Knee & hip replacement surgery recommendations for people living with obesity: Dr. Harman Chaudhry

– Welcome back to “Scale Up Your Practice,” the podcast from Obesity Canada. I’m Dr. Roshan Abraham, family physician and associate professor at the University of Alberta.

– And I’m Michelle McMillan, a lived experience advocate, and part of the Obesity Canada community. This podcast is where we bring together research, clinical expertise, and lived experience to explore how obesity care can be more compassionate and evidence-based.

– We’re really excited about today’s conversation, which focuses on a real world issue many clinicians face, knee and hip replacements for people living with obesity. For years, patients have encountered delays, denials, and stigma when seeking these surgeries, sometimes based on weight or BMI cutoffs rather than health outcomes.

– Thankfully, the Canadian Orthopedic Association in collaboration with Obesity Canada, recently released new recommendations for knee and hip replacement surgery for people living with obesity to challenge bias, improve fairness, and ensure surgical decisions are guided by evidence and equity.

– We are delighted to be joined by one of the steering committee members, orthopedic surgeon, Dr. Harman Chaudhry. Dr. Chaudhry, welcome to the show.

– Thank you very much, my pleasure to be here.

– So let’s start our conversation today with a bit of context. For years, many patients living with obesity have been told they can’t even be referred for joint replacement until they lose weight. What prompted the Canadian Orthopedic Association and Obesity Canada to step in and release these recommendations, Dr. Chaudhry?

– So a couple of reasons. So I’ll go through a couple of the reasons. So first of all, the number of patients living with obesity has increased over the past couple of decades, right? The population has grown, and also proportionately, we’re seeing more of these patients. And so it’s become an issue that’s more common in all communities. So we’ll go to these national meetings, and I’ll speak to my colleagues from across the country. Some are academic in big cities, some are in smaller rural towns. And very quickly after speaking to the surgeons, I realized, you know, their views, their opinions, their practices across the country differed widely, and therefore access and type of care received, the patient would receive depended more on luck than actual, you know, any scientific basis. So that was the first thing that kind of, you know, piqued a lot of our interest, including my own. Second, I think what we’re seeing is that patients living with obesity, especially those that are a bit younger, have become their own advocates, and rightfully started kind of questioning, you know, why it’s become so difficult to access high-quality medical and surgical care. And of course, we have Obesity Canada and other patient empowerment kind of organizations to thank for that as well. And then finally, I think, you know, in terms of the COA and the Canadian Orthopedic Association, I think the time was right. The leadership has really become, over the past few years, increasingly progressive and policy-focused, and wants to have a real role in advocating for our patients. And so, you know, I was quite pleasantly surprised at the interest this garnered when we first proposed it, and how the COA kind of took it on and pushed it past the finish line. And so I think it was the right milieu, you know, perhaps you know, the timing was right, maybe a little bit delayed. But nonetheless, we had the uncertainty in practice, we had the need as we saw among patients and the organizational support to finally start having this topic kind of addressed explicitly.

– It’s so amazing when the community sees a need, comes together, and works on a solution to it. I’m always impressed by the medical community and when they do this. So from a patient’s perspective, if you’re being denied surgery based on your body size alone, it can feel not only unfair, but you know, deeply stigmatizing. And I know from people that I’ve talked to, it also feels impossible, right? Because there’s a lot of people living with obesity, it’s not like they haven’t tried to lose weight, right? So being told that you can’t have a pain-free life and do the things you love to do because of your BMI and you feel like you can’t change it a great deal, it is really, really frustrating, right? So maybe you could talk a little bit about how these new recommendations reframe the conversation from simply being about weight, and that impacting your access to surgery, and how it changes now with this new guidelines.

