The Fat Doctor Podcast

Cameron's Story

• Dr Asher Larmie • Season 5 • Episode 20

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Medical weight stigma creates dangerous catch-22 situations for patients seeking care. In this episode, I share Cameron's story of developing gallstones after weight loss surgery, only to be denied treatment because their BMI was "still too high." 

In this episode, I expose how rapid weight loss can trigger gallstone formation and how medical professionals often ignore evidence-based care when treating higher weight patients. I challenge the "lose weight to get treatment" narrative while offering practical advocacy strategies for navigating a biased healthcare system. 

Today’s journal article was Gregori, Matteo et al. “Day case laparoscopic cholecystectomy: Safety and feasibility in obese patients.” International journal of surgery (London, England) vol. 49 (2018)

For free resources on the management of galbladder disease head to noweigh.org 

And don't forget to check out my masterclass on gallstones 

Got a question for the next podcast? Let me know!

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Hi, everyone and welcome to episode 20 of Series 5 of the Fat Doctor Podcast. I'm your host, Dr. Asher Larmie. And this is Cameron's story. I'm excited to tell you a little bit about Cameron. I have met some Camerons in my lifetime. Obviously, I'm not basing this individual on any one particular person, or an amalgamation of several people, patients, clients that have come across over the last few years, all with a very similar story, and some of you will be able to relate to this story. It's all about gallstones. Well, it's not about gallstones, it's about medical trauma, but in this case Cameron has gallstones, but you can replace gallstones with many, many conditions, especially conditions that require surgical intervention. I want to offer up a content warning. I think I should do this with every single episode that I do. But I will be talking about weight loss surgery. I will be talking about medical trauma. I will be talking about weight stigma. So just be prepared for that. As always, my fictional characters have gender neutral pronouns. Not because I'm trying to piss people off, but just because I don't like giving my characters genders, because then I think it means people can't always relate to them. And I want as many people to be able to relate to this character as possible. So they're Cameron. They're 32. I have made them a social worker because they work hard. They advocate for vulnerable teenagers because they're good people. Cameron loves a bit of gardening. Got a green thumb. Got lots of friends, quite sociable. Live in a nice little flat, apartment, whatever you call it. Just cozy. Spend some time on Pinterest trying to make their living space pretty on a budget. Good people, as I said. Cameron was diagnosed with PCOS at the age of 15, and at the time it was a GP who diagnosed it and basically said, 'Listen, the only way to manage your PCOS is to lose weight and stay thin. If you get fat, your PCOS is going to be out of control, and you're going to develop diabetes by the time you turn 30.' That was the message right from the beginning, and that had a very profound impact on Cameron's life. They were young, in relatively good health, I mean irregular periods, a little bit of hair growth in places that they would rather it wasn't, quite a bad case of acne at the time, pretty good shape, but all of a sudden they have received this dire warning. They're going to get diabetes in their thirties unless they shape up and get thin, and they weren't fat. They weren't thin. They were kind of average, and didn't really pay much attention to their weight prior to that, but they certainly did afterwards. Of course, the GP, there was no conversation about hormonal treatments. There was no conversation about all the different options for PCOS. It was just weight, weight, weight, and you won't be surprised to find out that this began 15-20 years of dieting and weight cycling. Because that's what happens when a doctor tells you you're going to get diabetes and get really sick, and you won't be able to manage your symptoms unless you stay thin, you start dieting. The first diet works for a while, and then you gain weight, and so you try the next one, and then the next one, and then the next one. So by the time they've hit their early thirties, Cameron has tried Weight Watchers. They've tried Slimming World. They've tried Keto. Intermittent fasting. You name it. They've tried it, those horrible Slim Fast shakes because they were on offer one January, and they bought them in Costco. And of course, as we would expect, especially in someone with PCOS, but actually in anyone, because weight loss isn't sustainable in the long term, they lost some weight. Then they started regaining weight. Then they felt really bad about themselves, blamed themselves, and tried again, and the same thing happened. Those of you who have participated in Unshrinkable or downloaded Unshrinkable, it's a very low cost course that's available on my website. And it's all about why weight loss is just simply impossible. Our bodies were not designed to shrink. So this isn't - there's nothing wrong with Cameron. This is normal. This is normal behaviour, but of course that's not what society tells us, certainly not what the medical profession tells us. So Cameron is feeling really crappy about themselves. And they don't want to go anywhere near their doctor, unsurprisingly. They don't seek out any help with their PCOS. Acne hasn't settled down, even by the time they've reached their late twenties. Doesn't matter. We'll put up with it because it's their fault, right? They are to blame. They didn't manage to keep in control of the weight. If anything, their weight has ballooned and ballooned, and now they have a weight that is so extraordinarily high that if the GP even looked at Cameron, they know exactly what's going to happen. Too fat to pretend to be anything otherwise, and so they don't go and see the doctor ever. Instead, they do some research because Keto didn't work, intermittent fasting didn't work. Weight Watchers didn't work, none of it worked. And so they start hearing about people they know who tried weight loss surgery. There are a few people on social media that are talking about their weight loss surgery journey. They've got a friend who's doing it. They've got a cousin who's done it and think to themselves, maybe this is the solution. 