When Healthcare Becomes Compliance Theater

Healthcare's approach to diabetes has become less about treating a disease and more about fixing the person. In this episode, I walk through Cosmo's fictional-but-familiar journey from diagnosis through multiple medications to a specialist referral that came with a homework assignment. When we receive forms asking us to set goals, rate our confidence, and think about what our blood sugar levels "mean to us" before we've even met a clinician, we're being set up to fail. I examine how medical professionals have shifted responsibility for treatment outcomes onto patients, turning a manageable chronic condition into a moral failure requiring correction—and why this approach drives people away from the care they desperately need. 

If you're dreading your next diabetic review, my online course gives you everything the diabetes clinic should have given you: understanding, empowerment, and practical tools—without the shame. 

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Chapters

• 0:41 Introducing Cosmo
• 7:34 Cosmo's Journey Through Diabetes Medications
• 17:52 The Diabetes Care Planning Form
• 28:47 The Real Problems With How We Treat Diabetes
• 43:08 Why Cosmo Never Went to That Appointment

Transcript

Hello, and welcome to episode 37 of season 5 of the Fat Doctor Podcast. We're well into November, heading towards the end of November. That means there's one month left, just over a month left, till the end of the year. And what a year it's been!

I cannot believe we're getting to the end of Season 5. We've got one month left of the podcast, and then I'm gonna take a one-week break, then come back in 2026 with Season 6 of the Fat Doctor podcast. But let's not get too far ahead of ourselves, because today I've got quite a treat for you.

I'm gonna be sharing Cosmo's story. And as I said last week, Cosmo was a name that came to me in a flash of brilliance, and now I'm quite obsessed with the name Cosmo. That feels like such a non-binary sort of name. It just feels good to me. I'm almost tempted to maybe make it a middle name. Like Asher Cosmo Larmie, I don't know.

Anyway, for those who are not familiar with this style of episode of Fat Doctor Podcast, once every three weeks, I'm autistic, so I do things in a very predictable, very measured way. So once every three weeks at the moment, on the Fat Doctor podcast, I come up with a fictional character, one I've completely made up. This has absolutely no bearing in real life, and when you hear this story, it's not me that I'm talking about.

I assure you it's not at all me. It's a little bit me. I'm not gonna lie, but it's not. I want Cosmo to be a fictional character. I want Cosmo to be whoever you want Cosmo to be. I want you to be able to imagine them however you want to imagine them. That's why I always give them a weird and wonderful gender-neutral name. I always give them they/them pronouns, not because I've got a trans agenda, although I do like the idea of having a trans agenda, but just because I'm trying to make things just neutral. Why should my fictional characters have genders?

So Cosmo. Let's get into it.

Cosmo's 46. I'm 45, so see? We are not the same. Cosmo is diabetic, type 2 diabetes. Now, that might possibly be similar to me. Has a strong family history of diabetes. So diabetes was inevitable. Mother had it. Aunt. Grandfather had it. They showed signs of it at an early age. It was inevitable.

It was inevitable. And yet, when Cosmo was diagnosed with diabetes a few years ago, the shame of it all. The shame. The blame. It's my fault, I did it, I brought it upon myself, you know, it was all because of my weight, and because I just ate too much sugar, and had no self-control, and was lazy and, you know, less self-discipline, and all of those moral judgments that we associate with both fatness and with diabetes. It's interesting, actually, the Venn diagram when it comes to weight stigma and diabetes stigma, it is a circle for the most part. It's just a circle. It's not separate at all. Unless you're a thin diabetic, and there's a separate category for you. I actually started hearing healthcare professionals talk about, quote-unquote, lean diabetes. Like it's a separate diabetes.

It's not a separate diabetes, it's just that they look different and are treated differently, but it is exactly the same kind of diabetes. It works in the exact same kind of way. I'm not going down that little spiral there. You could see it was very easy to go, but I'm not going there. I've written notes. I'm staying on topic! So Cosmo, strong family history. Inevitable diabetes diagnosis, but filled with shame, and all the other stuff.

And then they started on metformin, and began to shit the bed, literally. Not quite, but you know what I mean. It's not pleasant. Those who've been on metformin understand. Those who haven't will never know. And I hope you never do. It's not fun. You go on metformin, and then when you shit the bed, inevitably, then they go, oh, okay, fine, we'll put you on the slow-release one. Like, why didn't you just put me on the slow release one if you knew I was gonna shit the bed? Why did you wait for me to shit the bed before you put me on the slow release? Like, that's just sucky behaviour, but that's what they do. That's what we do! I don't know. That's what the protocol says, so we do it. Maybe there's a reason, I don't think there is, but whatever. Now, moving on to slow release.

