Discussions in pre-surgery consultations with WLS surgeons were scenes of searching for and discovering the Holy Grail. This was the opportunity to change bodies (Frost, 1999). The pre-consultation period was reminiscent of Philip Larkin’s24 description of the holiday atmosphere amongst men queuing to enlist at to go to the First World War when the direness of war has yet to penetrate. Women sought the ultimate fix for weight and surgeons promised the cure.
partipantR reflects
I transferred to another surgeon after my first surgery failed. He says: “I’ve got a procedure that will work for you.” Even after my first surgery has failed, I am tantalised. Yet again the holy grail! The ultimate fix. When he eventually
introduces me to the laparoscopic bypass, I no longer recognise it as stomach stapling: My fears and concerns about radical surgery have been vanished.
Notwithstanding their research, participants consented to procedures when they lacked significant understanding of WLS realities. In their pre-surgery consultation, Scrapper and Rosie were classified as morbidly obese and this supported their acceptance for the surgery.25 While Rosie recalled her lapband surgeon’s disclaimer that, “It doesn’t work for everybody,” she also described how this opening gambit was qualified positively and personally. Rosie clearly recalled his words delivered alongside a range of powerful, encouraging interpersonal gestures that informed her decisions. Roter and Hall (2006) have pointed to the presence and critical nature of non-verbal behaviour within doctor/patient consultation. Rosie wanted to know whether this procedure was safe for her. In looking for “information behind the information” (Roter & Hall, p.17), the obvious enthusiasm of her surgeon for the procedure and his approval of it as a procedure for herself was convincing: “I’ve got a good feeling about you. I don’t know why, but I think it will work for you.” This acted to minimise any formal disclaimer. When the surgeon dispelled Rosie’s fears about surgery, “all my fears straight away,” the road to WLS was begun. The surgeon’s personal disclaimer shaped Rosie’s decision to opt for surgery.
When tests confirmed that Marjorie’s gall bladder needed to be removed, she was referred by her GP for a cholecystectomy and lapbanding. She was impressed with the surgeon whom she described as “the first surgeon I had come across that didn’t actually put himself on a pedestal, and think that he was God, a regular guy, really nice.” This promoted her confidence in the surgeon and the procedure when he said to her:
“There’s no way that this cannot work. Simply what you are doing is that once you have this band put on, it restricts how much you can eat so you have to lose weight. … Hunger disappears.” Now this for me was amazing: your hunger would disappear! Yes, this was now finally the last resort. I thought, “Great. OK.”
Marjorie was advised formally that there are “significant risks” with WLS. But persuasive elements within the consultation convinced her of the appropriateness of this procedure for her: the logical simplicity of the mechanism; a good presentation of the process; the potential to resolve her issues with weight and hunger; the standing of this
surgeon to whom she had been referred; the surgeon’s demeanour and affability; and her surgeon’s enthusiastic support of his skills and procedure.
Meryl approved her surgeon’s clarity in describing the WLS procedure even while commenting that he seemed to “kind of tick off the boxes.” She was accepted for surgery without being required to meet with a dietician or have a psychological assessment. Patients such as Meryl responded with relief as though they had been “let off the hook” when surgeons validated their new patients’ long run, physical and mental struggle to lose weight. Although Meryl emphasised technical competence as being paramount in a surgeon, she did not question him about his surgery statistics. She did not attach significance to choosing a surgeon experienced in laparoscopic WLS procedures and there was no discussion of significant complications with WLS procedures performed by surgeons learning these techniques.26
Shona’s pre-surgery consultation for a laparoscopic bypass was described as “a very entertaining forty minutes.” Having “clicked” with the surgeon, she characterised the length of the consultation as “quite a long time with a specialist.” Her wish for an equal and satisfying relationship was begun. Two moments in this pre-surgery consultation threatened the beginning relationship. When the surgeon told Shona that he had done his first laparoscopic bypass on his local pastor, she felt uneasy because she believed that the surgeon was breaching medical privilege, and, because “I don’t like religious people!” A second moment arose when Shona joked as she stepped onto the scales, and the surgeon interpreted her joke as being typical for large persons to hide their hurt with humour. She was impressed by the surgeon’s ability to “switch immediately” when she disputed this psychodynamic interpretation. As well, she interrupted his “spiel,” complete with the operation video on the screen, several times; she demonstrated her own competency by fixing his computer. Paying for WLS gave Shona a feeling of power over the surgeon because unless he answered her questions, “I don’t give you my money basically.”
