Adding obesity medicine to a busy practice

[callmeanesthesia]

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Hi all, I figured IM is the best group of people to ask about how to go about this, and maybe point me in the direction of pre-made resources so I’m not reinventing the wheel. I’m a busy interventional pain doctor (anesthesia primary specialty) in a relatively rural, medically underserved area. PCPs are hard to come by, and obviously overworked. My practice is, admittedly, a bit of a block shop (heavy on injections), but I still like to pretend I’m a real doctor when I get the chance.

I have a lot of patients where obesity is a major contributor to their pain, and I’d like to help them with it. I had a lady yesterday who seemed quite surprised by the advice to add some non-starch vegetables to her diet. Maybe she’ll even listen. If I’m going to do it, I want to do it right. I’m in the process of doing the CMEs for a board certification in obesity medicine. But, I’m in private practice and my income comes from doing lots of injections, so if I’m going to avoid losing money on this, I need to make it efficient, with thorough intake and screening forms, order sets, and standard patient education handouts, and delegate as much as possible. I’m considering hiring an RN (or even better, an LCSW, who could bill separately for their services) to do the bulk of the patient education and counseling. If I can find the right person, I’ll hire a PA or NP to do most of the follow ups as well. I’m not looking to dabble in compounded meds or make a bunch of money on this, just filling an unmet need in the community.

For anyone who has added obesity medicine to an already busy practice, can you give me some pointers?

Thank you in advance!

 

[DrMetal]

Hi all, I figured IM is the best group of people to ask about how to go about this, and maybe point me in the direction of pre-made resources so I’m not reinventing the wheel. I’m a busy interventional pain doctor (anesthesia primary specialty) in a relatively rural, medically underserved area. PCPs are hard to come by, and obviously overworked. My practice is, admittedly, a bit of a block shop (heavy on injections), but I still like to pretend I’m a real doctor when I get the chance.

I have a lot of patients where obesity is a major contributor to their pain, and I’d like to help them with it. I had a lady yesterday who seemed quite surprised by the advice to add some non-starch vegetables to her diet. Maybe she’ll even listen. If I’m going to do it, I want to do it right. I’m in the process of doing the CMEs for a board certification in obesity medicine. But, I’m in private practice and my income comes from doing lots of injections, so if I’m going to avoid losing money on this, I need to make it efficient, with thorough intake and screening forms, order sets, and standard patient education handouts, and delegate as much as possible. I’m considering hiring an RN (or even better, an LCSW, who could bill separately for their services) to do the bulk of the patient education and counseling. If I can find the right person, I’ll hire a PA or NP to do most of the follow ups as well. I’m not looking to dabble in compounded meds or make a bunch of money on this, just filling an unmet need in the community.

For anyone who has added obesity medicine to an already busy practice, can you give me some pointers?

Thank you in advance!

Are you willing to pass out scripts for GLP1 agonists? That's what 'obesity' medicine has succumb to. Nobody cares about 'non-starch vegetables'.

 

[callmeanesthesia]

Are you willing to pass out scripts for GLP1 agonists? That's what 'obesity' medicine has succumb to. Nobody cares about 'non-starch vegetables'.

Absolutely. I’ve had patients who have made great lifestyle changes while on GLP-1s. A1C under control, weight down 20% or more, and with that, the inflammation in their body is less and their pain is less. Trouble is, GLP-1s are a lot of work in terms to getting them covered, and helping patients titrate them effectively so they don’t wash out due to GI side effects.

I haven’t started writing for them yet, but I’ve had several long conversations with patients during procedures, and written down some recommendations for them to talk to their PCP. For example, a patient who wanted it for weight loss but didn’t have diabetes, but did have sleep apnea so should be able to qualify for tirzepatide. Also wrote down a few apps for him to start tracking his calories, and gave him a PT Rx to start a home exercise program.

 

[chessknt]

Absolutely. I’ve had patients who have made great lifestyle changes while on GLP-1s. A1C under control, weight down 20% or more, and with that, the inflammation in their body is less and their pain is less. Trouble is, GLP-1s are a lot of work in terms to getting them covered, and helping patients titrate them effectively so they don’t wash out due to GI side effects.

