One can't always assume congratulations are in order

“Congratulations on losing that much weight! Whatever you’re doing, keep it up,” my attending says as she bobs her head vigorously in approval, then turning back to the EMR computer to type up some notes.

And all I could see was the patient slightly shifting on the exam table, their face smiling — but their whole body seemingly screaming discomfort and dismay.

Before my attending sailed into the room, the patient told me everything that had been going on: Their 10-inch bust causing severe lower back pain and preventing upright posture, the inability to find clothing that fit or bras that support anything more than minimal exertion, the weight gained during pandemic depression, the weight lost from anxiety about university dining halls leading to missed meal after meal until they could finally brave the thought of prying eyes. They pepper their explanation with apologies for overreaching, for saying that they might have body dysmorphia or an eating disorder or anxiety or breasts that need reduction, all this without first obtaining a physician’s approval. They hurriedly preempted my questions about eating habits, exercise and sleep. Or how they’re doing better, but obviously, of course, rest assured, they know not enough yet.

I’m left to think — if they offer up their medical sins unprompted, perhaps they will appear to me as a “good” fat person, one who endears themself by knowing the wrongness of their habitus. They protect themself from me if they’re hard on themself first, taking away any reason to invite my unwieldy medical dissection that might hit a nerve and provoke pain.

All of these details get remorselessly trimmed away from the lean, essential details in my oral presentation to the attending like these details are the same fat they anatomically and emotionally describe. I wince as my attending chews over the above 35 BMI, emphasizing as a teacher that a BMI this high when this young requires targeted communication because of our duty to care. We don’t talk about what kind of BMI it is, a number that obscures disabling breasts, physically induced dysphoria, distress exacerbated by a pandemic and college shock and earnest efforts to find ways forward to health.

My attending enters, introduces herself, and says, “So Jade has been telling me what’s been going on.” And all of a sudden, I’ve been identified as the messenger. Anytime my attending strays from what the patient thought they told me, I’m at fault, in this game of telephone between patient and attending separated by the soundproofed clinic door. Any attention, understanding, validation the patient remembers from my interview before they turn sour at the idea that behind the door, I retold everything as a doctor would — measuring the clinical distance from the goal rather than the efforts and vulnerability that brought this patient to the here and now.

“Whatever you’re doing, keep it up!”

Recent unintentional weight loss, fevers, chills, night sweats. Red flags that scream danger is lurking in the body. Note the word unintentional, an acknowledgment that not all weight loss is loved in this time of obesity. That there are types of weight loss that signal the train going off the tracks rather than back on, that the suffering of the body has increased rather than abated, that the shrinking of the body is proportional to its consumption by disease.

Don’t keep that up.

Maybe I’m projecting. Because I remember, at this patient’s age, not leaving my college dorm room days at a time because I was too anxious to get food with my overweight body as a vehicle. Running in almost the dead of night to protect my jiggly movements from the eyes of others. Stressfully sweating in-between classes not because of the exertion but by how I occupied space, with my most sensitive vulnerability on full display for anyone to notice and judge without invitation. Periods of disordered eating for which I never got a stamp of authenticity from a physician.

Losing almost 30 pounds to the delight of my parents, my extended family, some no longer close friends, and most importantly, my primary care physician. The skinny spoke louder than any of my distress could, provoking congratulations that trampled the opening for me to say, “No, things haven’t been going well.” And I politely accepted in the face of seeing my loved ones and physicians celebrating my obvious efforts towards improving my health.

And though I claim to know the suffocation of assumption intimately, I am not immune to trampling others in my healing practice. Meditations on language, intention and perception do not come easily when treading water to meet the minimum clinical needs of an encounter — the history, the assessment, the differential, the planning, the time constraints.

Until recently, I used to say “congratulations” to every pregnant individual or any patient with a newborn. A way to communicate I cared, intending to connect with them through their joy, an easy transformation from stranger to a friendly face.

Easy, simple, and undetectably estranging. Those who experienced or know of miscarriages, vanished heartbeats, sexual coercion, abuse, childfree lifestyles, restrictive abortion laws, closed or open adoptions, wrong timings, tumultuous situations, complications, or simple lack of want probably wince at this mention of unsolicited celebration. Missing where the patient is, I find myself mistakenly alone in that place of joy I imagined for them, denying space for any hurt the patient might have brought for care.