Did nothing for their HbA1C. And then they were started on dapagliflozin, Forxiga, for those of you who are in the know. That makes you piss yourself! So now you're shitting the bed and pissing yourself. It's delightful! Glorious! It makes you wee, basically. You wee out sugar, and the sugar draws out water, and so you're basically peeing all the time. So now, metformin, the Forxiga, 6 months later, HbA1c still not coming down. The high numbers. Still in the red zone.

It's alright, Cosmo. We'll add a third drug in. You know what I'm gonna say now, don't you? What I'm gonna start you on, it's obvious. Surprisingly didn't get it before. It's to do with cost, because Cosmo is British in the NHS. If Cosmo lived somewhere else where the cost was less relevant, then they would have been put on it earlier on. But you know what it is, don't you? You know what I'm gonna say. Ozempic.

Cosmo's put on Ozempic. Injection once a week. And to be fair to Ozempic, it's not that big of a deal. Injection once a week, that's quite nice, you don't have to remember a tablet every day. And there are side effects. There are, but there are side effects with all the drugs, and you start off slow, so not the end of the world, but it's pretty miserable. If we're honest.

You thought metformin was bad. You were like, oh, I handled metformin, I can handle this. They are not the same. So pretty much intolerable, the Ozempic. Couldn't last, couldn't make it.

Come off the Ozempic, mate. There's nothing we can do about it. If you can't tolerate it, if you're vomiting all the time, there's nothing we can do about it. So Cosmo stops the Ozempic. Switched over to Sitagliptin, Januvia. Which doesn't work.

But put on it anyway. 6 months later, HbA1C, yeah, still high! Still not working. Crap.

That's three medications Cosmo's on now. One makes them shit the bed, one makes them piss themselves. One medication was just so bad, they had to stop it, and now a drug that doesn't work. Alright, so what's next? What's next, Doc? It's not a doc, it's the UK. It's a nurse. A lovely nurse. We'll make her lovely.

I used to work at one of the practices where I really learned a lot about diabetes. Most of what I learned about diabetes as a GP, I learn from nurses, because they are experts in the UK. But there's this amazing nurse, her name was Marie. I absolutely loved Marie. She was Scottish. I was living in England at the time, and she was a lovely Scottish nurse, she was so lovely. Really, really thin, and really, really pretty. And one of the least judgmental people I'd ever met in my life. And I remember once telling her how scared I was of a diabetes diagnosis, and she was like, oh, hey. And I'm like, well, you know, I don't want to get diabetes. And she was just like, oh, of all the, you know, all the conditions you're worried about, don't worry about diabetes. She's like, so easy to treat. So easy to treat. She said, we start you on metformin, and if that doesn't work, we'll add in Gliclazide.

Because in those days, that was our second-line drug. The sulfonylureas, that's the term for this kind of group of drugs, gliclazide, glipizide, all of those ones. They were drugs that we used for quite some time, they have their side effects, and they've definitely fallen out of favor. One of the side effects is they can make you hypoglycemic, which, in Cosmo's case, Cosmo's blood sugar is really, really high. We're not so worried about it going so low that they have hypos, but still, you know, you have to do finger prick tests, measure blood sugar all the time. It's a bit of faff, is gliclazide, but that's not the reason we don't use it anymore.

That's the reason we pretend not to use it anymore. And, you know, there are certain groups of people, frail people, older people, that perhaps we shouldn't be using them on, but for fairly robust 46-year-old Cosmo. Not a problem. Absolutely well-tolerated. Fairly, you know, in a generally well person, fairly well tolerated, fairly few side effects, actually. Fewer side effects than most of the drugs. Why do we not like sulfonylureas?

What's the real reason, medical professionals out there, who know the answer? Because we know the answer. The answer is because it makes you gain weight.

It causes weight gain as a side effect.

So does insulin. The two drugs we do not give diabetic patients, unless it's essential, because it causes weight gain.

Sulfonylureas are cheap. They are effective. And as my friend, Nurse Marie, used to say, it works really, really well.

But that's the, what, the fifth drug that Cosmo's offered?

