Obesity Medicine For Internists

[VA Hopeful Dr]

Which is why it probably should be restricted to who can prescribe it.

Do you really want me to refer every obese patient to you?

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[sloh]

When the patients become real savvy, they'll realize that if they just let themselves go a little bit (A1c 6.3-->6.8), then they'll get the DM diagnosis. Claim a metformin intolerance, and they can go straight to the injectable, with coverage from insurance.

Haha I think you overestimate how intelligent/savvy patients are

 

[DrMetal]

Haha I think you overestimate how intelligent/savvy patients are

Oh they're plenty savvy when they want certain things (Adderall, Percocet, and soon Ozempic).

But they're not the problem. The problem is us physicians who don't know how say 'No'. For in 21st century medicine, the patient is a customer, and the customer is always right [We damn well know the patient is not always right. In fact, he's often wrong, that's why he's in front of us.] And the customer has access to Yelp and Google reviews.

We're cowardly. Instead of telling the patient that he doesn't need a $2K/month injection for a 10% weight loss, that the same result could easily be achieved by good diet, exercise, addressing mental health concerns . . .we create an 'Obesity Fellowship', train in it, and prescribe this crap.

Then we marvel at the cost of healthcare and that there's a 6-month wait to see an Endocrinologist.

God how dumb are we?

 

[rokshana]

Do you really want me to refer every obese patient to you?

no but the GOLO people shouldn't be able to prescribe it.

 

[rokshana]

Oh they're plenty savvy when they want certain things (Adderall, Percocet, and soon Ozempic).

But they're not the problem. The problem is us physicians who don't know how say 'No'. For in 21st century medicine, the patient is a customer, and the customer is always right [We damn well know the patient is not always right. In fact, he's often wrong, that's why he's in front of us.] And the customer has access to Yelp and Google reviews.

We're cowardly. Instead of telling the patient that he doesn't need a $2K/month injection for a 10% weight loss, that the same result could easily be achieved by good diet, exercise, addressing mental health concerns . . .we create an 'Obesity Fellowship', train in it, and prescribe this crap.

Then we marvel at the cost of healthcare and that there's a 6-month wait to see an Endocrinologist.

God how dumb are we?

lol, you act like there is no reason for sub specialists...maybe in the time of dinosaurs when the medical books were tiny and full of pictures, that may have been true...

realize the old notion of being obese is a personality trait and a will power issue is again something that dinosaurs still think is true...medicine has actually advanced.

i had an attending that use to say...physicians (particularlyly community ones) practice the way they were trained...they trained 20 years ago, that's the medical knowledge that they have retained...generally i don't believe that...but you do seem to prove him true.

 

[DrMetal]

lol, you act like there is no reason for sub specialists...maybe in the time of dinosaurs when the medical books were tiny and full of pictures, that may have been true...

realize the old notion of being obese is a personality trait and a will power issue is again something that dinosaurs still think is true...medicine has actually advanced.

i had an attending that use to say...physicians (particularlyly community ones) practice the way they were trained...they trained 20 years ago, that's the medical knowledge that they have retained...generally i don't believe that...but you do seem to prove him true.

Would you not agree, that in most patients, the obesity is not a primary disease, but rather a manifestation or symptom of some other condition? (including undiagnosed mental health conditions?) And are we not enabling those patients in a bad way, if we prescribe un-necessary and costly treatments, without addressing the primary pathology first? (in the same way we prescribed narcotics for psychosomatic pain?)

I'm not entirely against the notion that obesity, in and of itself, may be a disease process. There's genetic and molecular evidence for it. [Unlike fibromyalgia and CFS, which I think is total BS.] But in most patients, I don't think that's the case.

I'm trying to argue for you, that your time (as a sub-specialist) should be better spent, helping people with real pathology, vice prescribing Ozempic for some slob who's plagued by 'metastatic' obesity. [in the same way now that the Rheumatologists are hard to get into, because they're seeing every joke fibro patient instead of debilitating RA, Lupus etc].

And why are we knocking dinosaurs?! Their species lived for 60 million years, only to be extinguished by a meteor. Modern man on the hand, has only been around for 300K years; and at the idiotic rate we're going, we'll cause our own extinction event in the next 500k years. So who really are the smart ones?

 

[chessknt]

Would you not agree, that in most patients, the obesity is not a primary disease, but rather a manifestation or symptom of some other condition? (including undiagnosed mental health conditions?) And are we not enabling those patients in a bad way, if we prescribe un-necessary and costly treatments, without addressing the primary pathology first? (in the same way we prescribed narcotics for psychosomatic pain?)

I'm not entirely against the notion that obesity, in and of itself, may be a disease process. There's genetic and molecular evidence for it. [Unlike fibromyalgia and CFS, which I think is total BS.] But in most patients, I don't think that's the case.

I'm trying to argue for you, that your time (as a sub-specialist) should be better spent, helping people with real pathology, vice prescribing Ozempic for some slob who's plagued by 'metastatic' obesity. [in the same way now that the Rheumatologists are hard to get into, because they're seeing every joke fibro patient instead of debilitating RA, Lupus etc].

And why are we knocking dinosaurs?! Their species lived for 60 million years, only to be extinguished by a meteor. Modern man on the hand, has only been around for 300K years; and at the idiotic rate we're going, we'll cause our own extinction event in the next 500k years. So who really are the smart ones?

You do realize that the GLP agonists get more than 10% body weight off and that losing that much can have exponential health benefits. Almost half of America is obese, you can look down on them all you want but it is a massive ****ing problem and I for one welcome any therapy that can offer relief because telling people to eat less and exercise more simply is not working. Shaking your fist at the sky doesnt change reality. The decreased appetite from GLP agonist IS treating the underlying pathology--ie excess calorie consumption.

Obesity is way more common that fibromyalgia or CFS or almost any other disease you can think of. Do you think the same thing about meds for heart failure? Or hypertension? Just let them run around with their chronic conditions untreated because they need to do the DASH diet and more cardiac rehab?

 

[DrMetal]

You do realize that the GLP agonists get more than 10% body weight off and that losing that much can have exponential health benefits. Almost half of America is obese, you can look down on them all you want but it is a massive ****ing problem and I for one welcome any therapy that can offer relief because telling people to eat less and exercise more simply is not working. Shaking your fist at the sky doesnt change reality. The decreased appetite from GLP agonist IS treating the underlying pathology--ie excess calorie consumption.

Obesity is way more common that fibromyalgia or CFS or almost any other disease you can think of. Do you think the same thing about meds for heart failure? Or hypertension? Just let them run around with their chronic conditions untreated because they need to do the DASH diet and more cardiac rehab?

