Psychologist Rachel L. Goldman, PhD, says she will never forget a young man who was so obese he couldn't even raise his leg a few inches off the chair while sitting in her office.
"The average person doesn't understand why people need bariatric surgery and thinks, ‘Why can't they just go to the gym like I do?'" says Goldman, now the senior bariatric psychologist at the Bellevue Center for Obesity and Weight Management at New York's NYC Health + Hospitals/Bellevue and clinical assistant professor at New York University School of Medicine. "What I realized was that there really were morbidly obese people who couldn't take the usual recommendation of just walking to the mailbox."
That realization shaped Goldman's career. She got her first exposure to bariatric surgery during her internship at the Medical University of South Carolina (MUSC). After earning her doctorate in clinical psychology from Fairleigh Dickinson University in 2010, she did a postdoc specializing in obesity and bariatric surgery back at MUSC.
By restricting access to the stomach or simply removing most of the stomach altogether, gastric bypass and similar procedures help people lose weight by reducing the amount of food they can eat or how well they can absorb nutrients or both. According to the American Society for Metabolic and Bariatric Surgeryopens in new window, longitudinal research has found that most patients maintain significant weight loss — at least half of their "excess" body weight, or the difference between their current and ideal weights — over the long haul.
While any surgery entails some risk, for obese patients who haven't been able to lose weight through dieting and exercise it can be a medical necessity, says Goldman. In fact, bariatric surgery doesn't just help with obesity. According to a 2016 study in Diabetologia opens in new window, bariatric surgery is a much more effective way to reverse Type 2 diabetes in patients with mild to moderate obesity than an intensive lifestyle intervention involving exercise, a dietician-directed diet and medication, for example.
The number of psychologists specializing in bariatric surgery is small, Goldman says, explaining that most hospitals simply refer patients to outside psychologists, who often lack specialized training. As in-house staff members, she and the center's other bariatric psychologist are part of a team that includes surgeons, physician assistants, nurse practitioners and nutritionists.
"Our work is very much built around the idea that we are a multidisciplinary team because we really need to all work together to get patients ready for surgery," she says.
Since joining Bellevue as its first specially trained bariatric psychologist in 2011, Goldman has spent her days evaluating patients planning surgery and helping to monitor their needs before and after procedures.
Goldman begins by going over patients' motives for having the procedure, their mental health histories and any symptoms, such as disordered eating. She checks whether cognitive deficits, behavioral issues or stressors in patients' lives might keep them from adhering to post-surgery lifestyle changes. She also assesses their social support. Spouses, for instance, can become jealous or feel neglected when patients want to exercise instead of watching television the way they used to.
Goldman also educates patients who view surgery as a quick fix. "Surgery is just a tool, not a cure for obesity," she tells her patients. "It's like we're giving you a prescription and you have to fill it."
She also helps patients understand the recommendations given by their physicians and other providers. "They might know they can't eat certain foods, but not understand the reason," says Goldman. Patients may think that chicken breasts and fruit are healthy, for example, but overly dry chicken and some fruit skins can get stuck in patients' rearranged digestive systems.
Goldman helps patients start breaking bad habits even before they have surgery, encouraging them to make small changes and helping them plan for such potential pitfalls as holiday parties. She may meet with patients a few times before or after surgery or invite them to join one of the center's support groups.
Then she and the surgeons discuss whether patients are ready for surgery or whether they are depressed or have other psychological issues that could reduce their chances of success.
"I don't want to be the one deciding if a patient gets surgery or not," says Goldman. "But surgeons usually want a yes or no answer." While deciding whether patients' medical need for surgery outweighs their psychological issues was challenging at first, it has gotten easier after almost five years. "I hear all the time now, ‘If you don't think this patient is ready or think he or she needs more help, we're going with it,'" says Goldman. "They really do appreciate my input."
Goldman also works closely with the nutritionists. She helps patients figure out how to make dietary guidelines work in their day-to-day lives and avoid overeating, which can cause nausea and vomiting. Goldman also finds herself fielding questions such as whether a particular brand of protein shake is safe for patients with diabetes. "I spend a lot of time with patients, so they feel comfortable coming to me," she says.
Goldman and her patients celebrate successes together, whether achieving a goal weight or simply reviewing food diaries to see how much better they're eating than three weeks earlier.
"I sometimes feel like a cheerleader at work," says Goldman, who encourages other psychologists to join a field that's growing along with the obesity epidemic. "I love seeing patients who were struggling before so successful and happy."
For more information about this area of integrated care, contact Dr. Goldman at Rachel.Goldman2@nyumc.org.
