The Fat Doctor Podcast

Fat People Are Being Denied Surgery for Money (Say It Isn't So!)

• Dr Asher Larmie • Season 5 • Episode 22

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 A third of NHS areas are denying hip and knee replacements based on BMI alone—not for medical reasons, but purely to save money. In this episode, I expose how the medical establishment openly admits these discriminatory policies lack evidence while pushing profitable weight loss interventions instead. Meanwhile, actual surgeons and researchers confirm what we've known all along: this is financial discrimination masquerading as healthcare. 

Have you been denied a knee replacement because of your BMI? Get your free, customizable template here. 

The Newspaper article by Rebecca Thomas is "Obese patients denied knee and hip replacements to slash NHS costs"

The Journal Article is: Pavlovic, Natalie et al. “The effect of body mass index and preoperative weight loss in people with obesity on postoperative outcomes to 6 months following total hip or knee arthroplasty: a retrospective study.” Arthroplasty (London, England) vol. 5,1 48. 1 Oct. 2023 

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Episode 22, Season 5: Fat Doctor Podcast

Hi everyone and welcome to episode 22 of season 5 of Fat Doctor Podcast. Today I am going to be talking about an article that I read in the paper. It was printed on Saturday, the 31st of May, which is very recently.

It was written by Rebecca Thomas, Health correspondent for the Independent, which is a UK-based newspaper.

The title - Content Warning for stigmatising language. But you know I'm just reading, and it's not my fault - "Obese patients denied knee and hip replacements to slash NHS costs."

Don't say it isn't so.

Rebecca Thomas, for those who are interested, is a thin cis woman. That's not in her bio, but I'm just telling you. We looked at pictures of her, so thin cis woman. She's the Independent Health correspondent, a health journalist for 6 years. She has a particular focus on patient safety. In 2022 she won the Health and Science journalism award at the British media awards for her revelatory journalism. She's a revelatory journalist.

And this is a revelation. Of course none of us knew this until today. Fat people are being denied knee and hip replacements to slash NHS costs.

Underneath the title it says, "Former Health Minister, James Bethell calls on the Government to do more to tackle the obesity crisis and end 'misery for millions.'"

Not sure how I feel about that. I'm really not. My first question is, who the hell is James Bethell, and we'll get to that. So you can tell that there's going to be some stigmatizing issues with this newspaper article, as there always is, because you know already we're using terms like "obesity crisis." Because, you know, fat people are a crisis and we are miserable.

Okay, don't worry. There are some really good parts of this article. I wouldn't be reading it out. I mean, they publish hundreds of fatphobic articles in the Independent all the time. Why would I read any of them out? This one is quite important, I think, if you're able to pass through all of the crap. You know, sort of like pull away the layers of shit, which means you have to get your hands dirty, which I've done for you folks so you can stand back. Keep your hands by your side. Keep them nice and clean whilst I get my hands a bit grubby.

First things first, there is a paywall, because you know, like when you read the Independent, you can either pay them a subscription which I refuse to do, because if I pay a subscription, that means that my money will be helping to fund the salary of Rebecca Thomas health correspondent, and I have no interest in doing that. She doesn't get my money, so I have to choose the one that says that I will allow adverts, and then guess which advert is playing right now in the corner of my screen.

Guess which one. You'll never guess. You'll never guess. Oh, my God! You'll never guess. It's just you won't believe me. It's none other than Ozempic. Ozempic. There's this big spiel about how you know you can use Ozempic for weight loss, which is doubly insulting, because first of all, you know how I feel about Ozempic, and second of all, as a diabetic, I am entitled to an Ozempic prescription for my diabetes, but if you're diabetic in the UK, you can't get it.

You can't get it because of manufacturing problems. Manufacturing issues. There isn't enough. And all of the Ozempic in the UK is being sold privately for weight loss. So if you're a diabetic, you can't get it. But if you want weight loss and you pay privately, you can have it as being advertised as we speak.

I'll ignore it, shall I? And soldier on? Because, like I said, I'm here to pass through the shit so that you don't have to. The second thing I'll tell you is that you know right at the top there'll be like a hyperlink.

And it says "obese patients are being denied life-changing hip and knee replacements and left in pain in a bid to slash spiraling NHS costs." I was like, oh, there's a hyperlink here. Maybe it will take me to a study, or, you know, a press release or something. So I clicked on it, and when I clicked on it, it took me to an article from a few days ago which says, "Weight loss jabs sent through the post could help 15 million people and boost economic growth," according to Rebecca Whittaker.