'I'm so sick and tired of feeling like crap. I'm so sick and tired of going on a diet. I'm so sick and tired of feeling like a failure. This is probably the solution.' And they weren't keen to begin with, but slowly began to be worn down. And of course, deep down inside, they want to be rid of this acne. They don't want to get diabetes, and they're being told that this is the only solution - weight loss. And so eventually they build up the courage to go and see their GP and say, 'I want to try bariatric surgery.' And the GP says, 'Yeah, that's a great idea. But listen. The waiting lists are really long on the NHS. So be prepared. You've got to do this, and you've got to do this to even just get into it.' And by that point in time Cameron's like, 'No, no, no, I've made a decision now. I'm not waiting that long,' so they take out a loan. They fly to Turkey, and they get a gastric bypass. And they're dealing with all sorts of emotions around this - feeling like a failure, feeling really ashamed, but also really hoping that this is the thing that works, and anxious, and all that stuff. But they do it. They go to Turkey. They survive. Come back. It's not great to begin with. They've got pain. They've got a bit of nausea, they're having to adjust to these tiny portions. Life isn't great, but the weight just falls off. It just seems to melt away, and it's so sudden people begin to notice. People begin to treat Cameron better. They tell Cameron 'well done, keep going, do what you're doing.' All of a sudden, Cameron is feeling better about themselves, and feeling that they are able to fit into spaces they couldn't fit into before. Get on a bus now without having to worry about spilling over into the next seat. And 'I can sit on a bike without it being so uncomfortable. And I can buy clothes in shops that I never used to be able to buy clothes in.' So Cameron's beginning to feel a little bit better about life, is losing significant amounts of weight, and their acne seems to be clearing up. So the doctor was right. Except that didn't last. The weight loss was profound - they lost a good 30% of their body weight, possibly even more. It was dramatic. PCOS symptoms really didn't change all that much. And, interestingly enough, despite the fact that they looked dramatically different, they were still classed as 'obese,' because their BMI never got down below 30, which is not surprising, because even if you lose 30%, 40% of your body weight, which is a massive amount to lose, that doesn't necessarily mean that you'll go down to a 'normal weight.' So they did their surgery. It's done now, they're getting used to it. Life moves on. And then, after a few months, they were doing okay, and then they get this pain. And this pain is in the center of their abdomen, the top of their abdomen. It's a grumbly pain, comes and goes. When it comes, it's really very unpleasant. They think it's maybe indigestion, or possibly it's something to do with their surgery, or maybe they ate too much or whatever, but it keeps coming back. It keeps coming back. Sometimes they feel really sick with it. And they don't want to go and see their doctor because they're afraid of their doctor, but it gets to the point where they have one particular episode when it's so severe. They cannot do anything. They have to leave work, they go home. It's ripping pain. Painkillers over the counter aren't working, hot water bottle isn't working. They're clutching their gut, just feeling like they just can't possibly go on. And so they think 'I'm going to have to do it. I'm gonna have to bite the bullet, and I'm going to have to go to the doctor.' So they do. They go to the doctor. Urgent care refers them back to their GP. GP has a feel of their tummy, actually, which is surprising because oftentimes GPs don't even do that. Nothing much to find, says, 'Well, maybe it's just you ate too much, or you had a bit of trapped wind. I wouldn't worry too much about it. Give yourself time to adjust to your new digestive system,' says the GP. 'It's been 6 months, but give yourself more time, perhaps try not to eat so much, because you know, the whole point of surgery is you're not supposed to eat so much anymore.' Cameron's like, 'I assure you I'm not doing that.' The GP doesn't want to know. Second time round. It's not going away. It keeps happening. Goes back. GP says, 'Well, maybe it's a bit of reflux, you know, that's not surprising in somebody with your weight. So maybe we want to give you some medication.' So they prescribe a proton pump inhibitor. That doesn't work. It's getting worse. It's getting worse. One day it gets so bad that the people at work, Cameron's colleagues, are so concerned. They call a paramedic. That's how bad it gets. Cameron is pale, sweating, doubled over in pain. They're like, 'No, this is not something that we can just send you home with.' They call a paramedic. The paramedic arrives, takes them into hospital. Whole bunch of tests done. Blood tests are normal. Nothing much to see. 