When exploring a local clinic, we should consider the broader cultural and social contexts in which the actors operate. As scholars noted, obesity biomedicine is multifaceted (Felder et al. 2016). Yet, it does tend to pathologize obesity, connoting weight loss with health, and considers bariatric surgery an optimal solution (Elmaleh-Sachs et al. 2023; Lupton 2018; Rail 2012). We follow critical obesity research that has problematized biomedical diagnosis and procedures, pointing out the cultural prejudice against bigger bodies (Jutel 2006; McCullough 2013; Phelan et al. 2015; Rail 2012); analyzing how fatness is de-politicized by ignoring the structural conditions that produce health disparities (Medvedyuk and Dennis 2018); and demonstrating how patients are left disempowered, hostile and with general disbelief in medicine (Greenhalgh 2015: p. 122).

Further, we should note the moral evaluations echoed in the clinic. WLS and its cultural underpinnings should be juxtaposed with a fundamental assumption of current neoliberal ideas–encouraging individuals to take responsibility for their lives. Accordingly, the biomedical field urges patients to “become active and responsible consumers of medical services” (Rose 2007: p. 4). Patients are further encouraged to become autonomous, self-governing “entrepreneurs” who manage risks and make conscious choices (Guthman 2009; Lowenheim 2007; Rasooly et al. 2020; Singer 2017).

Since unhealthy individuals are conceived of as victims of their undoing and as “bad citizens” (Galvin 2002; Gard and Wright 2005), large bodies are often marked as a moral failure (Boero 2010; Nehushtan 2023; Ringel and Ditto 2019; Saguy and Gruys 2010). People with a higher body weight are often perceived in much of the global North as lacking control over their bodies and lives, lazy, ignorant, and failing in their health and beauty (Brewis 2014; Farrell 2011; Glenn et al. 2013; Greenhalgh 2015; Trainer et al. 2021). Israel, where we conducted our research, is no exception: People of size are socially marginalized and stigmatized, depicted as being of weak character and self-indulgent (Maor 2014; Sagi-Dain et al. 2022). This stigmatization is carried over into clinical settings through the views held by family physicians (Fogelman et al. 2002; Sagi-Dain et al. 2022).

Studies have exemplified the effects of the moralizing tensions between biomedical obesity knowledge and the pressure for personal responsibility in many ways. For instance, biomedical interventions are often conceived as the answer to being overweight, but individuals are still held responsible for their bodies (Boero 2010; Glenn et al. 2013; Meleo-Erwin 2019). In another setting, when marketing WLS, personal behavior was downplayed as the cause of obesity, hence the need for surgery. This softened pre-operation language contradicted the needed post-surgical lifestyle changes considered indispensable for successful weight reduction (Salant and Santry 2006: p. 2451). WLS is repeatedly presented as “just a tool” given by health professionals, underscoring patients’ responsibility for correctly using it (Groven et al. 2013; Trainer et al. 2017).

Regarding patients’ voice, studies have shown how their feelings are often in tension with the voice of medicine (cf. Mishler 1984). Some patients embrace the medical protocols and thus challenge the dichotomy of agency and biomedicalization (Felder et al. 2016; Lupton 1997), while others resist professionals’ expectations. Patients’ support groups emphasize patients’ independence and agency (Fox et al. 2005; Meleo-Erwin 2019), offer advice based on patients’ experiences, and encourage the use of diverse sources of knowledge about bodies (Ferry and Richards 2015; Versteeg et al. 2018).

Furthermore, as we demonstrate below, patients’ voices are not straightforward. They are constantly negotiated with pressures and advice from family, friends, peers, and patients’ tacit knowledge, including embodied experiences and socially shared advice (Greenhalgh 2015). Thus, in articulating the various tensions in the clinic, we also observed how significant others’ advice and support participate in patients’ deliberations within the clinic and face-to-face interactions with surgeons.

When analyzing the interface of doctors and patients, we noted the complex networks of professionals within which patients work their way through their treatment options and delivery. Since weight-loss management today regards obesity as a complex issue (Jeske 2021), we are witnessing a growing collaboration among experts from many fields. Studies show the need for professionals–besides the surgeons–who guide patients in making behavioral changes in diet habits, exercise, and food consumption (Mechanick et al. 2020: pp. 16, 33).

Hence, counseling by dietitians and mental health professionals is thriving. These additional interventions cater to a holistic approach according to which post-surgery patients are expected to (and need support in managing) lifestyle changes (Godoy et al. 2012; Knutsen et al. 2013; Kruseman et al. 2010; Marshall et al. 2020; Nehushtan 2021). This attitude expresses a humane approach that views patients in their wholeness instead of dealing with biological processes alone. Their efforts expand professional health management to all daily activities, thus medicalizing everyday life (Crawford 2006). As we note below, it may also create tensions among the various experts working presumably together within the same professional field.

