When "Everything's Normal" Isn't Good Enough

When your blood tests come back normal and your doctor sends you on your way, that's not a diagnosis – that's a dismissal. In this episode, I follow Priya, a self-employed autistic woman in her late 30s whose 18 months of worsening fatigue, hair loss, skin changes, and irregular periods have been met with advice to exercise more and download a mindfulness app.

I walk you through why "normal bloods" and "everything's fine" are not the same thing, which conditions are routinely missed in fat patients, and what it actually looks like when a doctor does their job properly.

Because basic care isn't heroics. It's just medicine.

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Transcript

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Hello, and welcome to episode 22 of season 6 of the Fat Doctor Podcast. I am your host, Dr. Asher Larmie, and today we're going to be talking about a lady named Priya.

I made her up, just like I made up the last two people we've been talking about, but she's very real in my mind. I can see her in my mind's eye. And we're going to be talking about her experience. Why is she struggling to get the healthcare that she is entitled to, that she deserves? Just basic healthcare. Not anything extraordinary. Not pit-level healthcare. I'm talking about standard, basic — here's the bar, you just need to step over it. We're not pole vaulting here, we're just stepping over the bar.

And Priya's not even getting that. So let's talk about it, shall we? Let's get straight into it.

Priya is in her late 30s. She is self-employed. She's autistic. And very cool. She wears cool clothes, and she's one of those people who can just draw. You want to be on her team in Pictionary, because everything she does is beautiful, and you admire her, and slightly envy her. She has really long, beautiful hair.

She has spent her whole entire life putting everyone else first. She's one of those people. You know you want to hate her, but you can't, because she's really kind. And as a result of putting everyone else's needs first, Priya's always a little bit tired. She works too hard.

But for the last 18 months, she's been experiencing a level of fatigue she's never had before. It's been building slowly, it's not dramatic. She's just noticing she is more and more and more drained. She's had blood tests twice, both times they've come back normal. Her doctor said everything's fine, nothing to worry about. Off you go! Get more rest. Try mindfulness, or whatever it is that doctors do when they're just like, I don't know what's wrong with you, and I need to get you out of my chair.

And do you know what? I'm always hard on doctors, but there are times when we really just don't know. You're looking to us for answers, and we're thinking, I don't know. I'm also drained, I'm also exhausted, I'm also not getting enough sleep. So it's difficult sometimes. I don't want to constantly make it about how bad doctors are — sometimes we really don't know. So she's been fobbed off, because her blood tests have been normal.

But that's not helping, is it? Priya's still in a bit of a pickle. She is now cancelling commitments, saying no to things she used to love, putting things off. She's a bit more forgetful, and she's putting it all down to burnout, which is understandable, because she's in her late 30s, and she's a giver, and she's somebody who's always helping other people. Of course she's burning out. Makes perfect sense.

But something's telling her — what if it's something else? She's got this niggly feeling. She's talked herself out of trusting her own instincts, because her doctors have said everything's normal. So okay, the doctor said everything's normal, everything must be normal.

What the doctor should have said is: your blood tests are normal. The blood tests that we ordered, that we thought to order, have come back normal. That's not the same as saying everything is normal. It's clearly not normal — if it was normal, she wouldn't be feeling this level of fatigue for the last 18 months. But when somebody in a position of authority has blood tests in front of them and says, nope, everything's fine, you learn to trust them over your own instincts. You learn to trust their ruling over your own experience. Which is a real shame. That's why language matters. If you say to someone, the blood tests that we ordered are coming back normal, that is a very different vibe to: everything's fine, everything's normal. Very different vibe.

So, obviously, Priya's fat, because otherwise I wouldn't be talking about her. She's also South Asian. And so doctors make a lot of assumptions about her. I don't need to tell you what they are. You already know what they are. You already know that they're problematic.

One of the things she's often told is she needs to exercise more. You're feeling tired? Exercise more, move more, go out, have a walk. They've never asked her whether she actually exercises in the first place, whether she goes for a daily walk. We don't ask. We'll assume you don't, and tell you to go out and exercise more.

