The Fat Doctor Podcast

Why I Can't Move On: Staying Put When I Want to Run Away

• Dr Asher Larmie • Season 5 • Episode 23

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During my supposed break, I wrote a 45-page booklet called "Jenny Needs a New Knee, But She's Too Fat to Get One"—complete with 29 clinical references proving that denying joint replacements based on weight is medically unjustified and harmful. Coz that's what people do during their time off, right?

Instead of moving on to the next project like I always do, I'm trying something different and terrifying: staying put. In this vulnerable episode, I explore my lifelong pattern of pivoting when things get uncomfortable, the childhood trauma that drives my need to run, and why I'm fighting every instinct to abandon this work when fat patients desperately need advocates willing to stick around for the long haul. 

Check out the eBook Jenny Needs a New Knee, But She's Too Fat to Get One

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Hi, everyone. Welcome to episode 23 of the Fat Doctor Podcast, Season 5 of the Fat Doctor Podcast. I should say.

Well, took a few weeks off. When we last spoke, I had read an article in the paper all about how knee replacements, well, joint replacements I should say, were being denied to patients in the UK based on financial reasons alone, and I was shook. I couldn't believe it. This was brand new information, and for those who can't tell, because you're not watching me on YouTube or because you're not so good at picking up, that was sarcasm.

I was being sarcastic, because of course I knew that was the reason. And it makes me really mad. Makes me really super duper mad.

So yeah, there was that, and I took a few weeks off because I said I need some time off. I need a rest, needed a break. That's why I took a break, but I didn't rest.

And I think that sometimes happens. I don't know if it happens to you, but we say, all right, I'm going to give myself a bit of a break. Now I'm going to take some time off. I'm going to relax, and those can be some of the most productive moments in our life when all of a sudden a spark, for want of a better word, all of a sudden has room to breathe and is met with oxygen, and that little spark turns into a small flame, and then if you give it a chance it turns into a bigger flame and into a bigger flame. And for me, well, let me go back.

Prior to reading this article and talking to people about joint replacements, I had come into contact with quite a few patients recently who had a number of musculoskeletal problems, which is ironic because musculoskeletal medicine is like my least favorite part of medicine. Give me metabolic endocrine, give me cardio respiratory, give me gastroenterology, give me neurology. Give me anything but musculoskeletal. It stems all the way back to first year medical school anatomy class, having to learn all the names of all the bones and the ligaments and the vessels in the arm and in the hand. And honestly, I was like, no, I don't like this. I'm not enjoying this, and I've never really enjoyed musculoskeletal stuff. I've never really enjoyed orthopedics. I've never really been a massive fan of rheumatology. When I used to work in emergency medicine, my least favorite place to be was in minors where I'd be dealing with sprains and breaks, and people would be looking at X-rays, and I'd be looking at the X-ray with them going like, I have no idea what that looks like. So yeah, it's never been my thing. But ironically now I spend a lot of time with people who have back pain, knee pain, hip pain.

And that's not surprising, is it? Because back pain, knee pain, hip pain are almost always universally blamed on weight. And so it makes sense that a lot of the clients that I work with, a lot of the people that I come into contact with, a lot of the conversations that I'm having are about conditions that are traditionally blamed on weight. So I meet a lot of people who are in pain, constant pain.

And as someone who had a period of having constant shoulder pain, which really was nothing compared to some of the people that I've come into contact with. Like some of the people I've been talking to, their pain really is extraordinarily more painful than my pain, but even experiencing it on a much gentler level, I appreciate just how devastating chronic pain can be.

So I met a lot of people with chronic pain. A lot of people who have all these interactions with their doctor, and there were these questions that kept coming up. Why doesn't anyone care?

That's a very difficult question to answer, because I know that people do care, especially healthcare professionals. They don't care. They don't care that their patients are in pain. They just don't care. They're like, oh yeah, you're in pain. I don't care.

That's pretty bad, right? Especially because they're paid to care. That's their job. If you are a physiotherapist, a physical therapist, or an orthopedist, or a specialist nurse, or whatever it is, whatever your role is within a pain clinic or an orthopedic clinic or a musculoskeletal service, you are literally getting paid to care about pain. That's your job. And yet they don't care.

And the question is always like, why don't people care? And I don't have an answer for that. I have theories and they're not very nice. They're probably correct, but not very nice.