'You probably need a scan, but it's not urgent. So go back to your GP and ask your GP to order a scan.' So Cameron goes back to see the GP. And the GP says, 'Fine, I'll organize you a scan.' So they reluctantly request an ultrasound scan, and the ultrasound scan is done. Ultrasound scan of the abdomen shows, lo and behold! Surprise, surprise, multiple gallstones in the gallbladder. Oh, I wonder why that happened? Could it be that gallstones is a very common complication after rapid weight loss? It can affect up to 40% of bariatric surgery patients depending on what study you read - at least 10%. But it depends on the study. Why? Because rapid weight loss increases the level of cholesterol in your bile, and your bile is stored in the gallbladder. And when there's lots of cholesterol there, it can come together to form a stone. Gallstones in the gallbladder, especially if they kind of get stuck in the neck of the gallbladder, can cause tremendous pain. If it's just pain, we call it biliary colic. If it's pain plus inflammation of the gallbladder, that's cholecystitis, acute cholecystitis or chronic cholecystitis - inflammation of the gallbladder. But yeah, it's really common. It's not surprising. In fact, it's so common that you've got to wonder why the GP didn't think of it earlier on, because it's just such a common presentation. Gallstones are more common in people with ovaries, especially when there's an imbalance in the ovaries, so possibly the PCOS could have also increased their risk. Weight cycling can also increase your risk of gallstone formation. Gallstones can take a really long time to form, so they could have been forming since the first lot of weight cycling, the first loss of rapid weight loss followed by weight gain. So who knows? All we know is, there's gallstones in the gallbladder. It's causing severe pain. Cameron's been to urgent care. They've been admitted to hospital. Something needs to be done, doesn't it? Because there are risks of leaving it. If we leave it untreated, you could get an infection of the gallbladder, you can get pancreatitis, which is infection of the pancreas that's life threatening, can be fatal. You can get obstruction. A gallstone can get lodged in the bile duct, and that can cause jaundice and damage the liver. You could become very unwell, could develop an acute surgical abdomen, could end up in hospital - all sorts of things if left untreated. We can't just ignore it, can we? Apparently so. Apparently we can, because the GP says, 'Well, there's nothing much we can do about this. I can't refer you to a surgeon because of your BMI. Too high. Has to get under 35. Can't refer you otherwise. There's no point. Even if I send you to a surgeon, the surgeon's going to say there's nothing we can do. We can't do surgery. Your BMI is too high. So that's it. That is how it ends. Well, you know, we can always refer you for weight loss injections. Get your weight down, then refer you for gallstone surgery.' And so now Cameron is left with recurrent attacks of severe abdominal pain which they are forced to treat with over the counter painkillers, hot water bottles, etc. It's interfering with their life and their work. And they can't eat because it hurts when they eat. And they're just really freaking miserable. And beyond that, it's impacting work, that's causing financial stress. And don't forget they've taken out a loan to have this surgery. So they have to pay that loan back. There's the risk to their job because of all their absences. They're developing, unsurprisingly, depression, feeling very low at the moment, feeling really low because they're in pain all the time, and because even the weight loss surgery wasn't enough to get them the help that they needed when they needed it. Every time they visit a doctor, the medical trauma intensifies. Every episode just adds one more layer, another layer, another layer, and on the one hand, they feel really betrayed because weight loss was supposed to improve their health. That's what they were told, but, on the other hand, they continue to blame themselves because the message that they learned from a very early age and certainly over the last 10-15 years is when something goes wrong with your health, that's your fault. That's always your fault. You are to blame. When something goes right, we, the medical profession, can accept responsibility - feel free to praise us. But when something goes wrong, that's not us. That's you. That's a you problem. That's the message that Cameron has learned from a very early stage, and that is the message that Cameron continues repeating to themselves on a daily basis. 'Well, it's my fault. It's my fault I'm in this situation.' And it's impacting their entire life. As I said, financial stability and security. But also socially, it's impacting them socially, it's impacting them energetically. It's impacting their relationships. They are constantly living in fear that they're going to have another episode of colic. It is agonizingly painful. And so it's impacting their life - 'What if I do this? Is that what caused it? Or maybe that's because I ate that one thing. I'd better not have that.' And it's just all they think about now. Their life seems to revolve around their gallbladder. Cameron is desperate for help, but deeply distrustful - rightly so - of the medical system. They're looking into private healthcare, but they already have the financial strain of having private surgery which didn't help. So that's a struggle. They're feeling trapped in an impossible situation. They're thinking 'I'm going to have to do the Ozempic. I don't have any other choices.' They're angry, and they should be angry because it doesn't feel fair, and it doesn't feel right. They're beginning to regret their decision to have bariatric surgery. And this anger is fueling them to perhaps ask questions. Is this fair? Is this right? Why is this happening? Am I the only one this is happening to? And the answer to these questions is, No, it's not fair. No, it's not right. No, you're not the only one this is happening to. You are not alone. And if you're listening to this podcast and you're relating, I need you to know you're not alone. This is happening around the world. And it's really problematic.