But she's actually very, very active — or she has been. The fact that she isn't active anymore is actually a sign that something's wrong. She's exhausted, not inactive. So this "just exercise more" is quite devastating. It's like — A, you're missing the point, and B, you're rubbing salt in the wound. I'd love to be more active, thanks! I just don't have the energy for it.

Also, and she's really not happy about this, she's developed a rash on her face — a little bit darker on her skin, here and here. She looks like she's got acne, which is no fun when you're in your late 30s. And her beautiful long hair is starting to thin in places, especially at the back and around the front. These are all things she's feeling really ashamed of. And the fatigue, and the burnout, and cancelling plans — it's all starting to pile up, and it's affecting her mood. This isn't like her. It's really not like her.

Now, one day, she stumbles across a video on YouTube. She's doing something sensible, and then she comes across this video all about PCOS. Somebody in the PCOS community is talking about their symptoms and starts listing them off, and Priya's like — whoa, hang on a second! I can tick literally every single one of those. What is going on here?

She's always had irregular periods. She's mentioned her irregular periods. She's had them since she was a teenager. She was always fobbed off: oh, well, when you try to get pregnant, if you've got any issues, come back and see us. As if that's her only job in life — to reproduce, to have children — and at that point we'll deal with it, but other than that, who cares? Periods? We don't care about periods. That was sarcasm, for those of you who couldn't read that. We should be caring about periods. The fact that we don't is because of medical misogyny, and it's very problematic.

But anyway — she's had blood tests twice. Why haven't they picked up on it? The reason they haven't is because they didn't think to ask. They didn't include that in the blood test, although, to be fair, you don't need a blood test to diagnose PCOS. You can diagnose PCOS based solely on symptoms. I, as a doctor, can make a diagnosis of PCOS — through this podcast, for my imaginary character — she meets all the diagnostic criteria.

I should say that the name for PCOS has just changed. We're going to call it PCOS for now. But it has changed — the official name. It's basically telling people: this isn't just about your ovaries. Yes, of course your ovaries are involved, but this is an endocrine condition, a hormonal imbalance. It's metabolic. It's about much more than whether or not you can reproduce, because that's all we cared about once upon a time.

But yes — she meets the criteria for PCOS. They've clearly not asked her about it, they've clearly not put two and two together. Maybe Priya's not been able to offer all the details, but she's going to the GP about this rash, which is acne. Maybe she's mentioned the hair thinning, maybe she hasn't. The doctor certainly knows about irregular periods — that's a code on the computer right there for them to see. She's talking about fatigue. Put all of these things together — the diagnosis is fairly obvious.

She's in her late 30s, so perimenopause is less likely, possible but less likely, because this would actually be premature ovarian failure if you're under the age of 40. However, doctors should be thinking hormones, and they very rarely do. And let's say it all together, ready? On the count of 3. 1, 2, 3 — medical misogyny! That's right.

The thing about normal bloods — normal in inverted commas — is that it's only the blood tests that we request that come back normal. I made this point already. If we don't ask, if we don't look, then we don't know. Now, I'm not saying that doctors should request every single blood test on the planet for every patient. You know they're going to test for diabetes, because you're fat. Especially if you're fat and South Asian. So they'll have done that. They'll have done a full blood count, certainly. They've probably tested kidney and liver function. They might have tested your thyroid, but they might not have — so that's important. Was thyroid function tested? Because that could be it.

Less likely, in the first instance, to test iron, B12, or vitamin D. Iron and B12 are probably only tested for if you're anaemic. It depends on where you are. If you're in the States, they've probably tested for everything, because money. If you're in the UK, they've probably tested for a lot less, because also money, but the other way around. Either way, you can't guarantee that all of these things have been checked.

It's possible that you're not anaemic, but you still have a low iron or low B12, and that might explain the symptoms. With your thyroid, it's possible that you're in the early stages of thyroid dysfunction, so your thyroid level might be normal but your TSH is abnormal. It's tricky — I don't want to get into the nitty-gritty details, but it's worth thinking about. And there are loads of other conditions that often get missed, that doctors don't think about, and just blame on your weight.

Hormones. Menopause. PCOS — really important. If you have XY chromosomes, it could be low testosterone, which is very common and again will get blamed on your weight. Fibromyalgia. Hypermobile EDS. Long COVID. ME, or Chronic Fatigue Syndrome. Those are more diagnoses of exclusion — once we've ruled out the other things, because there's no test to rule those conditions in.