Shona emphasised her “right to ask” questions. In indicating that interrupting a surgeon was neither common practice nor had any certainty of being accepted, she approved his accommodation of her interruptions. She displayed confidence and made a number of attempts to establish her equality. The power of the surgeon was
26In one review, a New Zealand surgeon wrote: “In (a particular) series of patients, 81% of the deaths occurred in patients operated upon in the surgeon’s first 19 cases, emphasising that this is technically demanding surgery requiring a skilled and experienced surgeon and a team for optimal outcomes” ((Martin, 2004, p. 1207).
minimised as she described participation in this relationship as satisfying the social needs of both participants: “We had a lot of fun. We laughed and carried on and it was completely unprofessional, I’m sure. I made him run late actually, we ended up yacking so long.”
Michelle recalled a strongly negative reaction to Dr Z at her first consultation, and a very positive response to Dr M2. Dr Z was described as “obvious about his god complex,” and pushing his procedure as “a magic bullet.” Alerted to the availability of an improved lapband, Michelle requested the improved version:
He didn’t do a bloody thing about it. I gave him ten days and he gave me some patronising bloody phone call about “Are you sure?” I thought well that doesn’t bode well. He made me feel stupid, like I didn’t know what I was talking about, and it seemed completely unprofessional to me, that if there was a vague possibility that there was a new band and he was using the old one. He just completely dismissed it and I knew at that point that there was no way that I wanted to proceed with surgery.
She rebooked her surgery with Dr M2, the surgeon who had “not talked down to me.” This surgeon’s greater experience with the procedure and his ready agreement to source the new band made him a safer choice. She described him as being more forthcoming about the procedure, providing her with a more balanced view than Dr Z.
Having had the lapbanding procedure explained to her in her pre-surgery consultation, Susie B told the surgeon: “I want this done now!” The surgeon laughingly reminded her of his mandatory one-month stand down period. SusieB’ was committed to lapbanding following this initial consultation: “I never ever wanted another Monday morning. I wanted to have the surgery and say, ‘Right, this is the start of my life.’” Her assessments with the dietician and psychologist did not occur until a few days before her first lapbanding. Most participants became confident that they would be accepted for surgery during the initial consultation. Indeed, they booked surgery before any discussion took place between the surgeon and the ancillary professionals. Ancillary referrals were referred to as a waste of money, a “rubber-stamping” of the surgeon’s opinion, and a money-spinner for the professionals involved. Acceptance for surgery was less certain for two patients: Pammy’s surgeon “didn’t really think I was heavy enough for it” and Karlie was considered “barely obese enough.” Karlie’s surgeon asked her “Why would you want to take this drastic step?” and I said “Well, wouldn’t
The only operation that Janice considered was the locally available, open gastric bypass, “the 20 thousand dollars operation.” Although Janice was informed that the surgery was major, the surgeon focused on WLS as the cure for her diabetes. Sheree was assured that she would lose weight with lapbanding. When the surgeon diagnosed her longstanding issue with abdominal pain as gallstones, Sheree articulated absolute trust in her surgeon. Her surgeon’s word had become “gospel.”
7.7 Discussion
Participants portrayed WLS as an intrepid last stand in a gruelling, lifelong battle, against overweight. At a point when participants were almost surprised to find themselves heavy enough to consider radical interventions, the search for the definitive solution to weight loss and weight control over a lifetime was embarked upon. The contemplation of weight spiralling out of control and the need to deal with intractable weight on a long-term basis increased the possibility that participants would take up radical WLS options.
These participants viewed themselves as autonomous in relation to choosing medical care even while they were clearly the target of medical device and pharmaceutical marketing (Andereck, 2007; Ryan & Carryer, 2000). Participants and doctors learned about WLS from media sources and people in their wider networks. The media, whether in the form of newspapers, magazines, radio and, more latterly, television and Internet, played a cogent role in the formation of public opinion about weight, based on the words of “[…] experts who decide you need to shed pounds (but) work for the industry that profits from their declarations” (MacPherson & Silverman, 2008, p.1). Participants were exposed to selective, often salacious, cultural commentary about weight presented in the guise of news,27 and medical documentaries and reality television focus on making over and reforming the erring weightfull citizens. The growth in articles and programmes beckoning readers and watchers to medical and surgical interventions has grown apace. For instance, in New Zealand during July/August, 2008, TV One showed Real Life: Eating Themselves to Death and TV3 showed Half Ton Mum, while Prime was due to give the viewers “a fatty-a-week on the upcoming British series, Fat Doctor” (Hunkin, 2008). Sensationalised personal narratives and reality television series formed the backdrop against which these participants opted for WLS.