The HTN and HF patients who do the best are those who do engage in a DASH diet, cardiac rehab, and take their meds. The meds are crucial, of course, but all the diuretics in the world wont help your volume status if you're pounding KFC/McDonalds every night.

So by analogy: if an obese patient is compliant with all other treatments (including psych), follows up properly, assumes a good diet/exercise regimen, and then additionally needs a medication to help get to goal . . . then yeah, I might be ok with giving the medication (even if expensive).

But if he's not compliant, doesn't want to diet/exercise at all, and is just looking for a quick fix, I'm not ok with it. We're just enabling him in that case. Even the bariatric surgeons realized you can't cut out the 'crazy', you need to be compliant with all other treatments (Dietician, Nutrition, Psych, etc) to maximize the benefit of the surgery.

So which patient are you most likely to see in your clinic asking for the GLP agonist, the 'compliant' well intentioned one, or the 'non compliant' slob looking for a quick fix? In America, I'd bet the latter. For that reason, I hope it stays a cash business. If you're paying $2K/month for it, you might think twice about pounding the KFC. [Nothing against KFC, I love it, have it twice a year]

 

[caterwaiter]

The HTN and HF patients who do the best are those who do engage in a DASH diet, cardiac rehab, and take their meds. The meds are crucial, of course, but all the diuretics in the world wont help your volume status if you're pounding KFC/McDonalds every night.

So by analogy: if an obese patient is compliant with all other treatments (including psych), follows up properly, assumes a good diet/exercise regimen, and then additionally needs a medication to help get to goal . . . then yeah, I might be ok with giving the medication (even if expensive).

But if he's not compliant, doesn't want to diet/exercise at all, and is just looking for a quick fix, I'm not ok with it. We're just enabling him in that case. Even the bariatric surgeons realized you can't cut out the 'crazy', you need to be compliant with all other treatments (Dietician, Nutrition, Psych, etc) to maximize the benefit of the surgery.

So which patient are you most likely to see in your clinic asking for the GLP agonist, the 'compliant' well intentioned one, or the 'non compliant' slob looking for a quick fix? In America, I'd bet the latter. For that reason, I hope it stays a cash business. If you're paying $2K/month for it, you might think twice about pounding the KFC. [Nothing against KFC, I love it, have it twice a year]

I surely hope that, as a physician [who is punishing your patients for being "non-compliant" with diet, exercise, and psychiatric therapies], you are educating every one of these patients. Providing resources on how to access healthy, low-cost food in their neighborhood? Putting in referrals for psychiatrists who might have openings for counseling? Or even acknowledging that these things are outside of a patient's direct control?

[Congrats on your twice-a-year KFC. You get a special willpower award.]

 

[DrMetal]

I surely hope that, as a physician [who is punishing your patients for being "non-compliant" with diet, exercise, and psychiatric therapies], you are educating every one of these patients. Providing resources on how to access healthy, low-cost food in their neighborhood? Putting in referrals for psychiatrists who might have openings for counseling? Or even acknowledging that these things are outside of a patient's direct control?

All excellent suggestions. It's not about 'punishing' the patient. It's about making the patient buy into their own health, accepting their problem, and buying into the treatment plan. I would do all of the above for an obese patient and ask him to lose 5% on his own (15 lbs if he weighs 300 originally), then maybe consider prescribing the $1000/wk injectable to help with an additional 5%.

In other words, before prescribing the costly medication, I'd like to make sure that they're really committed to their health and have some discipline to do the right thing.

Is there something wrong with that? Would you do differently?

No, here's what's going to happen (we've seen this tape before): the patients (aka the customers) are going to pressure the insurance companies to cover these injectables. Doctors are going to be pressured to prescribe them blanketly, even to patients they know to be mal-compliant with their healthcare. The intervention is not going to work all that well and side effects will ensue (we'll see this manifest on a large scale, once they're being used on the mass population), then we'll all cry foul and wonder what went wrong. (see the opioid crisis with respect to pain treatment, for a lovely analogy).

[Congrats on your twice-a-year KFC. You get a special willpower award.]

The original recipe is to die for. The biscuits too.

 

[chessknt]

All excellent suggestions. It's not about 'punishing' the patient. It's about making the patient buy into their own health, accepting their problem, and buying into the treatment plan. I would do all of the above for an obese patient and ask him to lose 5% on his own (15 lbs if he weighs 300 originally), then maybe consider prescribing the $1000/wk injectable to help with an additional 5%.

In other words, before prescribing the costly medication, I'd like to make sure that they're really committed to their health and have some discipline to do the right thing.

Is there something wrong with that? Would you do differently?

No, here's what's going to happen (we've seen this tape before): the patients (aka the customers) are going to pressure the insurance companies to cover these injectables. Doctors are going to be pressured to prescribe them blanketly, even to patients they know to be mal-compliant with their healthcare. The intervention is not going to work all that well and side effects will ensue (we'll see this manifest on a large scale, once they're being used on the mass population), then we'll all cry foul and wonder what went wrong. (see the opioid crisis with respect to pain treatment, for a lovely analogy).



The original recipe is to die for. The biscuits too.

I know you are pretty far on the nihilistic cynic scale of inevitability but can you at least acknowledge if there was a drug that we could inject for 1500/month (not per week) that cured opiate addiction that it would still be a net save to the healthcare system to avoid costly hospitalizations? I don't think even the most dedicated can manage to not lose weight if they are following the dosing regimen appropriately on the GLP agonists, it simply isn't physiologically possible.

 

[NewYorkDoctors]

I hope these individual are also on a proper diet and exercise regimen before the medications and gastric sleeves get done.
Proper diet as if saw a dietitian, did own research on macronutrient versus time restricted eating strategies (which by themselves have not shown to lead to sustained weight loss. but should be used in conjunction with everything else. let's not be one of those "no mortality benefit so i aint doing it" academic nihilists... such as the doctor who read the recent NEJM article stating time restricted intermittent fasting did not lead to a significantly different weight loss compared to caloric restriction alone and decided nahhhh doesn't work... and this physician has quite large waist circumference too. the point of the no mortality benefit so there is no point to doing it is suppose to refer to medications or invasive procedures that cost money and resources. Asking a patient to do something without such a cost to society and has no immediate downsides and possible benefit should not be dismissed so easily. There is no mortality benefit associated with using Mucinex and benzontate for a URI... yet people still prescribe it....) , and have a partner / family member who can support the plan.

