Over recent weeks, I’ve been dealing with one of the biggest challenges I’ve met since starting to lose weight. Not just for this time — for any time.

If you’ve been reading along, you know I was sent home from my orthopedic surgeon’s office with instructions to lose 20 to 25 pounds. That was roughly six weeks ago, and at that time, I managed to get them to pencil in a surgery date in December, with the agreement that I’d lose the weight. I was pretty angry after that appointment because I felt like I hadn’t been heard. On the advice of friends who are also medical professionals, I rescheduled the checkup to make sure I met with the actual surgeon. And that appointment was on Wednesday.

There’s bad news, and there’s good news — of a sort. First, the bad news: I was turned away yet again. I lost 16 pounds between the appointments but was sent home with the instructions to lose 20 to 25 more pounds. I fought my case; I showed my progress photos of 140 pounds lost, I lined out the previous four years of progress I’ve made, I pointed out that it’s quite likely at least 15 pounds of the weight I currently carry is excess skin.

I’d rather be a pirate and make my own rules.

But it didn’t make a difference: their goal, pure and simple, is to be below a BMI of 40. I’m hovering just above it. I have until February 2, now, to get below that mark. If I meet it by then, I’ll have surgery in early summer.

Just as an aside, I think BMI is a convenient construct of insurance companies, and I wouldn’t doubt it a bit if my insurance company has a hand in this; I’ve never been a fan of insurance companies dictating health care. Those decisions should be between my doctor and me. Even the creator of BMI stated that he thought it was too general a rule, but at the time, it was at least a consistent measure. And apparently, being over a BMI of 40 brings with it notable increases in health risk.

I understand that. With a few exceptions, the more weight we carry, the more health issues we end up with. I’m talking averages — not specific cases — but I totally disagree with the (insurance-driven?) notion that those risk factors suddenly drop off once we pass a magical number. No, risk factors are on a sliding scale, not a drop-off. While I am more than willing to embrace the idea that my risks were far greater when I was at my original weight, I don’t truly believe that the risk factors are all that different for me at my current BMI and the mere two points I am away from their magic number.

Nonetheless — my surgeon will not do a total knee replacement for me until I lose even more weight, no matter what evidence I was able to present. What stands between me and knee surgery is an illogical (and mathematically rather than biologically based) number devised by a mathematician in the 1830’s, before The Alamo fell. For all our technology, we cling to this outdated and unreliable system of measurement. Regardless, I’m stuck and my choices are to abide by it or keeping living with debilitating knee pain.

The good news? I was heard, at least. I was treated with kindness and respect. I was listened to. I was given options. Not all of them are viable or preferable, but if I want this particular surgeon to perform my knee surgery, I have to go by his requirements — and I do want that. He did talk with me about my biggest concern: that I am at an impasse with my weight and my ability to exercise, so asking me to lose more weight seems nearly insurmountable.

He made some recommendations that I am considering, and I was also fitted with (yet another) knee brace that may help me get a few more steps a day without as much pain, and therefore, burn a few more calories.

I have to fight for this. I refuse to do anything else than fight; giving up never got me anywhere. I suppose on some level, I’m angry because I felt I was ready and I was not prepared to hear otherwise, but what I have done to this point is not enough. Imagine that — losing close to 150 pounds isn’t good enough. Not for this.

For the first time, I’m being pushed to change when I stubbornly want to remain on my current path, and it’s a hard thing to internalize. To this point, the choice has been mine; but now, if I want to achieve what I believe is the next step in pushing my health forward, I have to play by someone else’s rules.

I’ll do what needs to be done. I don’t like being told no.