Obesity Medicine As A Way Out

[Backpack234]

Anyone around these parts consider obesity medicine certification as a way out of the pit?

---

Members don't see this ad.

 

[Dr Mantis Toboggan]

Anyone around these parts consider obesity medicine certification as a way out of the pit?

I have to fix my own weight problem before I could respectably help anyone else with that lol.

 

[EctopicFetus]

Anyone around these parts consider obesity medicine certification as a way out of the pit?

Is this basically prescribing glp-1 inhibitors and the like?
i think that plus some voodoo medicine stuff life lifestyle medicine and Botox and such is a way out. It’s not my cup of tea bit neither are med spas or urgent cares. Distasteful to me personally but I get the allure. The key in my opinion is spending A ton of time getting insurance to approve the meds as they are apparently hard to find and expensive.

 

[VA Hopeful Dr]

Is this basically prescribing glp-1 inhibitors and the like?
i think that plus some voodoo medicine stuff life lifestyle medicine and Botox and such is a way out. It’s not my cup of tea bit neither are med spas or urgent cares. Distasteful to me personally but I get the allure. The key in my opinion is spending A ton of time getting insurance to approve the meds as they are apparently hard to find and expensive.

You end up writing for lots of adipex/b12/hcg. The stuff regular doctors don't do much of.

Us PCP types all write for GLP1s like crazy as is.

 

[BoardingDoc]

You end up writing for lots of adipex/b12/hcg. The stuff regular doctors don't do much of.

Did you mean HGH? Also possible that I'm simply entirely out of my depth here.

 

[RustedFox]

Did you mean HGH? Also possible that I'm simply entirely out of my depth here.

Definitely HGC. My dad would bother me to write him for "another round like his doctor did" a few years back. He would lose weight, only to readopt his entirely sedentary lifestyle.
I said no.

 

[VA Hopeful Dr]

Did you mean HGH? Also possible that I'm simply entirely out of my depth here.

Nope, HCG.

Here's a clinic near me (I'm Greenville adjacent):

Medications | The Bariatric Clinic Greenville

greenville.bariatricclinic.net

 

[BoardingDoc]

Nope, HCG.

Here's a clinic near me (I'm Greenville adjacent):

Medications | The Bariatric Clinic Greenville

greenville.bariatricclinic.net

Wtf? Man, you don't know what you don't know I guess.

 

[Apollyon]

Nope, HCG.

Here's a clinic near me (I'm Greenville adjacent):

Medications | The Bariatric Clinic Greenville

greenville.bariatricclinic.net

I didn't read that web page past just making sure it was THE HCG. However, I recall a story from 35 or 40 years ago about a UT med school (don't know which one) that gave nulliparous females and males a shot of HCG to let them experience morning sickness. Doesn't that happen?

 

[namethatsmell]

Assuming real-life outcomes even half-way mirror the outcomes in the GLP1 papers, these drugs are going to be the biggest thing since Viagra. Decent chance they'll also significantly reduce the need for obesity med docs (and bariatric surgeons).

 

[VA Hopeful Dr]

I didn't read that web page past just making sure it was THE HCG. However, I recall a story from 35 or 40 years ago about a UT med school (don't know which one) that gave nulliparous females and males a shot of HCG to let them experience morning sickness. Doesn't that happen?

No idea, but if you're nauseated you're likely eating less. Part of how GLP1s work as well.

 

[Brigade4Radiant]

Seems like a good gig low risk can do also do hair loss and viagra

Cash only

 

[TooMuchResearch]

Nope, HCG.

Here's a clinic near me (I'm Greenville adjacent):

Medications | The Bariatric Clinic Greenville

greenville.bariatricclinic.net

Holy ****. I just checked and there are no comprehensive and physician run clinics like this within reasonable driving distance from me...
There is one half baked looking one run by a chiropractor.
A couple that mention they have a physician but not who it is.
Then just bariatric surgeons.

Did you just show me the way?