Exercise regimen as if find a fitness trainer and really engage in exercise that gets the HR to a level to exceed anaerobic threshold.
I have done CPETs for obese individuals before (sometimes at the behest of the bariatric surgeon. there is some data regarding operative outcomes based on their VO2max) as well as to use their resting VO2 to calculate their RMR (for tailor a caloric strategy) and also an exercise prescription. There is a very nice website that can inform patients which physical activity they can do based on their highest METS. This way they do not get discouraged. MET Values for 800+ Activities - Golf - ProCon.org

Out of the clinical trials I have read (I read through the Columbia obesity course slides), it seems when an isolated intervention is test (which honestly is the proper way to run an RCT), none of these strategies seem to lead to sustained long term weight loss.

But no RCT (not even those done during those monthly long inpatient stays at Rockefeller University with a metabolic kitchen and also under room calorimetry) can properly capture real life successful stories and losing weight when one "throws the kitchen sink at weight management" and includes macronutrient diet restriction, time restricted eating, resistive exercise / weight lifting, aerobic exercise, pharmacotherapy, and possibly surgery (for the Class 3 and above BMI levels).

There is plenty of anecdotal data for patients with Class 3 obesity who "threw the kitchen sink"
Some state it is "expensive" to do so and only "rich people" can afford to do this and there is another instance of the socioeconomic divide.
Well.... there are plenty of youtube do it yourselfers who teach you how to eat healthy and wholesome on a budget ... while those may not be RCTs... we should not dismiss that advice so readily as physicians (especially if you a physician who is overweight yourself).
There is also 24 hour fitness... $10 a month (though they won't ever let you cancel lol) ...
So it's all a mindset.

What about those people who work and are busy? stuck in traffic? have to watch kids? do other stuff?

Buy some weights and put it in your home in your basement, If you are in an apartment, get some dumbells and barbells (tuck them away in the corner when not in use) and use them for a few sets few 5 minute interval. then go do something else then come back

there really is no excuse other than "i just dont feel like it."


but that pretty much highlights the crux of (what I think) Dr Metal is getting at. while the meds work wonderfully, they should not be the only tool. We need to throw the whole kitchen sink at the problem.

 

[NewYorkDoctors]

Does caterwaiter care to offer a rebuttal ? Not even a DM ? Lol .without a rebuttal I’ll have to respond based on assumptions . Yes I know what an ASSumption can lead to . So perhaps respond with your rebuttal soon.

Body positivity is fine. I agree that Not everyone needs to be athletic or rail thin . But let’s not live in the world of hyperbole and get caught up in the (satire) twitter account of Dr Anita B Etin PhD lol. There are plenty of overweight individuals who have no major diseases and can be healthy (no DM , ascvd , joint issues , sleep apnea, etc ) if you fit in that category (and yes you need a physician evaluation and not just twitters reinforcement of your own values ) then you are a wonderful example of a health human being .

But the key to all of this is to reduce all of the health care expenditures for the US and it really takes the whole kitchen sink . One part of that equation is (let me borrow some woke terminology that the body positive crowd likes to use ) individual agency and equity . (Lol)

 

[chessknt]

Is quitting heroin or smoking the same idea? Just stay away from places with drugs and cigarettes and stop buying and using it? Or do we think there is actually physiologic explanations as to why people have trouble doing those things which is why we have medical interventions to help people which is what these drugs are? Of course in isolation it doesn't work without some other buy in but the same is true for nicotine supplements, Suboxone, and clonidine but I don't see those being withheld intentionally in people who are trying to quit....

I just don't understand the logic of wanting to see people fail multiple times before deigning to prescribe an approved medication. I have never told someone to quit smoking without nicotine supplements first and if they fail multiple times then go get them, it makes no damn sense to not set them up for maximum success the first time.

 

[rokshana]

I’ll rebutt for him…obesity is a disease and actually recognized as one since 2013.
If you are obese, you are not healthy.

If someone has high blood pressure, do you tell them to do just lifestyle modifications and let’s see if you need medications?

Does lifestyle modification help? Of course it does…as it does with cad, htn, dm, etc…obesity is no different…no.different.

It is not a lifestyle choice…long ago it was thought that being gay was a lifestyle choice… that using drugs was a lifestyle choice…and the same thought process is still allowed for obesity…it’s not…there are real pathological issues at play in obesity and we now have medications that actually work…

Should someone use glp1a to lose 10lbs or so they can look pretty in their clothes? No… but for those that struggle and have struggled with significant weight … that is a disease and is a known contributor to other diseases… why should they not have a chance to help their disease ?

Like those who feel that they can’t give birth control… fine don’t prescribe it… but refer them to someone who can.

 

[VA Hopeful Dr]

I know you are pretty far on the nihilistic cynic scale of inevitability but can you at least acknowledge if there was a drug that we could inject for 1500/month (not per week) that cured opiate addiction that it would still be a net save to the healthcare system to avoid costly hospitalizations? I don't think even the most dedicated can manage to not lose weight if they are following the dosing regimen appropriately on the GLP agonists, it simply isn't physiologically possible.

I have quite a few patients who prove that wrong every week.

 

[chessknt]

I have quite a few patients who prove that wrong every week.

On the weight loss dosing or the diabetes dosing?

 

[DrMetal]

I’ll rebutt for him…obesity is a disease and actually recognized as one since 2013.

Maybe. Sure in some instances it may be its own disease process, but I think most times (most of the obese patients we deal with) the obesity is a manifestation, a symptoms of something else (non-compliance with other treatments, poor lifestyle choices, untreated mental health conditions).

If it is a disease process, what's the pathophysiology? Sure, it's multi-factorial, maybe there's genetic evidence, enzymatic mutations here or there, but most of these cases are rare.

How did the state of Texas go from <15% prevalence in 1940 to >50% in 2020? Was there a viral outbreak that caused obesity or some genetic mutation promulgated through the generations that lead to it? . . . .OR, was is an unethical food industry (including fast food, sodas etc) that went rampant over the past 80 years, coupled with a society that de-emphasized good life style choices?

I'll put my money on the latter.

Sometimes, we're not so good at defining 'diseases'.

I have quite a few patients who prove that wrong every week.

Of course. Like the post op bariatric surgery/sleeve patient, who finds a way to gain weight, b/c she still eats compulsively. You can't cut the 'crazy' out.

 

[NewYorkDoctors]

I’ll rebutt for him…obesity is a disease and actually recognized as one since 2013.
If you are obese, you are not healthy.

If someone has high blood pressure, do you tell them to do just lifestyle modifications and let’s see if you need medications?

Does lifestyle modification help? Of course it does…as it does with cad, htn, dm, etc…obesity is no different…no.different.

It is not a lifestyle choice…long ago it was thought that being gay was a lifestyle choice… that using drugs was a lifestyle choice…and the same thought process is still allowed for obesity…it’s not…there are real pathological issues at play in obesity and we now have medications that actually work…

Should someone use glp1a to lose 10lbs or so they can look pretty in their clothes? No… but for those that struggle and have struggled with significant weight … that is a disease and is a known contributor to other diseases… why should they not have a chance to help their disease ?