In sum, our ethnographic inquiry continues studies of the tensions in obesity care by exploring the intricate discursive and social negotiations of such tensions and, at times, paradoxes within a local clinic (cf., Felder et al. 2016). We examine, in particular, how actors at the clinic work out their ways with diverse discourses–a biomedical discourse and intervention, neoliberal emphasis on the responsibilization of individuals, multidisciplinary discourses of various experts alongside the surgeons, and discourses of care within social networks. On another level of analysis, we aim to shed new light on the theoretical significance of such tensions and negotiations and their practical implications (Vogel 2018: p. 405).

Our primary research site is a WLS clinic in Israel. WLS is included in Israeli insurance plans and, resonating with WLS statistics worldwide (Buchwald and Oien 2013), the number of surgeries for adult patients in 2022 was 6643, which is relatively high given the Israeli population of approximately 9.1 million (cf., Kaplan et al. 2020).^Footnote1 Many patients visit private clinics to reduce waiting times and to allow for choosing a specific surgeon.

Given the subsidy granted to patients by Israel’s Health Maintenance Organization (HMO), the WLS patients in the clinic belonged to diverse social groups and categories, including men and women, secular and orthodox Jews, Israeli Jews and Palestinians, and younger and older patients. Patients pay some percentage of the treatment as in other private medical services in Israel. Since the clinic is in a central urban area, the patients were primarily upper-middle class.

This clinic operates a comprehensive multidisciplinary obesity care program. In addition to surgery and follow-ups with the surgeons, the care includes three free post-surgery encounters with a dietitian and psychotherapist and a weekly free-of-charge support group. Patients can continue to attend these encounters with pay, according to their needs.

The first author conducted extensive fieldwork from 2014 to 2020, including participant observations and interviews with patients, surgeons, and other professionals in the clinic and other WLS sites. Ethical clearance was provided by the clinic’s Helsinki committee and the authors’ university ethics committee. As mentioned above, our ethnographic inquiry had the advantage of following the narratives, statements, tensions, and contradictions as these were played out in action throughout the different stages of the treatment process. This allowed them to listen to what interlocutors were saying to patients or the interviewer and “pick up on their minor grunts and groans as they talk about their situations” (Goffman 2002: p. 149).

The first author formed close working relationships with six surgeons: Adelman, Berger, Haled, Katz, Ron, and Salim (all names in this paper are pseudonyms). Dr. Ron is the only female in this group of doctors; Doctors Salim and Haled are Israeli Palestinians, and the other doctors are Israeli Jews. Participant observations were conducted in about 100 clinical patient-surgeon consultations (10–30 min each) with four surgeons: Doctors Adelman, Salim, Berger, and Katz.

In addition to many conversations during fieldwork, semi-structured in-depth interviews were conducted with Doctors Adelman, Salim, Ron, and Haled. All interviews were audiotaped and later transcribed. Interviews lasted about an hour and a half, were conducted in Hebrew, and were held face-to-face. While using a set of thematic questions, the interviewer maintained flexibility depending on the interviewees’ answers and the topics raised (Bernard 2006). The different pieces of data were logged into MaxQDA for clustering and analysis of key themes, concepts, and events that emerged from the data. As in ethnographic research projects, we inductively identified key analytic categories that emerged in transcripts and fieldnotes, and these categories guided the codes we developed in our interpretations (Bernard et al. 2016: p. 541).

We discovered that the daily interactions, discourses, and visuality of weight management in the clinical consultations were not easily recognized and organized according to existing discourses frequently analyzed in the literature (e.g., ‘personal responsibility’ and ‘medical power’), nor were they clearly understood under categories of ‘family’ or ‘community care’ (Yates-Doerr 2012). Instead, we followed how diverse categories were constantly negotiated, played with, downplayed, challenged, contradicted, denied, or reaffirmed by the diverse actors within the various encounters in the clinic and in interviews.

The surgeons’ discourse and practice are embedded in tensions between explicit and implicit messages. They emphasize the long work waiting for patients after the surgery, thus constantly undermining common perceptions of WLS as a ‘quick fix’ (Drew 2011; Groven 2014; Trainer et al. 2017). For example, they say: “We don’t do magic tricks,” “it’s not hocus-pocus,” and “it’s not a magic wand.” Surgeons remind their patients that obesity is complex (Jeske 2021) and continuously underscore that only hard work can get them to their goal, thus prompting patients to change their lifestyles to improve their health (Crawford 2006; Trainer et al. 2017). Such messages have roots in Western, neoliberal, and the ‘Protestant work ethic’ that participate in the complicated discourses of capitalism, the thin-body ideal, and stigmatizing fatness (Lester and Anderson-Fye 2017). In Israel, as well, the ethics of personal responsibility and self-control are quite prevalent.

