Authors: Atul Gawande
I asked Vince how his business was going. Not well, he said. Except for a few jobs in late winter plowing snow for the city in his pickup truck, he had brought in no income since the previous August. He’d had to sell two of his three pickups, his Mack dump truck, and most of the small equipment for road building. Danny came to his defense. “Well, he’s been out of action,” he said. “And you see we’re just coming into the summer season. It’s a seasonal business.” But we all knew that wasn’t the issue.
Vince told me that he weighed about three hundred and twenty pounds. This was about thirty pounds less than when I had last seen him, and he was proud of that. “He don’t eat,” Danny said. “He eats half of what I eat.” But Vince was still unable to climb up into the Gradall and operate it. And he was beginning to wonder whether that would ever change. The rate of weight loss was slowing down, and he noticed that he was able to eat more. Before, he could eat only a couple of bites of a burger, but now he could sometimes eat half of one. And he still found himself eating more than he could handle. “Last week, Danny and this other fellow, we had to do some business,” he said. “We had Chinese food. Lots of days, I don’t eat the right stuff—I try to do what I can do, but I ate a little bit too much. I had to bring Danny back to Boston College, and before I left the parking lot there I just couldn’t take it anymore. I had to vomit.
“I’m finding that I’m getting back into that pattern where I’ve always got to eat,” he went on. His gut still stopped him, but he was worried. What if one day it didn’t? He had heard about people whose staples gave way, returning their stomach to its original size, or who managed to put the weight back on in some other way.
I tried to reassure him. I told him what I knew Dr. Randall had already told him during a recent appointment: that a small increase
in the capacity of his stomach pouch was to be expected, and that what he was experiencing seemed normal. But could something worse happen? I didn’t want to say.
Among the gastric-bypass patients I had talked with was a man whose story remains a warning and a mystery to me. He was forty-two years old, married, and had two daughters, both of whom were single mothers with babies and still lived at home, and he had been the senior computer-systems manager for a large local company. At the age of thirty-eight, he had had to retire and go on disability because his weight—which had been above three hundred pounds since high school—had increased to more than four hundred and fifty pounds and was causing unmanageable back pain. He was soon confined to his home. He could not walk half a block. He could stand for only brief periods. He went out, on average, once a week, usually for medical appointments. In December 1998, he had a gastric bypass. By June of the following year, he had lost a hundred pounds.
Then, as he put it, “I started eating again.” Pizzas. Boxes of sugar cookies. Packages of doughnuts. He found it hard to say how, exactly. His stomach was still tiny and admitted only a small amount of food at a time, and he experienced the severe nausea and pain that gastric-bypass patients get whenever they eat sweet or rich things. Yet his drive was stronger than ever. “I’d eat right through pain—even to the point of throwing up,” he told me. “If I threw up, it was just room for more. I would eat straight through the day.” He did not pass a waking hour without eating something. “I’d just shut the bedroom door. The kids would be screaming. The babes would be crying. My wife would be at work. And I would be eating.” His weight returned to four hundred and fifty pounds, and then more. The surgery had failed. And his life had been shrunk to the needs of pure appetite.
He is among the 5 to 20 percent of patients—the published reports conflict on the exact number—who regain weight despite gastric-bypass surgery. (When we spoke, he had recently submitted to another, more radical gastric bypass, in the desperate hope that
something would work.) In these failures, one begins to grasp the depth of the power that one is up against. An operation that makes overeating both extremely difficult and extremely unpleasant—which, for more than 80 percent of patients, is finally sufficient to cause appetite to surrender and be transformed—can sometimes be defeated after all. Studies have yet to uncover a single consistent risk factor for this outcome. It could, apparently, happen to anyone.
Several months passed before I saw Vince Caselli again. Winter came, and I called him to see how he was doing. He said he was well, and I did not press for details. When we talked about getting together, though, he mentioned that it might be fun to go see a Boston Bruins game together, and my ears pricked up. Perhaps he
was
doing well.