Sleep apnoea is a very obvious one. Now, again, if you're fat, doctors will often think of sleep apnoea. If you're waking up every morning with a headache, or you just don't feel like you've had a decent night's sleep even though you actually did sleep for eight hours, then you need to be tested for sleep apnoea. It's much more common than we think it is.

It could be related to your mood. It could be burnout. Priya, like many of us, could be somebody who was autistic, and has always been autistic, but was never diagnosed. The fact that she's always helping people, and always trying to be kind, and always putting other people's needs before her own, could just be because she's masking — and actually, this is autistic burnout. Possible. Ask me how I know.

So, a good doctor sees that Priya's fatigued. Priya's come in and said: I'm fatigued, it's been going on for 18 months. A good doctor — A, believes her. B, doesn't make any assumptions about why this is happening. And C, gets curious. Oh. You're fatigued. Alright. Tell me more!

And asks some very open-ended questions. Listens actively, maybe makes some notes — it's okay if they're typing away, just so they've got it fresh in their mind, but still paying attention, still listening. Maybe asks some insightful questions: oh, hang on a minute, you mentioned your periods — tell me a bit more about your periods? And then: anything else?

Which, if you've only got 10 minutes, is a very risky question — you are opening up an entire can of worms, potentially. But unless you ask, you won't know. Sometimes people don't offer up important information unless you give them that opportunity. So, ideally, ask. Anything else?

Then the doctor takes a history and thinks: right, okay. With fatigue, there's probably not an examination that needs to be done, unless the patient mentioned something specific — oh, and I'm losing my hair, let's have a look. Or, this rash, let's have a look at the rash. But if there's nothing specific, an examination isn't necessarily warranted. Pain warrants an examination. Shortness of breath warrants an examination. It depends on the individual.

We've already done blood tests. There might be some additional ones — do you know what, we didn't do these ones, maybe we ought to. But if more blood tests aren't warranted, there might be other things we can do. If I thought it was perimenopause, for example, I might give them a questionnaire to fill in. If I think it's PCOS, we might start chatting about that.

There'll come a point in the consultation where the doctor has taken the history, done any examination that's warranted, requested any blood tests — and then needs to think: what do I think is going on, and what's next? A good doctor is really honest and says: I don't actually know what's going on, or I can't say for sure, or it's not clear, there's no clear diagnosis here. It could be X, and we might list some things it could be.

Do you have any idea what you think it is? Is there anything you're concerned about? We have to be honest about what we do know and what we don't know. And then: here's what I think we should do. We're going to order some tests, refer you to a specialist, look into something more, follow up in three weeks' time, try a treatment. A number of options, depending on what the doctor thinks is going on.

And then the good doctor offers it up and says: what do you think? Which one appeals? What's your instinct? Which one would you like to try?

Because a good doctor knows that patients have autonomy. They have the right to decide what happens to their own body and to their healthcare. They need information from their doctors — information that only doctors can provide. That's why we're here in the first place, why doctors go to medical school and do all of that training, so that they can offer up the information. And then the patient gets to decide what to do next.

That's what a good doctor should do. That's what should happen. And by the way — again — this is basic care. It's not heroics. This is not wishful thinking. This is what you learn day one when you're learning how to be a doctor. Doctoring 101. This is the first thing they teach you. It's not new information. No doctor can claim this is brand new information. It is just what we should be doing.

And 10 minutes isn't an awful long time, bearing in mind that after the patient leaves, the doctor has to write up the notes, see the next patient, request blood tests then and there, write the prescription, make sure it's correct, sign it, send it off. There are lots of things a doctor has to do in those 10 minutes. 10 minutes is never enough. It's a really bad system.

Going back to my favourite programme, The Pit — there is a moment in the second season, no spoilers, where two senior doctors are having a conversation about AI in medicine. And the other doctor makes a really good point: the moment you use AI, it might cut down on the doctor's time and improve efficiency — but all that means is they're going to add more patients. It's not like they're going to say, oh cool, take a break. And that is the problem. The only way to improve the system is for the people at the top to decide to prioritise patients over profit. I don't see that happening anytime soon.