I'm assuming another health correspondent for the Independent. Oh, my God, this post is actually paid for by Novo Nordisk, because it's quoting Sir Tony Blair's think tank. And Sir Tony Blair's think tank - Tony Blair, I have talked about him recently. I think in a podcast episode. Yes, when I was talking about the cost of obesity. Sir Tony Blair, war criminal, and his think tank is funded by Novo Nordisk. So there you go, anyway.

I just thought I'd point these things out just to give you a flavour of what to expect as you go into this article. So the headline news is that a third of NHS areas in England and some in Wales as well, are blocking patient access based on their body mass index.

And it's very clear that this move has been deemed unfair, discriminatory, and goes against guidance.

Oh, saying that out loud, are they? I mean, we've been saying this for ages, but it's nice to know that other people are saying it as well, and if you're wondering who's saying it, scroll down because all of the stuff in the article is just like, yeah, we already knew that. But if you scroll down you'll find a woman named Dr. Joanna McLaughlin. She is the lead researcher for the National Institute for Health and Care Research. So she's the lead researcher for, like, the Institute that is responsible for health and care research.

Quite an important role, if you ask me. She's also a clinical lecturer at the University of Bristol. So rather an accomplished person one could argue, and she's done a load of research and has been doing it actually for about 10 years. She's done a load of research on policymakers, commissioners, surgeons and says that they acknowledge that NHS financial pressures were a main driver for BMI threshold policy use, and that they didn't have confidence that the policies were based in evidence of health benefits.

So she's out here, this clinical lecturer and lead researcher at the NIHR. She's out here saying, you know it's financial. That's the reason it's financial. I've been saying it for ages. I'm so glad to hear another doctor saying it. It's financial, and they basically know there's no real evidence for this. It's just all about money.

That's impressive, isn't it? I was like, oh, Joanna, I need to get in touch with her and tell her how much I love her.

She also talks about the postcode lottery, because there's all different BMI limits depending on where you live. So you know, you might be lucky in some areas. And if you live down the road in a different postcode, that's tough. Zip code, postcode, same thing.

So that was Joanna McLaughlin. And then there was a chap called Tim Mitchell. He is the President of the Royal College of Surgeons of England.

Quite an important person. Not only is he a surgeon, he's the president of the Royal College of Surgeons. These are the people. This is the kind of regulatory body for all surgeons in the UK. So quite an important organization, and he said that whilst he agrees that losing weight before surgery could reduce the risk of complications - we'll get back to that, Tim, in a moment - he said that BMI alone should not be a barrier. "We must not penalize those who are less fit, but still eligible for surgery. As this approach is unfair and ignores clinical guidance."

So we've got Dr. Joanna McLaughlin. He's not called Dr. Tim Mitchell, because in the UK, if you're a surgeon, you revert back to Mr. That's actually a very important title. It's Mr. Tim Mitchell, but president of the Royal College of Surgeons. And then there's another surgeon, an orthopaedic surgeon at that, Mark.

It's either Bowditch or Balditch, I'm going to say Bowditch, who knows, apologies if I got your name wrong. I mispronounce your name, Mark, but he's the President of the British Orthopaedic Association.

So relatively relevant organization, British Orthopaedic Association, says, "Losing weight before surgery can be very difficult for people with limited mobility issues." Yeah, no shit. Thanks, Mark, for saying that, because it's so true. How do you expect me to lose weight when I can't move my knee or my hip?

The answer, of course, is the weight loss jab. But again we'll get to that. Furthermore, "obesity is more likely in people from certain socioeconomically deprived areas or ethnic groups, so care must be taken to avoid unintentionally disadvantaging certain patient groups."

So we've got, there's no evidence to support this, we've got it's financial reasons only, we've got this is discrimination and it's not acceptable. This is also, it's very difficult to lose weight before surgery if you've got limited mobility, we've got, hey, you know, we've got to be careful, because it seems like we are disadvantaging certain patient groups. Almost like Mark is saying that certain groups of the population are oppressed, and we should be taking care not to oppress them further.

Then we've got Deborah - again, I hope I said this right - Alsina, chief executive of the charity Versus Arthritis. This is the UK national charity for arthritis, and she says, "We hear heartbreaking stories from people desperate for the pain to stop, and accounts from people who face barriers to access even when they are referred for the surgery they urgently needed. We frequently hear of people denied a referral or being taken off the waiting list because of their weight with body mass index being cited as a rationale. We must make sure this discriminatory practice doesn't become standard."