I have a few things that I want to share with you. First of all, when it comes to gallstones, there is no evidence that being fat impacts the outcomes of a laparoscopic cholecystectomy. So lap coli is the standardized treatment for removing your gallbladder. Basically, it's keyhole surgery. Make 4 incisions. Inflate your abdomen with gas with CO2 and remove the gallbladder via keyhole. So you don't even have to make a large incision or anything. It's usually done as a day case. There is a study which I'm going to talk about later that demonstrates it's perfectly safe, no matter what your weight is. Doctors will say all sorts of things. 'Oh, yes, but you're more likely to need an open procedure, for the surgery to convert from a laparoscopic to an open cholecystectomy.' An open Coley is basically when they have to make an incision in the abdomen and remove the gallbladder literally from the abdomen as opposed to via keyhole. They'll threaten you with this. First of all, there are some studies that show this is the case in higher weight people. There are more studies that show it's not the case in higher weight people. So in one meta-analysis they found 19 studies altogether that compared BMIs, and 8 of them found that higher weight people were more likely to need to convert from a laparoscopic to an open procedure, and 11 of the studies show that they won't. So you do the maths. Second of all, the chances of having to convert to open are very low, it's between one and 2%. So even if being fat doubles your chance, it goes from one to 2% to 2 to 4%. It's not a very high chance. Furthermore, the impact is really twofold. Number one, it's a longer recovery period. Number two, it's more hassle for the surgeon. It means that you go from a day case to having to stay in hospital. It means they have to do a longer procedure. An average day case lap coli takes about half an hour roughly, but if you have to turn it into open, it's going to take much longer. That means their lunch break is going to be shortened. Possibly even won't get a lunch break. Nobody wants that, and if you get admitted into hospital, if you're in a nationalized health system like we are here in the UK, well, that's going to cost the NHS money. So there are lots of reasons why surgeons don't want you to go from a laparoscopic to an open cholecystectomy. But a Cochrane review, a big, thorough study into whether one was safer than the other actually showed there's no real difference in long term outcomes. People recover just fine. It takes longer to recover from an open cholecystectomy. But it's not the end of the world. You're not going to die. You're not more likely to die of complications or get serious complications as a result of it. So this big threat 'Oh, you're going to end up needing an open procedure' - well, that's probably not true. And even if it is true, chances of that happening are very low, and even if that is what happens, I'll be fine. I'll deal with it. I'll deal with the 5 week recovery rather than the 2 week recovery, 6 week recovery rather than 2 week recovery. I would rather it wasn't. But I'll deal with that if that's the route that I choose to go down. And, furthermore, not even referring somebody to speak to a surgeon is absolutely unacceptable. When did we get to this stage? It's really interesting. If you look at the history of this in the UK - and again, if you live outside the UK, I'm sorry this may not apply to you - but I was working in East and North Hertfordshire Trust in 2016, and you might be thinking 'So?' Well, it's really important, because in 2016 there were 3 trusts, hospital trusts. There's several hundred in the country, but out of the country there were 3 hospital trusts that refused to refer you to a surgeon if your BMI was over 30. You couldn't even be referred. The decision was made - now they'll never admit to it, but the decision was made for financial reasons only, and you know how I know that? Cause I was there. I was there when it happened. I was even part of the CCG, like the people who were making these decisions. I was even going to the meetings, so I know exactly why. They'll say it wasn't to do with money. It was everything to do with money, and mine was one of the only CCG - you don't need to worry about what that stands for. But basically it's like the Hospital Trust. Mine was one of the only ones that was doing it back in 2016. It's 2025, pretty much everyone's doing it now. You can't even be referred to a surgeon. And what's really interesting is that when it was happening, the Royal College of Surgeons was really quite upset about it, and wrote a paper about it, did lots of research into it, made a statement about it - how this was completely and utterly unethical. There is no evidence to suggest that losing weight prior to surgery, any surgery, is going to benefit you, and that is the case with gallstones. In fact, I would argue that the last thing you want to do is lose weight prior to surgery, because that's actually going to worsen your symptoms, especially rapid weight loss, because we know that causes gallstones. But also it doesn't matter what the surgery is. There's no evidence that losing weight prior to surgery is going to improve outcomes at all. Not at all. The only people it's going to benefit is, it's going to make the surgeon's life slightly easier. That's the only person who gets to benefit. And last time I checked we weren't in the business of making surgeons' lives easier. Surgeons were here to provide care for their patients, to do what is in their best interest, to make sure that they do not