Resources to Fight Joint Replacement Denials for Fat Patients

ITISAN~1I get a lot of e-mails from people who need joint replacements,  but whose doctors have refused to perform the surgery unless and until the person loses weight.

Sometimes the doctor suggests that the patient attempt weight loss through diet and exercise.  I would point out that even if diet and exercise might lead to short term weight loss (and even if they could manage exercise on a joint that requires replacement!) the most likely outcome, based on the research, is that they would gain the weight back, with many ending up heavier than they started, which begs the question: If you think that our size is the problem, then why are you are prescribing an intervention whose most common outcome is a larger body?

Now I’m hearing more and more from people whose doctor has claimed that knee surgery is “too dangerous” at their weight and has recommended … wait for it … weight loss surgery.  You aren’t reading that wrong – doctors are refusing to fix someone’s knee until they are willing to have a surgery in which their perfect healthy digestive system will be mutilated to create a disease state, forcing them to starve – though most people who have the surgery still end up in the so-called  “ob*se” category.

Suggesting these dangerous surgeries is an extraordinary breach of the promise to do no harm, since they are asking fat patients to risk their lives and quality of life by having a surgery that is a complete crapshoot in terms of outcome (some people are happy, some people die, some people have horrific lifelong side effects and people don’t know which group they’ll be in until they are in it) so that in theory, the doctor can perform an easier surgery and despite the fact that two surgeries are riskier than one. Jumping through hoops to receive knee surgery is bad enough, risking your life to receive it should be out of the question.

Even if you believe that fat people face additional risk from the surgery and/or receive less benefit, that doesn’t mean that the procedure should be denied. Less pain and more mobility is a reasonable motivation for seeking healthcare even for patients who are unlikely to have the absolute best outcome for any of many reasons (which is why so many other professional athletes have received these surgeries, even though it was their plan to continue the professional athlete lifestyle that trashed their joints in the first place.)

RESOURCE LIST 

Happily, the absolutely brilliant Deb Burgard, PhD, FAED has created a list of research to help fat people and our advocates who want to fight joint replacement denials. She has graciously agreed to let me share them here.

Before I do, I want to be clear that none of this is to suggest that if you are refused joint replacement surgery you are under any obligation to try to change your doctor’s mind. That’s certainly an option (and for those who live in areas with limited practitioners and the inability to travel to see another doctor it may be the only option that works for them.)  Many people have found that their best option was simply to find a more compassionate and talented surgeon who isn’t interested in simply cherry-picking only the easiest surgeries. It’s important to remember that, while this becomes our problem, it’s not our fault and we should never have had to deal with this in the first place.

In addition to these resources, you might want to check out these posts:
Fat People And Our Knees

Does Being Fat Cause Arthritis? Does That Even Matter?

Trigger Warning: These studies used are not written from a Health at Every Size paradigm, and use terms like “ob*sity” and “overweight” that stigmatize fat bodies and may contain other triggering wording and weight stigma.  The material in quotations under each study link was written by Deb.

Resources for joint replacement surgery denial

https://online.boneandjoint.org.uk/doi/full/10.1302/0301-620X.96B5.33136

This is actually a study OF KAISER MEMBERS that shows worse outcomes with intentional weight loss before surgery

https://ueaeprints.uea.ac.uk/58880/1/Bariatric_surgery_paper_ACCEPTED_10.05.2016.pdf

This review shows weight loss surgery does not improve surgical complication rates:

https://www.sciencedaily.com/releases/2017/07/170719084707.htm?fbclid=IwAR3b9XS0fzqrY4GYXw8wbW3fYHsTlnIDby0h_9ftiZlgSg7KtOpziiPY8aU

This review shows longer term outcomes are just as good for higher weight people

http://www.gaudianiclinic.com/gaudiani-clinic-blog/2017/7/27/the-1-medical-complication-of-binge-eating-disorder-poor-general-medical-and-surgical-care-arising-from-weight-stigma