I don't know what to tell you, Deborah. It's already become standard, not just in the UK, but worldwide. It has already been standard. It's been standard for a really long time. And, as I said in a previous podcast, I was there when it was becoming standard. I was part of the organization that was sort of creating one of the first organizations in fact that put BMI as a barrier to surgery, and I know that it was 10 years ago, over 10 years ago now, and it was done for financial reasons only, and it's taken 10 years. But people are now openly admitting it rather than pretending that there is a scientific rationale behind it. They're just openly admitting it's about money.

So I think they've made a really good case for why this is unacceptable practice. But of course our revelatory journalist, Rebecca - I forget her name already. Oh, Thomas, yeah, I think it's Rebecca Thomas. Go right back up to the top. Our revelatory journalist, Rebecca Thomas, has to give us both sides of the story, does she not? So she has chosen an absolute gem.

An absolute legend who features right beneath the title. Remember, Lord Bethell talks about the obesity crisis and misery for millions. Oh, he goes on, he's got so much more to say.

He says the NHS needs to make a choice over preventing disease with weight loss jabs which cost 100 pounds a month, or treat obesity-related disease, such as those that lead to hip operations which can cost 10,000 pounds, he said. "The government has a choice to either crack down on junk food Britain with a tough food strategy or give the NHS a lot more money to pay for the consequences of a sick population."

There's a lot there, James. I'm not going to lie. It's a lot, but something fishy is going on here. For example, he brought up weight loss jabs. It's odd that he did that like. Why weight loss jabs? We're talking about knee and hip operations. Why are you talking about weight loss jabs?

Who the hell is James Bethell? I asked myself. This chap apparently was a health secretary. I'm like, not during my tenure in the NHS. And that was over 20 years.

James Nicholas Bethell, the 5th Baron Bethell. According to Wikipedia, the 5th. He is a hereditary peer, British hereditary peer, and a Conservative politician in the House of Lords. For those of you who don't know what a Conservative hereditary peer is, he's a lord, because his daddy was lord, and his daddy before him was a lord, and his daddy before him was a lord, and his daddy before him was a lord, because he is the 5th Baron Bethell.

And he wasn't the Health Secretary, but he was Parliamentary Undersecretary of State for Innovation - never heard of that title before - for the Department of Health and Social Care during the Covid-19 pandemic, and I was like, hang on, something's ringing a bell here. Yes, he is one of the main people responsible for the shit storm, the disasters and the failures that I personally experienced as a healthcare professional during the covid-19 pandemic. Thanks to the Lord Bethells of the world, he really messed up over and over again. And you've got to ask yourself, Lord Bethell, what is it that qualifies you to talk about junk food Britain and hip operations and stuff like that? Maybe maybe he's a doctor in his spare time. You don't know. You don't know.

Shall we guess where Lord Bethell was educated? Do you want to have a little guess? I'll pause for a moment, and you shout out, Ready! Go!

Those of you who said Eton were wrong. It wasn't Eton, it was Harrow. It was the Harrow School. It's the same thing. And then he went on, unfortunately, to study for a Scottish Master of Arts at the University of Edinburgh. So he did head my way for a bit, which is a bit of a shame.

Edinburgh didn't know what it was doing at the time, that's all I can say. They weren't aware of what they were creating, and Bethell has worked as a journalist, and then my favourite, managed the Ministry of Sound Nightclub before founding Westbourne Communications, which he then sold after succeeding to his family titles. I imagine Daddy died.

And Lord James Nicholas Bethell, the 5th Baron Bethell got to be the lord he always wanted to be.

Yeah, yeah. What a tosser.

You just have to Google him and look at his picture. The term "dick cheese" comes to mind. I can't think of a better way to describe him than dick cheese, like he just looks like how dick cheese smells, you know, like that's what he looks like.

I've put that into your head now. You're all thinking about dick cheese. You don't like that. Yeah, well, I had to wade through the shit. You get to enjoy it from a safe distance, anyway. So Lord Bethell.

Former manager of the Ministry of Sound Nightclub, absolute expert. We've had a university professor, 2 surgeons, the CEO of a charity. And then we've got this guy, this guy, and he talks about junk food Britain, because, of course, everybody's fat because they eat too much junk food, and they all need knee replacements and hip replacements because they eat too much junk food. And don't you know thin people don't eat junk food, only fat people. And of course he's talking about the weight loss jab. And I was thinking to myself, Lord Bethell.