– So first of all, you’re absolutely right, words matter, right? So for many of us who practice in this area with many patients in our practice living with obesity, some of the most heartbreaking stories that we hear are of, you know, whether intentional or not, are kind of insensitive interactions with the healthcare system, with other healthcare professionals. You know, I’ve had patients in tears in my office, in my clinic, and they’re just so grateful to be heard, to not be blamed for their own condition, and to have some sense of direction, whether that involves surgery or not. And that’s why I think, you know, the very first and most important recommendation is around communication, and communicating in a way that’s free from judgment, free of stigmas, free of bias. And I’ll be the first to admit, you know, as surgeons, this is not something we’re very good at, it’s not something we’ve been explicitly trained to do. And it’s something that, you know, the first step really is being aware of it, and continually work to improve it. And you know, this may represent something that is maybe a next step in getting it, you know, reaching out to the training programs, holding workshops and so forth, and trying to improve this. But we’re at least identifying the issue and giving some recommendation around that and trying to get rid of really, you know, get that stigma out of practice completely.

– I think it’s just incredible that we’re having these conversations. And I agree, it’s a little late, but it’s so refreshing to hear from a colleague in surgery, in orthopedic surgery, speak to the importance of addressing bias in this particular area, right? I’m a family doctor, I see sort of the ups, I mean, both the upstream and downstream effects of the challenges of accessing knee and hip arthroplasty or replacement surgeries. And the fact that we’re having this conversation, the fact that leadership is pushing forward, the fact that the community is sort of rallying around it is just really heartwarming, and really says a lot, not just about the profession, about sort of around obesity medicine, but really the whole aspect of medical education and medicine in general. It’s really refreshing to hear. So I’m really excited about this.

– Oh, absolutely, and I’ll just add that, you know as well as I, that medicine in particular is very, you know, slow to change. We still still use the fax machine, right? So, you know, it’s-

– And people!

– Yeah, exactly. So, you know, even surgery, and even more so I think in surgery, you know, the training is such an apprenticeship-based model that even when new evidence comes out, it’s very slow to trickle through the ranks. And so I agree with you, it’s better late than ever, but certainly, you know, it could have been more timely. But like similar to you, I’m just very happy that we’re moving forward with kind of more evidence-based practice.

– Yeah, and maybe we could focus a little bit about that. ‘Cause I am, you know, I am curious about the evidence too. So what does the research show about outcomes for people living with obesity who are undergoing hip and knee replacements?

– Yeah, so the evidence is very clear that if there are no, you know, short-term complications, the outcomes in patients with obesity following hip and knee replacement are excellent, the same or better than any other patient. And so really the key and the fears and everything we’re talking about is around avoiding complications. And so, what do I mean by outcomes? I mean like functional scores, pain relief, improvement in overall quality of life. Like that’s the same, you know, for patients if they can get through the operation without a complication. And the caveat is, you know, maybe in the long term, ’cause you know, we haven’t really operated on patients with obesity for a very long time, right? This is kind of new progressive stuff. So, you know, maybe in the long term we’ll find maybe the implants aren’t lasting 20, 25 years, maybe they’re lasting 15 to 20 years. But still, I think, you know, for patients that are living with conditions that are debilitating, this is definitely, you know, worth the risk. So yeah, so in terms of outcomes, the key is to avoid complications, and we can talk a bit more about that if you want, what the complications are, right? So that’s what we’re all worried about, right?

– Exactly, and it’s hard to answer definitively, as you said, that we’re still in very much early stages of, in sort of the surgical realm of sort of seeing more patients coming through with obesity. But how should clinicians be weighing risks versus benefits in light of the guidance?