That's why it's helpful to have very specific language. That's why it's helpful to have community. That's why it's helpful to have an advocate. That's why it's helpful to join the No Weigh! movement and get yourself a free script, so you can use my language. And for some of you, that's why it's helpful to book a one-to-one consultation with me. Ninety minutes, not ten. Ninety. And I do 90 minutes because it takes 90 minutes, and usually it takes longer. It might feel like a really long time, but it's not. It goes really, really quickly.

The most important thing is that you have the information. And I cannot stress this enough — you shouldn't have to become an expert in your own symptoms to get decent care. It's not fair that this is happening. It's totally unfair and totally unreasonable, and also sometimes it's the only way for you to get decent care. And that sucks.

I often say, I shouldn't exist — my aim in life is for the conversation to move forward, and for things to change so dramatically that people just no longer need me. That's when I'll be able to say my job is done. I really would like to work myself out of a job, because none of it's fair, and none of this should happen. If the system worked the way it's supposed to — and I'm not even asking for special measures, just for doctors to do the very thing they're supposed to do, the basics — then none of you would need this podcast, because you'd be getting the medical care that you need.

Just because your doctor says everything is fine doesn't mean that everything is fine. If you don't feel fine, then everything is not fine. It's not about numbers, it's not about what the doctor has decided. You know your body better than anyone else. You are the expert. And there is explicit language within a doctor's duty of care that says the patient is an expert in their own body. I'm paraphrasing, but it's explicit. It's not implied.

Don't allow anyone to make you feel like they know more about your body than you do. Nobody does.

There is a very big difference between being managed and being heard. The good doctor listens. The bad doctor manages. You deserve a good doctor.

When the system works well, Priya gets a diagnosis and is offered a treatment. Treatment of PCOS — that's a whole different conversation, that's another podcast. But she's offered the treatment she deserves, and is given the choice. That's when the system works.

If you're interested in knowing what the system should be doing, how the system should be operating, I recommend my book, No Weigh! — Everything You've Been Told About Weight Loss Is a Lie. It takes you through from the very beginning. The first chapter is all about the fact that there is no such thing as a healthy weight. It might sound very basic, but most people are under the impression that there is something pathologically wrong with their body just because they're fat. And that is a lie. Fatness is not a disease — it's just some nonsense made up by insurance companies, and the pharmaceutical industry, and Weight Watchers. Fatness is not a disease, and I'm willing to stake my medical career on it.

And then the book takes you through from there. It tells you all about how weight loss isn't sustainable, and even if it were sustainable, being fat is not the reason you're sick, and even if it was the reason you're sick, trying to lose weight is going to make you more sick — because it results in weight cycling, and weight cycling is bad for your health. Dieting is bad for your health. So the so-called cure to the disease that is fatness is actually the problem. It's causing the problem, not solving it.

I talk about doctors, and how doctors are making you sick because of their weight stigma. I show, with a lot of evidence, and leaving very little room for doubt, that weight loss has never been shown to improve your health in any way, shape, or form — to prevent conditions, to treat conditions, to extend your life expectancy, to put you into remission. All the things they've lied to you and said it will do. There's no evidence that it does.

But I spend the last three chapters of the book talking about why, in spite of all this evidence, doctors treat you the way that they do. I talk about how corrupt the guidelines are, how corrupt the experts are. I talk about the pharmaceutical industry, and how it has bought and paid for your current medical healthcare. The pharmaceutical industry — especially the manufacturers of GLP-1s — pays for the research, pays for the guidelines, educates the doctors, buys politicians. And I talk about just how problematic and harmful that is, and just how infected society has become by the weight loss agenda. The last chapter is called Know Your Enemy. I really believe that knowing your enemy is how you win the war — not just knowing yourself, but knowing your enemy. And a lot of times we focus on what you can do to advocate for yourself, which is really important, but it's also about knowing your enemy and how to defeat them. So yeah, that's my book.

Book a consultation with me if you want. Join the No Weigh! Movement. Consider joining our lovely little Weighting Room online community — we're a lovely bunch, and we do so many fun things together, so if that appeals, we'd love to have you. And I'll be back next week with another character. Until then, take care of yourself.