I feel like you showed your hand, your cards a bit too early. Why'd you bring that up? So I thought I'd do a little Google search. I wrote James Bethell, Novo Nordisk.

See what Google came up with. And right at the top was a LinkedIn post from 8 months ago. "Many thanks to the team at Novo Nordisk for a remarkable CEO summit," says James Bethell, as he goes on and on. See, he's working towards a healthy nation. Is James working towards a healthy nation? Again, why does the former manager of the Ministry of Sound Nightclub get to work towards a healthier? What the hell does he know about health? What the hell does he know about health? He knows nothing.

All he knows is how to be a lord, because his daddy was a lord, and his daddy before him was a lord, that's all he knows.

He's nothing, he's nobody. He is a Conservative hereditary peer in the House of Lords.

And yet Rebecca stuck his quote right beneath the title. She also ended the article. She gave him more airspace than anyone else.

Because he's important right, because what he has to say is important.

He's talking about the misery for millions, and he's talking about bankruptcy of our nation and at the end of the Starmer administration, bankruptcy of our nation.

Because fat people aren't getting their hip operations. Apparently that's going to bankrupt the nation.

Yeah, that's what's going to bankrupt the nation. Look, I don't imagine the NHS is going to be standing for much longer. I think most of us have been saying this for a long time, but it's getting to the point where it's not really a nationalised health service now. It's been privatised in many respects already. It's just been done behind our backs. Nobody's talking about it. But this is another thing. You see, what's happening is that NHS is paying hospitals to remove patients from their waiting list. Like, if you can get rid of this person on your waiting list, we'll give you a payment. And so anybody who's fat is automatically just getting kicked off the way, even if they've been waiting for a year for surgery. Tough shit, boom! You're off.

And they're getting paid. They're getting financially - there's a financial incentive to do this, even though it's not based on any evidence. And I quite literally mean it's not based on any evidence. And let's put James and Rebecca to one side, shall we? And let's look at the actual evidence. And here are some of the things that surgeons will say which are absolute lies. The first thing they'll say is, there's an increased risk of infection and implant failure.

If you're fat and you have a hip or knee operation, and so I had a look at the NICE guidance, and there's a little bit more for knees. It's slightly less for hips in terms of evidence. But the evidence is pretty overwhelming that the odds ratio for adverse events is pretty low. Pretty low.

And you know the odds ratio for - so you're 1.3 times more likely to have an adverse event after a hip op. So 1.3. So that's 30% more likely. But the risk of that happening is very low. It's like one to 2%. So like we go from 2% to 3% or something like that. It's really quite ridiculous. And that's based on NICE guidance that's based on like actual guidance. There's no question about this.

And also, of course the evidence is flimsy. There was only one study for hip replacements, one study in the whole entire world that was eligible, and it was deemed very low, very low quality, according to GRADE criteria. So it wasn't even a good study. Just one study. It had a very high risk of bias, but that's according to the National Institute of Care and Excellence.

For health care and excellence. Yeah, then, we have the next thing they say. So increased risk of serious infection, increased risk of implant failure.

Yeah, I mean, it's just a tiny little bit more, isn't it? I mean, it's not like, you know, your risk goes from 1% to 10% or something, because that would be nominal. So when they ask, and they say it was a seriously increased risk, you have to say, what is the risk exactly, and how much more increased is it?

And if they say they don't know, you say, well, yeah, there's a NICE document. You can absolutely tell me the risk, because it's documented by NICE since 2022.

The next thing they'll say is that there's a higher chance of instability or dislocation, post-surgery. And of course we don't want that. We don't want the hip to be unstable or whatever. So again, the risk is approximately 2% of dislocation, and that went up to just under 3% for people with a BMI of over 50 compared to those with a BMI of less than 50.

I mean, I feel like we're splitting hairs here, really, I mean, come on, it's not a significant risk, is it? And actually, that same study says that surgeon experience and high surgeon procedure volume decreases the risk of dislocation. That's the main key factor here. So you know, I suppose if surgeons haven't been practicing on fat people for the last 10 years, I mean, it's reasonable to assume that they've become de-skilled. It's up to them to upskill themselves. That's their responsibility, not yours.

"Greater risk of complications during and after surgery." Actually, there's plenty of evidence to show that's not the case. In fact, according to a meta-analysis, the results of this are quite mixed. So 3 studies show a detrimental effect on outcome if you had a BMI of over 30 and 8 studies showed no effect.

3 studies show there was an effect, and 8 studies showed there wasn't an effect. I'll say it again, 3 studies showed there was an effect, and 8 studies showed there wasn't an effect.