A few days later, he picked me up at the hospital in his rumbling six-wheel Dodge Ram. For the first time since I’d met him, he looked almost small in that outsize truck. He was down to about two hundred and fifty pounds. “I’m still no Gregory Peck,” he said, but he was now one of the crowd—chubby, in an ordinary way. The rolls beneath his chin were gone. His face had a shape. His middle no longer rested between his legs. And, almost a year and a half after the surgery, he was still losing weight. At the FleetCenter, where the Bruins play, he walked up the escalator without getting winded. Our tickets were taken at the gate—the Bruins were playing the Pittsburgh Penguins—and we walked through the turnstiles. Suddenly, he stopped. “Look at that,” he exclaimed. “I went right through, no problem. I never would have made it through there before.” It was the first time he’d gone to an event like this in years.
We took our seats about two dozen rows up from the ice, and he laughed a little about how easily he fit. The seats were as tight as coach class, but he was quite comfortable. (I, with my long legs, was the one who had trouble finding room.) Vince was right at home here. He had been a hockey fan his whole life, and could supply me with all the details: the Penguins’ goalie Garth Snow was a local
boy, from Wrentham, and a friend of one of Vince’s cousins; Joe Thornton and Jason Allison were the Bruins’ best forwards, but neither could hold a candle to the Penguins’ Mario Lemieux. There were nearly twenty thousand people at the game, but within ten minutes Vince had found a friend from his barbershop sitting just a few rows away.
The Bruins won, and we left cheered and buzzing. Afterward, we went out to dinner at a grill near the hospital. Vince told me that his business was finally up and running. He could operate the Gradall without difficulty, and he’d had full-time Gradall work for the past three months. He was even thinking of buying a new model. At home, he had moved back upstairs. He and Teresa had taken a vacation in the Adirondacks; they were going out evenings, and visiting their grandchildren.
I asked him what had changed since I saw him the previous spring. He could not say precisely, but he gave me an example. “I used to love Italian cookies, and I still do,” he said. A year ago, he would have eaten to the point of nausea. “But now they’re, I don’t know, they’re too sweet. I eat one now, and after one or two bites I just don’t want it.” It was the same with pasta, which had always been a problem for him. “Now I can have a taste and I’m satisfied.”
Partly, it appeared that his taste in food had changed. He pointed to the nachos and Buffalo wings and hamburgers on the menu, and said that, to his surprise, he no longer felt like eating any of them. “It seems like I lean toward protein and vegetables nowadays,” he said, and he ordered a chicken Caesar salad. But he also no longer felt the need to stuff himself. “I used to be real reluctant to push food away,” he told me. “Now it’s just—it’s different.” But when did this happen? And how? He shook his head. “I wish I could pinpoint it for you,” he said. He paused to consider. “As a human, you adjust to conditions. You don’t think you are. But you are.”
These days, it isn’t the failure of obesity surgery that is prompting concerns but its success. For a long time it was something of a
bastard child in respectable surgical circles. Bariatric surgeons—as obesity surgery specialists are called—faced widespread skepticism about the wisdom of forging ahead with such a radical operation when so many previous versions had failed, and there was sometimes fierce resistance to their even presenting their results at the top surgical conferences. They sensed the contempt other surgeons had for their patients (who were regarded as having an emotional, even moral, problem) and often for them.
This has all changed now. The American College of Surgeons recently recognized bariatric surgery as an accepted specialty. The National Institutes of Health issued a consensus statement endorsing gastric-bypass surgery as the only known effective therapy for morbid obesity, one able to produce long-term weight loss and improvement in health. And most insurers have agreed to pay for it.