– Exactly, so I think the key is to know like numerically what are the complication risks, right? So I kind of got an interest in this in my fellowship when I did a couple of reviews on this topic. And so, you know, the complication risk is indeed elevated around BMI… You know, okay, so forgive me for a second, I’m going to talk about BMI, I know BMI is not the perfect measure, but unfortunately it’s the only measure we have to go on in the research, that’s what people use, right, BMI 40, 30. So in BMI 40, we’ve seen that the risk goes up. Below that, it seems to be, you know, not negligibly, maybe a little bit higher, not really. So BMI 40, it goes up in terms of two major complications, one’s being really bad infections, and the second being the implant kind of failing and needing a second surgery to fix that problem. So we know that, I’m just looking at my notes here, we know that basically at BMI 40 to 50, it probably doubles, and that above 60, it may go as high as 5 to 10 times higher in terms of the risk of an infection or implant failure. Now, you have to put that into context. So the baseline risk is probably .5% or less. So, you know, even at 10 times the risk of that, you’re still looking at a 5% risk, you know, or 10% risk, which is, you know, don’t get me wrong, if you have a complication, it’s horrible, but I don’t think that’s a high enough number to, you know, definitively decline every single patient surgery based on that without a discussion, right? So that’s kind of… I think that’s where we have to kind of start, the risks are higher. They’re not astronomically high. And let’s talk about what your risks are and what the benefits are, and let’s weigh this on a scale and decide, you know, where do we go from here?

– Again, it is so refreshing to hear this because this is really the thought process that’s gone through my mind when I have seen sort of the rejections from clinician, sorry, from surgeons, not just orthopedic surgeons, but a variety of surgeons based off of strict BMI cutoffs, because I know my patient, we’ve had conversations, and there’s maybe one or two where I’ve been a bit more hesitant to send off because of the sort of the overall picture of their health. But the vast majority with elevated BMI don’t necessarily have the type of risk factors that would predispose them to sort of really severe complications. And it is really about that strict BMI cutoff that is essentially stigmatizing and creating this narrative about the patient before you actually get to know them. And so as a family doctor, it is so refreshing to hear this because the vast majority of my patients who do have an elevated BMI have probably have a lower stage, quite a low stage, when we think about the Edmonton Obesity Staging when it comes to obesity. But because of that BMI cutoff, they’re just automatically not seen. So I think it’s amazing that there are these big changes about stepping away from, again, these strict BMI cutoffs. So it clearly matters. Are there still BMI cutoffs that are in place?

– So this was very important to us. And in surgery specifically, you know, like you’ve mentioned, the BMI’s almost become like this impenetrable wall, right? It’s almost like you can hide behind it with, you know, here’s surgery and the patients are on the other side, and, you know, there’s no way to get over it. So, you know, BMI was never meant to be used this way, right? But now it’s given us some, you know, people, this, you know, this is an objective criteria, you know, it’s not my personal bias. This is a number, right? And all of a sudden, you know, this is something that we can use to decline people or not see these individuals. And it’s a slippery slope. So we get a lot of trainees from the UK, and in the UK, they actually have whole health systems that have BMI cutoffs. You can’t even access surgery, like the surgeon has nothing to do with it. Like the entire system won’t even see you or treat you or give you the opportunity to have surgery, and we don’t want to go in that direction. And so that’s why this was so important that we say BMI is not a cutoff. Because we certainly don’t want to go in that direction ’cause it can, you know, if you’re not careful, and we’ve seen that in other countries. So that’s one important part, I agree. The other thing is, and similar, like you mentioned, like every patient deserves a personalized assessment, right? Like obesity is a diverse condition, it’s not just like one monolithic thing. And so, you know, I think, like you said, it has to be a case by case. You know, everyone’s different and we gotta look at the comorbidities and we gotta look at, you know, the distribution of obesity, and we gotta look at the patient’s symptoms and severity. ‘Cause you know, somebody who can’t golf is much different than somebody who can’t even, you know, stand up, right? So, you know, I think it’s very important in our recommendations that everybody be assessed, it’s a case by case decision, and it’s done mutually with the patient in their specific condition.

– I mean, I love that. I love when physicians consider the person living with obesity as a person first who is complex and is more than just excess adipose tissue, right? So I think that’s amazing. One question I would have for you, because I think most of us know that, you know, we have more people who need new knees and hips than we surgeons in the operating space to do it.

– Mm-hmm!

– And I can see the appeal of, well, if we just have this magic number, we can eliminate a whole bunch of people from the list, right?

– Yeah, yeah.