 

[beebermd]

Obesity is huge reason I have been able to cut back to part time ER this year. Hopefully I'll be totally out in another year. HCG has been largely proven to be snake oil. It doesnt have a place in my practice. There are a multitude of medications that can be used depending on indications. I was utilzing semaglutide before it was cool.........But it really is a game changer for those that meet criteria. I get them down to reasonable fat % and then I perform liposuction to shape and make it permanent. One good lipo case is worth to 2-3 shifts in the ED. I'm slowly crawling out of the pit. Lol

 

[miacomet]

Obesity is huge reason I have been able to cut back to part time ER this year. Hopefully I'll be totally out in another year. HCG has been largely proven to be snake oil. It doesnt have a place in my practice. There are a multitude of medications that can be used depending on indications. I was utilzing semaglutide before it was cool.........But it really is a game changer for those that meet criteria. I get them down to reasonable fat % and then I perform liposuction to shape and make it permanent. One good lipo case is worth to 2-3 shifts in the ED. I'm slowly crawling out of the pit. Lol

Did you do a fellowship? Do you know any fellowships that accept EM docs? It looks like most want IM/Peds/FP.

Really interested in this.

 

[DocEspana]

You end up writing for lots of adipex/b12/hcg. The stuff regular doctors don't do much of.

Us PCP types all write for GLP1s like crazy as is.

Idk how many people are out there on adipex, but here in highly superficial south florida adipex intolerance is essentially a daily patient complaint... often 2 or 3. So there is plenty of people who can't cut it on adipex.

 

[cyanide12345678]

Assuming real-life outcomes even half-way mirror the outcomes in the GLP1 papers, these drugs are going to be the biggest thing since Viagra. Decent chance they'll also significantly reduce the need for obesity med docs (and bariatric surgeons).

Did 1 month of mounjaro. Lost 14 ish pounds.

Probably going to do another 1 month sooner or later.

 

[cyanide12345678]

Idk how many people are out there on adipex, but here in highly superficial south florida adipex intolerance is essentially a daily patient complaint... often 2 or 3. So there is plenty of people who can't cut it on adipex.

Did a couple weeks of adipex, completely niave to any stimulants, don’t even drink coffee. Made no difference to appetite. Barely did anything from a weight loss perspective, though i was cutting the pill in half since even a cup of coffee results in my inability to sleep. Probably going back to 1 month of mounjaro because of incredible results previously.

 

[VA Hopeful Dr]

Idk how many people are out there on adipex, but here in highly superficial south florida adipex intolerance is essentially a daily patient complaint... often 2 or 3. So there is plenty of people who can't cut it on adipex.

Adipex doesn't really work very well, but it's a cheap pill so people will take it and pretend otherwise.

 

[CoolDoc1729]

Adipex doesn't really work very well, but it's a cheap pill so people will take it and pretend otherwise.

My husband was prescribed adipex a few years ago. It seemed to boost his energy a bit so he exercised more .. seemed to curb his appetite a little .. but caused him to be profoundly irritable/short tempered - his doctor said she’d never heard of that before but 🤷🏻‍♀️ it was really noticeable

 

[DocEspana]

Adipex doesn't really work very well, but it's a cheap pill so people will take it and pretend otherwise.

Give me full fen-phen or give me death.

Which can be arranged

 

[miacomet]

Assuming real-life outcomes even half-way mirror the outcomes in the GLP1 papers, these drugs are going to be the biggest thing since Viagra. Decent chance they'll also significantly reduce the need for obesity med docs (and bariatric surgeons).

Lifelong injections (or now pills)- that's $$$ the health system doesn't want to pay for, though. Seems like the weight comes right back if patients stop taking the medications.

 

[TooMuchResearch]

Lifelong injections (or now pills)- that's $$$ the health system doesn't want to pay for, though. Seems like the weight comes right back if patients stop taking the medications.

The best way for me to do my part to not over eat is to target 1 gram protein per pound of body weight. It doesn't leave me too much capacity to eat non-nutritious foods. I still can, but I then feel physically terrible.

 

[EctopicFetus]

Lifelong injections (or now pills)- that's $$$ the health system doesn't want to pay for, though. Seems like the weight comes right back if patients stop taking the medications.

People pay for so much. Botox comes to mind. All the juvederm etc. Crazy to think people won’t pay for this imo. Price will come down. At some point maybe a quarterly or annual injection. Maybe even monthly. I think there is a big segment of society who would pay 5-6k a year to be 30 lbs lighter. I could also see a segment doing this for a big vacation, weddings etc. Also it would help with dm htn etc. My opinion not verified as far as I know by science is that when people do this they are probably more likely to be better with diet and excercise but maybe that effect wanes.