Like those who feel that they can’t give birth control… fine don’t prescribe it… but refer them to someone who can.

that's not really a rebuttal. that affirms what I am saying. The whole kitchen sink approach.
I do agree with all points in your statement.

But it should be real attempts at exercise and diet first before going to the meds. Ultimately the meds and surgery can be used as I have only seen anecdotal online reports of individual patients who used dieting and exercise to drop from BMI 50 to 30 (though real pictures and weight logs on online blogs) and no big studies (not that there will be one) at the population level.

I got the vibe that caterwaiter disliked my post because that individual was part of the woke body positive crowd. Beauty is in the eye of the beholder and I make no judgments on that aspect of the body positive crowd. There should be no bullying or putting people down for something beyond their control. But I can only hope these individuals are taking steps to make positive changes for their health.

I do indeed believe that obesity is more than just willpower. however, paying lip service to that fact and not being active in engaging individuals to "use the whole kitchen sink approach" and just giving them weight loss meds (without first instituting a regimen of good eating and exercise habits) is not being complete and merely feeds into the Medical-Industrial Complex.

I was trying to bait caterwater into responding. i guess sometimes when I try to go fishing, I get a discarded toilet seat or some other piece of refuse instead.


Addendum: I am not some conservative right wing MAGA bully. I empathize with my obese patients and I never put them down. I do not even use the words obese or weight loss. I say weight management. I make it clear to them the goal is not to look like some kind of anorexic model or Adonis statue (unless that is one's personal goal). I make it clear the goal is to improve health and prevent long term disease.

I empathize with my older patients who cannot go to the gym like myself (I do not even go to the gym myself. I purchased weights and a bench in my basement. I have kids and I have parenting duties like doing additional home school curriculum to their regular school curriculum. I work 80 hours a week - not all seeing patients this includes my office administrative and business tasks - yet I find the time to stay in shape and appear somewhat athletic like I was in my 20s. cant say that for all other doctors) so I run CPET on them and give them a careful exercise prescription and give them positive support.

I have a nutritionist next door whom I utilize frequently. I actually spend time (and bill accordingly of course 97802/3 - though one would make more money not even dealing with this and going to the next 99213) going over nutritional concepts in 6th grade level terms as well.

The meds are great and will help a nation with an obesity epidemic. But the foundations of diet exercise and hardwork should be in place first. I understand many patients cannot break through this wall due to the "ghrelin gremlins" and other homeostatic factors in the hypothalamus that make it very hard for "willpower" to break through. But the foundation must in place first before building a house or else the whole structure will collapse.

 

[VA Hopeful Dr]

On the weight loss dosing or the diabetes dosing?

I've got 2 very large patients on ozempic 2mg, so a little short of the full Wegovy dose but at 2mg we should see SOME weight loss.

 

[caterwaiter]

I got the vibe that caterwaiter disliked my post because that individual was part of the woke body positive crowd.

I disliked your comment because I think it represents a particularly non-empathetic way to think about your patients.

Do I consider myself body positive? Sure! If you'd like to lump me in with the "woke body positive crowd".....go for it, I guess.

I was trying to bait caterwater into responding. i guess sometimes when I try to go fishing, I get a discarded toilet seat or some other piece of refuse instead.

Happy fishing, dude.

 

[DrMetal]

The meds are great and will help a nation with an obesity epidemic. But the foundations of diet exercise and hardwork should be in place first. I understand many patients cannot break through this wall due to the "ghrelin gremlins" and other homeostatic factors in the hypothalamus that make it very hard for "willpower" to break through. But the foundation must in place first before building a house or else the whole structure will collapse.

Well said. You and I seem to be on the same wavelength. You're being more eloquent than I. I'm quickly losing my patience in this profession (pun intended).

I disliked your comment because I think it represents a particularly non-empathetic way to think about your patients.

That's the problem. Sometimes we're a little too empathetic/sympathetic in this business. It can lead to cloudy judgement. The opioid crisis was a great example. We make up diagnoses (fibromyalgia, CFS), insist on prescribing expensive (at the time they were, still under patent) narcotics, all in the name of empathy, sympathy . . . then something bad happens (addiction, death), crisis ensues.

Similar pattern here with obesity, a very loosely defined 'disease' entity, we're prescribing expensive medications, some side effect may ensue (now I don't think ozempic is addictive or will cause the turmoil that opioids did . . . .but nonetheless, this trajectory is eerily familiar).

Whatever the case: there should be no objection in asking your patient to pull some of their own weight (pun intended). You weigh 300 lbs, lose 5% on your own first. 5 frickin percent, not 50%. If you can't do that on your own, peace be with you.

 

[NewYorkDoctors]

I disliked your comment because I think it represents a particularly non-empathetic way to think about your patients.

Do I consider myself body positive? Sure! If you'd like to lump me in with the "woke body positive crowd".....go for it, I guess.

Happy fishing, dude.

There is a difference between being empathetic with patients (which I am. I am a sweet caring physician who holds the hands of the patients because that's how I get adherence and good ratings. but I am a nasty mofo online with other doctors whom I feel are satisfied with the status quo and do not take the extra miles to get things done no matter how time consuming it may be. while i talk the smack, I walk to walk and literally spend time talking about these points in detail. it's really time consuming but it does pay dividends down the line for the patient care... after repeating myself like 50 times) and promoting therapeutic inertia or therapeutic nihilism.

I never tell my patients they must look like an anorexic model or an athlete unless its him/her/they/moon whatever pronoun they want to use desires it as a personal goal.

For the obese patients I see, if I can get their joints feeling better, their restrictive lung disease better, then BP under control, their OSA controlled, their A1c and lipids controlled... then I tell them you are in great shape regardless of what the BMI, body fat %, or the waist circumference is! Keep it up! You are beautiful the way you are!

Anyway, looks like I caught a live one when you replied. lol.


Anyway good day to you. Let's agree to disagree and both work hard for our patients.

 

[NewYorkDoctors]

Well said. You and I seem to be on the same wavelength. You're being more eloquent than I. I'm quickly losing my patience in this profession (pun intended).



That's the problem. Sometimes we're a little too empathetic/sympathetic in this business. It can lead to cloudy judgement. The opioid crisis was a great example. We make up diagnoses (fibromyalgia, CFS), insist on prescribing expensive (at the time they were, still under patent) narcotics, all in the name of empathy, sympathy . . . then something bad happens (addiction, death), crisis ensues.

Similar pattern here with obesity, a very loosely defined 'disease' entity, we're prescribing expensive medications, some side effect may ensue (now I don't think ozempic is addictive or will cause the turmoil that opioids did . . . .but nonetheless, this trajectory is eerily familiar).