– And so I’m curious with the guidelines and your experience, you know, how do you balance those two things?

– Yeah, so this is very interesting, ’cause this gets at the crux of why this is even happening, right? Because, you know, in a system that has long waitlists, you know, it becomes very easy to start, you know, for hospitals, for surgeons, and policy makers to start excluding complex, what I call complex cases, whether it’s patients with obesity, ’cause it is complex, right, surgically and with complications, but also other complex cases. It becomes almost, you know, it almost comes desirable to do the cases that are most cost efficient, fastest, easiest. ‘Cause then you’re getting through numbers without, you know, slowing yourself down, and you can tell the public, “Listen, we’ve done all these cases and our waitlists are getting shorter.” So I think that’s why it’s so important that, you know, we release these recommendations, but also that other organizations continue to push for this, ’cause that’s the counterbalance to this. You know, with the long waitlists and everyone pushing to kind of decrease costs, we have to be on the other side advocating for our patients and ourselves to make sure that we’re not forgotten in this whole piece of the puzzles. But you’re right, this is the reason that it’s become such a big issue, especially in Canada, I would say, you know? ‘Cause in some countries with shorter waitlists, you know, you just go down the street and you kind of doctor shop. You can’t really do that, right, in Canada, and to any considerable extent. So that’s why we have to keep pushing, I think, you know, I would agree with you.

– Yeah, I mean, yeah, and I appreciate that people within the system are pushing, right? There are people outside the system who are trying to push too, but in the system, may be more effective, I think. So what we like to do on the show is what we have what we call the “Bias Break”. And so this is unique ’cause we’ve never had an orthopedic surgeon on the podcast before. So I would love to hear from you if you have something in your thoughts about, you know, an experience you’ve been involved in or you’ve seen that is around weight bias, and how it shows up in the healthcare system, and you know, what your thoughts are about it.

– Yeah, now that you frame it this way, I gotta think about it. So, I mean, it’s a great question. I do have so many cases of just seeing like subtle biases and explicit biases. I had a patient who had been seeking, you know, for example, knee replacement for 10 years and was told he was, you know, too young, too heavy, had to lose weight, and was never actually seen by an orthopedic surgeon. And by the time I saw him, it was my first year of practice, so I was kind of in this, you know, mode where I would just see everybody. Like, I wasn’t kind of trying to screen people, I was just kind of seeing everybody. And he came in and I looked at him, I’m like, you know, I asked him, I said, you know, “Why haven’t you had knee replacement? Your knees are horrible.” And he told me he’s been trying to find somebody to do it for 10 years. And at this point, his knees were so bad, I wasn’t even sure I could operate on them. And I kind of talked to him about this, I said, “This is kind of complex, like I’m not sure you’re going to have a great outcome.” And he basically said, “Listen, if you can’t do anything, just cut them off, like, these legs are completely useless to me.” Like, he was in such dire straits, he couldn’t sleep, he couldn’t do anything. And so, you know, it kind of showed me, you know, this patient wasn’t even able ever to see a surgeon. Like, if he had surgery earlier, he would’ve been able to have a good outcome probably. But because he wasn’t even seen by anybody, it had gone so bad. Even after I operated on him, and he was very happy, it would never reach the state that it probably could have. And so to me that was kind of just like, you know, nobody had seen this poor guy and, you know, it could have been a much easier situation than it ended up being. So that was one of them. And again, I’ve had a number of people like this. Like, I also had a woman who was so disillusioned that no one would replace her hip that she actually was, you know, sadly looking into the process of medically assisted dying. ‘Cause she couldn’t even get off her sofa, she couldn’t fall asleep, and her mental health had suffered. And again, she was just told by everybody that her risks were too high. But, you know, there’s no risk really higher than death, right? So again, just seeing somebody would’ve probably solved that problem. And again, we replaced her hip and she did fine. So, you know, those are kind of instances with a bias of like people just not being seen by anybody and never being assessed for their personalized kind of circumstances.