I haven’t started writing for them yet, but I’ve had several long conversations with patients during procedures, and written down some recommendations for them to talk to their PCP. For example, a patient who wanted it for weight loss but didn’t have diabetes, but did have sleep apnea so should be able to qualify for tirzepatide. Also wrote down a few apps for him to start tracking his calories, and gave him a PT Rx to start a home exercise program.

Now imagine having that conversation but only getting paid a paltry E/M code instead of whatever astronomical facility fee your procedure pays but using just as much of your time plus all the uncompensated time appealing denials and answering calls about side effects from medications...

Just keep doing blocks on people while it still gets paid for, you can take an obesity fellowship or something later once your specialty dies and join the ranks of the E/M peons who get paid Walmart wages to perform cognitive (ie pretend) medicine.

 

[callmeanesthesia]

Now imagine having that conversation but only getting paid a paltry E/M code instead of whatever astronomical facility fee your procedure pays but using just as much of your time plus all the uncompensated time appealing denials and answering calls about side effects from medications...

Just keep doing blocks on people while it still gets paid for, you can take an obesity fellowship or something later once your specialty dies and join the ranks of the E/M peons who get paid Walmart wages to perform cognitive (ie pretend) medicine.

That’s why I want a mid level or LCSW to do most of the talking. And yes, a follow up pays about half what an epidural does and takes longer. On the other hand, if I have that conversation while doing a procedure, it’s a separately identifiable E&M service. I just have to write a little note and I can bill for it on top of the procedure, with a 25 modifier. Then if I can get my handouts and templates in order like I described, I can give them intake paperwork and lab orders before they leave, and at follow up review that data and give them a prescription.

 

[DrMetal]

That’s why I want a mid level or LCSW

You don't even that. Hire a secretary to manage your orders, buy the materials, a peptide synthesizer, and a gas chromatograph (to confirm purity). < $250K, small business loan, cheaper than running a micro-brewery.

Everyone's "Breaking Bad" with these GLP1 agonists.

 

[chessknt]

That’s why I want a mid level or LCSW to do most of the talking. And yes, a follow up pays about half what an epidural does and takes longer. On the other hand, if I have that conversation while doing a procedure, it’s a separately identifiable E&M service. I just have to write a little note and I can bill for it on top of the procedure, with a 25 modifier. Then if I can get my handouts and templates in order like I described, I can give them intake paperwork and lab orders before they leave, and at follow up review that data and give them a prescription.

How good are you at E/M billing really though and is it worth it? I could easily imagine an audit if suddenly your E/M billing shoots up on completely unrelated procedures. You should look in to the placeb... err I mean SGB injections for cash instead. That is what the pain guy does in my area and he clears multiple millions a year selling it for literally every medical condition in existence.

Makes no sense trying to monetize obesity education-our broken ass ****ty medical system places almost 0 value on this service and $$$$$ on doing things to people regardless of indication or efficacy. You are in a specialty that can massively capitalize on this and since you are trying to monetize things you should monetize that.

 

[callmeanesthesia]

How good are you at E/M billing really though and is it worth it? I could easily imagine an audit if suddenly your E/M billing shoots up on completely unrelated procedures. You should look in to the placeb... err I mean SGB injections for cash instead. That is what the pain guy does in my area and he clears multiple millions a year selling it for literally every medical condition in existence.

Makes no sense trying to monetize obesity education-our broken ass ****ty medical system places almost 0 value on this service and $$$$$ on doing things to people regardless of indication or efficacy. You are in a specialty that can massively capitalize on this and since you are trying to monetize things you should monetize that.

Not in it to make more money. Just trying not to lose money, while providing a service I think could really help my patients. I think I’m pretty good at billing and coding. Blue Cross basically doesn’t pay for 25 modifier but these will be mostly Medicare/Medicaid patients anyway (we have a unique Medicaid carrier in our area that pays better than Medicare when you include the specialist incentives)

If that’s what’s going on around you, I can see why you’d be cynical about pain docs. I don’t really like doing stellate blocks, or cash pay services in general. Not a good enough salesman.

 

[dozitgetchahi]

How good are you at E/M billing really though and is it worth it? I could easily imagine an audit if suddenly your E/M billing shoots up on completely unrelated procedures. You should look in to the placeb... err I mean SGB injections for cash instead. That is what the pain guy does in my area and he clears multiple millions a year selling it for literally every medical condition in existence.

