirled out.
There was no telling what was going to happen now. This was just the kind of stupid idea that could take wings, and take my reputation with it. I started having, as psychologists say, catastrophic expectations. I had a vision I fully expected to take place a few months in the future. I saw our local bariatric surgeon come into our office to pay me a professional call. He entered my office door with a pile of brochures from his clinic and a smirk on his face. He slapped the brochures on my desk. "I have to thank you, pal," he was saying. "The 'Living Within Yourself Diet.' What genius! Patients eat whatever they want, and when they reach 100 pounds overweight, they come to my office for an expensive surgery. You don't know how much money you have made for my clinic!"
I saw myself flushing, then stammering. "Well, that's not exactly the way I intended it . . ."
"Whatever you intended, it was a great idea. And it would make a great book. You and me, pal. We'll call it The Living Within Yourself Diet Book. Fatten yourself up and then get surgery. We could go in fifty-fifty on the royalty deal!"
"I'd love to help you out," I said, my nervousness rising, "But somehow I don't think it would be a good idea to advise people to gain weight. And in a way, by encouraging people to modify their bodies to meet insurance criteria, we would be showing them how to commit fraud."
He thought about it a minute. "Yeah, you're probably right. Telling people to do stuff that would force insurance companies to pony up could be a kind of fraud. Well, too bad. I was just trying to find a way to cut you in on the bonanza. After all, it is fraud for me to pay you directly, right?"
I said nothing. He pressed a thick stack of business cards into my moist palm. "Anyway, if you do convince more people to try out your great diet, send 'em my way, won't you?"
As the vision faded, I was assuring him I would.
Those are the kind of dreams that wake me up at night. The thought that a patient would attribute a stupid idea to me and then spread it across town like a frenzied Johnny Appleseed.
I have not heard from Maria again, thank God. I imagine her at home this very moment with a family size bag of Frito's on her lap, doing just what the doctor ordered.