 

[Brigade4Radiant]

People pay for so much. Botox comes to mind. All the juvederm etc. Crazy to think people won’t pay for this imo. Price will come down. At some point maybe a quarterly or annual injection. Maybe even monthly. I think there is a big segment of society who would pay 5-6k a year to be 30 lbs lighter. I could also see a segment doing this for a big vacation, weddings etc. Also it would help with dm htn etc. My opinion not verified as far as I know by science is that when people do this they are probably more likely to be better with diet and excercise but maybe that effect wanes.

This is true just imagine just dropping your insurance and just paying for a doctor visit and these drugs or a direct primary care.

When you evaluate the cost losing the weight prevents a lot of chronic illnesses and if you have a good amount of savings you can get a cash discount in the ER

 

[EctopicFetus]

This is true just imagine just dropping your insurance and just paying for a doctor visit and these drugs or a direct primary care.

When you evaluate the cost losing the weight prevents a lot of chronic illnesses and if you have a good amount of savings you can get a cash discount in the ER

When i worked in a border state we would get a ton of post op complications of plastic surgery from Mexico. These were US citizens. They paid cash for the work and the surgeons in Mexico would tell these people to go into the ED to get their drains pulled. They would get post op infections etc yet no insurance and admission to the hospital where the hospital probably got close to $0.

People are irrational. IV antibiotics for post op infection they dont want to pay a penny but 10k for a boob job.. no probz

 

[thegenius]

When i worked in a border state we would get a ton of post op complications of plastic surgery from Mexico. These were US citizens. They paid cash for the work and the surgeons in Mexico would tell these people to go into the ED to get their drains pulled. They would get post op infections etc yet no insurance and admission to the hospital where the hospital probably got close to $0.

People are irrational. IV antibiotics for post op infection they dont want to pay a penny but 10k for a boob job.. no probz

Then they get stuck with a big fat hospital bill.
I had a woman in the Bay Area come in and ask to have her stitches removed from her arms, boobs, and waist after a plastic surgery job in Mexico. After I removed a few of them I told myself "no way am I doing this. It's ridiculous." And I discharged her

 

[Pudortu]

Then they get stuck with a big fat hospital bill.
I had a woman in the Bay Area come in and ask to have her stitches removed from her arms, boobs, and waist after a plastic surgery job in Mexico. After I removed a few of them I told myself "no way am I doing this. It's ridiculous." And I discharged her

I’ve had patients like this before and always absolutely refuse to remove their stitches unless there’s an infection. Tell them to follow back up. If there’s a cosmetic complication, who do you think they are suing. They can either see a plastic surgeon, or use the money they saved to go back to Mexico.

 

[GatorCHOMPions]

When i worked in a border state we would get a ton of post op complications of plastic surgery from Mexico. These were US citizens. They paid cash for the work and the surgeons in Mexico would tell these people to go into the ED to get their drains pulled. They would get post op infections etc yet no insurance and admission to the hospital where the hospital probably got close to $0.

People are irrational. IV antibiotics for post op infection they dont want to pay a penny but 10k for a boob job.. no probz

Once saw a young patient who got butt implants in a foreign country, arrived back home via airplane with tachypnea, hypoxia, and had to be urgently intubated. Ended up having silicon emboli and was shipped out for ECMO. I never found out what ultimately happened.

 

[TooMuchResearch]

Once saw a young patient who got butt implants in a foreign country, arrived back home via airplane with tachypnea, hypoxia, and had to be urgently intubated. Ended up having silicon emboli and was shipped out for ECMO. I never found out what ultimately happened.

You already know.

 

[BoardingDoc]

I’ve had patients like this before and always absolutely refuse to remove their stitches unless there’s an infection. Tell them to follow back up. If there’s a cosmetic complication, who do you think they are suing. They can either see a plastic surgeon, or use the money they saved to go back to Mexico.

Indeed. I have very rapidly stopped allowing the ER to be used as the convenience department. Had a patient last night that came in asking for a PICC line to be replaced for his IV antibiotics at his nursing facility because he ripped it out. I had the nurses put a peripheral IV in and discharged him. They can sort that out as an outpatient. This is not an emergency and not my problem.