Makes no sense trying to monetize obesity education-our broken ass ****ty medical system places almost 0 value on this service and $$$$$ on doing things to people regardless of indication or efficacy. You are in a specialty that can massively capitalize on this and since you are trying to monetize things you should monetize that.

Stellate ganglion blocks? Barf. When I lived in Alabama, there was a psych office that was selling these to local veterans as “the *cure* for PTSD”. They had veterans lining up for that stupid snake oil, and were sponsoring fundraisers in town at the American Legion and such so that the “local vets could get the care they needed for their mental illness”. (Which was really just another SGB every 6 months.)

Such a scam. So sleazy. It still makes me mad thinking about it.

 

[thecentral09]

Hi all, I figured IM is the best group of people to ask about how to go about this, and maybe point me in the direction of pre-made resources so I’m not reinventing the wheel. I’m a busy interventional pain doctor (anesthesia primary specialty) in a relatively rural, medically underserved area. PCPs are hard to come by, and obviously overworked. My practice is, admittedly, a bit of a block shop (heavy on injections), but I still like to pretend I’m a real doctor when I get the chance.

I have a lot of patients where obesity is a major contributor to their pain, and I’d like to help them with it. I had a lady yesterday who seemed quite surprised by the advice to add some non-starch vegetables to her diet. Maybe she’ll even listen. If I’m going to do it, I want to do it right. I’m in the process of doing the CMEs for a board certification in obesity medicine. But, I’m in private practice and my income comes from doing lots of injections, so if I’m going to avoid losing money on this, I need to make it efficient, with thorough intake and screening forms, order sets, and standard patient education handouts, and delegate as much as possible. I’m considering hiring an RN (or even better, an LCSW, who could bill separately for their services) to do the bulk of the patient education and counseling. If I can find the right person, I’ll hire a PA or NP to do most of the follow ups as well. I’m not looking to dabble in compounded meds or make a bunch of money on this, just filling an unmet need in the community.

For anyone who has added obesity medicine to an already busy practice, can you give me some pointers?

Thank you in advance!

im am interested in the exact same thing and am in a very similar position as you. i would love to chat about where you are on this experience so far, and what you may have learned.

 

[PugsAndHugs]

Absolutely. I’ve had patients who have made great lifestyle changes while on GLP-1s. A1C under control, weight down 20% or more, and with that, the inflammation in their body is less and their pain is less. Trouble is, GLP-1s are a lot of work in terms to getting them covered, and helping patients titrate them effectively so they don’t wash out due to GI side effects.

I haven’t started writing for them yet, but I’ve had several long conversations with patients during procedures, and written down some recommendations for them to talk to their PCP. For example, a patient who wanted it for weight loss but didn’t have diabetes, but did have sleep apnea so should be able to qualify for tirzepatide. Also wrote down a few apps for him to start tracking his calories, and gave him a PT Rx to start a home exercise program.

I was under the impression you write a PT Rx if there is some kind of issue - can you write a PT Rx just so they can help a patient make a workout plan?

 

[callmeanesthesia]

I was under the impression you write a PT Rx if there is some kind of issue - can you write a PT Rx just so they can help a patient make a workout plan?

All of my patients have some focal pain I can justify PT for but if they have some general reconditioning that’s usable as well.

 

[DrMetal]

All of my patients have some focal pain I can justify PT for but if they have some general reconditioning that’s usable as well.

Most Msk Pains are psychosomatic, especially when in the absence of real mechanism of injury (or a very remote MOI).

I have neck pain every morning before I go to work, M-Fri. On Saturday, when I get up same time for golf tee time, said pain is gone, imagine that!

Most of the things we prescribe for it (PT, OT, Acupuncture, etc) are all placebo.

If we could teach people to self-manage their psychosomatic symptoms---which everyone has, does not necessarily mean you have a mental health condition---we'd save a lot of money in healthcare.

 

[callmeanesthesia]

Most Msk Pains are psychosomatic, especially when in the absence of real mechanism of injury (or a very remote MOI).

I have neck pain every morning before I go to work, M-Fri. On Saturday, when I get up same time for golf tee time, said pain is gone, imagine that!

Most of the things we prescribe for it (PT, OT, Acupuncture, etc) are all placebo.