And it works! Actually, this one works better than most of the other drugs. I'm gonna say that Cosmo's numbers are coming down, but they're not coming down fast enough. And so, and this is what I really wanted to share with you today, folks. This has nothing to do with my story whatsoever, I promise you, except for it does. Cosmo is invited, or referred, I should say, not invited, there was no invite. Not an invite, it was told. You have to go and see the specialist diabetes clinic now. Like, you are too much for us to handle right here in the community diabetic clinic. Too much, you need to step it up. Step up your care, go see a professional. Now, look, if you live in the US, and you get diagnosed with diabetes, I imagine that, you know, maybe some of you are being looked after by your practice nurse or, you know, a physician's associate or something. Maybe you're looked after by your general practitioner, your family practitioner, but a lot of you will have been referred up to a diabetes endocrinologist, somebody, you know. In the UK, not so much.

The vast majority of type 2 diabetics never see an endocrinologist. Type 1, of course, but not type 2. So, you're looked after in general practice, for the most part, and then there is a community specialist diabetic clinic for those bad diabetics.

So Cosmo is invited, referred, to attend, and gets a letter in the post. And amongst the paperwork is the Diabetes Care Planning Results Letter.

And on the front, it's printed out on paper, grey paper, it's the NHS. And I'm trying to guess what font it is. It's the NHS font, whatever that font is. And it's got details filled in, some bits written down. Before your appointment, take time to make a note of anything you would like to discuss at the appointment. That's very sensible. Nice. I approve. Gets the Asher Seal of approval. Look over your results on page 2 to 3, and think about what they mean to you. Sorry, I didn't mean to laugh. I shouldn't have. We do that good. And think about what they mean to you.

No. I'm a doctor, so I look at the results on page 2, and I know exactly what they mean, because I know what the figures mean. But if you're not a doctor, what you see is just a whole bunch of results that, you know, like cholesterol, EGFR, just words that you just like, okay, you've heard of cholesterol. EGFR, urine ACR, LDL to HDL ratio, creatinine. The only one you recognize is HbA1c. A1C, HbA1C, you've heard of that one, you know what that one is, but all the others, you're looking at like... And they've been kind enough to at least tell you that this one's kidney, this one's cholesterol, and this one here is, you know, they at least separated them out, so you have some idea of what they mean. And then, what they did, which was really nice of them, was they used the traffic light system to tell you whether you're green in the good range. Whether you're amber in the, oh shit, you need to panic range, or if you're red and you're in the high-risk range.

So it's low risk, increased risk, and high risk. And there's just a whole bunch of numbers, so you have to look at your results and think about what they mean to you. It's like...

The thing... the reason I'm laughing is I do say that, or I used to say that to my young children, I don't say to my children anymore, they're teenagers, but when they were really young. I want you to sit in the corner, and I want you to think about what that means. I want you to think about what, you know, what that means to you.

Just think about it. It feels like I'm being told off. I don't know, maybe I'm just projecting. And then the last thing is think about any goals you want to achieve, and how you might achieve them.

And please bring this to your appointment so we can use it to help decide how you want to manage your diabetes.

So then, there is here are some of the things which people ask about, circle any which are most relevant to you. I'm just reading this. So, medical checkups. Taking medication, avoiding sugary foods, monitoring glucose levels, healthier eating, pregnancy and conception, driving, employment work issues, your mood. Hypoglycemia, or low glucose level, giving up smoking, alcohol within limits, foot care, regular physical activity, sexual health.

What a mishmash. What a combination. And in my mind, as an autistic person, not in any order. You just... They were just spitballing, right? They were brainstorming, and then they just put them all down. Someone just wrote, what might diabetics want to talk about? I just wrote them all down, randomly, in no apparent order, and just threw them on there. And was that intentional? Was it to get you thinking outside the box, I don't know... I don't know, but then, also, they want you to circle, but they didn't give you any room for circling, so that just also upsets me. You'd have to underline or highlight, there's no room for circling here. Oh gosh. I'm just... I'm overwhelmed by this. All of these things are relevant, by the way, if you're a diabetic.

But some of them... Some of them are things that I think are really important conversations, like, how's your mood? Because depression is very common in diabetes, and so they actually have a screening question for diabetes... for depression. Just the next one. They screen for depression every time. I don't know if you know this, but every time you have a diabetic appointment, you're being screened. Poor Cosmo doesn't even realize they're being screened for depression. But, you know, your mood, you know, employment and work issues, driving, I'm not sure why, but sure. Monitoring, you know, glucose levels. Like, there's some medical checkups, there's some really good, important conversations. And then they've mixed it in with some, I don't know...

It's like moral signposting, maybe? It's mixed in, that's what's confusing me. Like, you've put my mood, and you've put medical checkups, and you've put employment and work issues in the same breath, in the same sentence, as avoiding sugary foods.