– I think that paints such a vivid picture of the impact of bias and stigma within our system, especially when it comes to things that even our listeners can relate to or think about. I mean, we all have joints, we know they can wear down. Imagine having one of your joints, right, a knee or a hip that is so severe that you want to just cut it off because you haven’t actually been seen by someone. And yeah, maybe you’ve been seen, quote-unquote, like through the screening process and maybe even seen a couple of orthopedic surgeons. But truly be seen for who you are and what your needs are as an individual, I think it’s incredibly powerful when you think about the imagery again that this conjures up.

– Yeah.

– So thank you for sharing that.

– No problem, and I would say like, it’s almost like, you know, if they’re seen, they may be in a different condition, right? Like maybe they’re having some pain and they were just told, “Listen, you’re not a surgical candidate, like, you just deal with this non-operatively,” and then it gets worse and worse and worse. And in this patient’s mind, you know, and maybe even their primary care team’s mind, like this person’s not a surgical candidate, despite them deteriorating to a point where maybe they should be reassessed, but now you’ve given them this kind of message, like you’re not wanted in this system, you’re not somebody, you’re not worthy of having this type of care. So yeah, I think the way we communicate it is also important, right? So if you tell this patient, “Listen, right now, the risks are probably a bit high, but, you know, if things change, we should keep an eye on this,” and it may change, right? The situation may evolve, and if it gets so bad, you may become a candidate. And that’s also important to communicate to the person.

– Yeah, I like that too, because as you know, luckily I haven’t had to deal with this issue, but, you know, many times, as a patient when you hear “No,” you’re like, “Oh, it’s just no, like, okay, it’s never going to be yes.” So it’s just no, and you try to do the best you can. So, yeah, I think for many of our health practitioners who are listening, I think that’s a really key thing to pass on to patients, ’cause patients don’t know it, right? You need to tell them, you know, “Right now, this isn’t the best path for you, but if things change, we can have this conversation again.” And yeah, I think that’s such an important message. Thank you so much for bringing that up.

– Yeah, no problem. And that’s a line I use all the time. And I’m very clear. I say, “Listen, I am not saying no, ’cause I would never say no, right? I’m saying let’s keep an eye on you, let’s bring you back in a year, and see where you’re at. And if things change, you can always call back sooner.” And I think that’s the best, it’s an ongoing dialogue, you know, that’s the best way for anybody, and certainly with patients in this situation, with, you know, all this kind of context of stigma and bias in the background, it’s very important to be very clear with that.

– Bringing this to the primary care perspective, and I’m always curious about this because I experienced this on a somewhat regular basis, unsurprisingly. So if a patient is coming in with obesity, who needs joint replacement, what steps should we potentially be taking differently now? And and recognizing that, as you mentioned, a lot of the referral processes or even culture that’s developed around joint replacement is location-dependent, right? I mean, I live and work in Alberta and that’s going to be different than Ontario or BC, and obviously some provinces, or even within provinces have sort of established different processes. But sort of generally speaking, what steps should we consider or reflections can we consider taking differently now?