Same goes for all of this post-op cosmetic crap. Unless acutely ill, go follow-up with your surgeon. If your surgeon is in Mexico, sucks to be you I guess? Via con dios.

 

[namethatsmell]

Lifelong injections (or now pills)- that's $$$ the health system doesn't want to pay for, though. Seems like the weight comes right back if patients stop taking the medications.

It's so early in life of this class of meds...it's the wild west. Nobody knows the "right" dosing, duration of treatment, maintenance of treatment (or at what point it's necessary). Basically the wild west in terms of "what's next"...

But these meds offer a rare overlap in the Venn diagram of meaningfully improving somebody's health and what people can "see" and "feel" and thus put a premium on. Nobody talks about how good they feel from having their BP controlled or their cholesterol lowered...but everybody who loses weight talks about it (or at least likes it) and how good it makes them feel/look.

People are already paying 1000s of out of pocket for these meds to shed a few pounds. The results are already similar to bariatric surgery. You're right that the meds are super expensive, but the cost will come down over time. Remember how insanely expensive the hep c meds were? Insurer ended up covering them due to combination of doctor/public backlash of them not+insurers realizing that they'd save significant downstream costs...I'd be shocked if the same thing doesn't play out here.

 

[rokshana]

It's so early in life of this class of meds...it's the wild west. Nobody knows the "right" dosing, duration of treatment, maintenance of treatment (or at what point it's necessary). Basically the wild west in terms of "what's next"...

But these meds offer a rare overlap in the Venn diagram of meaningfully improving somebody's health and what people can "see" and "feel" and thus put a premium on. Nobody talks about how good they feel from having their BP controlled or their cholesterol lowered...but everybody who loses weight talks about it (or at least likes it) and how good it makes them feel/look.

People are already paying 1000s of out of pocket for these meds to shed a few pounds. The results are already similar to bariatric surgery. You're right that the meds are super expensive, but the cost will come down over time. Remember how insanely expensive the hep c meds were? Insurer ended up covering them due to combination of doctor/public backlash of them not+insurers realizing that they'd save significant downstream costs...I'd be shocked if the same thing doesn't play out here.

Uhhh… these medications ( glp1a) have been around for 15-20 years…we have long term data and do indeed know the proper dosing and duration pf treatment( lifelong).
Tik tok has only been aware for the last year or 2.

 

[HemorrhagicShock]

Indeed. I have very rapidly stopped allowing the ER to be used as the convenience department. Had a patient last night that came in asking for a PICC line to be replaced for his IV antibiotics at his nursing facility because he ripped it out. I had the nurses put a peripheral IV in and discharged him. They can sort that out as an outpatient. This is not an emergency and not my problem.

Same goes for all of this post-op cosmetic crap. Unless acutely ill, go follow-up with your surgeon. If your surgeon is in Mexico, sucks to be you I guess? Via con dios.

Legitimate question:

How do you discharge these patients without getting massive complaints and back-end issues with hospital administrators for "poor patient experience."

 

[JacobMcCandles]

You already know.

Laid flat for too long and now the butt implants are flat. Probably looks like she’s got a cutting board in her pants.

 

[JacobMcCandles]

Legitimate question:

How do you discharge these patients without getting massive complaints and back-end issues with hospital administrators for "poor patient experience."

Easy. You have a medical director worth their salt and that complaint shouldn’t ever get back to the doc.

 

[namethatsmell]

Uhhh… these medications ( glp1a) have been around for 15-20 years…we have long term data and do indeed know the proper dosing and duration pf treatment( lifelong).
Tik tok has only been aware for the last year or 2.

So it’s more than just glp agonists now as I’m sure you know, but I didn’t know there’s 15-20 years of dedicated data on dosing/duration of treatment for obesity—what are sources and what specific questions do they answer? Sounds interesting.

 

[Brigade4Radiant]

Easy. You have a medical director worth their salt and that complaint shouldn’t ever get back to the doc.

So mostly luck. Mostly CMGs have medical directors who are yes men. When a new group takes over the medical director usually loses their job

 

[VA Hopeful Dr]

So it’s more than just glp agonists now as I’m sure you know, but I didn’t know there’s 15-20 years of dedicated data on dosing/duration of treatment for obesity—what are sources and what specific questions do they answer? Sounds interesting.