come to harm, either through their actions or their inactions, and to respect their patients' autonomy. When it comes to Cameron, Cameron needs their gallbladder removed, or at least Cameron needs a consultation to discuss having their gallbladder removed. That is in their best interest. By not referring Cameron to a surgeon, the doctor is putting Cameron at risk through their inaction, because if something were to happen - Cameron were to develop pancreatitis or cholecystitis or jaundice, or any of the complications of gallstones, or even just end up in an emergency room in pain, or even just suffer at home in silence - that is putting Cameron at risk, that is causing harm through inaction. Third, if the risks are higher, even if they are, autonomy means we respect a person's decision to do what they want to do with their own body. So if they want to take the additional risk, if they say, 'Okay, I hear you, it's going to double my risk of turning into an open procedure. It's going to triple my risk. I don't care. You give me the numbers. Tell me the numbers, and I will make a decision.' And one of the things I often talk about when people come to me - and this happens all the time - 'I've been told that I have to lose weight before surgery. I'm considering weight loss surgery.' And I say, 'Okay, have you weighed up the risks of weight loss surgery, and compared them to the additional risks of having the surgery that you need in the first place, at your weight?' Because let's just say a doctor says, 'Yeah, well, you know, it's going to increase your risk of infection.' Even if that's true - I'm not even going to ask if you've got the data - fine. What's the number? If the risk of infection is 2%, if that's the risk of infection, but if you're fat, the risk of infection is 4%, it's twice as much. But it's 2% right, like it's 4% in total. But the risks of gallstones from having bariatric surgery is up to 40%. Allow me to weigh those risks myself and make a decision for myself. That's called respecting autonomy, and when surgeons fail to do this, they are in breach of their duty of care, and it was very clear the Royal College of Surgeons made that very clear back in 2016. When we were messing around, the Royal College of Surgeons says you cannot do that. It is wrong. There's no evidence to show that it's beneficial to patients, and you can't deny patient surgery based purely on their BMI. In fact, at the time they urged health ministers and government officials to get involved in this, and said, 'You can't let this happen. They can't be allowed to do this,' but they are. The people making these decisions in the UK belong to the CCG, the clinical commissioning groups. That's what CCG stands for. It's made up of primarily GPs. As I said, I sat in on the meetings around that time. I was there. I was in the room when it happened. Unfortunately I wasn't smart enough or well spoken enough at the time to say, 'That's wrong.' I wish I could go back in time, but I can't. And there's the trauma of it all. You know the trauma of all of it, and if you go back through Cameron's history, the trauma started at the age of 15, probably before that, but certainly the medical trauma started when they were 15, where a teenager, a vulnerable teenager, who has a condition that probably existed since birth - nobody could blame anyone for a medical condition. But it just happened. All of a sudden, they're getting diagnosed with this condition, which is really impacting them because, hello! 'I've come to see you because I've got facial hair, and I've got hair on my chest, and I've got spots all over my face and back, and I'm feeling really shitty because I'm a 15 year old, and I'm getting teased all the time, and I came here for help, and your advice was, Don't get fat.' Not 'Oh, I'm really sorry to hear that you're going through that. I really want to help you. Here are your options. Let's discuss them. Let's validate you. Let's make you feel better about yourself. Let's educate you.' Because there's plenty of evidence to show that actually, sometimes education is what people need, so that they can make their own choices. Because they may choose not to have any treatment. They might say, 'You know what? Okay, I hear you. This is my condition. I'm not going to do anything about it,' but it's their choice. You don't get to choose for them. And so that's traumatic. Being called fat by your doctor as a teenager - that's traumatic. Weight stigma, knowing that you're constantly going to get treated like garbage by your doctor. Every time you go and see them they're going to bring up your weight. They're going to blame everything on your weight. They're not going to examine you. They're going to assume that your problem is down to your weight. They're going to dismiss you with weight loss advice. They're not going to help you. That is trauma. That is traumatic, because you don't have anywhere else to go, and you're sick and you're vulnerable, and they're in position of power and authority, and you are disempowered. You are asking, sometimes begging for help, and you're being rejected over and over again. 