Interesting. Don't you think it's almost as if they're kind of over exaggerating a little bit and saying, "I can't possibly do that risk of risk of complications."

Well, you know, according to 3 studies. But then there were 8 studies that didn't say that.

Oh, chances of instability and dislocation! You mean the 2% chance that might happen, which, quite frankly, if you were good at your job, it's going to be less. Oh, serious risk of failure! Is it a risk of failure? Is it really like the 1% risk of failure?

Here's what I do know. And here's what the evidence is very, very clear. Studies have consistently shown that weight loss prior to surgery has no impact on post-operative complications or outcomes.

So whether you're fat or not, losing weight isn't going to make a damn bit of difference, and the studies are very clear on this.

Studies have also shown that the vast majority of people who attempt to lose weight in order to get their joint replacement are likely to fail. Less than 10% will succeed.

So if you have a financial reason to keep people off the waiting list, and you tell them you need to lose weight, you know that you're going to be successful 90% of the time. So that's, I mean, that's good odds, right?

We know, of course, that short term weight loss increases the risk of long-term weight gain. We also know that weight cycling has an impact on fat and lean mass distribution throughout the body. We also know that weight loss reduces skeletal muscle mass and can impact bone density.

We also know that bariatric surgery carries a lot of risks. So if a surgeon says you can't have hip surgery, which carries a very low risk, but you can have bariatric surgery instead, well, that carries a very high risk.

We know that reflux and gallstones occur in at least 10% of patients. We know that lifelong nutritional deficiencies are almost to be expected. Stenosis or gastrojejunal stenosis is common. Dumping syndrome which you may have heard of is common. We know that postprandial hypoglycemia is common after bariatric surgery. We know that ulceration in the GI tract happens in 15% of cases. We know that bowel obstruction is a risk, and we also know that death is a risk, and in some bariatric surgery, sometimes bariatric surgery, the risk of death is up to 1%, which is much, much higher than the risk of death from having hip replacement, which is much lower than 1%, much much lower. So

once again, you're telling me that I need to have surgery that has many more risks associated with it in order to have surgery that has less risks associated with it.

And they'll argue, well, there are benefits to having weight loss surgery? Sure. Okay, even if you argue that, are the benefits for my hip or my knee? No. So am I going to suddenly, miraculously recover from my severe osteoarthritis of the knee? No. So whether I choose to pursue those benefits is none of your business. If you're telling me, yeah, it will reduce your risk of heart disease. It won't. But even if you're telling me that, it's got nothing to do with my knee, thanks.

And of course, then there are these weight loss drugs that Lord Bethell is pushing.

Do you know that there is a study that came out recently that showed a 5 year analysis that showed that there was a greater risk of progression to hip and knee arthritis in fat people and not fat people taking GLP-1s.

Did you know there's a study that shows that it actually worsens arthritis?

It's 1 study, because obviously, these drugs have only been around for a few years. So to have a 5 year analysis is actually quite important. It was only licensed for weight loss in 2021. So to have a 5 year analysis is pretty impressive, but already we're sounding the alarms. Oh, hang on a minute! It actually looks like this could cause more damage than good, and that would make sense because people lose a lot of skeletal muscle.

And when you lose a lot of skeletal muscle during weight loss, and the studies on semaglutide have shown how much skeletal muscle people lose, because in the first trial they actually looked at fat mass versus lean mass. So we know that people lose a lot of lean mass when they go on Ozempic, and you just have to look at people with Ozempic face to see that, and as a result it seems to be worsening arthritis. I'm not surprised. Not a surprise there at all. So here we have a situation in which people are being denied basic care and basic human dignity, decency, pain relief, all of that stuff. Why?

Because of money.

And we're not doing anything about it. People are being left in chronic pain, with chronic disabilities that can be fixed. Simple op. Relatively simple op. Right? Relatively low risk. I've told you. I've read the risk so you can go look it up yourself if you want. Page 223 of the NICE guidance supplement. Or whatever one it is.

Like relatively low risk procedure. But we're not giving it to people because we don't want to, because we want to save money, because it's okay to punish fat people.

They're only fat people. We're at war. Fat is a crisis in our nation. We're at war with fat people so not relieving their pain seems pretty standard for warfare. Right? Seems about right.

The misery for millions is not because we're fat. It's because of the way that society treats us because we're fat.