Which, by the way, is a bit of a myth. Diabetics should be avoiding sugary foods. Should we? Is that true? The more we try to avoid foods, the more we want to eat them. So I'm not sure that that's entirely true. I'm also not sure that diabetics can't eat sugary foods. I'm not sure that the science really backs that up, but okay. This is... you can tell this is quite basic.

Basic amount of thought that's gone into this. It wasn't... it wasn't... nobody took too much time. You know, there's healthier eating, physical activity, and then things like sexual health, really important. We don't talk about that enough. Really great that they're mentioning it, but it's right under regular physical activity, so I'm not sure what to make of that, you know?

Foot care, regular physical activity, sexual health. You gotta wonder when they were brainstorming, and someone went foot care, and then somebody else pinged off that and went, physical activity, and then someone else was like, feet, sexual health, you know? Like, is that what happened? I don't know. In my mind, that's what happened. Anyway, this is... we said page one, then we're page 2 with the results.

Actually, Page 3 is the one that I take the most umbrage with.

There's little sections now for you to write in. What do you want to work on?

This is the bit that really gets Cosmo.

Cosmo, what do you want to work on? What do you want to achieve?

And then... is this the really... the bit that really gets my goat... How important is it for you? And it's on a sliding scale of 1 to 10. 1 is not important, 10 is important.

How are you supposed to answer that question? Then there's an action plan.

What exactly are you GOING to do?

That's scary!

First of all, you have to be thinking about what it means to you. Then you have to answer, what are you working on? What do you want to work on? What do you want to achieve? And then, what exactly are you going to do?

What might stop you? And what can you do about it?

This... I feel like we've... somebody, somewhere, did a course, probably a free one, online, about coaching, you know?

And they helped write this. There was definitely a coach involved, or, you know, a wannabe coach, like an amateur coach there. What might stop you, what can you do about it? And then, how confident do you feel where one is not confident and 10 is confident?

And then right at the bottom, there's a little sign that says Medication Changes, a little box for medication changes.

Again, we went from coaching to medication changes. Do you see how confusing this is? Poor Cosmo.

Poor, poor Cosmo.

So... Let me tell you some of the issues I have. I don't know if people listening to this may have had something similar. It might not be about diabetes, it might be about something else, you know, maybe it was cholesterol, blood pressure, it could be about all sorts of things. Arthritis, all sorts of things. It's something that I'm noticing is happening more and more and more within the medical profession.

And here, I'm trying to... I was trying... I was looking at this, flabbergasted and upset and angry and all sorts of information, and I just... Wanna put out there.

That, the staff in the clinics that hand out these pieces of paper don't always agree with those pieces of paper. And also sometimes quite relieved when you don't bring those pieces of paper with you. Not all of them, some of them. Some people are assholes, some of them are really lovely, and some of them know this is bullshit.

Some of them, especially the ones that have been around for long enough, realize that this isn't how we should be practicing healthcare medicine. This is not right. It's not appropriate. So I just want to put that as a caveat out there. Not all health professionals will stand behind this bullshit form that you have to fill in.

Starting off there.

But, so I'm trying to tease out, what is it? Poor Cosmo, what Cosmo has to go through? What is it? Why is it so unsettling? Why is it so upsetting?

And the first thing that I noticed is there's a confusion, there's a real confusion here about whether we are treating a disease, or whether we are treating a person.

As a doctor, it's my job to treat diseases. I literally went and studied for years at university, and it is my job description. Treat diseases.

Somewhere, somehow, we got a bit confused. We lost our way. We've started treating people, not diseases.

And so, we start treating... People are... they're the problem.

Cosmo is the problem, not Cosmo's diabetes. This is a diabetes clinic, this is a specialized diabetic clinic for people who are not responding to usual diabetic care. Cosmo's diabetic nurse at the local diabetic clinic has said, I'm sorry, there's not much more I can do. I wash my hands of you, go see someone who... go see an expert. Not an expert, but do you know what I mean? Someone who's got the power to do something, to change something. And yet.

Rather than just being like, oh, this is somebody with, you know, a complex disease. No, no, this is a problematic person. So there's a real confusion here. If we are confused about whether we're treating people or diseases, then we're gonna get it wrong right from the outset. When we're trying to fix people, fix people's behavior, fix their choices, and sometimes fix their moral character, rather than actually just treating the medical condition that this person has been diagnosed with, then we're already... we've already failed. Before we even started.

The issue with Cosmo is that they are insulin resistant. Their cells are not cooperating properly. In particular, their muscle cells, skeletal muscle cells, and their fat cells, and their liver cells, all of their cells, are resistant to this very important hormone. It's insulin. Insulin is like a key that unlocks the doors of the cells and allows the glucose that we've digested to pass from the blood into the cells. It is essential. If glucose doesn't get into the cells, glucose is the main source of energy for the cells. So if glucose can't get into the cells, then there is no energy in the cells.