In contrast to the ethics of ‘hard work,’ the esthetics, images, and spatial arrangements of doctors’ offices tell a different story. Through these material and imaginary registries, the doctors promise a profound and miraculous transformation. The shelf behind the doctor’s chair is filled with small gifts, patients’ thankful notes, and, most prominently, before-and-after pictures of satisfied clients. Some photos are accompanied by letters thanking the surgeons and praising them. These objects, images, texts, and space organization form a semiotic map representing the desired outcome and encouraging clients to choose this surgeon. The pictures are iconic, showing an overweight person becoming thin and indexical, connecting the image with the doctor sitting at the table. They direct clients’ attention and signal the outcome to be achieved by submitting their bodies to the surgeon’s hands–who can create the transformation (Stasch 2011).

Patients entering the room are instantaneously faced with these artifacts and messages, setting a specific context of the clinical consultation, implicitly suggesting that they can expect to achieve the same miraculous and dramatic results. Patients willingly participate in this social and interpersonal construction of the surgery. Occasionally, they show the doctors before-and-after pictures of themselves on their cellphones, thus sharing their metamorphosis. The doctors usually collaborate and express their amazement.

In a session with Dr. Katz, a patient opened his cell phone to show the doctor his extreme weight loss. Dr. Katz looked at the photos and said: “This is incredible; It’s hard to believe this is really you!” Many patients allude to their own or others’ images in the room. Ella said: “Why don’t you have a picture of Sharon? [a post-surgery friend of hers]. She is so gorgeous with her new miniskirts!” “Is this for real?” asked Dalia, another patient, amazed at one of the pictures, “is this really the same person?”

Clients view these images–placed by surgeons and signifying successful transformations–in pre- and post-surgical consultations, thus strengthening their desire to undergo the process and implicitly identifying health with appearance (Metzl 2010). These before-and-after images, also widespread in social and mass media representations of the body, further reproduce the obesity stigma. Pre-surgery persons are supposedly miserable and ill, while post-surgery persons are assumed to be thin and happy (Maor 2014; Salant and Santry 2006). No less critical, such images further strengthen the doctor’s authority as the ‘hero’ who saves the unfortunate fat subject (Glenn et al. 2013). Additionally, they reinforce patients’ belief in WLS as a biotechnological fix, attributing weight loss to the biomedical procedure alone (Felder et al. 2016).

Manifesting the surgeons’ power and underscoring a swift body modification is not limited to the presentation and conversation about these images. These notions are evident in the post-surgery follow-ups, as patients express joy over the surgery’s results and physical transformation. Patients enter the room, saying: “People don’t recognize me” and “I can’t take the smile off my face!” These statements are accompanied by compliments to the surgeon: “You are an angel! A savior!” and “I was so depressed before the surgery! Thank you so much, doctor!” People shake the doctors’ hands in gratitude; some bring small personal and handmade gifts. Patients see themselves as new persons and view their surgeons as responsible for their weight loss.

Furthermore, these notions are expressed through diverse, at times implicit, statements and discursive practices. In particular, doctors and patients use phrases and metaphors to refer to quick transformation, conversion, and rebirth. They do so even when emphasizing the need to “work.” Surgeons urge patients to start over and explain that they must change and switch their state of mind.

Another strategy conveys a quick, magical fix by offering clear-cut steps that outline how the change will be obtained. For example, Dr. Salim set homework for a post-surgery patient, stating: “Your weight loss is ok, but not great. I want you to stay away from sweets and snacks and exercise more. I would like to see you drop a kilo a week in the coming three months, please.” This attitude diverges from the contemporary views of dietitians worldwide (Jovanovski et al. 2023) and in Israeli bariatric settings that advocate for a less controlling and strict approach to weight management (Nehushtan 2021).

The messages in this clinic are full of tension and, at times, quite contradictory and confusing. Surgeons explain that the overall responsibility for the surgery’s success lies in the patients’ hands. It is their responsibility to become and remain thin and happy. Still, the doctors’ power and the strict biomedical discourse, emphasizing the significance of the medical procedure, are consistently affirmed. These two different conflicting messages at the clinic resonate with the broader cultural competition between hard work and miraculous conversion. The doctors’ pressure to lose weight, their expectations of instant, quick change, and the transformation pictures strategically placed in the room all express WLS as a biomagical event. It is a conceptualization that doctors explicitly oppose, but advance in the subtle fine printy and paradoxically enough, they also advance.

The tensions emerging through the work at the clinic become even more apparent when we follow doctor and patient encounters more closely, the procedures doctors use, and, in particular, the issue of responsibility. The patient’s responsibility and the need for hard work are constantly stressed, as demonstrated in our opening vignette. We also see how the doctors’ authority, how they try to teach patients to become responsible, and the complexities of the body and self are all constantly negotiated. These complexities are worked out in intakes and follow-up consultations, which consist of fixed questions and expected replies led by the doctor. For example, in the following intake conversation:

Dr. Adelman: You have a BMI of 39, so you have been suffering from obesity for the past four years. What happened in those four years?