'No, you're not good enough. It's because you're fat. Fat people aren't entitled to care.' That's the message. Over and over again. You carry that in your body. You carry that in your body, and I know you do, because every time you go and sit in that waiting room, and you're waiting to see your doctor, you feel it in your body. You feel all kinds of ways about it, but you don't get to express that because you don't speak ill of the doctor. Don't doubt the doctor. Every time somebody says 'Oh, that doctor treated me bad because of my weight,' people are like, 'Oh, you're such a weak snowflake! Doctors should be allowed to speak the truth without having to worry about hurting your feelings.' It's nothing to do with hurting your feelings. Doctors aren't allowed to traumatize their patients, according to the duty of care principle in the UK. It's good medical care. But whatever contract you signed when you took this job, you are not allowed to harm your patients. It's an absolute no-no. So all of it, all of that trauma. You experience it in your relationships. You experience it socially, you experience it spiritually, even energetically. It has an impact on you, and I know Cameron is not a real person, but it breaks my heart to hear Cameron's story, because there are so many people out there who are in a similar situation and are probably listening right now, going, 'Yeah, that's a hard relate for me.' I am thinking more and more about what I can do to support people with this. We had our first coffee and catch up where we were talking about trauma, and people share their trauma. And in the waiting room on Tuesdays I have office hours, and people are coming to me and telling me what's going on with their own doctors, and I am genuinely horrified, and sometimes I'm terrified because I'm like, 'No, no, that's dangerous. No, no, actually, that's negligent. Oh, no, this is putting your life at risk.' So it's terrifying. And sometimes I'm just horrified. It's like seeing a car crash. It's so awful to hear the pain and the anguish and the horror of it. The horror! Knowing that it's my colleagues, my peers, who are doing this, and they're doing it over and over again during the day every day, and they're going to sleep at night, and they are not thinking about it. It is not impacting them in any way, shape or form. They don't know. Most of them don't even know, and if they do know they don't care. I just can't quite get my head around that. And I'm thinking more and more, what can I do to help people in this situation? As I said, watch this space. I didn't expect it to be a fun episode, but I feel like we need to take a breath. Don't despair. I have some advice coming later on in the ask me anything portion of this podcast. But before we do that, I want to do 'Everything you've been told about weight loss is a lie' - the portion of the podcast where I take a study and I say, 'Here you go. This proves everything that you've been told about weight loss is a lie.' In this one I am going to do one about gallstones. It's by Gregory et al. 'Day case laparoscopic cholecystectomy, safety and feasibility in obese patients.' Forget that word, apologies for that word. It's a very good article, apart from the stigmatizing language. So what did they do? Between November 2012 to October 2015, they took 730 patients listed for a day case laparoscopic cholecystectomy. 436 of them were not obese. 294 of them were obese. Let me just put them into the 2 categories. They followed them up, that simple. It's not a groundbreaking study, but it was quite interesting. Here's what they found. Number one, the overall rate of conversion to open cholecystectomy from a day case laparoscopic procedure to an open cholecystectomy was 1.6% - only 12 out of the 730, and there was no significant difference between the 2 groups, in other words, fat and not fat. So if you're going to convert, you're going to convert, and there was no difference. They did find that the American Society of Anesthesiologists score was higher in fat patients. That's not surprising, because if you're fat, you automatically have a higher grade - that's part of the grading system. So if you're in the fat group, I'm going to keep calling it fat rather than obese, because obese is a very offensive word. But if you're in the fat group, then you're going to automatically have a higher score. So they're just stating the obvious here. The overall post-operative complication rate was 8.3%. That was 61 out of the 730 patients. There was no significant difference among the groups, the 2 groups. It didn't matter whether you were fat or thin. There was no difference. It was very unusual to develop a complication. 4.2% of them developed early complications. So it was 8.3% in total, and half of them basically developed early complications and had to stay in overnight, and the remaining half developed later complications and were readmitted. So the chance of going - this is a day case procedure, right? You go in, you fast. You go in, they take out your gallbladder, you get up after your anesthetic, you make sure that you can drink and pee and eat, and then they're like, 'Get out.' So 60 patients ended up with complications. Half of them weren't allowed to get out. They had to go back, go into hospital overnight, and the other 30 patients went home, but had to come back in. So quite low risk, and only 1.6% - only 12 of them couldn't be done as a laparoscopy. The main reason why people were admitted was vomiting, pain, and/or not able to pass urine. I can't tell you why they were readmitted. I don't have the data. I don't think they gave the data, or I didn't put it down. But anyway, suffice it to say, what did we learn from this? It's a really safe procedure, a laparoscopic cholecystectomy. It takes about 30 min. It's done as a day case. Risks are low. A very, very small percentage of people ended up having to go from a laparoscopic procedure to an open procedure. 