And then the question that comes after "why don't people care?" is often, "what do I have to do to get people to care? What do I have to do in order to get my doctor to care? What do I have to sacrifice? What do I have to put myself through? What level of mental gymnastics, performative bullshit do I have to go through in order to get my doctor to care?" And the obvious answer is to lose a shit ton of weight, get thin, which isn't possible.

So it's not possible to get thin. It's possible to lose weight, sure, but to get thin, chances of that are very slim. If you're a very fat person, the chances of you becoming a slim person are next to none. There is an actual number, because there was a study that was done that looked at what were the chances of somebody in their lifetime going from a BMI of over 40 to a BMI of under 25, and it was some stupidly low number.

But anyway, since that's not possible, what do I have to do to get my health professionals to care about me? I don't know, which is really annoying because I'm trying to help people, and I keep telling them that I can help them, and I will help them. I can do a lot of things, but I can't get doctors to care about their patients.

And it makes me really angry that I'm actually having this conversation with you. Why doctors should care about their patients, for fuck's sake. It is our job to care about our patients. What kind of fucking sociopath you have to be to listen to a person talking about how much pain they're in, and to not give one single shit. I don't know, but that is the case for most doctors. They don't care.

And so yeah, I've met a lot of people who are like, why don't people care? Why don't my doctors care? What do I have to do to get my doctors to care about me? And are also at a place where, and I suppose I always feel a little bit apprehensive about talking about this, but I think we need to talk about it. People who are just like, I don't want to be here anymore. If this is my life, if I'm going to be in this much pain for the rest of my life, and there is literally nobody out there that cares enough to do anything about it, I don't want to be here anymore. What's the point?

And I get it. I get it. And I'd had a few interactions with a few patients who were being denied joint replacement surgery that was essential for their life. Like they had become so disabled as a result of their severe arthritis, and they needed a joint replacement. It was clinically indicated. Everyone agreed. But they were just being told, no, you can't have one. You're too fat. You just can't have one, because it's risky, it's dangerous.

And so yeah, that was some context. So I read an article in the paper about how, and you have to go back to episode 21 or whatever it was, where I was talking about this, that we probably shouldn't be denying people joint replacement surgery like it was a revelation, like there was some groundbreaking breaking news. We probably shouldn't be denying fat people joint replacement surgery. It's not breaking, it's not news, but whatever.

And this was in the context of having these conversations with several clients and just people in my DMs.

And so I said I was going to give myself some time off. I said, okay June, I need time. I need a break. I'm tired. I don't know. I've run out of inspiration. I'm feeling a bit burnt out. It's time to take a break.

So I took some time off. But I didn't really rest. I wrote a book. It wasn't an actual book. It's not a book. I don't know what qualifies as a book. How many pages do you have to write in order for it to be a book? I like to think of it as a booklet.

I envision it. The way I see it in my mind is a booklet, one of those booklets you can get sometimes in the waiting room, a doctor's office, like an A5 paper that's been folded in half, stapled. It doesn't have to be fancy. It could just be regular paper, doesn't even have to be glossy. Glossy would be nice, though. I quite like the idea of having nice texture to it, but it's a booklet.

And the title of the booklet is "Jenny Needs a New Knee, But She's Too Fat to Get One," and this title has been in my brain for months and months and months. I just really like the title, because I thought it was funny. "Jenny Needs a New Knee, But She's Too Fat to Get One." It's very much the truth. It's just telling it like it is because she does need a new knee, but she's too fat to get one. I tell the story of a woman named Jenny, and the point of this booklet was that I wanted it to have lots of information in it. Lots of statistics and evidence, and I wanted there to be references, lots of clinical references, so that people would know that I wasn't cherry picking the evidence. I wasn't just talking out my arse, and I can cite my sources. I cited my sources. It ended up being 29, which is really problematic, that it was 29 and not 30. I almost wanted to go out and find a 30th just to put it in there, because 29 felt like a terrible number. But anyway, I did it. I left it at 29 references. 45 pages. And at the very center of this book is a person.

She's a made-up person. Her name is Jenny. I made her up. I got some pictures of Canada, and I made her up, turned her into a real person, a real patient experience at the very heart of this booklet. Every chapter in this booklet tells the story of Jenny and Jenny's experience of being told that it's all her fault that she's in pain, and really she'd do well to lose some weight, because that would fix her pain, which of course it didn't.