Edna (46-year-old woman): Look, I am raising my children alone. I am divorced with three children. I am independent. I opened a business, and after half a year, I fell [in a work-related accident]; I couldn’t [physically] promote the business, and due to my mental health at the time…

Dr. Adelman: So, you drowned your sorrow in food; Your eating is emotional! What kinds of foods do you like? Sweets, snacks, savory dishes?

Edna: Whatever is available, not something that takes time to make.

Dr. Adelman: So, it’s junk food?

Edna: Yes. This surgery is a trigger to change my way of life.

Dr. Adelman: Let me put things for you [to understand]. The procedure doesn’t make you lose a pound! You get off the surgical table at the exact same weight. The process you do is what causes you to lose weight […]. If you make this change correctly–and we will guide you on how to do it right, it will become part of you.

Edna: No, no… You misunderstood me…

Dr. Adelman [interrupts her]: I am explaining now. […] In gastric sleeve surgery, we subtract…

Edna [interrupts]: 75 percent.

Dr. Adelman: We do not measure percentages…

Edna [interrupts]: Of course, you take off the whole front and… sorry… sorry… [for interrupting]. (Laughs, burying her face in her hands while the doctor explains).

The bio-psycho-social complexities of the procedure are built into the formulations the doctor is using. The protocol relates to pure bodily facts and to the person’s life story and mental and familial difficulties. It includes questions about diseases in the family, weight history, past dieting attempts, smoking and alcohol consumption, medications, and allergies. Some surgeons directly address patients’ answers, and some further cast responsibility onto patients when stressing the need for post-surgery support, asking about familial status, and discussing the harmful effects of smoking.

The authority of doctors was commonly kept quite firmly, even in the face of patients trying to establish an understanding of their bodies. In the above encounter, when Edna is starting to elaborate on her lifeworld (and trying to demonstrate her medical knowledge), Dr. Adelman quickly cuts her off, re-establishes his authority, and returns to the strict biomedical protocol. Hence, Edna eventually is framed as an ‘emotional eater,’ a gendered category that blames the (female) patient for her obesity (Boero 2010), and the surgeon ‘absorbs’ the patient’s lifeworld into the technocratic biomedical voice (Hunt et al. 2017; Mishler 1984).

The surgeons’ authority and control of patients’ bodies is expressed in how they teach them about their responsibility and the surgery. For example, surgeons ask patients to classify their eating habits. They use three categories: sweets, snacks, and savory dishes, and explain to patients that the surgery type is adapted to the person’s eating routines. Surgery is questionable, they explain, for people whose eating is disordered as they may find it difficult to eat every three hours. The inquiry into patients’ eating habits is sometimes used to teach a moral lesson. In the quote above, for example, ‘Junk food’ was an umbrella term for wrong choices, reinforcing the patient’s responsibility for her body size.

In the above example, the participants frequently interrupt each other during turn-taking in conversations. A local communication pattern perhaps exacerbates these interruptions, as shown below, and may also express a subtle question of doctors’ authority. The patient apologizes for interrupting the doctor, buries her face in her hands, and laughs in embarrassment; she reaffirms the doctor’s power in this classical gendered power structure.

Further, doctors advocate patients’ responsibility as a moral mission. They indicate that the surgery’s success is always uncertain since it depends on the patients’ work. Dr. Adelman said (in an interview):

Since I really believe that the success of the surgery depends on what they [patients] do with it, on their behavior, I always say—Okay, your responsibility begins today: You choose to do the surgery. I gave you all the information—the advantages and disadvantages, the risks, the odds, […] now you decide. You are a grown person. You’re an adult. Your responsibility starts today.

Assigning responsibility to patients starts before the surgery, carefully navigating between encouraging patients to be knowledgeable and decide for themselves and maintaining the surgeons’ authority. For example, Dr. Adelman’s criticism of Edna’s attempt to express her knowledge—“we do not measure percentages”–points to the inherent tension in this doctor-patient encounter. The doctor provides information and encourages patients’ autonomy but cements his authority, demonstrating his assumption that medical knowledge is hardly accessible to laypeople.

Cultural values also contribute to the complex doctor and patient relationship. The Israeli cultural context and local forms of communication may explain some aspects of the interactions. Straightforwardness and sincerity in social interactions are highly significant for communication in Israeli society (Kaneh-Shalit 2017; Katriel 1986). Being characterized as straightforward and even blunt is considered a compliment for public and political figures (Kampf and Danziger 2019). Further, being too polite or flattering is considered manipulative, dishonest, and inauthentic (Danziger 2020). Hence, in these clinical encounters, we may be witnessing an Israeli version of neoliberal selfhood that includes tensions between straightforwardness and politeness and between authoritarian assertions and empathetic concerns (Kaneh-Shalit 2017).