Whatever the case: there should be no objection in asking your patient to pull some of their own weight (pun intended). You weigh 300 lbs, lose 5% on your own first. 5 frickin percent, not 50%. If you can't do that on your own, peace be with you.

we should be nice and caring to the patient. we should hold hands and cry with them a little bit (or at least fake it like me) since that is how patients will connect with you and buy in.

but if we think too empathetically and 100% put ourselves into the patients shoes, we run the risk of therapeutic inertia / nihilism and get nothing done. they we complain why health outcomes are so bad.

I am not saying we need to be old school paternalistic, but we should probably strike a balance in between.

 

[rokshana]

Well said. You and I seem to be on the same wavelength. You're being more eloquent than I. I'm quickly losing my patience in this profession (pun intended).



That's the problem. Sometimes we're a little too empathetic/sympathetic in this business. It can lead to cloudy judgement. The opioid crisis was a great example. We make up diagnoses (fibromyalgia, CFS), insist on prescribing expensive (at the time they were, still under patent) narcotics, all in the name of empathy, sympathy . . . then something bad happens (addiction, death), crisis ensues.

Similar pattern here with obesity, a very loosely defined 'disease' entity, we're prescribing expensive medications, some side effect may ensue (now I don't think ozempic is addictive or will cause the turmoil that opioids did . . . .but nonetheless, this trajectory is eerily familiar).

Whatever the case: there should be no objection in asking your patient to pull some of their own weight (pun intended). You weigh 300 lbs, lose 5% on your own first. 5 frickin percent, not 50%. If you can't do that on your own, peace be with you.

the better example would be the other diabetes medications that have been game changers like SGLT2i as well as GLPLa...and its not like GLP1a are new! they have been around for over 15 years! Its only because Hollywood and TikToc have gotten hold!
another better comparison would be immunotherapy for metastatic cancer like the checkpoint inhibitors...these treat a defined disease (whether you believe these are disease is beside the point) and they have EBM in the form of RCTs that show they actually treat the disease.

would tell a pt with a bp or 180/100 that they need to drop their bp by 20 points before you give them antihypertensive drugs?
would you tell someone with diabetes and an a1c of 10% that they need to change their diet and exercise habits before starting medications?

because that is exactly what you are advocating here.

 

[anonperson]

Well said. You and I seem to be on the same wavelength. You're being more eloquent than I. I'm quickly losing my patience in this profession (pun intended).



That's the problem. Sometimes we're a little too empathetic/sympathetic in this business. It can lead to cloudy judgement. The opioid crisis was a great example. We make up diagnoses (fibromyalgia, CFS), insist on prescribing expensive (at the time they were, still under patent) narcotics, all in the name of empathy, sympathy . . . then something bad happens (addiction, death), crisis ensues.

Similar pattern here with obesity, a very loosely defined 'disease' entity, we're prescribing expensive medications, some side effect may ensue (now I don't think ozempic is addictive or will cause the turmoil that opioids did . . . .but nonetheless, this trajectory is eerily familiar).

Whatever the case: there should be no objection in asking your patient to pull some of their own weight (pun intended). You weigh 300 lbs, lose 5% on your own first. 5 frickin percent, not 50%. If you can't do that on your own, peace be with you.

I thought bariatric surgeons will require patients to lose weight on their own before they even operate on patients. Not a huge asking but typically 20 or 30 lbs.

At least all the patients I have referred have indicated this.

Why would losing some weight on their own be a controversial take?

 

[anonperson]

There is a difference between being empathetic with patients (which I am. I am a sweet caring physician who holds the hands of the patients because that's how I get adherence and good ratings. but I am a nasty mofo online with other doctors whom I feel are satisfied with the status quo and do not take the extra miles to get things done no matter how time consuming it may be. while i talk the smack, I walk to walk and literally spend time talking about these points in detail. it's really time consuming but it does pay dividends down the line for the patient care... after repeating myself like 50 times) and promoting therapeutic inertia or therapeutic nihilism.

I never tell my patients they must look like an anorexic model or an athlete unless its him/her/they/moon whatever pronoun they want to use desires it as a personal goal.

For the obese patients I see, if I can get their joints feeling better, their restrictive lung disease better, then BP under control, their OSA controlled, their A1c and lipids controlled... then I tell them you are in great shape regardless of what the BMI, body fat %, or the waist circumference is! Keep it up! You are beautiful the way you are!

Anyway, looks like I caught a live one when you replied. lol.


Anyway good day to you. Let's agree to disagree and both work hard for our patients.

Patients don't need to look anorexic but they gotta get their BMI in check.

It's not a perfect metric but it's reasonable. Even if they're BPs are normal, no diabetes etc, it's not beneficial to walk around with a very high BMI.

 

[chessknt]

I thought bariatric surgeons will require patients to lose weight on their own before they even operate on patients. Not a huge asking but typically 20 or 30 lbs.

At least all the patients I have referred have indicated this.

Why would losing some weight on their own be a controversial take?

The risk:benefit consideration is very different for a GLP agonist vs. bariatric surgery. I have seen all sorts of complications from new and old bariatric surgery in the ICU and the floors, the same is not true with GLP agonists. I dont see why the bar needs to be as high. Also bariatric surgery costs way more.

 

[NewYorkDoctors]

Patients don't need to look anorexic but they gotta get their BMI in check.

It's not a perfect metric but it's reasonable. Even if they're BPs are normal, no diabetes etc, it's not beneficial to walk around with a very high BMI.

Yes . I concur .

 

[NewYorkDoctors]

the better example would be the other diabetes medications that have been game changers like SGLT2i as well as GLPLa...and its not like GLP1a are new! they have been around for over 15 years! Its only because Hollywood and TikToc have gotten hold!
another better comparison would be immunotherapy for metastatic cancer like the checkpoint inhibitors...these treat a defined disease (whether you believe these are disease is beside the point) and they have EBM in the form of RCTs that show they actually treat the disease.

would tell a pt with a bp or 180/100 that they need to drop their bp by 20 points before you give them antihypertensive drugs?
would you tell someone with diabetes and an a1c of 10% that they need to change their diet and exercise habits before starting medications?

because that is exactly what you are advocating here.

Perfectly valid points

But after the meds are started to “get the ball rolling,” a patient will lose some weight and the joints feel a little better and the breathing is a little easier and the hunger goes away , more effort should be put into establishing those good diet and exercise habits .

This is where the doctor should put more effort into ensuring patients get into a life long habit of Healthier eating and exercise . After all is the goal to be on meds forever and support the medical industrial complex forever ?

If the doctor has no idea how to eat right and exercise , then the doctor should refer to dietitians and exercise trainers accordingly .