– Yeah, I mean, so unfortunately, I wish, you know, it was like with all guidelines, you don’t just release them and then, you know, overnight, all of a sudden the system’s like, “Okay, the doors are open, everybody come.” Like, I wish it was like that easy. So I think this is just more knowledge and kind of, you know, gives us a bit more ammunition to kind of tackle this with. So now, you know, a lot of times, similar to patients, we have family physicians who don’t even know that, you know, there’s some variation in practice, and they’ll send it to somebody who has historically not treated patients with obesity for various reasons, and then assume that that’s just the way it is. And then fortunately then, you know, moving forward, they may even not refer their patients anymore. They’ll just tell them, “Listen, your BMI is too high” or, you know, they won’t treat you, et cetera. So I think that first of all, you know, just having this out there and continuing to kind of educate everybody that, you know, there’s a different approach here, we’re trying to change things and, you know, everybody needs to have access to care is important. You know, it’s kind of hard otherwise, you know, it gives you kind of information. The other thing is, as a primary care practitioner, the other thing that you’re kind of constrained by is kinda the waitlist, right? You refer a patient, you wait a year, they see the surgeon, the surgeon says “Lose weight,” they leave, they come back a year later, like the time is is wild, you know, the time spent. So one of the recommendations is actually about, you know, managing the obesity, involving a team, managing all the other conditions, and I’m sure everybody already does this. But if you could try to optimize the patient, have them see an endocrinologist even, and ensure that they, from an obesity perspective, everything is kind of optimized, that gives that patient and the primary care physician more leverage when they see the surgeon. When surgeon says, “Listen, go lose weight,” “No, no, I’ve already seen this person, I’ve been on these medications, I’ve optimized my diabetes,” right? And then, you know, then the surgeon has to kind of pause and say, “Okay, I can’t just, you know, send this patient out the door. They’ve already tried everything, so let’s come up with the next step here,” right? So again, it’s a slow process, right?

– I really love both of those. One, interestingly, the second one was an area that I think I’ve always tried to do, no matter whether it’s obesity or any other condition, is try to optimize things from my perspective as much as possible. I mean, I see a lot of obesity medicine in my practice, so I try to optimize things regardless. But the first point I think is incredibly valuable just from an advocacy standpoint even if you get a no, like understanding the local, even if you don’t understand the local referral processes, recognizing now with the guidelines especially, or the recommendations that are coming through that we should be pushing for either a second opinion or really pushing for and advocating for the patient. Because a lot of these BMI cutoffs are older and we shouldn’t be relying on them anymore. I think that’s a really powerful statement, and it’s important and it’s great to hear from you to tell our listeners that that’s an area that we can and should be advocating for. And I think that’s really powerful.

– And a lot of, it’s kind of, like you said for primary care, but some of it’s also, it gives us leverage at the policy level. So, you know, there’s more and more, you know, discussion about doing central intake and these kind of central… You know, so you refer to a central center. And so in Ontario, in Toronto region anyways, we do have central intake for hip and knee. So they’ll go through a center where they’ll be assessed by advanced practice physical therapists and other providers. And so we’ve worked on educating those individuals so they know then they get people with certain conditions like obesity or other conditions, “Okay, these people are best for perhaps this surgeon at this center and these patients are best.” So ultimately, if we can design it structurally, so it’s easy, right? The family doc really shouldn’t be going through, you know, the yellow pages of, you know, orthopedic surgeons trying to find who’s going to take this patient. Like that’s the suboptimal, right? But yeah, that’s kind of future directions, and hopefully we’ll get there.

– Yeah, yes, I mean, it’s challenging, right? Because one of the things you talked about earlier, particularly with your patient that had been trying for 10 years, right? If there’s a central intake place, right, and they’ve decided, without even the consultation of the surgeons, right, but this is the criteria, and these people get yes and these people get no, you know, there is some challenges with that central… It can be great in the way that you framed it that, okay, people leaving with these kind of conditions will probably do well with this group of surgeons because of experience and that, you know? But it can also be, “Oh, nope, here’s all the check boxes, and you only made four of the 10, so I’m sorry, go away.” And so, you know, part of it, you know, patients also have to advocate for themselves. They need support in the system, but they need to advocate for themselves. So I’d be curious about, you know, how do we encourage people who, you know, are encountering some of these blocks, you know, to advocate for themselves when they encounter some resistance from the system or from a particular practitioner?

