My Pain Keeps Getting Dismissed!

 Fat patients with chronic pain are routinely sent away with a weight loss lecture. No examination, no blood tests, no referrals. In this episode, I introduce Suki, a teacher and mother whose two years of worsening hip and back pain have been dismissed at every turn, while her thinner colleagues walk away with physiotherapy and x-rays. I break down exactly what conditions get missed, why weight stigma is a clinical shortcut that the system is designed to profit from, and (most importantly) what to say in the room to finally get the care you deserve. 

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Transcript

Hello, everybody, and welcome to episode 21 of Season 6 of the Fat Doctor Podcast. I am your host, Dr. Asher Larmie — fat person, fat doctor, author of No Weigh! Everything You've Been Told About Weight Loss is a Lie, founder of the No Weigh Movement, NoWeigh.org, and podcast host.

Most of you already know me, some of you are new, and that's great — welcome. Today we are going to meet Suki. She's a character I created to help people who are trying to navigate a system that is very much set up to deny adequate healthcare to fat people.

Suki is in her mid-40s, works in education, has two kids, and approximately zero spare time. She's lovely. She's warm, she's very practical, she's not a complainer. She's the kind of person who just pushes through, who just gets on with it — just keeps going.

In spite of the fact that, for the last two years, she has been in genuine pain. Hips and back. Every day. It's getting worse — slowly but surely it's getting worse. She has internalized the message that this is just what happens when you're fat. That's what she's been told by pretty much everybody her whole life, so she's like: it's my fault, so I just have to put up with it.

She has actually been to see her GP. Unlike Ren, who was understandably putting off seeking help, Suki pushed through and made an appointment — went to see her GP on three separate occasions. On each occasion, she received a weight loss lecture, and that was about it. Eat less, exercise more, make sure you move — nothing much else.

Recently, she noticed that a couple of her colleagues — other teachers at her school — had similar symptoms to hers and got referred to physiotherapy. One got an x-ray. And Suki's thinking: no one has ever offered me that. What's going on? She's a smart cookie; she knows what's going on. But she doesn't want to be difficult.

And this is the thing — people who have been told not to take up space, because if you're fat, you're not supposed to take up any more space, you're already taking up enough. Not to take up resources from people who "actually need them." To be quiet, to be kind at all costs, to defer to people in authority. When that's the way you've been conditioned your whole life, you don't want to make waves. You don't want to waste the doctor's time. You don't want to be difficult.

And that is exactly what the healthcare system relies on. I don't care whether you live in the UK, where resources are stretched because we have a nationalised health service, or in a country where you have private healthcare and insurance — it doesn't matter. Resources are always stretched. The people at the top are making the most money, and the people actually providing the care are always overworked and underpaid. NHS salaries are not great and haven't risen in line with inflation in the last 20 years. Your doctor is not minted just because they're a doctor.

And if nothing else, the biggest resource is time. GPs in the UK usually have just 10 minutes with each patient. Specialists might have 15 minutes, half an hour if they're really lucky. That's not enough time to do the work they're supposed to do. So the system relies on the fact that you don't want to make waves, that you don't want to cause problems, that you don't want to be difficult. They are relying on that so that certain people at the very top of the pyramid can make as much money as possible with the least amount of output.

They are trying to profit off your patience. Whether it's a nationalised healthcare system or not, somebody out there is profiting off your silence and your complicity in this charade of "I can't possibly bother the doctor." That is literally what the doctor is there for. And doctors can make you feel sometimes, can't they? Like: why are you here? You could have managed this at home. Why are you wasting my time? Even if they don't say it out loud, you know what they're thinking. It's just a cycle that never ends.

So, Suki has just been carrying on as she does. But there's a moment — the kids are playing, and the youngest one says, "Mummy, play with us!" And the older one says, "Don't ask Mum. You know Mum can't do that because of her back."

And Suki hears this, and she thinks: I can't even do the things that make me happy anymore. She's in education, she already has one of the hardest jobs on the planet, she's tired, under-resourced, underpaid, overworked. She's a warrior. She's raising her kids, she's doing her best, she's keeping silent — and as a result, she can't even do the things she wants to do. One of these days, the kids are going to be too old, and they're not going to want to play with her anymore, and she will have missed that opportunity. She gets to a breaking point: this is not fair. Other people are getting support — why is she being punished?