Other doctors put the discrepancies between a technological intervention and the responsibilization of patients slightly differently by emphatically downplaying the impacts of the surgery. Dr. Ron said (in an interview):

People think the surgery is a magic wand; That’s the most common thing. You must understand that the surgery induces food restriction, and you lose weight. However, it takes a year. After that, you create some new status quo, as if we were born again […]. It’s not that the surgery does some hocus-pocus and that it changes you genetically or changes you psychologically. No, [it does not].

Dr. Ron thus claims that she tries to demystify patients’ false beliefs about the power of the operation. The surgery, she explains, only restricts food for just a year; then, it is up to the patient. Furthermore, patients must start working on their bodies right after the surgery. The possible conversion, “as if we were born again,” is not miraculous,“hocus-pocus.” Here, she argues that the surgery is merely a starting point, inciting weight loss but not magically provoking it or maintaining it.

Also, note that the ‘rebirth’ discourse of WLS problematizes the surgery as presumably a simple, automatic body modification. Instead, it resonates with a spiritual change and advocates a moral demand to work hard to achieve the desired transformation. It invites “the reconfiguration of the self as a disciplined subject, who can exercise control and restraint over consumption, and who is willing (and able) to take responsibility for the body” (Throsby 2008, p. 120).

Alongside the optimistic metaphors of rebirth, the risk of failure is also underscored. As Dr. Ron states: “It takes a year.” After that, weight loss is entirely in the patient’s hands. Once again, patients are placed under biomedical surveillance and urged to feel responsible for potential failures.

The doctors discussed tensions and conflicting messages in various ways. While most highlighted patients’ responsibilities, some underscored the surgeon’s role. Dr. Haled shared how much he stresses and explains to bariatric patients their responsibility, also claiming that people sometimes gain weight and request a second surgery not because of stomach expansion and overeating (a common fear among patients). Instead, it is because occasionally, surgeons remove a too-small percentage of the stomach, primarily in Sleeve Gastrectomy. Thus, perhaps inadvertently, while underscoring patients’ responsibilities, he also strengthened the idea that WLS is a biological intervention that assumes a direct unilateral causal relationship between stomach reduction and weight loss.

A fundamental implication of responsibilizing patients is downplaying the surgeons’ responsibility for any problems. Doctors tended to shrug off patients’ complaints (e.g., aches, nausea, or diarrhea) after the surgery. They often denied a causal link between the surgery and these symptoms, suggesting that the problem lies in the patient’s behavior or, in any case, not related to the surgery:

Aviva (32-year-old woman at a follow-up consultation): Every night I get up twice [to go to the toilet], I can’t breathe [due to the pain of diarrhea], it’s terrible!

Dr. Salim: This specific operation is not considered severe regarding diarrhea […]

Aviva: My mother also underwent surgery; she didn’t suffer like that; it’s not normal!

Dr. Salim: Do you drink enough?

Aviva: I try.

Dr. Salim: A person with diarrhea loses fluids, which is bad for blood pressure. You must drink more often. Are you doing any physical activity?

Aviva: No.

Dr. Salim: I do not like this [attitude]! I carried out a complicated surgery, and you tell me, “I try.” […] You are not serious; you’re still young, and you need to start a new chapter in your life!

The patient’s physical habits are perceived as a moral failure. Further, Dr. Salim rejects the patient’s knowledge based on a family member’s experience and her assertions that the pains are abnormal and an outcome of the surgery. The doctor seems to deny or ignore such claims, urging instead the patient to change her ways.

Thus, a discrepancy often occurs between the representation of the imaginary post-surgical body and the actual post-surgical experience. Doctors seemed to search for causes for pains and other bodily issues patients complained about, but not in the surgery itself. For example, in responding to a patient’s complaints of severe nausea that made it difficult for her to eat and exercise, Dr. Berger said:

Take something for the pain and start exercising; you might be out of shape. […] You have to do sports, and you don’t eat enough protein. […] You must work hard; there’s no magic here.

Here, too, the doctor attaches little importance to the difficulties of nausea and pains, points to the patient being out of shape, guides her to exercise, and hints that she thinks the surgery will cause weight loss without her putting in an effort.

It is important to note that doctors always check the patients’ surgery scars by touch and sight and ask questions to determine whether the complaint is relevant to problems deriving from the surgery. When doctors deemed an issue severe, it was addressed with care, and patients were referred for further tests as needed. However, many patients’ complaints made doctors slightly criticize them for not behaving according to the post-surgical rules. Following numerous participant observations, it became apparent that problems or pains were often dismissed by doctors, explaining that such pains were a normal part of the surgical process or resulted from patients’ misbehaviors. Hence, when the operated body was not acting as intended by the biomedical system and was not disciplined due to its open-endedness, elusiveness, and pliability (cf., Grosz 1994), doctors tended to place the blame squarely upon the shoulders of ‘misbehaved’ patients.