We are not miserable because we're fat. We're miserable because you treat us badly. You deny us basic health care for money only, and it's all here in black and white. Written and ready for you to read. Don't check the comments, but if you do, you'll find that everyone is like more power to them. They should be denying fat people more things, punishing them more, punish them, make them suffer.

That's what people really think, isn't it?

And in case you think I'm cherry-picking the evidence, I'm not cherry-picking the evidence. Other people are saying it now. The President of the Royal College of Surgeons is saying it. Trust me, we're not mates. We're not friends on Facebook. I'm not on Facebook. That's why. Anyway, there is a study.

And we'll get to that section of the podcast. Everything you've been told about weight loss is a lie, and I think this is very apt. This study is called "The effect of body mass index and preoperative weight loss in people with obesity on post-operative outcomes to 6 months following total hip or knee arthroplasty: A retrospective study." Okay? Actually, if you break it down, this is a case of it does exactly what it says on the tin, the effect of BMI and preoperative weight loss, weight loss prior to surgery in fat people.

That's what we're looking at. The effects of being fat and weight loss on fat people 6 months after they've had a hip or knee replacement.

That's what this study's about. Right. That's exactly what we've been looking at.

And they took 2 independent data sets of people undergoing either a total knee replacement or a total hip replacement between January 2013, and June 2018, at 2 public hospitals. They took the samples and they grouped them into fat, not fat. They use different terms, but you know what I mean. And then they also took the fat people who did lose at least 5% of their baseline weight, and the people who didn't and compared them.

And they looked at basically what happened in those 6 months after surgery.

And they found, after adjusting for covariates, there was no difference in post-operative complication rates up to 6 months post-surgery according to BMI category. So it didn't matter whether you were fat or not fat. There was no difference in complications rates.

Or with preoperative weight loss. Made no difference whatsoever, absolutely none whatsoever.

Simple right?

So a reduction of at least 5% of weight, a reduction of at least 5% in pre-operative BMI was not associated with post-operative outcomes to 6 months following total knee or hip arthroplasty.

Didn't have any implication on outcomes whatsoever.

Okay, it's not the only study, it's just one of the studies. But I think I've made my point. And if you're listening to this podcast and you're like that's happening to me. Or it's happening to someone I know, they're being denied surgery. They have to lose weight. They've been told they have to go on weight loss drugs, or they have to have weight loss surgery, otherwise they won't be entitled to their surgery. Well, I'm about to put all of this in a document. It's free.

Feel free to download it, copy and paste it, stick it in a letter of complaint, because I'm so sick and tired of people being told they can't have surgery, even though everybody has made it clear that it is not okay. I'm tired of it.

So feel free to copy and paste. I will link it to the podcast. You just click on the show notes, and you just go straight to the document and just download the document and copy and paste to your heart's content.

I'm so so so sick and tired of it.

So we've got to the ask me anything portion of the podcast. And I'm a little bit... Oh, I'm gonna take a sip of water.

That's right, let me, because this one really got me, put me in the feels.

So as you know, ask me anything posted on the podcast is for you to ask me a question that you'd like me to answer on the podcast and usually people ask me questions about a health condition that they're struggling with, or an article that they read, or you know, something that their cousin said, or whatever, and they asked me for my advice. And so this question really threw me off.

Because the question was very simple. "How are you doing, Asher?"

That was the question. It wasn't like "Hi, Asher! How are you? Here's my question." The question was, "How are you doing, Asher?"

And I thought to myself, hmm! I don't know that I've ever been asked that before.

I have been asked that by the people I'm close to, my one-to-one clients will often inquire after me. My friends absolutely inquire after me. Members of my community ask me how I'm doing all the time, my family, my loved ones. I'm not saying no one's ever asked me how I'm doing. Don't get me wrong, but not in this context, not in this kind of like, oh, Asher's offering me something. But actually, I'm more interested in how he's doing.

So it kind of threw me off. And I was like, oh, I don't know if I'm going to answer that like, obviously, that's not appropriate for the podcast and I thought, well, hang on. Why not? Why isn't it appropriate for the podcast. And why don't people ask me how I'm doing?

So I thought, I'd answer, and I am gonna answer it. You know, I'm going to assume that the question was genuine, and I truly believe it was, and I'm not going to answer it as we in Britain do. "I'm fine. Thanks. How are you?" That's not how I'm going to answer it. I'm going to be real and honest. How am I doing?

[Here he pauses for a moment]

Honestly, it's not great. Actually, it's not been an easy couple of years, if I'm honest.