If the patient prefers to be a couch potato and does want to take these steps , then this patient has the freedom to do so. In that case therapeutic inertia with some weight loss is better than getting sicker and being hospitalized all the time .

Yet the crux If my argument is the doctor needs to put a greater emphasis of proper eating and exercise as well . We need all pieces of the puzzle and not just the shiniest piece .

This is not a maga right vs antifa left hyperbolic all or nothing argument .

Cancer is a different analogy as there is nothing you can do “naturally” to cure it . Willl there ever be an RCT for meds and no exercise diet vs no meds and intensive hardcore exercise diet ? No one will pay for that . If no rct exists , does that mean you should not do it ? Not necessarily . This is where the art of medicine comes in. Academic doctors tend to be a little too rigid . No evidence ? I ain’t doing it jack !

Absence of proof is not proof of absence after all

 

[DrMetal]

would tell a pt with a bp or 180/100 that they need to drop their bp by 20 points before you give them antihypertensive drugs?
would you tell someone with diabetes and an a1c of 10% that they need to change their diet and exercise habits before starting medications?

Not quite. These can be more acute situations that require faster attention. Someone with a SBP > 180, I'm worried about them going into a hypertensive crisis this weekend. A1c >10%, could go into DKA/HHS this weekend. So that requires more acute medical intervention.

Someone who's been > 300 lbs for over 10 years . . .not so acute (still concerning, but not acute).

Also the meds for BP/DM treatment are cheaper, very-well studied, insurance companies will pay for them, and I as a PCM can prescribe and titrate them. (I'm sorry, but such logistical/financial concerns matter, it's 2023).

Problem with ozempic and other weight loss drugs is that they're not all that well-studied, they're expensive, insurance companies wont cover them, the patient population is largely mal-compliant with their healthcare, and they will likely require an Endocrine consult (thus flooding a subspecialty that's already tapped out). It's a recipe for disaster. [and we will be stupid enough to allow it]

 

[rokshana]

Not quite. These can be more acute situations that require faster attention. Someone with a SBP > 180, I'm worried about them going into a hypertensive crisis this weekend. A1c >10%, could go into DKA/HHS this weekend. So that requires more acute medical intervention.

Someone who's been > 300 lbs for over 10 years . . .not so acute (still concerning, but not acute).

Also the meds for BP/DM treatment are cheaper, very-well studied, insurance companies will pay for them, and I as a PCM can prescribe and titrate them. (I'm sorry, but such logistical/financial concerns matter, it's 2023).

Problem with ozempic and other weight loss drugs is that they're not all that well-studied, they're expensive, insurance companies wont cover them, the patient population is largely mal-compliant with their healthcare, and they will likely require an Endocrine consult (thus flooding a subspecialty that's already tapped out). It's a recipe for disaster. [and we will be stupid enough to allow it]

fyi, an A1c of 10% is very low risk for either DKA or HHS...type 2 pts need BG in excess of 800 and really 1000+ (and yes have seen these) to become so insulinopenic that they go into DKA or HHS...I'm not generally worried about that as much as I am of the MI that they will have or the amputation that they will need.

and its a big loophole that companies were given for group insurance that obesity doesn't have to be covered...close the loophole, and insurances will cover.

and actually the glpt1a and sglt2i are pretty well studied...happy to give you articles to read if you want them.

and trust me, as an endocrinologist, you don't have to tell me that financial concerns and the unending paperwork is there (we probably have to do far more PAs than any other specialty for stupid ****).

and insurance not covering brand medications is not solely the realm of these medications...its a problem for everyone.

and you will be amazed at the levels of compliance that comes when they actually see a good result from use of the medications.

and stop checking TPO ab and testosterone on everyone that says they are tired and losing their hair and then send an urgent endocrine consult...that will help a lot more (and tell them they don't need to bring their bag of hair to the appt).

 

[rokshana]

Perfectly valid points

But after the meds are started to “get the ball rolling,” a patient will lose some weight and the joints feel a little better and the breathing is a little easier and the hunger goes away , more effort should be put into establishing those good diet and exercise habits .

This is where the doctor should put more effort into ensuring patients get into a life long habit of Healthier eating and exercise . After all is the goal to be on meds forever and support the medical industrial complex forever ?

If the doctor has no idea how to eat right and exercise , then the doctor should refer to dietitians and exercise trainers accordingly .

If the patient prefers to be a couch potato and does want to take these steps , then this patient has the freedom to do so. In that case therapeutic inertia with some weight loss is better than getting sicker and being hospitalized all the time .

Yet the crux If my argument is the doctor needs to put a greater emphasis of proper eating and exercise as well . We need all pieces of the puzzle and not just the shiniest piece .

This is not a maga right vs antifa left hyperbolic all or nothing argument .

Cancer is a different analogy as there is nothing you can do “naturally” to cure it . Willl there ever be an RCT for meds and no exercise diet vs no meds and intensive hardcore exercise diet ? No one will pay for that . If no rct exists , does that mean you should not do it ? Not necessarily . This is where the art of medicine comes in. Academic doctors tend to be a little too rigid . No evidence ? I ain’t doing it jack !

Absence of proof is not proof of absence after all

it gets the ball rolling in a certain population per se...these medications are chronic lifelong medications...just like bp meds and cad meds...they are not to be d/c once started...that part is getting lost with many...physicans and patients alike.

lifestyle modifications both physical and dietary are the bedrock of all diabetes and obesity treatment...utilization of medication and lifestyle changes are not mutually exclusive.

i get what you are saying...and any endocrinologist that sees these pts, either diabetes, obesity, and usually both, stresses lifelong lifestyle changes...all my new dm pts see the dietician/diabetes educator at least once...and will have them do refresher course if they haven't seen anyone in a few years. I don't make it sound like an option...its part of the interdisciplinary aspect of seeing Endocrinology ...at least that is how i approach it with them...and if they have been either referred or asked to be referred, they tend to be willing to try.

but these medications really are the first to be really effective after medications that have disappointed over and over in the last few decades...they are gift and we should be utilizing them...just like we utilize other medication that have the ability to have our pts become healthier...or at least slow the progression of their disease.

 

[NewYorkDoctors]

it gets the ball rolling in a certain population per se...these medications are chronic lifelong medications...just like bp meds and cad meds...they are not to be d/c once started...that part is getting lost with many...physicans and patients alike.

lifestyle modifications both physical and dietary are the bedrock of all diabetes and obesity treatment...utilization of medication and lifestyle changes are not mutually exclusive.

i get what you are saying...and any endocrinologist that sees these pts, either diabetes, obesity, and usually both, stresses lifelong lifestyle changes...all my new dm pts see the dietician/diabetes educator at least once...and will have them do refresher course if they haven't seen anyone in a few years. I don't make it sound like an option...its part of the interdisciplinary aspect of seeing Endocrinology ...at least that is how i approach it with them...and if they have been either referred or asked to be referred, they tend to be willing to try.

but these medications really are the first to be really effective after medications that have disappointed over and over in the last few decades...they are gift and we should be utilizing them...just like we utilize other medication that have the ability to have our pts become healthier...or at least slow the progression of their disease.