– It is hard, you know? And it really, I always say it shouldn’t be this way. But there is a such thing as an institutional bias, right? Like, institutions are biased. So I’m going to just give a story about a patient I operate on recently. I did one of their hips, and then they unfortunately they stopped their GLP-1 and then they gained a bit of weight. Now, they came back for their second hip, and all of a sudden they crossed some threshold I didn’t know even know existed, but apparently somebody said it was unsafe. ’cause you know, we didn’t have enough, that the equipment wouldn’t be able to handle the additional weight or something, so we couldn’t do the hip replacement. So everybody I talked to in that situation was very, very sad. Like, they genuinely felt bad for the patient. But everybody you went to, there was no way to actually overcome the issue. You know, everybody kind of referred me on to somebody else, talk to this person, talk to this person. But at the end of the day, the whole institution was just confused, right? Like they didn’t know what to do. So in the end, you know, fortunately the patient was amenable to going back on the GLP-1, they lost a bit of weight and had their other hip done. So it was fine. But you know, the question is, you know, sometimes you’re right, like institutions themselves have barriers that are not necessarily attributable to any one person. So sometimes patients do have to speak up, you know, know about, you know, the family doc can certainly help them in this way of letting them know that there’s different options, what the guidelines say, what the recommendations say. I would say, you know, be willing to speak up, be willing to ask for a second opinion, take a friend. Sometimes very, you know, it’s much easier for someone else to advocate for you, unfortunately, you know? If it’s much harder to, you know, dismiss somebody if they’re with somebody who is also speaking up for them and advocating for them. And, yeah, I mean, and you know, if you need to reach out to Obesity Canada, COA, somebody, like try to get a little bit of extra resources, that’s always another option, you know? So it’s hard, you know, the system is complex and intimidating even at the best of times, you know? And so with these additional issues, it’s always harder, right, with the stigma and the biases and all that. So that’s what I would say. You know, speak up, don’t be afraid, ask for second opinion, take a friend.

– Yeah, and if I was to reiterate something that you said earlier that really struck me is that because it’s a long process, right? You just don’t show up one day at the orthopedic surgeon’s office and you’ll say like, “I’ll see you tomorrow for surgery.” Like it doesn’t work that way. So what you had said before about, you know, on subsequent meetings for patients what I would kind of take away from it, is that, you know, you need to emphasize to the surgeon the changes that you’ve made, right? We talked about things, “Okay, I’ve gone on a GLP-1, you know, my blood sugars are really controlled now,” you know? “I’m having a healthier lifestyle,” and you know, list the things that you’ve done just to kind of advocate a little bit that, you know, I’m trying to change things to reduce the risk, what can we do about it, right?

– Yeah, yeah. And ask, you know, what are… Yeah, exactly, like what are the objective kind of endpoints that where we can proceed with the surgical treatment or not. But you know, you should have specific concrete, objective plan when you leave. And that plan might just be, “Listen, like, let’s see you again in a few months,” or, you know, whatever. But at least there’s a plan. It’s not like you’ve gone into the void and then, you know, we never see this patient again. You don’t want to be that person that’s kind of floating around and there’s no plan, right? So don’t leave the appointment without some kind of plan, right? So that would be my advice.

– I like that too, yeah, don’t leave without a plan, right?

– Don’t leave without a plan.

– Yeah, great, that’s great advice.

– Yeah, hold your practitioners to a plan, right?

– Yes!

– Yes!

– So we’ll get back to our conversation in a moment, but first we want to tell you about something big coming up next year. The Canadian Obesity Summit 2026 is happening March 25th to 29th in Montreal. This is Obesity Canada’s flagship scientific congress on obesity, bringing together researchers, healthcare professionals, and policy leaders from across the country and around the world in five days of learning. So it’s five days of learning, a collaboration and community all centered around this year’s theme, “Obesity across the lifespan, connecting research to real-world care.” If you’re planning to be there, now’s the time to get your tickets. Early bird registration is open until November 30th, 2025. Again, that’s November 30th. So don’t wait to secure the best pricing. Learn more and secure your spot at the link in the show notes, or by scanning the QR code on your screen if you’re watching on YouTube. So, looking ahead, Dr. Chaudhry, as someone who helped author these recommendations, what gives you hope about how they’ll change practice?