The clinic’s work transcends mere biomedical intervention, advocating an interdisciplinary approach. The clinic offers guidance on lifestyle and eating habits. The doctors themselves advocate self-discipline, new dietary habits, and exercise post-surgery. Dr. Ron, for instance, highlighted the extensive professional support patients require, including a fitness trainer, complementary medicine, and life coaching. She further explained that due to the complexity of WLS, she often assumes the role of a psychologist or a life coach. In an interview, Dr. Salim explicitly stated that weight loss is contingent on the professionals’ interdisciplinary approach:

People get the whole package here. […] As long as they are ‘wrapped’ by professionals, they continue to lose weight. If they leave this envelope, they slowly start to gain weight.

Working with additional professionals creates new challenges, sometimes a new ambivalence, for patients. Their responsibility is consistently underscored, yet Dr. Salim claims patients will gain weight without the professional’s guidance and support. It seems that patients cannot accomplish the task on their own.

Still, complications entailed in the presence of multiple professionals are exacerbated at times since the patient herself is supposed to be working on the body. In a post-surgery consultation, Dr. Berger told a patient, “You gain weight, exercise more, come see the dietitian, come get psychological support. But you control it now. We can’t make you … The ball is in your hands.” Thus, multiple professionals treat the patients, yet the patients are constantly reminded about their responsibilities, including attending support groups and psychotherapeutic consultations and following the professionals’ various, at times competing, guiding principles.

The doctors repeatedly underscored the importance of this continued multidisciplinary work while underscoring that the overall responsibility remains on the patient’s shoulders.

Dr. Katz: [talking to a post-surgery patient] Do you know those old tables with three legs? These three legs keep the table [standing]. You take one leg off, and the whole table falls. The surgery also has three legs: One is the surgery, the other is diet, and the third is physical fitness. OK? If you are gaining weight, you must consider what you ate and whether you have followed the dietitian’s instructions or done enough workouts. […] We gave you a tool. But now, control is in your hands.

Dr. Katz expresses the clinic’s multidisciplinary ideology using the metaphor of a three-leg table. Besides the surgery, he explains, patients need to change their eating routines (based on consultation with a dietitian) and exercise. Interestingly, Dr. Katz omitted a fourth leg of the table in this conversation, for patients need the help of a psychotherapist who works in the clinic. Adding professionals and duties, such as consultations with a dietitian and a therapist after the surgery and joining support group sessions, introduces an additional layer to the patients’ work and complicates the multilayered encounters with doctors.

The tension surfaces in the patients’ and professionals’ interface and among the professionals. Hence, patients and doctors often said: “The stomach was operated on, not the mind.” They thus referred to the continuous struggle with eating habits after the surgery. Still, the surgeons assumed that other professionals, not them, were to handle the many issues and factors that were at play that did not directly concern the body, specifically the stomach. When handling this complicated set of interventions, doctors often found they needed, or decided, to outline professional boundaries when patients consulted with them on various matters, such as eating habits. Dr. Katz said he could not leave his office for forty minutes once since the patient kept talking about her daily eating habits. Dr. Salim claimed that sometimes patients confused him with their primary care physician, assuming he should deal with issues that are, in his view, unrelated to his role. He also mentioned that he used to give patients his cell phone number. This was “too much eventually,” he claimed, “patients used to call me all the time. I had no life due to their numerous calls.” It seems then that the multidisciplinarity approach hindered a more holistic approach within the doctor’s office, leading instead to a stricter division of labor among the professionals at the clinic, especially placing less responsibility on the surgeons.

The complex relationships among the professionals were discussed, for example, by Avishay, a mental health professional at the clinic, who analyzed the tensions inherent in the division of labor at the clinic:

An issue occasionally arises here that troubles us all. A patient complains that it hurts when he eats; [that he suffers from] intense pain that he cannot bear. The doctor does medical tests and finds nothing unusual. However, the patient is still in pain. The doctor claims this is a psychological rather than a physiological problem. He sends the patient to the dietitian and me. Then I wonder: If a person says he has physical pain, how do they claim it’s only psychological?

Avishay thus complicates the division of labor among professionals, which resonates with the profound Western conundrum concerning the body and mind bond. Patients’ bodies are handed over to other professionals without an agreed-upon intervention. Avishay points to the elusive knowledge obesity medicine has of the body and the dynamics of the material body that is not organized according to expectations. When a patient reports pain, tests are given to rule out ‘pure’ medical problems, following biomedical reasoning of targeting an exact cell or damaged tissue. Then, when opting for a psychological cause, the therapist becomes puzzled and doubtful.

Avishay points thus to an ambiguous outcome of a supposedly clear division between professionals and between body and mind. Post-surgery pains form a problem that is not easily handled, for the clinic eventually follows an organ-specific approach that disadvantages people with complex conditions (Nugus 2019). Paradoxically enough, multidisciplinary care expands the scope of treatment yet blurs the possibility of clearly sorting out the body and mind distinction. It turns out that often, no one can decisively trace the source of pain.