I dunno... I get your point but...

For CAD I would agree because the data is clear about secondary prevention and statins.

If someone's diabetes fully gets resolved with diet and exercise over several years, A1c from 9% down to 5.5%, you would want these meds on board for the rest of their lives? I mean it should be a joint discussion with the patient of course.

But if someone is on ASA81 or statin for primary prevention because their Reynolds or Framingham were elevated .. then this patient improved the diet and exercise to the point that the numbers improved and the risk score is now low... you would keep the ASA81 or statin for life?

If the RCTs show clear cut mortality benefit and the disease is still present, I prescribe those statins forever also in CAD, CVA, and PAD patients. I am not recommending taking away medications if the disease process is still present.

If the statin were for primary prevention, I am always considering if it can come off.

while I also put my fair share of resistant hypertensives onto four or five BP medications, I do set up remote BP monitoring and then if they are reaching their goal, I titrate down meds. I will admit I have never ran into any secondary hypertension patient (I have a few primary hyperaldos) that got off their aldactone (because they declined surgical intervention or declined doing the adrenal vein sampling after I confirmed with salt suppression test). But some essential hypertension patients get better sometimes due to a combination of weight loss, reduced sodium intake, sleep apnea treatment (which is one treatment CPAP for another... so i guess that' doesnt help my point too much) and I titrate down medications accordingly.

Again, meds are great. If meds a proven to prolong life, I keep it on board as well.

In certain (I will admit infrequent) situations, I have noticed the original indication for the medication is no longer present. I titrate off accordingly.

 

[TooMuchResearch]

fyi, an A1c of 10% is very low risk for either DKA or HHS...type 2 pts need BG in excess of 800 and really 1000+ (and yes have seen these) to become so insulinopenic that they go into DKA or HHS...I'm not generally worried about that as much as I am of the MI that they will have or the amputation that they will need.

and its a big loophole that companies were given for group insurance that obesity doesn't have to be covered...close the loophole, and insurances will cover.

and actually the glpt1a and sglt2i are pretty well studied...happy to give you articles to read if you want them.

and trust me, as an endocrinologist, you don't have to tell me that financial concerns and the unending paperwork is there (we probably have to do far more PAs than any other specialty for stupid ****).

and insurance not covering brand medications is not solely the realm of these medications...its a problem for everyone.

and you will be amazed at the levels of compliance that comes when they actually see a good result from use of the medications.

and stop checking TPO ab and testosterone on everyone that says they are tired and losing their hair and then send an urgent endocrine consult...that will help a lot more (and tell them they don't need to bring their bag of hair to the appt).

May I ask, what do they want you to do with their bags of hair?

 

[NewYorkDoctors]

May I ask, what do they want you to do with their bags of hair?

Perhaps the patients think the doctor is a classic Sir William Osler classic diagnostician who can tell a million things by performing a close inspection of the hair strands.

I wonder what Sir William Osler himself would say!

Elementary My Dear NYD (that was Sherlock Holmes i know... i know...) , it turns out it was stress and telogen effluvium all along! Drat if it werent for your meddling kids, I would have gotten away with a million dollar workup for the patient! (Scooby Doo Fred reference there).

 

[Meerkatology]

would tell a pt with a bp or 180/100 that they need to drop their bp by 20 points before you give them antihypertensive drugs?
would you tell someone with diabetes and an a1c of 10% that they need to change their diet and exercise habits before starting medications?

because that is exactly what you are advocating here.

i think the issue is 1. you cant really drop ur bp by 20, realistic speaking. 2. antihtn drugs actually work and can be taken over a long time.

bariatric surgeons ask pts to lose some wt first to know that the patients are determined to change, because weight loss surgery has much bigger side effect than antihtn meds and patients will just gain all the weight back after surgery if they do nothing to change. you can take norvasc everyday until u die , but u can't have another bariatric surgery every two years until u die.

its almost like asking cirrhosis patients to stop drinking before they can go on the transplant list

 

[chessknt]

i think the issue is 1. you cant really drop ur bp by 20, realistic speaking. 2. antihtn drugs actually work and can be taken over a long time.

bariatric surgeons ask pts to lose some wt first to know that the patients are determined to change, because weight loss surgery has much bigger side effect than antihtn meds and patients will just gain all the weight back after surgery if they do nothing to change. you can take norvasc everyday until u die , but u can't have another bariatric surgery every two years until u die.

its almost like asking cirrhosis patients to stop drinking before they can go on the transplant list

And do you think taking a GLP agonist is more like bariatric surgery or norvasc?

Do you think Wegovy actually works?

 

[Meerkatology]

And do you think taking a GLP agonist is more like bariatric surgery or norvasc?

Do you think Wegovy actually works?

wdym? i am not commenting on whether wt loss medications work.
i was speculating on the reasoning behind bariatric surgeons asking patients to first lose some weight before doing surgery

 

[sloh]

i think the issue is 1. you cant really drop ur bp by 20, realistic speaking. 2. antihtn drugs actually work and can be taken over a long time.

bariatric surgeons ask pts to lose some wt first to know that the patients are determined to change, because weight loss surgery has much bigger side effect than antihtn meds and patients will just gain all the weight back after surgery if they do nothing to change. you can take norvasc everyday until u die , but u can't have another bariatric surgery every two years until u die.

its almost like asking cirrhosis patients to stop drinking before they can go on the transplant list

For many patients who take GLP-1 agonists and titrate up to an effective dose, the nausea and vomiting is very extreme even if they try eating like they once did. It really isn't an exaggeration to say that it is physiologically impossible for many of these patients not to lose significant BW while on these meds.

 

[rokshana]

i think the issue is 1. you cant really drop ur bp by 20, realistic speaking. 2. antihtn drugs actually work and can be taken over a long time.

bariatric surgeons ask pts to lose some wt first to know that the patients are determined to change, because weight loss surgery has much bigger side effect than antihtn meds and patients will just gain all the weight back after surgery if they do nothing to change. you can take norvasc everyday until u die , but u can't have another bariatric surgery every two years until u die.

its almost like asking cirrhosis patients to stop drinking before they can go on the transplant list

I take it you haven’t used minoxidil, huh? 😊

And the same can be said of these medications… while it seems these medications are new, it’s only the demand… glp1a have been around for about 15 year now…the both work and can be taken long term.