I mean, apart from the shit show that is the world around us, the genocide of hundreds of thousands of people around the world. One particular genocide that my family are actively complicit in is just somewhat problematic for me to digest. It's very problematic for me. So much so that I don't have any family anymore. I mean, I have a sister. But that's about it, because I'm not talking to the rest of them. Because we disagree about genocide, and that kind of, that was kind of that.

And also people are not being particularly kind to trans people at the moment. I mean, I know historically, people have always been so lovely to us. So this has come as quite a shock. But yeah, people aren't being great to trans people, or fat people, or queer people or autistic people. And that's a bit of a problem, because I'm all of those things. So that's not great.

And then, you know the medical profession is, it is really quite horrendous.

And it's the little things and the big things. I was thinking about it the other day. I don't know if I've ever told you this. When I left my previous job and I moved to Scotland, I had to move from the list of providers which was in Hertfordshire, where I used to work to the Scottish list of providers.

And in order to do that I needed a reference, and it wasn't a special reference. It wasn't like a glowing reference. It was just a tick box exercise to ensure that I wasn't committing fraud, essentially, that I am who I say I am, and that I don't have, you know, there haven't been any serious incidents or complaints, or anything like that, and of course I wasn't committing fraud. I am who I say I am, and there haven't been any serious incidents, or, you know, concerns or complaints. In fact, I had a spotless record at my previous practice. I had no problems.