Byetta hit pharmacies in 2005...

 

[namethatsmell]

Byetta hit pharmacies in 2005...

My understanding is that the long-term data for byetta, like ozempic and the others, primarily focuses around DM2 and that there isn't really good/specific data on what to do when a patient taking it for weight loss reaches their goal. But as I'm not a PCP, endo, or weight loss doc I'm hardly an expert--is there long term data on how to Rx/titrate these meds for weight loss?

 

[VA Hopeful Dr]

My understanding is that the long-term data for byetta, like ozempic and the others, primarily focuses around DM2 and that there isn't really good/specific data on what to do when a patient taking it for weight loss reaches their goal. But as I'm not a PCP, endo, or weight loss doc I'm hardly an expert--is there long term data on how to Rx/titrate these meds for weight loss?

Why would it be any different?

Obesity, like diabetes, is a chronic disease where if you stop treatment it gets worse again.

 

[namethatsmell]

Why would it be any different?

Obesity, like diabetes, is a chronic disease where if you stop treatment it gets worse again.

I mean with regards to how to titrate from losing weight to maintaining weight, how far apart to dose, if it can fully titrated off after a period of many years, etc.

 

[BoardingDoc]

Legitimate question:

How do you discharge these patients without getting massive complaints and back-end issues with hospital administrators for "poor patient experience."

I have a good chief of the dept who filters out the bull**** complaints. If I screwed up (or if the complaint letter is really funny) I'll hear about it. Otherwise I'll never know it happened.

 

[miacomet]

I mean with regards to how to titrate from losing weight to maintaining weight, how far apart to dose, if it can fully titrated off after a period of many years, etc.

Biggest question to me is have we determined if these medications make a difference in morbidity and mortality in non diabetics/non pre diabetics, and at what weight class/with which comorbidities?

 

[VA Hopeful Dr]

I mean with regards to how to titrate from losing weight to maintaining weight, how far apart to dose, if it can fully titrated off after a period of many years, etc.

Heck, we don't have solid evidenced based answers to those questions with any meds we use for chronic diseases like diabetes or hypertension and those are much better studied than obesity

 

[GonnaBeADoc2222]

Easy. You have a medical director worth their salt and that complaint shouldn’t ever get back to the doc.

I have a good chief of the dept who filters out the bull**** complaints. If I screwed up (or if the complaint letter is really funny) I'll hear about it. Otherwise I'll never know it happened.

The importance of this cannot be overstated.

At one job I worked, I didn't hear about anything. I asked my chair about it. She said "oh we get plenty of complaints, but for 99% of them I respond 'this is medically appropriate care' and throw it out."

At my current job, we hear about everything. I heard about a complaint from a drunk patient once. Admin is ****ed.

One job was CMG, one is hospital employed. Your guess as to which was which is likely incorrect. Moral: sometimes CMG jobs aren't as bad as you think.

 

[RustedFox]

The importance of this cannot be overstated.

At one job I worked, I didn't hear about anything. I asked my chair about it. She said "oh we get plenty of complaints, but for 99% of them I respond 'this is medically appropriate care' and throw it out."

At my current job, we hear about everything. I heard about a complaint from a drunk patient once. Admin is ****ed.

One job was CMG, one is hospital employed. Your guess as to which was which is likely incorrect. Moral: sometimes CMG jobs aren't as bad as you think.

This.
This is what absolutely burned me out of Country Club Medical Center.

Kids: Don't take the job at CCMC. It looks flashy, but it's like that girlfriend that you had in undergrad with red flags all over her that you wish you had used better judgment on.

 

[miacomet]

This.
This is what absolutely burned me out of Country Club Medical Center.

Kids: Don't take the job at CCMC. It looks flashy, but it's like that girlfriend that you had in undergrad with red flags all over her that you wish you had used better judgment on.

I worked at CCMC for over a decade...it's certainly a gilded cage at best....

 

[JacobMcCandles]

Kids: Don't take the job at CCMC. It looks flashy, but it's like that girlfriend that you had in undergrad with red flags all over her that you wish you had used better judgment on.

Red flags and red lesions…

 

[RustedFox]

I worked at CCMC for over a decade...it's certainly a gilded cage at best....

5 years; and TH was stealing from me the whole time.