The reason that bariatric surgeon ask for some weight loss is because bariatric surgery isn’t just the surgery… there is a paradigm shift that needs to be made , physiologically amd well as psychologically for bariatric surgery to be successful… and reversing traditional rny and ileo/duodenal switch is very very complicated ( sleeve may be a little easier, but I’m not the surgeon for these pts) so effectively permanent… these pts have to, ideally, be treated with a multidisciplinary approach pre and post op.
Glp1a, are not permanent per se…expected to be chronic but can be stopped with the only big effect is rebound weight gain…so a reason for these medications not to be given Willy nilly, but comparing a medical therapy to a surgical is a bit apples and oranges.

And the data actually shows ( so far) that surgical intervention has better outcomes for than medical treatment for pts with diabetes, especially in the first few years after dx…i broach bariatric surgery early as oppose to the last ditch effort.

 

[rokshana]

wdym? i am not commenting on whether wt loss medications work.
i was speculating on the reasoning behind bariatric surgeons asking patients to first lose some weight before doing surgery

But you did.

 

[NewYorkDoctors]

in terms of coverage, I do find there is difficulty in getting GLP1 agonist therapy at times. I see quite a lot of Managed Medicaid patients (who happen to be obese but not yet with DM). All obesity medications are not covered. If this patient had diabetes and "failed" metformin, then I could get past the PA to get Ozempic for the DM indication ... which would be similar but not the exact same dosing strategy as Wegovy.

Since many obese individuals tend to be lower income (in NYC anyway... can't speak for the rest of the country... ) individuals on Managed Medicaid, the GLP-1 for weight loss usually is a non-starter.

However I have patients who go on it then lose some weight. Once the weight comes off, they are far more receptive to trying things like time restricted eating / intermittent fasting (since the hunger pangs are far reduced), starting exercise (if planning for aerobic exercise I measure their AT on CPET and measure their METS so I can give them a careful prescription for aerobic exercise so they dont hurt themselves and also so they know to watch their HR on a apple watch or fitbit or something to make sure they have past AT or else they dont lose much weight gently walking around), starting weight lifting, or trying some new macronutrient restriction diet (at their own discretion). I usually do not recommend any specific macronutrient diet unless a patient has read or saw something online and is interested in trying it. The most common inquiry is the ketogenic diet.

For certain select educated patients (who know how to count calories and count macronutrients) who have done the ketogenic diet (the "clean version" without processed foods or excess sodium) and also employed intermittent fasting and the GLP1 agonist therapy, I have had some patients BMI of 40+ go down to less than 30 with about 1+ year of time. it's quite something anecdotally...

I am aware of the ketogenic diet literature (from the columbia obesity course) not being superior to other diets. It does lead to some weight gain more so than other diets in the rockefeller studies.
However, it physiologically makes quite a bit of sense and anecdotally works quite well if "done right."
I trend their hsCRP and obtain the Quest lipoprotein analysis just to make sure that rather high isolated LDL that occurs on the ketogenic diet is probably not causing atherosclerosis.
But I do not recommend the keto diet to EVERY patient because if a patient cannot "do it right," that patient is just overeating processed foods, saturated fats, and sodium by accident. They will sprinkle in some carbs here and there or eat too much protein and then wonder why they aren't in ketosis on the fingersticks and why they are gaining weight.

 

[sloh]

But I do not recommend the keto diet to EVERY patient because if a patient cannot "do it right," that patient is just overeating processed foods, saturated fats, and sodium by accident.

Sticks of butter in coffee!

 

[Snooks]

Those are valid points. Just out of curiosity, what do you think of Geriatrics and Palliative Care as stand alone specialties? One could argue in the same way that those should easily be within the purview of a general internist. However, they are obviously challenging populations and I think it's hard to argue that we receive optimal training in medical school and residency alone to truly appreciate the subtleties. Whether Obesity is in a similar category is a reasonable point of debate. Most internists feel comfortable managing DM and COPD, or if they don't, a specialty exists to refer them to. I wouldn't say the same is true, specifically regarding pharmacotherapy, for obesity.

I am early in my career in obesity medicine and exploring pathways towards practice. Do you or someone in your network know of a source of data regarding obesity medicine clinician salaries for ABOM certified MDs? I am having great difficulty finding anything about this online.

 

[chessknt]

I am early in my career in obesity medicine and exploring pathways towards practice. Do you or someone in your network know of a source of data regarding obesity medicine clinician salaries for ABOM certified MDs? I am having great difficulty finding anything about this online.

You're looking somewhere between a poorly paid PCP and a regularly paid nephrologist.

 

[NewYorkDoctors]

I am early in my career in obesity medicine and exploring pathways towards practice. Do you or someone in your network know of a source of data regarding obesity medicine clinician salaries for ABOM certified MDs? I am having great difficulty finding anything about this online.

you have the same billing codes as an Internist.

there aren't any unique CPT codes that an obesity medicine specialist can use that an internist cannot also use. Though you may have more "clout" to use the nutrition CPT codes 97802, 97803, 97804, the therapeutic exercise code 97110 (if you wanted to set up some kind of physical activity course like an exercise trainer would), or the resting indirect calorimetry code 94690 (like the ReeVue Medical RMR metabolic rate system).

 

[Snooks]

you have the same billing codes as an Internist.

there aren't any unique CPT codes that an obesity medicine specialist can use that an internist cannot also use. Though you may have more "clout" to use the nutrition CPT codes 97802, 97803, 97804, the therapeutic exercise code 97110 (if you wanted to set up some kind of physical activity course like an exercise trainer would), or the resting indirect calorimetry code 94690 (like the ReeVue Medical RMR metabolic rate system).

Does this still hold true if not board certified in Internal Med but Preventive Medicine and Obesity?

 

[NewYorkDoctors]

Does this still hold true if not board certified in Internal Med but Preventive Medicine and Obesity?

I guess so. check with your insurance provider, billing department, or your IPA liaison.

In general PCPS can use these codes just fine. maybe a few smaller insurances have restrictions on certain CPT codes.

 

[NewYorkDoctors]

since April 1st, New York State has streamlined the formulary for Medicaid and all managed Medicaid plans. Basically they put a lot more medications onto the formulary without prior authorization requirement. Now I do not need a PA and get order SGLT2 and GLP1 agonists right away for diabetics... of off label for weight loss... no questions asked.

Semaglutide as Wegovy not covered? No issues Ozempic it is. just work it up to 2 to 2.5mg like the 2.4mg clinical trial dosage.

I can only hope this will lead to better outcomes... or at least more bariatric surgery done (after the obligatory 6 months of diet, exercise, and weight loss).