The consultant note read:
Weight 250 lb. BMI 40.3. Patient is morbidly obese. Counselled on the dangers of excess weight. Counselled to increase exercise and decrease calories.
I walked into her room. She smiled at me as I walked in, a lovely smile that reached her eyes. I scanned her record. She was in my office for an ankle injury. Blood pressure normal. Weight 248 lbs, BMI 40.
When I looked back at her, she was still smiling. "I lost another ten pounds," she said proudly.
I looked back in her records, noting a steady weight loss over the past two years. She started at... "Goodness. You have lost over 100 pounds! Amazing!" Her grin persisted as we started talking about her ankle injury.
Numbers. We obsess on the numbers. Is BMI over 30? Obesity. Is it over 40? Morbid obesity. No doubt these numbers are important, but in reality they are just points on the timeline. People come for care with an entire lifetime of narrative in tow. Yet most of the care that is given is ignorant, sometimes intentional and sometimes not, to the whole story of what is going on. My patient went to the specialist and was labelled as being "morbidly obese," and given counseling on the obvious (although I suspect the specialist just checked the box to avoid censure...and financial penalty). Yet this woman knew far more than anyone who could have counselled her. She had lost a quarter of her body mass and was continuing to lose. She was a hero, yet to anyone who didn't look back on her timeline, she was simply another data point proving the failures of our society.
The irony is that the way that she accomplished her weight loss was to focus on each day separately, ignoring her past history and trying to have a small victory each day. I've often used the analogy of a baseball player who does what he should do: gets a hit. But if that player gets hits in every game for a week, for a month, his season (and that of his team) can be significantly altered. But each game, each at bat, is a single data point where he's only asked to do something unspectacular. But do something unspectacular for enough days, you have something transformative.
We live in a world where patience is a diminishing commodity. We want each day to wrap up neatly like an episode of a TV show. We want to end all arguments by having the perfectly worded Facebook post. We want to figure out the solution to our problems, meet our soul-mate, elect the perfect candidate, and live the rest of our lives happy and contented. But every story has many pages, every timeline has many data points, and every life is made up of many days, many decisions.
As a human, I do best when I understand that I live in a timeline and that my solutions take a series of decisions, not just one. Yet I also do best when I try to win only the day's battle, not the whole war. Today matters only as a piece of something much bigger, yet today is the place where my pen is writing, and where the story is created.
As a doctor, I also do best to consider both things. We want to criticize people for where they are without considering where they've been. I am constantly frustrated by ER and Hospitalist providers who ignore the care I've been giving for years (and sometimes decades), viewing only what is now in front of them. Our job is to recognize that every one comes to us with a narrative, to enter that narrative, and to direct it in the best way possible. It's not our narrative, it's theirs. But we can have a huge impact on people if we listen, understand who it is we are seeing, and help them write today's narrative in a better way.
I know this sounds a little ethereal, or overly philosophical. But this woman will get discouraged if nobody sees where she's been and what she's accomplished, only to criticize today's number. Her exhilaration at my recognition of her incredible accomplishment will likely give her much more motivation and help than if I had lectured her on "eating less" and "getting more exercise." We do our best work when we appreciate the fact that we are simply a point in the timeline.