During the Covid pandemic I stepped up, I worked countless hours for free. You know, pulling my weight just like everyone else. I even managed to co-opt my husband into helping run one of the Covid clinics, so you know I certainly deserved the reference, and even if they didn't like me, they still owed me a reference. And do you know what they did? My former partners, my colleagues, people who I thought I was friends with, they refused to give me one. Didn't give me a reason, she said. "No, I'm not doing it." That's the kind of shittiness I deal with on a regular basis within the medical profession. People who I've worked with for years refused to give me a reference just because they didn't want to, because they didn't like me, because they didn't like what I had to say. I'm guessing. I mean, it all started after I became the fat doctor, became outspoken and transitioned, so there could be many reasons why they chose not to give me a reference. You pick. We'll never know. A man who had a picture of a gun on his Instagram profile, who was openly racist and everything else -ist and really like had had 2 previous accounts shut down because of community guidelines, put in a complaint against me to the GMC. Claiming that I was anti-semitic. Me, the Jewish grandchild of a holocaust survivor was anti-semitic because of my pro-Palestinian stance, and the GMC investigated me for over a year. And when I finally asked them, why are you choosing to believe the words of a man? And I showed them his profile picture with the gun on his profile picture and the things he said. And I was like, why are you choosing to believe this man over me? A doctor with 20 years of exemplary, you know, it's gonna say service, but, like, you know, record. They never had to investigate me. No one's ever had to do any investigation on me. There's nothing, there's no skeletons in my closet. There were all these doctors doing some nefarious things out there, you know, embezzling from the practice, and like sleeping with their patients, and, you know, committing crimes and all sorts of things. Here's me, couple of tweets that an alt-right maniac - I shouldn't say maniac. It's a really stigmatizing word, but an alt-right piece of dick cheese wrote about me, and they chose to make my life a living hell, and it wasn't the first time they've done it either. That's what I'm dealing with. And so for me, the medical profession is not only is it like systemically hostile and dangerous and fatphobic and transphobic and racist and homophobic, and all of those things, but I have perhaps to kind of reconcile with that in my own life. No one stood up for me. Not a single colleague stood up for me. I have one doctor friend. Her name is Dr. Molly Moffat, in the UK. She was on the show earlier on in the season, and she's left general practice. So one doctor friend who's kept in touch and who has shown the smallest bit of regard for me, everyone else, not a single doctor out there. It's amazing. A few nice ones in the States. When I say a few like I'm talking 3 or 4 who have shown some kindness. But that's it. One to Nicaragua. Yeah, so not great. I've had people really, even within the kind of little corner of the Internet that we live in have treated me really badly and got away with it. There's 1 particular thin, cisgender dietician who has a really problematic stance on fat trans people. He wrote a book about fat trans people. It's small. It wasn't just about fat trans people, but it was a bit gross. Who's done some podcasts about fat trans people which were really disgusting. And who just had it in for me, you know. Just felt like the way forward in, you know, in this community is to tear me down. I don't even get why, what's the point? Why tear me down? How does that serve you? I don't get it. So yeah, it hasn't been fun. A lot of the people who you are friends with and who you support and who you follow, and, like all their posts, have been really shitty to me. I'm not naming names or anything. They've been really shitty to me. Shit-posted about me, you know, blocked me, some of them. I don't even know which is really bizarre. There's 1 person who, like had a massive go at me a few weeks ago, and I was like, "Who is this person, and why do they hate me so much?" Apparently they've hated me for years. I'm like, wow, okay, so I guess it can feel a bit lonely is what I'm trying to say. And I keep telling myself, don't complain, Asher. Don't complain. It could be worse. Just let them do whatever they want, you know, rise above it. Take the high road, all of that shit. But, I'm not going to do that today because someone genuinely asked me how I was doing, and no one's ever asked me that before. And I have the right to say, not great. Actually, people have been really shitty to me. I've not had anyone to defend me. I've not had anyone stand up and say, "Oi, you cut that shit out." I mean obviously again friends and family and loved ones who are there to support me. But nobody's publicly stood up for me. Can't, I can't remember the last time someone publicly stood up for me. Maybe they are, and I just don't know about it. So yeah, I've not been doing great. If I'm honest, I had no choice but to take a step back from medicine. As I said, I couldn't even get a reference. But who would want to work in such a hostile environment. I certainly don't. And so I've had to pivot. And I hope that I'm able to make enough money, you know, through doing the work that I'm doing, and that hasn't happened every month, and there have been months where we just haven't had any money at all. And months when things went terribly wrong, but I've kept going. I've persevered because I believe very much in the work that I'm doing, and I enjoy the work that I'm doing, and I have hope that it will get better. Just kind of the story of my life. Really. Just hope it's going to get better. And I say all this because actually, even though things haven't been great in many respects, this is also one of the best times of my life. In fact, I would argue, it is the best time of my life. I have never felt more safe. Secure in myself. I have never felt more authentically me. I have never felt more calm and centered. I have never felt more in touch with my thoughts and emotions. I have been challenging a lot of the narratives that I learned, a lot of the stories that I've been telling myself all my life. I've been challenging them. I've been reframing them. I've been deconstructing. I've been learning. I've been growing. I've been thriving. And yeah, I have to say. I'm probably doing better than I've ever done. I have some health problems, physical health problems. But my mental health has never been better. In spite of all of the shit that keeps coming my way. Maybe because of all of the shit that keeps coming my way. There's 2 ways to look at that, isn't there? It's tough. It's really hard sometimes. I don't know about you, but I kind of, I look around me and I'm just like, I don't know what to be enraged about at any 1 point, because there's just too many things to be enraged about. And sometimes I wonder, like, am I doing the right thing, you know, like, here I am like worrying about BMI limits in knee and hip replacements like there are people starving or people dying. And then I remind myself that everybody has a role to play. And this is my role, and I will do whatever I can to support those who are helping those who are starving and who are playing that role. But that's not my role. And so I have to continue doing the role that I've been charged with. And it's a good one. I enjoy what I'm doing. I'm happy with what I'm doing, and I am very excited about the things that are on the horizon. There's a book that will be coming out like I am 3 quarters of the way through this book. Now, through the first draft of this book there are all these courses that are available, I'm starting a new course on medical trauma, which is going to be fantastic. Yeah, I'm working one to one with some fantastic clients. I'm so lucky. I love this podcast and I love all of it. Really, I could do without the social media. But whatever, nothing's ever perfect. So, anyway, thank you very much, dear listener, for asking me how I'm doing. I am very grateful to you, as you well know, because I kind of basically wept over my email back to you. You know who you are. But yeah, it's pride month folks. And you know, I'm not sure how I feel about that. What I do know is that I need a break. So I'm taking one. I'm just giving myself the month of June off. So this is the last you're going to be hearing from me until July. That's it. I made a decision. I'm my own boss, and that's great. I just take some time off. But no, I'm serious. It's been 6 months, and I'm you know, I'm running out of inspiration. And when you start running out of inspiration. It's just time to take a break. Put your feet up. No more emails. You won't be hearing from me. There are still things that will keep going like Weight Inclusive Wednesday is still on, and Coffee and Catch Up still be on, and you'll get a masterclass if you're a member of the masterclass membership. You'll still get your masterclass if you're a member of No Weigh. We're on Module 8, which is all about weight cycling that's coming up. So don't worry about any of that that's still on. But no more podcasts, no more emails, no more probably no more social media for a few weeks. Just give myself a bit of a break. And then I'll come back fresh and energized and rejuvenated in July. Thank you so much for listening. Keep your questions coming. And yeah, see you for episode 23 and the beginning of July. Take care, everyone.