Other agents have also proven critical in interrupting, challenging, and negotiating the professionals’ and the patients’ work. These were significant others, family, and friends who joined the medical consultation sessions—at times as mental companions–from whom patients took advice, support, knowledge, or inspiration. Entering the doctor’s office with a family member or a friend was routine. Doctors turned to these chaperones, stressing their crucial role in helping patients achieve post-surgery goals. Nevertheless, these supplemental agents often expressed competing messages. In a pre-surgery consultation, Yoram objected to his wife’s surgery and negotiated its necessity both with her and with the doctor. In response to Yoram’s doubts about Rina’s ability to change her bad eating habits after surgery, Dr. Adelman said:

I don’t know. I don’t know her. She will decide. […] Maybe you’ll decide together, but she’s likely to choose by herself, and you won’t decide for her because she’s past 18 and (sarcastically) has yet to be declared unfit. She will determine how she wants to deal with it. […] One last thing: If she does the surgery, you will be crucial to her success. You can put her down, or you can help her.

Yoram: I will never deliberately damage her surgery, but I will object to it until she does the surgery because I don’t think she should.

This puzzling exchange demonstrates how significant others in the patient’s social network constantly negotiate over the patient’s body. Rina’s decision depends not only on herself and the doctor’s opinion alone but also on her husband’s.

Indeed, researchers argue that social support is correlated with better outcomes following WLS (Conceição et al. 2020). This makes sense in many medical procedures. Yet, with WLS built-in tension between the surgery being an elective or a life-saving procedure, the disparate voices of loved ones form another layer of deliberation and negotiation over control of one’s body. These interactions also problematize the image of the surgery’s success or failure, presumably resting on patients’ willpower alone.

These consultations reflect the diverse agents’ power in patients’ considerations and in handling their bodies. They demonstrate how pre- and post-surgery patients negotiate their bodies and habits within their immediate environment: their spouses’ and friends’ reactions and the changing roles within their nuclear family (Meana and Ricciardi 2008).

Further, this familial and social interconnectedness begins much earlier. Patients turned to friends who went through the surgery to receive inspiration and consult peer virtual and non-virtual support groups. They also sought knowledge from their families, like Aviva (at the follow-up consultation with Dr. Salim), who consulted with her mother. Some went through the surgery because of pressures from family members. A patient jokingly told Dr. Salim: “My wife said she will divorce me if I don’t do the surgery.” Others chose a specific surgery due to its popularity among friends. Family members were asked to support patients’ recovery, like encouraging patients to seek additional help with house chores or stereotypically asking a wife to cook healthier food for her husband.

These practices should be understood within the local context, as they resonate with an Israeli “familial” culture of individuals merging into each other’s lives (Fogiel-Bijaoui 2002; Hashiloni-Dolev 2018).

Patients and their bodies are thus caught up in webs of knowledge and notions coming from family members, friends, social media, and their spouses’ desires. These actors, patients’ significant others, consult with the professionals and work on patients’ bodies inside and outside the clinic. Despite neoliberal ideas about individuals’ pure autonomy, patients’ wishes and bodies are channeled, problematized, and negotiated with these other actors.

Applying a pragmatic approach and exploring obesity bottom-up at a bariatric surgery clinic allowed for following how healthcare providers perceive and engage with modifying patients’ bodies and how they navigate, explain, and manage the dynamics of the material body within a complex web of tensions. We suggest these negotiations occur because WLS intervention is not easily reducible to opposing perspectives around personal responsibility and medical knowledge. It is also negotiated with diverse professionals and with patients’ significant others. We follow numerous scholars who identified ambivalence, contradiction, and messiness in medical treatment and management of weight (Mol 2002; Vogle 2016, 2018; Yates-Doerr 2012, 2015).

Reflecting on the inherent contradictions in biomedical discourse and work, Vogel (2016) proposed that contrasting different forms of care can provide new insights into the diverse meanings of bodies and care. Similarly, our exploration of situated care at the clinic has revealed tensions and paradoxes. We argue that these revolve around three interrelated types of ambivalence: (a) the contrast between the promise of a medically induced quick fix and the reality and moral demand for individuals’ hard work; (b) the tension between the holistic multiprotection offered by a professional team and the body’s evasiveness; and (c) the balance between patients’ autonomy and their reliance on friends and loved ones. Our ethnographic project has illuminated the intricate interplay of discourses, actors, and culture at the micro-level of obesity care:

First, our analysis elucidates the inherent tensions between and within discourses on obesity and provides a better understanding of how these tensions are manifested and worked out. Examining and mapping out the events and communications at the clinic points to discursive discrepancies. These tensions include the need to sort out the balance between a biomedical fix and patients’ responsibilities and the various professional discourses and their diverse underlying logics (e.g., medical procedure, individual and group therapy, dietary, lifestyle, and physical exercise).