And that causes fatigue, and it causes all sorts of problems, and it, you know, in worst-case scenarios, it can lead to death, but that doesn't happen with insulin resistance, it's never that bad. But it can make you feel really freaking miserable. And so if glucose can't get into the cells, glucose is traveling around the body instead, and what does the body do? The liver goes, oh, I'll have that, snatches out the glucose and turns it into fat.

So you have a high glucose level, you're tired all the time, and you're getting fatter. That's insulin resistance. And it is genetic, and it starts usually in your late teens to early 20s. That's when it begins. It is a really genetic thing. And we've got twin studies from the 1980s that support this. So there's no question about it, it's genetic in origin.

But we've forgotten that, conveniently, I don't know what happened, but we forgot that this was just a malfunctioning on a cellular level, the pancreas is trying to cope. After a while, it gets a bit knackered, and then the poor pancreas is exhausted. It's just not fun for anyone, but it's a pathological process, it's a disease process.

The other thing about diabetes that we don't talk about enough is that type 2 diabetes in and of itself doesn't kill you.

It makes you feel tired and shitty, but it doesn't actually kill you. It is a risk factor. It's a risk factor for other conditions that can kill you.

And the main ones are heart attacks, strokes, ischemic disease, so, like, ischemia to the limbs, so not getting enough blood supply into the legs mainly, so it can lead to amputations, it can damage the eyes, it can damage the kidneys, it can damage the nerves, peripheral nerves, in our hands and feet.

So yeah. I'm not saying we shouldn't treat it, we absolutely should treat it, but it's a sort of... we've also created this kind of mythological demon, the disease to end all diseases, you know, the worst possible condition you can be diagnosed with. Whereas my friend Marie was quite correct. It's not that big a deal. It's like high blood pressure or high cholesterol. It's a risk factor, but if we know that it's a risk factor, and we treat the risk factor, especially if we treat it earlier, you know, and most effectively as possible, and we manage it to a degree, actually it's really not the end of the world. There are loads of medical conditions out there with no treatment available. There are loads of medical conditions out there that are terminal that have, you know, not just risk factors for... there are some serious medical conditions out there, but for some reason, there's something about this one that's just really like the boogeyman, really scary.

And, at the same time, it's not a disease, and there's nothing pathological about this, folks. We are not treating the disease, we are treating the person. The person is a problem that needs to be fixed. Need to fix your behaviour, fix your choices, and ideally fix your character. Turn you into a better human being. Poor Cosmo.

We use, also, the language, my gosh!

We infantilize our patients a lot, the healthcare professional. We really do. Why are we talking to patients as if they're children? They're not children. They're adults, they're autonomous beings, who absolutely should be treated with respect, and without any kind of lying.

What are you gonna achieve? How are you gonna fix them? Like, that's not school. It's a clinic! Get over yourselves!

So that really pisses me off, the infantilization of it. And when you're infantilizing patients, then you are automatically being paternalistic. Paternalism, paternalistic medicine has no place in modern medicine. Paternalism is a thing of the past, where the doctor knows best, and we basically tell you what to do. Enough of this bullshit.

So we are not God. We are not dad, who knows best, paternalism. And we're also not teachers!

For fuck's sake! The word here that I... that came to mind was pedagogical. Pedagogical. I learned this when I was training to be a trainer, trained to be a trainer. So, basically, GPs need to be trained. So, trainee GPs come along, and they have a more seasoned doctor like myself who trains them. And so, I took on a course to learn how to train future GPs, and they were talking about learning styles and teaching styles, and there are lots of different types of teaching styles, and I'm not going to get into it, because I'm not an expert, but there's something really prescriptive about this. You know, we're gonna give you a form, you're gonna fill it in, and there are confidence scales, and goal setting, and... it's school!

It's a naff school, it's why it's school and you didn't even try. You phoned it in! You didn't even make it good school, fun school.

Cosmo is somebody with a condition, a medical condition. They are going to a clinic, they are taking time out of their working week, they are traveling to a clinic, sitting around for ages, waiting to be called in, finally sat down. They are not going to school, they do not want to be schooled, they do not want to be infantilized, they just want to be treated as quickly and efficiently as possible by somebody who is going to present the facts to them, here are the benefits, here are the risks. Here are the choices, here are the options, which ones do you want to do?

No preaching or teaching necessary.