4% of people couldn't go home that day. 4% of people went home but had to go back into hospital at a later date. And the rest - that's 92% for those who do maths well - fine. So when they say, 'Oh, it's not safe or feasible in fat patients,' that's a load of bullshit, because it absolutely is. And I'm sick and tired of doctors lying about things that they have no business lying about. If you're interested in that piece of evidence or any evidence, because there's loads of evidence out there, I've got all my resources available free on the No Weigh website. If you go to No Weigh, go to patient resources, go to the section on gallstones. You can read all about it, and then you can see the references there for free. I'm starting to add my references because people are like, 'Why don't you provide your references?' Because it's a hassle referencing them. It takes time. But I asked AI to do it, and AI did a relatively good job. So I'll start doing that now to satisfy the critics. But yeah, it's all on there now. So if you want that, and if you want to actually learn and you don't want to have to read through the research yourself, which I don't blame you, then join my masterclass, because it's all there. It's a 45 min talk, and there are slides and everything. Speaking of slides, I got a question. It's again, I don't have it word for word, because it wasn't a written question, but it was basically somebody who was really struggling to get their GP to do something quite simple. They knew that they needed to do it, but the GP was just like, 'No,' and they don't know what to do, and they're like, 'What do I do in this situation where I go to my GP and ask for something, and my GP just goes, No. I'm stuck. I don't know what to do.' So I am going to show you what you need to do now, okay? And if you're on YouTube, and you're watching this, I'm going to share my screen, which I never do. But I'm going to do it today. And if you're not on YouTube, then you're just going to have to listen to me talking about it. First things first is, I want you to go over to Google. And I want you to Google. I want you to type in the search engine, CKS, and then the name of your condition, whatever it is. I put in gallstones. Now, if you live outside the UK, you may want to find the guidelines that are appropriate for your condition, but if you can't do that, then you can always use the UK based guidelines because they're not going to be that different from anyone else's guidelines. But if you live in the UK, this is exactly what you want to do, and if you type in CKS, I did gallstones, you'll see here a thing comes up. First thing that will come up if you type that in in the UK - I don't know what would happen if you lived outside the UK - but in the UK the first thing that will come up is NICE CKS. NICE stands for the National Institute of Clinical Excellence. CKS stands for clinical knowledge summaries. These are the guidelines that we GPs use. So I'm going to click on it. And when you click on it you'll see this big long - I mean, there's lots to it. There's something here on the left hand side that says 'Background information.' So if you're looking for background information, like definitions, risk factors, things like that, then you can go to that. It is written for doctors, not for laypeople, but I believe there is a summary at the bottom, which is a little bit better for reading, and there usually is. If we go down, there's usually somewhere a patient information leaflet as well. But there are better ways to access that. I want you to do this so that you can take this to your doctor, and you can say, 'Hey, dude, this is what you're supposed to be doing.' So what we do in this case is, we go to the management section, and it gives you several scenarios. Often in this case there are 2 scenarios, asymptomatic gallstones, or symptomatic gallstones. We click on symptomatic gallstones, and usually there will be a question that says, 'How do I manage a person with?' And then, whatever you're looking at. So in this case, symptomatic gall states, and then it tells you exactly what you should be doing. So what you can do is you can print this out or you can screenshot it, whatever you want to do. And it usually starts with just the basics. And then, as a basis for recommendation, and if you show that it tells you where that's coming from. You don't need to know that. There's usually a bit about what advice you should give to people, and there's usually a bit about what follow up you should give if it's appropriate. In the case of gallstones, the treatment is send to a surgeon, so surgeons are supposed to be doing the follow up, but in other ones, where you, the GP would be doing a follow up, there's usually a section there for follow up. All right. So you just go through that. And then what you can do is you can highlight or tick or circle around all the things they didn't do and are supposed to do, because chances are you're right. And the person who asked this question - I've stopped sharing now - the person who asked this question was like, 'I think this is what needs to happen.' I was like, 'Absolutely! It's what needs to happen. The fact that you're even doubting yourself makes me really angry because it's really obvious. Why isn't your GP doing it? I don't understand.' So all I did was, I went onto the CKS, I clicked it, and I just put circles around the things the GP is supposed to do. And I said, 'You go back to the GP and you hand them this piece of paper. You say you do this, you do this, you do this, the end.' Now, you might be thinking, 'Okay, Asher, but that's not going to work, or my GP won't see me,' or whatever. The next thing you want to do, if you want to