Scholars have noted that patients and professionals perceive surgeons as knowledgeable and authoritative, yet hold patients responsible for a surgery’s success and perceive good health as a moral duty (Meleo-Erwin 2019; Salant and Santry 2006). This perspective is crucial in understanding the paradoxes in obesity care dynamics. Resonating with this argument, we demonstrated how this tension is worked out in practice. According to biomedical obesity logic, extreme weight holds health risks and often demands surgical intervention. There is a subtle paradox at play here, however, between the surgery as a quick fix, expressed, for example, in the semiotic signs decorating surgeons’ offices, and the grueling post-surgery healing process and demands of hard work.

Second, the ethnographic fieldwork allowed us to follow the work and negotiations among the various actors involved, including the surgeons, patients, dietitians, mental health professionals, and significant others. We thus analyze the social drama in handling obesity and explore how the various actors negotiate its meaning and their diverse understandings of appropriate interventions. The consequences of a multidisciplinary approach, combined with the medical procedure serving as a ‘magic bullet,’ eventually limit the surgeons’ role. Patients are transferred to other professionals who help them handle emotions and food intake. The deliberations on how to manage, fix, and control the body are thus exacerbated. This is also expressed in the competing narratives held by the different professionals, including the inability to determine the precise causes of pain patients suffer from. Thus, interdisciplinarity may eventually dissect the body (and self) into separate, distinct components, forsaking the holistic aspirations and failing to address the gaps between these components.

The complexity and messiness of conflicting messages among various actors at the clinic are further foregrounded when looking into the role of patients’ significant others and the embodied knowledge and advice offered on social media and by “expert patients” (cf., Fox et al. 2005; Ziebland 2004). This underlines the significant role of broader social influences in the treatment of obesity, a factor that is often overlooked. Both biomedical and personal responsibility discourses are undermined or at least problematized once we realize the impacts of patients’ significant others on healing processes and patients’ reliance on advice and support of social networks.

Third, looking carefully at the events and conversations at a local clinical site allowed for exploring how these may be, at times, related to local cultural sensitivities and forms of communication. We suggest that local cultural themes contribute to forming the meaning of obesity and how to handle it within patients’ relationships with surgeons, various professionals, and significant others. This is primarily exemplified by surgeons’ authoritative and blunt statements and caring for patients’ post-surgery success. This style of communication and its implication for the doctor and patient relationship seems to resonate with Kaneh-Shalit’s (2017: p. 110) analysis of Israeli coaching that includes “empathetic caring that is anchored in the caregiver’s assertion of authenticity at the expense of the care receiver’s current feelings.” Thus, patients and doctors do not explicitly challenge or question the communications and care forms so conspicuous in the clinic. This tendency echoes studies demonstrating how patients critically assess clinics in online forums but rarely within face-to-face encounters with their surgeons (Meleo-Erwin 2019).

Felder et al. (2016) found that whereas professionals at an obesity outpatient clinic adopted a “patient-centered” approach, patients themselves were invested in a “technological-fix” model of care. Exhausted by the “individual responsibility” discourse, patients were happy to attribute agency to biomedical knowledge and views. Indeed, we found that patients seemed to collaborate with the responsibilizing logic doctors preached. They usually tried to cooperate with the various post-surgery interventions offered to them, no matter how conflicting they were or how much self-blame they instilled.

Encouraging patients to become responsible for their pains seemed to make them believe that solutions are in their hands, giving them a sense of control and autonomy over the evasiveness of the body (e.g., pains, problems, and difficulty in losing weight). Too much attention to post-surgery diverse messages, problems, and aches may expose reservations about WLS as the optimal solution for obesity. Patients’ responsibility is thus negotiated and eventually adopted by them, at least explicitly, expressing their moral selves–embedded in a new appearance and their efforts to convert into the ideal body.

Our ethnographic inquiry speaks to ambivalences in current biomedical work, especially concerning the dynamic, unstable material bodies modified through surgery. Unpacking the discourses and negotiations over the modified body goes thus beyond a dichotomy between biomedicine and the patient’s “lifeworld” (Mishler 1984) or between objectification and agency (Felder et al. 2016). Exploring a WLS clinic invites a more comprehensive assessment of how illness exposes the paradoxes of obesity medicine and the human body and agency. Any attempt to stabilize the body, responsibility, agency, or professional coherence in such clinical sites becomes questionable.

Further, examining the encounters in the clinic invites us to look more closely at the possible implications of such tensions for the quality of care. We know that all professionals in the clinic approached their work with dedication and were committed to providing the best care for their patients. Yet, our exploration exposes the complexities of doctor-patient relationships when uncertainties surface and how these discursive complexities may affect the handling of obesity care.