Then there's this... there's this responsibility. The responsibility has shifted. If you're sick, and you go to a doctor to treat you, and the treatment doesn't work. Whose fault is it?

And maybe fault is not the right word, but whose responsibility? Let me take that back, say that again. Whose responsibility is it? You're sick, you go to a doctor to treat your sickness, and the treatment doesn't work. Whose responsibility is it?

The doctor's, right? It is the doctor's responsibility. They treated you, it didn't work. So to do something else, you know? Figure it out, doc, that's what you get paid for.

What happened? When did the responsibility for conditions like diabetes get shifted? So it's like, we clinicians wash our hands of the responsibility. It's nothing to do with us, it's all to do with you, because, again, we're not fixing a condition, it's not a disease, it's you, you're the problem. So you're responsible.

Your blood sugar levels are framed as your responsibility that you have to manage through behaviour change. What was it? Eating less sugary foods, more physical activity, healthy eating, blah blah blah.

Actually, there's very little evidence to support this shit, you know. Really very little evidence to support that. But even that diet and exercise is going to have a massive impact on your HbA1C. It's like with blood pressure and cholesterol, it's all the same thing, maybe we could drop it by one point, two points, but it's not enough, not enough to have a serious impact on your health and well-being. You want to reduce my risk? You want to stop me from having a heart attack, losing my eyesight, needing dialysis, losing a limb? Treat my condition! Give me the medication that I need.

That might be insulin. For some people, it's insulin. The answer is insulin. I know.

For some people, it's Gliclazide, this drug that, you know, sulfonylureas. Oh, it might make us gain weight, okay. But it works!

Stop taking my choices away. Stop painting this as a, what goals are you gonna set for yourself? No goals! And you know what really pissed me off about that form? There is no option to say, I don't have any goals.

My goal is for you to treat me. Where's the box for that?

The form, but more beyond the form. The attitudes of healthcare professionals, especially with conditions like diabetes. Preventive medicine, if you will. The attitude is that blood sugar results, test results, are a personal failing rather than a physiological reality.

It's just blood... it's a level. Your blood pressure is your blood pressure, your cholesterol is your cholesterol, your EGFR, your estimated GFR, this is your kidney function. There's nothing you can do about it. You cannot control your kidney function. It is what it is. So stop making it, stop giving me a traffic light system, stop asking me to look at those results and decide what they mean for me. They are my results, they're just facts, that's what they mean. The fact is, that's my cholesterol level.

It doesn't mean anything, it just is. And so, trying to find meaning in these results is pretty despicable, if you ask me.

Behaviour change is not a primary intervention, and I really need... we need to stop doing this.

If people want to change their behavior, IF they want to, and it's a big if, because nobody has a responsibility or an obligation to change their behavior, but if they want to, it is their business.

If they ask you for support, that's one thing. Hey, you might even offer your support. I don't even know that you should, because I think people are very sensible, and they know that if they need your support, they can just ask for it. But you might even say, hey, look, if you want some help stopping smoking, or, you know, you want to talk about diet or exercise, I'm here. That's one thing. Just offering it out.

But framing it as some kind of primary intervention, like, this is how we're going to treat your condition, that is unacceptable. We shouldn't have to change our behavior in order for you to treat our medical condition. And when I say we, I mean me and Cosmo, and everyone else.

It is your job! Do your job.

That's what I have to say to Cosmo's imaginary nurse. Wow.

Deep breath.

I think the other thing that really bugs me is the way that we are framing, the moral framing of a medical condition. And we keep doing this, don't we? We do it with arthritis, we do it with a lot of conditions. I picked diabetes because, you know, it's somewhat close to my heart, but I could have picked all sorts of conditions. The entire profession, actually, the whole of the profession. The framework that underpins diabetes management. It's based on a moral framework, and it's based on this idea that people who are diabetic had done something inherently wrong and need to commit to being better.

They don't treat diabetes as a sort of neutral, biological, pathological fact. It's not something that happened for reasons that we'll never understand fully, but can guess, something to do with genetics. It's a failure. It is a moral failing that requires correction. You need to be punished. This takes me back to the previous episode. You need to be punished for being a diabetic.

No sugary foods for you, the nurse says. And then gets on their break and has a Kit Kat.

I've met many diabetic nurses. They don't avoid sugar. Just saying.