If we could teach people to self-manage their psychosomatic symptoms---which everyone has, does not necessarily mean you have a mental health condition---we'd save a lot of money in healthcare.

Going to have to disagree with you there. Maybe it’s a patient population difference? I’m talking patients with degenerated joints, whether post-traumatic or in most cases just plain old. In the obesity population especially, an extra few hundred pounds riding around on those joints for a few decades can really grind them down. PT/OT - maybe placebo if you send them to a place where they spend 15 minutes with a hot towel then 30 minutes with a TENS unit, then go home. Not much use if the patient doesn’t actively engage in rehabilitation.

 

[DrMetal]

Going to have to disagree with you there.

Of course you do. Your specialty (anes) even created a fellowship (Pain) to capitalize on all it.

Human beings have been dealing with degenerative joints for 300,000 years. Somehow, over the last 30 years, we've found the need to overtreat: OTCs meds, PT/OT, chiro, aquatherapy, acupuncture, TENS units, massage therapy, CBT, injections, narcotics (--> opioid epidemic), implanted stimulators, multiple surgeries. You ever notice how these patients never seem to get better, no matter what you do?

It's because their symptoms are largely psychosomatic. We should be telling them (especially after we work them up completely) to ignore their pain and go about their daily routine (which many of them actually can do).

But we don't. We're afraid of the proverbial Yelp review and poor customer satisfaction survey. So we treat excessively. I get it, I do the same. But lets not kid ourselves; we're not actually treating any serious pathology.

 

[callmeanesthesia]

Of course you do. Your specialty (anes) even created a fellowship (Pain) to capitalize on all it.

Human beings have been dealing with degenerative joints for 300,000 years. Somehow, over the last 30 years, we've found the need to overtreat: OTCs meds, PT/OT, chiro, aquatherapy, acupuncture, TENS units, massage therapy, CBT, injections, narcotics (--> opioid epidemic), implanted stimulators, multiple surgeries. You ever notice how these patients never seem to get better, no matter what you do?

It's because their symptoms are largely psychosomatic. We should be telling them (especially after we work them up completely) to ignore their pain and go about their daily routine (which many of them actually can do).

But we don't. We're afraid of the proverbial Yelp review and poor customer satisfaction survey. So we treat excessively. I get it, I do the same. But lets not kid ourselves; we're not actually treating any serious pathology.

Just because we didn’t have treatments back then doesn’t mean chronic pain didn’t exist. Sure, like everything else it’s over diagnosed and over treated. The opioid epidemic really saw to that.

Sounds like you’ve had some bad experiences with pain doctors. Maybe it’s like what they say about lawyers, 95% of us give the rest a bad name.

Most of the injections I do are for old people with degenerated spines. Are you suggesting their golfball-sized facet joints are all in their head? The patient I saw today with no cartilage in her knees? (Possibly doing a nerve ablation for her knees. She’s on Wegovy and has lost about 60 lbs so far).

I do have plenty of patients with pain far out of proportion to their imaging findings, but it’s certainly not the majority. A lot of that category is Work comp or post-car accident.

 

[DrMetal]

doesn’t mean chronic pain didn’t exist. . . . their golfball-sized facet joints are all in their head?

Of course these things exist. They've existed since the dawn of man. What's different now is our perception: our perception of the pain, our sensitivity to it, our unwillingness to ignore it, our demand signal for treatment. These are all first world problems.

I guarantee you, if you took a poor remote Pacific islander village and scanned their 70-yr olds, you'd find much pathology (stenosis, herniated discs, etc). And yet, they continue to work, plowing farm lands, carrying a 100-lbs packs, etc. Somehow they get by without steroid injections.

Sounds like you’ve had some bad experiences with pain doctors.

I'm just jealous of their single-digit golf handicaps.

 

[callmeanesthesia]

Of course these things exist. They've existed since the dawn of man. What's different now is our perception: our perception of the pain, our sensitivity to it, our unwillingness to ignore it, our demand signal for treatment. These are all first world problems.

I guarantee you, if you took a poor remote Pacific islander village and scanned their 70-yr olds, you'd find much pathology (stenosis, herniated discs, etc). And yet, they continue to work, plowing farm lands, carrying a 100-lbs packs, etc. Somehow they get by without steroid injections.