escalate it, is you don't go back to the GP because the GP is being difficult. What you do is you contact the practice manager, and you say, 'I'd like to put in a formal complaint. I believe a significant event has occurred.' A significant event is a trigger word, sometimes called a significant untoward incident - very important in the NHS in the National Health Service, and I imagine that wherever you are in the world there will be a similar term that is used amongst doctors. And basically, what that says is, 'You missed something, and you put the patient in danger, and either something bad happened or something bad could have happened, but thankfully it didn't.' Either way, it's supposed to be a learning experience. Right? It's not a case of like we're going to punish you and make you pay compensation or anything like that. It's not like that. It's just 'You messed up and you need to learn from your mistake,' and sometimes it's like administrative errors. You know, a blood test didn't get addressed in time, because it was sitting in an inbox, and that doctor happened to be on sick leave or something, and no one caught the blood test, the abnormal blood test result, something like that. And so then we would do an analysis, we'd sit down and go, 'How did this happen? How can we stop it from happening again?' It can sometimes be a bit of a nightmare, but it's really important, because we need to stop these incidents from happening over and over again. Now, I wouldn't bring up weight stigma at this point in time. I would just say a significant event has happened, and in this case, 'I wasn't treated according to the guidelines, and as a result I was put at risk.' And what they'll do then is they'll take that very seriously, either as a complaint or a significant event. It's the doctor's job to decide whether it's a complaint or a significant event. But if you've raised the term, then it's going to get people to pay attention. You put down - you can do it by phone or in writing or face to face - you make it very clear all the things that got missed, and you've highlighted them, right? So it's very simple. You just list them. I would thoroughly recommend recording the conversation. So if it's a phone conversation or a face to face conversation, record it. You don't have to ask permission. You say 'I'm recording this for my own notes.' If it's in writing, it's in writing, and then you wait for them to get back to you. And when they get back to you and say, 'Yeah, you're right. We did not do what the NICE guidelines said we were supposed to do,' then the next question you want to ask them is, 'Why, and could it be because I'm fat? Would you have done it to a thin person?' And then what you're going to do is you're going to provide a ton of evidence that says that doctors will not examine their patients as often when they're fat. You can talk about the evidence about weight stigma. You can get that from my website, and you can say, 'Actually, I think it might have been because of weight stigma.' And they'll say, 'No, it wasn't.' And you'll say, 'Yeah, prove it. Prove it wasn't because of weight stigma.' And you might mention to them at the time, 'Don't you have a responsibility to demonstrate that you're not discriminating against your patients? Isn't there like a section of the appraisal process that focuses on this? Will you be discussing it at your next appraisal? How will you be demonstrating that you are not discriminating against your patients, based on weight,' etc. There are all these questions you can ask them. Make their lives miserable because they made your life miserable. You shouldn't have to be begging your GP to treat you correctly according to the guidelines. It's their job. You shouldn't have to be looking up guidelines. You shouldn't have to know what CKS looks like. Clinical knowledge summaries - it's not written for you. It's written for us. But if they're not doing what they're supposed to do, that's what you do - you Google it, you highlight it, you screenshot it or print it and highlight it. You take it to the doctor, if that's the easiest thing to do and say, 'This is what I expect you to do,' and you make them do it. And if you can't do that, you can go to the practice manager and put in a formal complaint. And if it's an ongoing issue, you talk, you use words like 'significant event, complaint, significant event, guidelines,' and then, and only then, you wait until they admit that they've made a mistake. And then you say, 'Why did you make that mistake? I believe it was because of weight stigma, and you have a duty of care to prove that it wasn't, or to demonstrate that you have at least considered that it might be due to weight stigma.' And that's their job, and they have to take it to their appraisal every year. Make them suffer. If you live in the UK and this is happening to you, make them suffer. And feel free to play this back to them as well. I don't care. I don't care if my colleagues are upset with me for telling, for giving you the secret sort of language that you need to use. I don't care. We've got to stop doing this. We can't do this anymore. We can't treat our patients like this. It's just not okay. You can't just ignore your duty of care to patients because you don't like them because they're fat. And with that I think I shall love you and leave you. Come back next week for a very special guest. I'm very super excited about - I'm not going to tell you what it's about. I'm going to leave it as a surprise. That's going to be really good. Thanks very much for listening as always, and have a good week."