Let's talk for a moment about what is often missed, or overlooked, in fat patients. Last week, we were talking about Ren, and I was saying that because of weight stigma, doctors often make snap decisions. "Oh, this is going to be weight-related." And as a result, they don't consider the other things that could be going on. And it's not just weight — sometimes it's: "clearly you don't get enough exercise, that would explain the breathlessness," or "clearly you eat too much, that explains the fatigue." It's not just your weight itself, it's everything people assume about you because of your weight. All of those assumptions, judgments, and stereotypes.

There are lots of common conditions that are routinely overlooked in fat patients — especially those with other marginalised identities too.

Joint pain, for example. It's often assumed: "You're fat, so it's almost certainly arthritis." But being fat doesn't mean you have arthritis, and thin people get arthritis too. Doctors are less likely to consider inflammatory arthritis. They'll say: too much weight on your hips, just lose some weight. But they won't consider other causes — cartilage, tendons, ligaments, inflammatory conditions like psoriatic arthritis or rheumatoid arthritis. There are lots of conditions that get ruled out without actually being ruled out through a blood test or x-ray.

There's plenty of evidence that doctors under-investigate fat patients. They don't order bloods, x-rays, or imaging. They're also less likely to examine a fat patient than a thin patient, which is a problem — because how can a doctor make a diagnosis if they don't examine you? The number of people who tell me they saw their doctor about back pain, and when I ask what the examination found, they look at me like: what examination? You went to see your doctor with a painful hip or a painful back, and they didn't touch it. It blows my mind every time, even though I know it's common.

Other conditions that are much less likely to be diagnosed include fibromyalgia and hypermobile EDS. And hormonal causes — perimenopause is a really common cause of joint pain that often gets missed.

If Suki came to see me, I'd be ordering bloods: inflammatory markers, thyroid, B12, vitamin D, and I'd try to rule out rheumatoid arthritis. I'd take a thorough history and examination. With ongoing hip pain, I'd probably send her for an x-ray of her hip. I'd do all of that first, and then consider other conditions. If it's something I can't easily diagnose in general practice, I'd refer her to a specialist — though there's a good chance the specialist would say no, and she'd probably end up in a musculoskeletal clinic with a physiotherapist. Physiotherapists are actually quite good — often better than doctors, honestly. But with backs, the triage protocol will almost certainly mean a weight loss lecture, maybe some exercises, and that's the end of it.

That is the reality of our failing medical system. And most fat people don't even get that far. Suki's thin colleagues get referred to physio straight away. The fat teachers get told to lose weight first. They're not even getting blood tests, examinations, or x-rays.

And even if you do get past that point, you're still not always going to get the care you need, because you'll face weight stigma every step of the way. If you do get referred for imaging, there will be a note at the top of the radiology report: "Interpretation difficult due to body habitus." That's code for "this patient is fat, so I can't draw any conclusions." Learn to interpret images better. It's perfectly possible — you just have to learn the skill. But this seems to be standard practice now; I'm pretty sure they just copy and paste it.

You face weight stigma when you go for an MRI too, because the machines don't accommodate people your size. With knee MRIs in particular, you have to put your knee into a bracket, and apparently something like 1 in 5 people get sent away because their knee doesn't fit. MRI machines have weight limits. And then there are the gowns — gowns that don't fit. Nobody wants to walk down a hospital corridor with their backside on show because the gown is too small. Just have larger gowns available. But I digress.

You're going to experience weight stigma every step of the way. Finally see a specialist? They'll blame your weight. See a physiotherapist? They'll blame your weight. And even if someone actually makes a diagnosis, they may still refuse to treat you because of your weight.

Weight stigma is a clinical shortcut. It allows doctors to do less work. If they can blame your weight and tell you to come back once you've lost some weight, that's made their lives a whole lot easier. And it's not just the individual doctor — it's the system that has created an environment in which this has become normalised. It's a way to save money, and sometimes to make money.

This is not about hurt feelings. This is a systemic failure with very real consequences. We don't know why Suki has back pain. It's unlikely, but she could have myeloma. And you won't know unless you at least do a blood test. I've had patients throughout my career where I thought it was probably a ligament issue, only to be shocked by a cancer diagnosis or some other serious condition I hadn't seen coming. That taught me, over 20 years of seeing patients: never assume. Better to be safe than sorry. That's my approach to practising medicine.

So, what do you do in this situation? As I said last week: if you know what you're entitled to, you're already halfway there.

You should be examined — especially for something that can be examined. If you go to see a doctor for the first time about pain and they don't examine you, you have every right to say: "Aren't you going to examine me?" Or, more politely: "When are you going to examine me?" That's a very legitimate question.