I'm just jealous of their single-digit golf handicaps.

That same logic applies to depression, anxiety, disfigurement, eczema, seasonal allergies, pretty much anything that’s not an imminent threat to life or limb.

Oh, and I’ve never played golf…

 

[DrMetal]

That same logic applies to depression, anxiety, disfigurement, eczema, seasonal allergies, pretty much anything that’s not an imminent threat to life or limb.

Quite true. The brain has an uncanny ability to generate a wide variety of symptoms, mostly to distract us from our emotions (stress, anxiety, depression), and sometime in the setting of severe mental illness (PTSD, trauma, MDD, etc). But mental illness does not necessarily have to co-exist.

The brain can generate Msk pain, GI symptoms, pseudoseizures, etc etc , and it happens in everyone. Every human being has a psycho-somatic symptom, at least once a day, usually as a reaction to emotional stress.

How we perceive these symptoms and what we do about it is how we differ. I don't go to the doctor for my Monday morning neck pain, I know why it's there and ignore it. By ignoring it, it goes away; that's how I know it's psycho-somatic and not some true pathology. And even when there is true pathology (a disc herniation), the brain (knowing that) 'pings' that part of the body that much more. The brain likes to pour salt on an open wound.

Now, every doctor is going to work things up (labs, xrays, MRI, etc) to make sure there's nothing else serious going on. Fine.

But what's stupid about us is---even after said diagnostic workup produces nothing---we insist on further treatments. We give it a label: fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, long Covid (each name more vague than the next) . . .so the patient can feel better about having a diagnosis, and we can code away.

I had a professor in med school that said (in 21st century American medicine), the hardest thing to say to a patient is, "You're fine, there's nothing wrong, you don't need anything further, go home." You'll have an easier time telling someone they have metastatic cancer.

None of the above are my original thoughts. I'm a disciple of Dr. John Sarno, who based much of his work off Sigmund Freud. John E. Sarno - Wikipedia Amazon.com : john sarno

Oh, and I’ve never played golf…

Is a great hobby. Is my placebo.

 

[sloh]

Quite true. The brain has an uncanny ability to generate a wide variety of symptoms, mostly to distract us from our emotions (stress, anxiety, depression), and sometime in the setting of severe mental illness (PTSD, trauma, MDD, etc). But mental illness does not necessarily have to co-exist.

The brain can generate Msk pain, GI symptoms, pseudoseizures, etc etc , and it happens in everyone. Every human being has a psycho-somatic symptom, at least once a day, usually as a reaction to emotional stress.

How we perceive these symptoms and what we do about it is how we differ. I don't go to the doctor for my Monday morning neck pain, I know why it's there and ignore it. By ignoring it, it goes away; that's how I know it's psycho-somatic and not some true pathology. And even when there is true pathology (a disc herniation), the brain (knowing that) 'pings' that part of the body that much more. The brain likes to pour salt on an open wound.

Now, every doctor is going to work things up (labs, xrays, MRI, etc) to make sure there's nothing else serious going on. Fine.

But what's stupid about us is---even after said diagnostic workup produces nothing---we insist on further treatments. We give it a label: fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, long Covid (each name more vague than the next) . . .so the patient can feel better about having a diagnosis, and we can code away.

I had a professor in med school that said (in 21st century American medicine), the hardest thing to say to a patient is, "You're fine, there's nothing wrong, you don't need anything further, go home." You'll have an easier time telling someone they have metastatic cancer.

None of the above are my original thoughts. I'm a disciple of Dr. John Sarno, who based much of his work off Sigmund Freud. John E. Sarno - Wikipedia Amazon.com : john sarno



Is a great hobby. Is my placebo.

Quite telling that despite there being more pain physicians, chronic pain rates in the U.S. have increased from around 20–21% in the mid-2010s to 24.3% in 2023, with high-impact chronic pain rising in parallel.

 

[DrMetal]

Quite telling that despite there being more pain physicians, chronic pain rates in the U.S. have increased from around 20–21% in the mid-2010s to 24.3% in 2023, with high-impact chronic pain rising in parallel.

Crazy isn't it? And then we wonder why the cost of healthcare is ballooning. An entire enterprise of medicine, that's basically chasing figments of the imagination.