To me, it's just the whole... you know, the other thing is, it's compliance theater. I wrote down, Compliance theater. It's like they give you this form, and they tell you to fill out your goals, or whatever. It's just, you know, it is literally a box-ticking exercise, but it's theater, because they know it's not going to work, by the way. They know that you can commit to eating healthier, or you can say, my goal is to eat fewer biscuits a week. It's not going to make a difference to your HbA1c, it really isn't. They know this, everybody knows this, but they do it anyway, because if your HbA1c doesn't improve, then again, it's not my responsibility. It's not my fault, as your clinician, that I cannot seem to find the drugs that make it work.

No, no, it's your fault, because you didn't eat fewer biscuits, you know? It's theater, it's a joke, it is a farce, it is bureaucracy, it's how we get paid, but it's a joke, but we have, honestly, the medical profession has convinced ourselves that we're doing something good here. Like, this is the thing to do. Goal setting!

I remember when it became really popular, and there were all these courses about, you know, how to do, how to affect change, and how to get your patients to be more compliant, and stuff like that. It was just horrendous. The whole thing is horrendous.

Yeah. You know, it's really interesting to me, because paternalistic medicine and the era of doctors are God, doctors know best. You know, I don't subscribe to any of that. That was terrible times. I'm not hearkening back to those days. I don't want to be like... remember the good old days when doctors thought they knew everything?

I don't want you to think that that's how I feel. However, there was a period of time when doctors shouldered, or doctors and nurses and healthcare professionals shouldered the responsibility for people's illnesses. People were ill, they came in, they told their story, the doctor examined them, and made a differential diagnosis, and ordered some tests, and created a treatment program, and, you know, like I said, it's not doctor knows best, doctor is God, doctor knows everything, not at all, but do you remember when that was a thing?

And now, you walk in, and the doctor doesn't listen, and the doctor doesn't examine you, and the doctor doesn't make a differential diagnosis, or order tests, or whatever, because the doctor has been given the green light to turn around and go, oh, well, it's all about health behaviour and health change. How can we make you more compliant? How can we fix you? You, you are the problem. You are the one that needs fixing, not the disease process. So it's almost like medical solutions no longer exist. The solution is to fix the person. Fix the patient, not the problem.

So what do doctors get paid for, then? What's my job? I'm just there to bear witness? Are you a cheerleader? What is the point?

If we can fix our problems just by changing the way that we behave, then what is the point of medicine in the first place? It's a joke. The whole thing is a joke.

The underlying philosophy of diabetes care is diabetes is what happens when people make bad choices, and therefore the treatment is getting them to make better choices.

Diabetes happens when you make bad choices, and I treat it by making you, guilting you, coercing you, schooling you into making better choices. That's the underlying philosophy. Rather than diabetes is a chronic medical condition requiring ongoing treatment and support, which may and usually does include medication, monitoring.

And I'm not saying no lifestyle adjustments. If people want to make lifestyle adjustments, go for it. I'm not saying don't. I've made some lifestyle adjustments, so has Cosmo. Cosmo has changed the way they do things.

But also, and, you know, sidebar, focusing on not eating bad foods and eating good foods is a recipe for an eating disorder. And ask anyone who has been diagnosed with diabetes, did you develop disordered eating behaviors? How quickly? Just ask them how quickly it happened. For me, it happened overnight. It was crazy.

I had done all this work on myself, all this intuitive eating stuff, I was doing really, really well, and the moment I got that diagnosis, it was right back to the drawing board. Can't eat that, can't eat that, that's bad for me. And I still have moments where I'm like, I really want to eat that, but I can't, because it's not got enough protein, or I can eat that, but only if I put protein with it, and I put some fiber with it, and I can do this, and I do that. It's not easy, but hey, it is part of the course of having a chronic medical condition. So, like Cosmo, I'm the kind of person that's just like, this is as much as I'm prepared to do.

You know? I'm not gonna have a breakfast that consists purely of toast and Nutella. I would love to, love toast and Nutella, but I'm not gonna just do that, because I know that if I just eat toast Nutella, that is not gonna do my blood sugars any good that day. So, I'm probably gonna have some kind of eggs, you know, and there will be vegetables involved. I might, hey, I might have some toast with Nutella. Not saying I don't. Not every day, but I might treat myself to toast Nutella if I really want to, because I am an intuitive eater. But I'm... the reality is I'm not gonna just... I can't fully eat intuitively anymore, which is a shame. Because I really enjoyed being an intuitive eater, but it is, you know, it is what it is. I have a medical condition, I'm aware of that.

Movement as well. I know that movement is good for me, and therefore I move. I don't force myself to move, I don't guilt myself, you know, and make myself feel bad if I don't move every day, but, you know, of course I do. And this is somebody, you know, I'm not saying that you should, by the way, it's not me saying that other people should, but this is the deal I made with myself, you know?