Physicians have gone from scorning it to encouraging, sometimes imploring, their severely overweight patients to undergo a gastric-bypass operation. And that’s not a small number of patients. More than five million adult Americans meet the strict definition of morbid obesity. (Their “body mass index”—that is, their weight in kilograms divided by the square of their height in meters—is forty or more, which for an average man is roughly a hundred pounds or more overweight.) Ten million more weigh just under the mark but may nevertheless have obesity-related health problems that are serious enough to warrant the surgery. There are ten times as many candidates for obesity surgery right now as there are for heart-bypass surgery in a year. So many patients are seeking the procedure that established surgeons cannot keep up with the demand. The American Society of Bariatric Surgery has only five hundred members nationwide who perform gastric-bypass operations, and their waiting lists are typically months long. Hence the too familiar troubles associated with new and lucrative surgical techniques (the fee can be as much as twenty thousand dollars): newcomers are stampeding to the field, including many who have proper training but have not yet mastered the procedure, and others who have no
training at all. Complicating matters further, individual surgeons are promoting a slew of variations on the standard operation which haven’t been fully researched—the “duodenal switch,” the “long limb” bypass, the laparoscopic bypass. And a few surgeons are pursuing new populations, such as adolescents and people who are only moderately obese.
Perhaps what’s most unsettling about the soaring popularity of gastric-bypass surgery, however, is simply the world that surrounds it. Ours is a culture in which fatness is seen as tantamount to failure, and get-thin-quick promises—whatever the risks—can have an irresistible allure. Doctors may recommend the operation out of concern for their patients’ health, but the stigma of obesity is clearly what drives many patients to the operating room. “How can you let yourself look like that?” is often society’s sneering, unspoken question, and sometimes its spoken one as well. (Caselli told me of strangers coming up to him on the street and asking him precisely this.) Women suffer even more than men from the social sanction, and it’s no accident that seven times as many women as men have had the operation. (Women are only an eighth more likely to be obese.)
Indeed, deciding
not
to undergo the surgery, if you qualify, is at risk of being considered the unreasonable thing to do. A three-hundred-fifty-pound woman who did not want the operation told me of doctors browbeating her for her choice. And I have learned of at least one patient with heart disease being refused treatment by a doctor unless she had a gastric bypass. If you don’t have the surgery, you will die, some doctors tell their patients. But we actually do not know this. Despite the striking improvements in weight and health, studies have not yet proved a corresponding reduction in mortality.
There are legitimate grounds for being wary of the procedure. As Paul Ernsberger, an obesity researcher at Case Western Reserve University, pointed out to me, many patients undergoing gastric bypass are in their twenties and thirties. “But is this really going to be effective and worthwhile over a forty-year span?” he asked. “No one
can say.” He was concerned about the possible long-term effects of nutritional deficiencies (for which patients are instructed to take a daily multivitamin). And he was concerned about evidence from rats that raises the possibility of an increased risk of bowel cancer.
We want progress in medicine to be clear and unequivocal, but of course it rarely is. Every new treatment has gaping unknowns—for both patients and society—and it can be hard to decide what to do about them. Perhaps a simpler, less radical operation will prove effective for obesity. Perhaps the long-sought satiety pill will be found. Nevertheless, the gastric bypass is the one thing we have now that works. Not all the questions have been answered, but there are more than a decade of studies behind it. And so we forge ahead. Hospitals everywhere are constructing obesity-surgery centers, ordering reinforced operating tables, training surgeons and staff. At the same time, everyone expects that, one day, something new and better will be discovered that will make what we’re now doing obsolete.
Across from me, in our booth at the grill, Vince Caselli pushed his chicken Caesar salad aside only half eaten. “No taste for it,” he said, and he told me he was grateful for that. He had no regrets about the operation. It had given him his life back, he said. But, after one more round of drinks and with the hour growing late, it was clear that he still felt uneasy.
“I had a serious problem and I had to take serious measures,” he said. “I think I had the best technology that is available at this point. But I do get concerned: Is this going to last my whole life? Someday, am I going to be right back to square one—or worse?” He fell silent for a moment, gazing into his glass. Then he looked up, his eyes clear. “Well, that’s the cards that God gave me. I can’t worry about stuff I can’t control.”
Y
our patient is dead; the family is gathered. And there is one last thing that you have to ask about: the autopsy. How should you go about it? You could do it offhandedly, as if it were the most ordinary thing in the world: “Shall we do an autopsy, then?” Or you could be firm, use your Sergeant Joe Friday voice: “Unless you have strong objections, we will need to do an autopsy, ma’am.” Or you could take yourself out of it: “I am sorry, but they require me to ask, Do you want an autopsy done?”