This doctor talks about weight stigma and withholding care

 https://www.ncbi.nlm.nih.gov/m/pubmed/30778723/?fbclid=IwAR3wbfLKvaJxl4CrxYqAio97jxRM5SumLoVVyoRLgwB25-T0VzcgniFK-xE

This review says the benefits are still there even with some complications

https://wellroundedmama.blogspot.com and search for “joint”

Well Rounded Mama has Part 1 and Part 2 blog posts on total joint replacement

https://journals.lww.com/jbjsjournal/Abstract/2018/04040/Risk_Reduction_Compared_with_Access_to_Care_.1.aspx

Notes: Difference between flip of coin and screening for BMI>+40 was 6.74-5.05  =  1.69% = less than 2 percentage points.  Positive predictive value is the number out of 100 who actually have the problem of the people who are identified by the screening – ie, there are 5 people identified by flipping a coin and 2 more identified by using BMI of 40 or more.

Remember that you get to choose the path you take and that sometimes trying to access medical care in a deeply fatphobic society means doing whatever it takes to get the care we deserve.

If you’re looking for a fat friendly doctor you can check out the international fat friendly doctor list at http://fatfriendlydocs.com (If you have a fat friendly doctor, please take a moment to add them to the list!.)

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10 thoughts on “Resources to Fight Joint Replacement Denials for Fat Patients

  1. Ragen made two excellent arguments for the conversations with surgeons – 1) If weight cycling would worsen what you are saying is threatening to my knees (ie more weight with less muscle mass to support them) and weight cycling is overwhelmingly likely, then why would you prescribe weight suppression before joint replacement? and 2) if surgery carries risk, why would you prescribe two risky procedures over one?

    In addition, an argument that sometimes sways some doctors I have spoken with is: “Your data saying thinner is better is from a study of the outcomes of always been thin people and the outcomes of fat people, correct?” [yes, so?] “Fat people can never be people who have always been thin. The actual test of the hypothesis that fat people should lose weight before surgery is to compare the outcomes of fat people who suppress their weight vs. the outcomes of fat people who do not.” [stunned silence – followed by, but that is too hard to study] “Yes, and why is that?” [Because people don’t maintain weight loss] “Exactly. So let’s look at what will actually happen with your proposal in real life.”

    There is only one study that I have seen that uses the correct design (the first one in the list in Ragen’s post) and no surprise, outcomes were worse for people whose bodies got less fuel in the months leading up to the trauma of surgery. Along those lines, there are more studies that are beginning to document ongoing, unending bone loss with weight loss surgery that deserve consideration, since the general advantage that fat people tend to have of stronger bones might be wiped out – and joint replacements are most successful for people with strong enough bones to support them. Why is this not yet another three alarm alert for prescribing weight loss surgery?

    The medical ethics consideration for giving a fat person a surgery is not, “will they do as well as a person who has always been thin?” It is rather, “will they do better than without the surgery?” and “do they understand the odds of different risks and benefits of the surgery in order to truly consent?” It is glaringly obvious that holding joint replacement surgeries hostage to bariatric surgery satisfies neither of these.

    Why is there so much denial of medical care for fat people right now? Pay-for-performance anxieties for doctor means that they are less willing to take on the problems of people who are less privileged in any way – who tend to have more varied outcomes because of the social determinants of health. It is a terrible consequence of overly simplistic metrics and “incentives” that seem to be about practicing better medicine, but turn out to have the consequence of limiting practice to patients who need less care.

    And in the US, the site of discrimination used to be that higher weight people couldn’t get insurance at all, unless your workplace covered all workers automatically. When the ACA laws required insurers to deliver care to all regardless of “preexisting conditions” they had to figure out a different strategy to deny care. Now they are doing it with clinical guidelines that say “treat the weight first” (ie send people off to diet before giving medical care), or restrictions on who can donate or receive organs, or logistical problems like weight limits on tables or MRI machines, or liability issues that get triggered if you are doing medicine with say, people over 300 pounds, because the procedures are designated “higher risk.” It all adds up to not having to deliver the care to the 2 out of 3 adults who are are arbitrarily deemed to be in higher weight categories. So: follow the money, not just the attitudes of individual doctors.