27As an example, one has only to follow the news items surrounding the trial for fraud by a Member of New Zealand’s Parliament, who used part of the money to pay for weight-loss surgery.
In advertising and public interest programmes, friendly, approachable non-blaming doctors assert the connections between weight and health and the potential of WLS interventions (Inside New Zealand, 2008; Unichem Medical File, 1999). Most lapband participants in this study viewed the Unichem Medical File programme. This programme stimulated desire for these surgeries and featured a local surgeon. DTCA for WLS options has highlighted the underbelly of drug and medical technology promotion to doctors (Rampton & Stauber, 2001). Overall, the trade in health technologies has stimulated and confirmed, pictorially and verbally, the riskiness of living overweight by employing starkly vivid images of unhappy, weighty persons. The science of medicine and the selling of news have coalesced to frame obesity as a social problem (Saguy & Almeling, 2008). News items, advertising, pseudo-documentaries and the Internet (Salant & Santry, 2006) have blurred the lines of demarcation surrounding BMI and WLS technologies. WLS has captured the interest of women living around the edges of overweight through DTCA advertising.
WLS is an elective surgery based on weight-loss for health but compellingly described as a life-saving procedure by WLS patients. Surgeons in the private sector of New Zealand medicine who wished to perform these surgeries and companies who profit by on-selling technologies have driven the discovery and promotion of surgical cures (Inside New Zealand, 2008; Unichem Medical File, 1999). Significantly, surgeons interviewed for the study28 were adamant about the benefits to patients of their particular WLS options. On interview and in pre-surgery consultations, surgeons made persuasive cases for their surgeries. While weight-loss surgery was the term in common use, the use of the term obesity surgery in interviews with surgeons reflected a desire to recast these surgeries as the surgical treatment of choice for a disease. This raised the profile of the procedure and the practitioner who performed it. Naming the disease differentiated it from its body-enhancing qualities as a form of cosmetic procedure. It also fostered its links within the tradition of heroic cures for disease. The epidemiology of weight and co-morbidities has presented the population and its individual citizens as being at grave risk from obesity. Supply-sensitive medical services guarantee the call for, and use of, medical technologies, less because they are needed and more because they are available (Abramson, 2005).
While the conundrums of what is a healthy weight for individuals and whether large citizens should concentrate on maintaining weight or gaining fitness at any weight, WLS is being promoted as the solution. While the efficacy of these surgeries remains in question, the legitimacy of claims that WLS is the ultimate fix for weight let alone for health remains debateable. Women were told that these surgeries were both viable and healthy cures and they were not informed of their experimental nature. This forms part of a deliberate move to position WLS as the exceptional weight-loss intervention, clearly promoting its commercial success. When making money is a primary goal in the performance of medical care, patient safety is patently at risk (Andereck, 2007). The period in which this research took place surfaced a proliferation of trade in lapbandings. Lynn McAfee, Council on Size and Weight Discrimination predicted that this would bring WLS into the realm of possibility as an appearance tool for an essentially healthy population (Gastroenterology and Urology Devices Advisory Panel, 2000).
In chapter seven, I argue that, if participants were being fully informed about the seriousness of choosing WLS, then pre-surgery consultations would have been described and enacted as sobering experiences. This was not the case and consultations for WLS echoed culturally-driven imperatives about reducing weight for health and the benefits of improved appearance. Participants who attended WLS consultations, with the exception of Pansy in this study, became eager for the duly promoted fix.
This research traces a ten-year development of WLS when participants undertook their procedures. In chapter eight, WLS participants have moved from contemplation into surgery and are beginning to live WLS lives. Some of the problems with WLS have begun to emerge. Recognition of the immensity, even horror, of the WLS undertaking has begun to emerge. Through chapter eight, I progress the argument that if the side effects and downsides of these procedures were being appropriately addressed in pre-surgery consultations, a number of participants would not have chosen surgery.
“The procedure was humane and daring – the spirit of benevolence enlivened by the boldness of a high-wire circus act” (McEwen, 2006, pp.44-5).