You can also ask: "When will you organise tests? At what point will you investigate further? How are you going to rule out X?" And if there's something specific you're worried about, you can ask directly how they plan to rule it out.

Now, fat patients have often had to become experts — doing all the reading and researching themselves so that a doctor will take them seriously. Sometimes people come in with things printed out, ready to do battle, because they know they'll be dismissed otherwise. This is deeply unfair. It puts an unnecessary burden on fat people who are already burdened by the healthcare profession.

And to the doctors listening: your patients should not have to tell you how to do your job. You should know that you're supposed to examine them. You should know what bloods to order, what x-rays to request. You went to medical school. If you don't want to do it, find another job. If you've burned out — and I get it, I understand — then step away, because you are harming people by staying in post.

For patients: know what you're entitled to. A full history, an examination, investigations. Ask: "What could be causing my symptoms? What do you need to rule out? What are the serious diagnoses we don't want to miss?" You can use collaborative language — "we," "together," "as a team" — but essentially what you're saying is: you're supposed to do your job, and I'll be your keeper if you won't.

If they bring up your weight, you can say: "We've talked about weight in previous consultations — I really don't want to talk about it today. Let's move on." If they haven't brought up your weight, you don't need to either. Just keep gently pushing back, asking directly for what you want and need.

If they're not acting on the first visit, make sure you leave with some kind of follow-up. "When do you want to see me back? What happens if I can't lose the weight? At what point should I be concerned? When will you order the tests?" Escalate gently. If none of that works, book a second appointment, ask for a different doctor, or seek a second opinion.

As I mentioned last week, there's a script available with a set of questions you can use when you need to escalate things.

Now let me imagine Suki going to the doctor. She's been fobbed off three times — fourth time's a charm. She's prepared. This is what I'd say if I were her:

"Hi! I'm here to talk to you about my back pain and hip pain, which, as you know, I've had for quite some time. I've been in a few times about this before. It's not getting any better — it's actually getting worse. I'm at the point now where we need to do something different. I can't put up with it any longer. It's impacting my ability to do my job, to look after my children — it's really bringing me down. I know you haven't examined me yet, or ordered any blood tests or x-rays, but I think we've reached the point where we need to do a bit more. I've come in today to figure out what's going on and what my next steps are."

Something like that. I'd share a little information — it's been 18 months, it's getting worse, starts in my back and spreads to my hips — but not too much. You don't want to overwhelm; give a little, see how it goes.

If the doctor brings up weight, I'd say: "Look, we've talked about weight in the last three consultations. I really don't want to talk about it today. I'm not planning to do anything about my weight — let's move on." A doctor might be taken aback and say, "Okay." They might ask why. And you can just say: "Because I don't want to." That's a good enough reason.

No is a complete sentence. You don't need to explain why. You don't have to defend your decision.

If a doctor says, "Unless you're willing to talk about your weight, I won't investigate further" — at that point, don't waste any more time with them. Just say: "I'd like you to document in your notes that you are refusing to examine me, take a history, order any investigations, or treat me because I won't discuss my weight. I will be seeing another doctor." And you can add that you'll be putting in a complaint — though you might not need to say the last bit.

With any luck, at the very least the doctor will examine Suki, and at the very least order some tests — if only to get her out the door.

Another thing Suki could do is bring an advocate. In an ideal world, a thin man — if you have one of those available. A thin woman would be second best. If you don't have any thin people, bring a mouthy fat person — someone who looks like they're about to jump in at any moment, ideally with some kind of folder or document in front of them, maybe some glasses if you're going with props. The role of the advocate is to advocate, obviously, but also to shift the power dynamics. Things change when there are two people in the room, especially one who looks like they're waiting for a moment to speak.

And hey — if you're already struggling and not getting anywhere, I consult with people. If you're looking for a doctor who cares, I'm a doctor who cares. You can book a consultation with me.

A lot of what I cover is also in my book: No Weigh! Everything You've Been Told About Weight Loss is a Lie. It's available now in paperback and Kindle. I'm going to keep talking about it — you'll be sick of hearing the title, but it took a really long time to write. It's like when you have a baby: it takes nine months to cook, and once you've pushed it out, you want to talk about it. Show people pictures. Look at this baby! So yes, I'm going to keep mentioning it, and I'm not apologising — just setting expectations.

Thank you very much for joining me today. I hope it was helpful. We'll be back next week with another person, another problem, and hopefully some more solutions. Thank you, and take care. Bye-bye.