So I'm not saying no lifestyle choices, I kind of got a bit lost there, sidebar, sidetracked, but my point is that, at the end of the day, diabetes is a chronic medical condition that requires ongoing treatment.

And we have GOT to stop failing our patients by turning them into problems.

We're trying to fix them. It's just, it's not okay. None of this is okay. It's just not okay, and it's also really lazy. It is not what we're paid for, it is not our job, it is not what we trained for. Come on, don't we want to do better? And this is my feeling, actually. My feeling is, boots on the ground, listening to healthcare professionals, I think they do want to do better.

I think they're tired of it. I think most diabetes nurses know this is a load of shit. They don't want to lecture people about biscuits anymore! They just want to leave them in peace, just want to treat them! And actually, my experience has been not always positive, but in general, positive. I do live in Scotland, so just everything's positive in Scotland, but it's been fine, for the most part.

Situations like this, God, put me off, and so what does it make me do? It makes me not go. It makes me avoid. And that's what I... that's how I wanted to finish Cosmo's story, is just by saying that Cosmo never went.

Canceled the appointment, right? Because that's the reality. Cosmo's not gonna go when they get given a sheet. They haven't even met anyone yet, no conversation, nothing. They got that letter in the post before it even began.

Do you know, this is completely random, but when I was referred to the gender identity clinic many years ago by my GP, I got a letter back, the first letter that I ever got back, and it said, Dear Natasha Larmie. The Gender Identity Clinic dead-named me. First ever correspondence I ever got from them.

And I remember looking at that letter and going, what is the point? What is the point? Why would I go if you dead-name me in the first letter you send me?

I think that, thankfully, I went anyway, and, you know, I told them, I said to them, this is what you did to me, and they were very apologetic, and they changed my name, but it shouldn't have happened. And it was an admin issue. It's just one of those things that happens, I can get over myself, but it just makes me think just how easy it is to fail a patient, and just to put them off the whole thing. I could have just as easily just gone, nope, done, never mind. If these guys dead-named me. I cannot trust any healthcare professional, and I think it's the same as a diabetic person, if I get that thing coming through the post, I'm done. I'm not even gonna go. I'm cancelling my appointment, and it's not like they're gonna follow me up. They won't follow me up.

And so, 2 years down the line, three years down the line, when my diabetes is really shit, and you know, my eyes are beginning to get affected, and everyone's like, this is so sad, what happened? What happened was, you sent me that form. That's what happened.

You treated me like I'm a child. You humiliated me, you stigmatized me. You made me feel like I was a problem that needed solving, and I didn't bother. Why would I? Why would I voluntarily put myself through that? And that's their fault.

That is the healthcare professional's fault, that is the clinic's fault.

And if I had the energy, I would be telling them this face-to-face, but instead what I'm going to do is I'm going to send them a link to this podcast episode, and I strongly suggest that if you're in a situation where you've had a similar experience, that instead of writing a complaint, a long-winded complaint, feel free to just send them the link to this podcast episode. Send them to Asher, I'll sort them out.

Anyway, thank you very much for listening, I think I've been going on far too long. Hope you enjoyed that. I've got a break next week, right? I don't even know. Where are we? So, what, it's the 19th of November today? So, break for the 26th, still writing, still plugging away. Speaking of which, if you want to get some updates, I'll put this in the newsletter, but if you want to get some updates for my book. You want sneak peeks into the chapters, and, no agenda here, I'm not trying to sell you anything, just, if you want to keep up, the reason I'm doing it, I think, is just to keep me accountable a little bit. So, if you want to... you can sign up. So, I have a newsletter, I send a newsletter out once a week.

Every 3 weeks, that comes out the same day as the podcast. So that goes out to everybody who's signed up to my mailing list. I've also got a separate newsletter for healthcare professionals that you can sign up to once a month. If you are a member of my paid community, you get an email a week as well, an additional email a week, just from me, special, from me to you. Whatever. And then, I'm gonna start doing, probably once a month, again, little book updates. Just for people who are interested, and you can sign up to them, you won't automatically get them, you have to sign up to them, but yeah, just for people who are interested in reading a chapter, giving me some feedback, just getting involved with the book, if you're interested. But yeah, why did I start talking about the book? Oh yeah, because next week I will be writing.

That's what I should be doing anyway. Remember, I've still got a few slots left before the end of the year. If you want to book a one-to-one with me, I would love to work with you. And just keep in touch. Just keep in touch. I love hearing from you. I appreciate you all so much. Thank you very much for being here.

And, yeah, have a good couple of weeks. See you in December!