– So I am tremendously hopeful. So as part of the recommendations, so we talk a little bit about our process. We held a couple of national consensus, what we called the consensus meetings. Because we didn’t want to just go through the literature with a group of four or five people come up with recommendation and release them. So we actually gathered people, it was very well attended actually, I think we had almost… We had well over 50 or 60 people from across the country, oh yeah, surgeons, and also patient representatives. We had endocrinologists. And we sat around and we kind of discussed all the different issues. And so despite the various opinions, you know, it was basically unanimous that we had to do better, that, you know, the communication had to improve, that access to care had to improve, and we can’t just keep denying surgery through these patients, like that was almost unanimous. And that was across the country. There was people from small hospitals, big hospitals, and different specialties. So that was very hopeful for me to see that. I’ve been pleased to see how positively it’s been received. You know, I’m not sure that 10, 15 years ago when I was going through my surgical training, it would’ve necessarily been true that people would’ve been kind of like, meh, you know, that this is reasonable. I think there would’ve been pushed back. I think people would’ve say, “No, this is not something we’re willing to consider,” ’cause the stigma was so much more intense back then. But I think things have improved, and I’m hopeful that, again, that people are looking forward and things are going to change for the positive. So I am hopeful, I think this will change. I think it’s going to be slow, I think it’s not an end point. I think we are just beginning our journey in orthopedics, and in general, I think, you know, this is something that needs to continue to be worked on, we can’t give up the fight, we have to keep going. But I’m very hopeful, like you said, I’m very hopeful this will work.

– I think that you’ve raised so many amazing points today. Like I’m taking away quite a few, including “Don’t leave without a plan,” that’s my new thing when I go to appointments, don’t leave without a plan.

– Oh yeah. No, it’s true, ’cause I’ll just mention, so from my perspective that, you know, I love the patients who come with a notepad, questions written. You know, it takes a little bit more time, but they can get their points across and they’ve written it all down, and, you know, they’re going to remember and, you know, it’s almost a very goal-directed appointment. So, you know, I agree with that. I think you should be very proactive at your appointments, and hold your doctor to account for sure, yes. Yeah, mm-hmm!

– So to kind of wrap things up a little bit here, if there was one takeaway, and we’ve had some great takeaways here, but if there was one takeaway that you’d want the clinicians listening to this podcast today to take back with them and bring to clinic tomorrow when they see patients or when they speak with their team tomorrow, what would be that key piece of advice that you’d want them to take away from this podcast?

– Well, so for clinicians, I would say to remember, you know, that our healthcare system can be intimidating and complex at the best of times, like I said, and even more so for patients that have, you know, personal and institutional stigmas to overcome. So sometimes I think helping patients navigate our system and overcome the barriers to care is actually the most important part of our jobs, you know? So I think, you know, you go leave your biases at the door, go in and, you know, really try to open your mind to, you know, what challenges a patient has faced, and try to help them navigate to a place where, you know, is helpful for them.

– So well put, Dr. Chaudhry, thank you for your leadership and for joining us today.

– No, my pleasure, I really appreciate the opportunity, and I hope this was helpful for whoever’s listening.

– For our listeners, if you like to read the full Canadian Orthopedic Association recommendations, you’ll find links in the show notes below. And don’t forget to register and attend the Canadian Obesity Summit in 2026, March, 2026, write it down in your books. I will be there, and I hope to meet many of you there as well.

– I’ll be excited to be there too. If this episode was helpful, leave us a review, share it with a colleague, and subscribe on your favorite podcast platform so you never miss a conversation.

– Until next time, stay curious, stay kind, and keep scaling up your practice.

– This podcast is intended for informational and educational purposes only, and does not constitute medical advice. The content shared in this podcast should never be used as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare professional with any questions you may have regarding your health or a medical condition. The information and treatments discussed in this podcast are based on Canadian guidelines and approved practices as of the time of recording. If you’re listening from outside of Canada, please consult your local healthcare professional to ensure compliance with your region’s medical standards, guidelines, and recommendations. The creators of this podcast disclaim all liability for any decisions or actions taken based on the content discussed. Listening to this podcast does not establish a professional or patient-client relationship.