 

[callmeanesthesia]

Quite telling that despite there being more pain physicians, chronic pain rates in the U.S. have increased from around 20–21% in the mid-2010s to 24.3% in 2023, with high-impact chronic pain rising in parallel.

There also more doctors in the US overall, yet we have way more sick people. What gives?

But seriously, I feel like these are criticisms not specific to pain but the general state of US healthcare. We treat a lot of things we shouldn’t. I’d say end of life care is a much bigger target than pain.

But back to the original thread topic, I think if you look at the obesity trend for the past 20 years it may also explain the increasing rates of chronic pain, as well as people generally being sicker. Maybe treating the obesity directly will help.

 

[sloh]

as well as people generally being sicker. Maybe treating the obesity directly will help.

Yeah and this is why most pain interventions and medications don't work for those with chronic pain.

 

[callmeanesthesia]

Yeah and this is why most pain interventions and medications don't work for those with chronic pain.

RFAs work great. Kyphoplasties work great in the acute phase, and are appropriate for a patient who is totally debilitated by the pain and at risk of deconditioning. Steroid injections in the spine are pretty iffy - I do often wonder how much they’re just a placebo outside of acute disc herniations. Spinal cord stimulators also might be mostly placebo, although I have some patients who really feel they’ve been life-changing. Meds, yeah, they’re probably mostly placebo. Gabapentin/lyrica for neuropathy, migraine meds, those work pretty well. Despite patients’ insistence to the contrary, we have pretty solid evidence that chronic opiates don’t work.

 

[sloh]

RFAs work great. Kyphoplasties work great in the acute phase, and are appropriate for a patient who is totally debilitated by the pain and at risk of deconditioning. Steroid injections in the spine are pretty iffy - I do often wonder how much they’re just a placebo outside of acute disc herniations. Spinal cord stimulators also might be mostly placebo, although I have some patients who really feel they’ve been life-changing. Meds, yeah, they’re probably mostly placebo. Gabapentin/lyrica for neuropathy, migraine meds, those work pretty well. Despite patients’ insistence to the contrary, we have pretty solid evidence that chronic opiates don’t work.

Gabapentin and lyrics more for conditions like diabetic neuropathy, not compressive neuropathy. Although even for diabetic neuropathy, effect size leaves much to be desired. Should have addressed the issue before spiraling into t2dm in the first place.

 

[VA Hopeful Dr]

Gabapentin and lyrics more for conditions like diabetic neuropathy, not compressive neuropathy. Although even for diabetic neuropathy, effect size leaves much to be desired. Should have addressed the issue before spiraling into t2dm in the first place.

That's like 80% of modern medicine...

 

[gutonc]

That's like 80% of modern medicine...

That estimate seems low.

 

[sloh]

That's like 80% of modern medicine...

Good thing is T2DM is reversible if the patient loses the weight, which is why I’m more in support of GLP’s. Though there is a concern about tachyphylaxis.

 

[NotAProgDirector]

I think part of the issue with this discussion is the term "psychsomatic" and what it means to different people.

To some, it means "it's all in your head". There's nothing physical wrong at all, all symptomatology is driven by psychosocial issues.

In this case, I expect that people are having "real pain". They have DJD, or back problems, or any number of other illnesses which then cause the sensation of pain.

What seems perhaps different is the expectation/demand that medicine will cure this pain. So an entire industry has grown up around this to "do something" to make the pain better. In other cultures / other times, people would just deal with the pain and continue onwards, not considering it medicine's job to fix it. And now the demand is often "I want my pain all gone", which is often impossible.

The data behind PT, OT, injections, chiro, TENS, dry needling, and a zillion other modalities is very poor. And one would expect that the placebo effect would be large. On the other hand, even if it is all placebo effect, if it makes 20% of people better perhaps it's worth it? Don't get me started with Reiki, naturopathy, crystal therapy, etc.

And then there's the whole industry around disability. That's a mess, on many levels. I've worked with physicians who feel that disability is their new welfare program that they can prescribe. And then there was my patient who was very excited to tell me that they just got a job at Walmart as did their friend, and they had their slip-and-fall to disability all planned out (just like their prior job). Why work when you can get paid for doing nothing? Not to say that we shouldn't have some disability type program -- just very difficult (if not impossible) to tell who "really" needs it.