    And: for those of us who are having this experience of not being able to get medical care for the first time: there have always been plenty of people who never had access to health care at all, and have never been included in medical research, and those giant gaps in medical knowledge and service delivery are the larger picture that determines the work ahead of equity and justice.

  2. Sounds like suffer and die are our only choices here.

    Second cousin, half my size, got weight loss surgery and has had major infections that put her in the hospital, increased pain and immobility issues from knees and hips, complications from new inability to absorb key (necessary) nutrients. BUT…she is ‘thinner’… So, SUCCESS!

    I hope the medical community is at least nicer to her, being as she was wiling to let them try to ‘fix/kil’l her for their erroneous, woman hating, bs values.

  3. What if it’s insurance that won’t cover you because you’re overweight? I’ve needed knee replacement for several years and have been told “There isn’t an insurance company on the planet that will pay for knee replacement, just so it can be destroyed again by excess body weight”. The average total knee replacement is around $57,000. Sooo, not putting that on the old credit card…

    1. Total lie. I had bilateral knee replacement surgery in 2014 at age 48 and it was totally covered by my insurance (which I think was Blue Cross at that time). My doctor had no problem doing it even though I’m fat – he actually never mentioned my weight, as far as I recall. I did get a second opinion (like you’re SUPPOSED to) prior to my surgery and that doctor suggested weight loss surgery. He was fat himself and I wish I had asked him if he had considered it personally! Needless to say, I ignored him. My bionic knees are totally fine now and I work out with a trainer 4 days a week, which I definitely couldn’t do prior to the surgery.

  4. Total moral judgement BS. Athletes rip the hell out of their bodies, some surgeries (Tommy John) you hear about all the time. Brain injuries in football, foot injuries in ballet, pulls, strains, sprains, breaks, tears, repetitive motion, cuts, scrapes, bruises, bleeds and ‘tennis elbow anyone?’. Crack your head on a diving board, dislocate you shoulder lifting weights. Fracture jaw on the ice. Broken back riding a horse. grind your cartilage into mush playing rugby. Compound fracture on the soccer field…Those are OK, so long as they are in the pursuit of SPORT or FITNESS or HEALTH. Entire fields for sports medicine and physical therapy, holistic, mental toughness, wellness center, in patient/out patient, chiropractic ‘lemme push that back in for ya there.’ Pre game/ post game what ever ya need!

    BUT. You need a procedure, replacement, brace, support or treatment AND you’re FAT! Even if they are not related…HOW DARE YOU ASK TO HAVE PAIN OR MOBILITY ISSUES ALEVIATED! YOU DID IT TO YOURSELF!

    First, do no harm… unless….

    1. I agree. Safety *is* an issue… but it’s a *created* issue, one that comes from medical students not getting to practice on fat cadavers or study the specifics of fat bodies, from fat patients being denied care so frequently that when a surgeon does get a fat patient, it may be the first time they ever had one or years since the last one, from hospitals not buying equipment that accommodates fat people.

      And at the core of all that are the cruel moral judgments that a) fat people deserve to be punished for being fat people, among the punishments we deserve are sickness, pain, and neglect, and if we get the same medical care a thin person would, we’re wheedling out of punishments we deserve, and b) healthcare is a finite resource that must be hoarded in case a thin person needs it; any supplies used on fat people (among other Others) is viewed as “wasted,” perhaps even stolen from a hypothetical thin person who would, were they to show up needing it, “deserve” it more.

      Or, to shorten it even further, it all boils down to “thin worthy, fat unworthy.” Which is also a moral judgment.

      1. Spot on and God help us.

        I am an organ donor, I’m sure they will have no trouble hacking me up to get to my organs to help someone else…

      2. It really is a BS argument. I mean, they can operate on babies, IN THE WOMB. They can study and learn to safely operate on fat people! It’s not ‘can’t’ it’s ‘won’t’.

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