And then having to see a physiotherapist or a physical therapist depending on what you like to call them wherever you live, and that physiotherapist says, you lose weight to fix the pain. That's not true. And I talk about that, and then goes to see a specialist, an orthopedic specialist who says, you know what, Jenny, you actually need a new knee, but you're not going to get one because you're too fat, and then have to go through the whole being denied surgery, and then Jenny gets told that she should have bariatric surgery instead, because you can't have knee replacement surgery, but you can have bariatric surgery, and I spend some time demonstrating unequivocally how that is really, really bad advice. That's dangerous advice. For lots of reasons. Number one, it doesn't actually improve outcomes. Number two, it worsens clinical outcomes. People who have bariatric surgery prior to knee replacement surgery actually end up having way worse complication rates, readmission rates, all sorts of things, and I also talk about the risks of bariatric surgery versus the risks of knee replacement surgery. Knee replacement surgery, hip replacement surgery are relatively low risk. These are quite low risk procedures. Risks are quite low, so they talk about infection. The risk of infection is like one to two percent. So I present the facts here about how actually, there's no benefit to bariatric surgery. If anything, bariatric surgery is dangerous, and should never be recommended ever, but certainly in the case of people who need a knee replacement.

I even mentioned GLP-1s, so I tell the whole story of Jenny. Jenny goes through this journey, which is a very familiar journey to a lot of people, and I provide reference after reference after reference proving, I think, without a shadow of a doubt, that weight loss prior to joint replacement surgery is unnecessary and clinically harmful, and we just shouldn't do it. We should never do that. That's wrong. We should just give people joint replacements, no matter what they weigh. I think I did a pretty good job proving it. I think you'd be hard pressed to refute the evidence.

So yeah, I wrote this little booklet during my time off. And then I was really cross with myself, because I was like, Asher, you're supposed to be resting and relaxing. You did the opposite of resting and relaxing. And now you have to go back to work.

And I'm not going to lie to you. I really didn't want to. I was like, oh, July is coming. I said I'd be back. I don't want to be back. I don't want to do another podcast. I don't want to do this, that and the other. I don't want to meet all of my obligations. If I'm honest, that just felt like a real noose around my neck.

Didn't feel like fun, didn't feel like it was something to look forward to, which is a shame, because I was really enjoying this work, but I don't know. Something just didn't sit right. But when I thought about Jenny and her new knee, I did get excited a bit. It's complicated.

So I find myself in this situation right now where I don't know what to do. I hate when that happens. I love always knowing what I'm supposed to do. I just don't like not knowing.

When I think about all the people out there who are struggling to get joint replacements because of their weight, I think we really need to do something about that. We need to make a change, and as much as I enjoy helping people on a one-to-one level, being able to make that change, I also want to be able to help people, but I want to create more systemic change as well.

And there are very few people, if any people talking about this. And I just feel like there's potentially so much there.

And there might be people listening to this going, well, why knee replacements? Why not something else? Why not all surgery? Why not this and that? And I agree with you. But I feel like this is a really good place to start. I feel like it's a good place to start, because there's a lot of evidence, supportive evidence. In fact, a lot of the references that I came up with came out within the last three or four years, which is pretty impressive. There is a lot of evidence that we shouldn't be denying fat people knee replacements or joint replacements. There's less evidence for other conditions.

So it's a good place to start. But I think once we start picking at the holes and examining the lies that the medical profession are telling its patients in this area, I think that has the potential to impact all other areas. I think it has the potential to impact all surgical denials based on BMI and then potentially to open up a conversation about BMI in the first place, within medicine, and I know that we're already having this conversation, but not really. And the people who are having this conversation are perhaps the most dangerous people out there. So that would be the weight loss industry.

So there's this part of me that's like, there's so much potential here, potential energy. And there's a part of me that's really excited about that. And then I'd say that's maybe like a quarter of me is excited about that. And then three quarters of me is ready to shut it down. Okay, I wrote the book. It was just a thing I did during my time off. There it is out there. If people need it, they can use it. Let's move on, shall we?

And that's a thing that I do. And I went to therapy earlier today. I talked to my therapist about it. I was like, why do I do that? Why do I just move on to the next thing really quickly, like just come up with a new idea. Come up with a new something. Don't spend too much time here.

And I don't know that I got any answers at the end of this one therapy session, but I am beginning to realize that it is a pattern for me, and it's a pattern that I'd like to break, that I would really like to stay focused on one thing rather than move on to the next thing. Move on to the next thing. I've been moving on to the next thing my whole entire life.

Pivoting, if you will. Yeah, tried that, didn't work, or even if it did work a little bit, but didn't work the way I thought it was going to work or didn't have the outcome I was expecting, or even did have the outcome I was expecting, but that's still not good enough. I'll just pivot, and I'll move on to the next thing. That's what I do.

Staying, sticking around and trying to see something through, that's a lot harder for me. I don't know what it is. I don't know if it's the not knowing. It's the unknown. I don't know what to do now. All right, I've written this booklet. Now what?

And perhaps if I gave myself a chance, perhaps if I spent some time thinking about that, or brainstorming, or even better, asking for help. That's the next problem. I'm not very good at that. Not very good at asking for help. I'm surrounded by these brilliant people. I have this fantastic community. I'm so resourced. I'm so lucky I could just turn around to any number of people in my life and go, hey! What do you think I should do next? What would your suggestion be? And I'm sure they could come up with 10 different ideas each. I mean, I bet if I asked you the audience, hey, what do you think I should do with this little booklet? Have you read it? You've seen it? It's called "Jenny Needs a New Knee, But She's Too Fat to Get One." I've put a lot of stuff in it, and you can buy it if you want for a small fee, or you can just go on Instagram and on Instagram, I've been sharing quite a lot of the information that's in the book.

So what do you think I should do with that? How, if I wanted to really stick with it and help people to fight, what's the next step? What are the next five steps? What do I do? I don't know, but I'm sure there are people out there that know, but I don't feel like I can ask for help, and I don't like not knowing.

And I also think I'm one of these people that just wants things to just happen instantly. I want instant change. I knew logically that I could write this booklet and put it out there and like that wasn't going to do anything. I mean that wasn't going to do anything. But that's not enough. If I want to really see change, systemic change is going to take a lot more than just writing a booklet. But there was a small part of me that was expecting something miraculous to happen, and it didn't.

I'm not afraid of the hard work. I just, yeah. I've come, it's funny. Even in this podcast I've come to this point, this moment where I'm like, I don't know what to do next. I don't know what to say next. I don't have the answers. I don't even know what the fucking questions are, having the answers to them. And there are all these fears up here in my head like how and when, and why, and what, and all the other questions beginning with W.

It's scary, holding still when my body is telling me to run. Run away, run, pivot, move on! Do not stay here. This is a scary place for all sorts of reasons, most of which I'm sure date back to my childhood.

I was never really emotionally supported. I imagine most of you were in the same place, especially if we were raised during a time when our parents, if you're my age, were less concerned about our emotional needs. I was talking to my therapist about the day that I moved to university. I will never forget it because I didn't get the grades I needed to get into medical school. So I got my place at university through something we call clearing in the UK. So basically, if you don't get in, you can, there are scraps for university. And you can basically get into your second choice if you didn't get into your first choice university. If you don't get the grades to get into your first choice university, you can apply to get into another university, which I did. But as a result, I didn't have anywhere to stay. It was too late for me to apply for university accommodation, dorms.

So I had to find my own place, and I was going to a university in London. I had planned to move somewhere else in the country, but I ended up moving to London, and I lived in London, but did not want to stay at home. I needed to move out.

So I looked for a place, and when I say I needed to move out, my parents kicked me out. My parents told me in no uncertain terms I couldn't stay in the house any longer, that I needed to leave, so I had to look for a place to stay, and I ended up in what we call a bedsit, renting a room in a house in a place called Leytonstone, a lovely part of the East End of London. This was 1998. Leytonstone wasn't the safest part of London. Let's put it that way, and I wasn't living in the safest part of Leytonstone, and the house that I was living in, in terms of security and safety, let me put it this way. If I was taking my child to university and I pulled up at that house, I wouldn't be like, all right, bye, I'd be like holy shit, but my parents literally took my boxes, dumped them in my room and just walked out. They're like, bye.

And not see you in a couple of weeks. Not we'll call. We'll check in. Nothing. They're like, bye. Good luck. Off you left.

The irony is, they did come to visit me a couple of weeks later. But I just remember being in this room in this house sharing one bathroom with five people and a kitchen with five strangers, and it was dark, and it was late, and I was freaking terrified. And that is how I feel.

Well, I feel that feeling is so familiar to me. It's something I felt before that when I was younger, every time I was dropped off at a new school, or put in a situation that I was just unfamiliar with and just was really, really scared, but didn't, couldn't tell my parents I was scared because they weren't interested. They would have used that against me. They would not have been supportive. They would have been the opposite of supportive.

I was joking with my therapist that I sold 36 copies of "Jenny Needs a New Knee." I sold 36 copies, and when I realized that I sold 36 copies, 36 is just a number. I don't know what to make of that. Is that good? Is it bad? Is there such a thing as good or bad?

But I was joking with my therapist that if I told my mother, if she was still alive, and I said, oh, you know I sold 36 copies, my mother's response would have been, call me when you get to a thousand. Not a hundred, not 500, a thousand, some impossible number that it was not possible to achieve. That's what she'd say. Call me when you get to a thousand.

So I find myself in this situation kind of like September 1st, 1998, when I was dumped unceremoniously in a bedsit in Leytonstone at the age of 18. I find myself quite isolated or feeling isolated, feeling scared, not able to reach out, not able to ask for help, very much in the unknown. Not knowing what I was doing with myself.

I look back now as an autistic person, I realize just how terrifying that would have been, and how I would never do that to my own kids, but different generations, I guess.

Oh yeah, it's a familiar feeling. It's a familiar feeling that I find myself in today.

I wasn't going to bother with recording a podcast. I was just like, ugh. I'm done. I'm tired. I have nothing interesting to say. No one's going to want to listen to this.

And part of me still thinks that. I don't think I've said anything interesting. I'm not sure. I wonder if I'm going to lose a whole bunch of listeners. And that's okay. This is the reality I find myself in.

I'm not sure what's going to happen next. I do think I need to stay here in this place rather than moving on to the next thing. I think I need to stay here.

And there's a part of me that's like, oh, people are going to get so sick and tired of you talking about the same thing, and maybe that's true, and that's okay.

And there's a part of me that's saying, how are you going to make enough money this month to keep the lights on if you don't do this, that and the other, and maybe that's true. Maybe this month will really be the month that sends me into, I don't know how much further into debt you can send me, but there comes a point in time where, wow! We'll cross that bridge when we come to it.

But yeah, there are financial worries always at the back of my mind.

But yeah, I'm going to live with those too. There is a part of me that just thinks, who the fuck do you think you are? What makes you think you're the one that's going to come in here and try and fix this problem? Don't be so arrogant. Don't be so full of yourself. You're nothing. You're nobody.

I mean, that's true. I am just one person. Maybe that's true too. But I'm still going to do it.

There's a part of me that just wants to run away. That's a big part of me that just wants to run away. Move on to the next thing. I could totally write another book. I mean, it just requires a bit of research, and I could do another one for another condition, and then I could just put that out there and then I could do another one for another condition and put that out there. And I could just keep doing that. I could just keep doing that. And I'm not saying that's wrong.

But I just wonder what would happen if I didn't, if I just stopped with this one for a little bit longer. If I did keep talking about it. If I took the next step and the step after that, and the step after that, and I don't know what those steps are yet, so don't ask me. And oh, by the way, if you have any ideas, please tell me.

But I am open to all suggestions, to all feedback.

And if you are like, oh, I'm not quite, I'm not keen on this new turn. I'm not a big fan of this new version of the Fat Doctor podcast, totally understand. No need to let me know, though. That's fine. You just keep your opinions to yourself and just move on. But other than that, yeah, any and all feedback welcome.

Let's see what happens, hey?

I'm not going to do all the other stuff that I normally do with my podcast. I'm not going to force myself to follow a set of rules that I've given myself. This is how we do podcasts here at the Fat Doctor. No, I'm not going to do that. I'm going to do what I want to do. I'm going to sign off. It's probably not long enough. Doesn't matter.

I don't know what next week's going to be about. I don't know what the week after that's going to be about. I don't know if I'm going to do a masterclass this month. Probably not. Probably not. People, I've done lots of masterclasses. There's plenty to choose from.

I'm still writing my book. No way. But I don't know. Am I going to put that on hold for a bit? How am I going to work that out? I don't know. Haven't figured it out. Doesn't matter.

I will figure it out. I'll let you know.

Thank you to those of you who are supporting me, especially those of you who are supporting me financially. You're literally keeping me and my family fed, and for that I am grateful.

Thank you to those of you who are supporting me emotionally, who are doing what my parents never did, not leaving me alone in the bedsit in Leytonstone, instead saying, hey, we're here. What can we do, Asher? Or just here to distract you, or here to support you? Thank you to all of you doing that.

Yeah, let's see what next week brings, shall we? I'll see you then.