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Setting Up An Obesity Program: Staffing

Once we have identified the appropriate medical or surgical leadership for our program, we turn to the issue of staffing.  Obviously, we need appropriate administrative support staff to man the front desk and take care of scheduling, record keeping, stocking and all of the other secretarial tasks that are so essential to running a smooth clinic. Obviously, they need not only be good at their work but also have undergone sensitivity training and generally work towards creating a welcoming, supportive, and empathic atmosphere for patients.  That said, the models for obesity programs vary widely. Whilst everyone probably agrees that most patients will need both dietary and psychological support, whether or not these can be directly integrated into the clinic or will be provided outside the clinic (but in close collaboration) may depend on the local circumstances and funding models. In our clinic in Edmonton, we are fortunate to have both dietitians and clinical psychologists as an integral part of our clinic. In addition, we have registered nurses, who take on the important role of “case managers” and guide the patients through the whole process. From time to time, we have also had occupational therapists, physiotherapists and exercise physiologists as valued partners in our team, but for various reasons, these have not become a fixed feature of our program.  Irrespective of the discipline, in my experience most dietitians, psychologists, nurses or other allied health professionals (similar to most doctors) have generally not had specific training in obesity management prior to joining the program. Thus, while they bring important generic tools of their trade to the team, learning to work with patients presenting with obesity, according to the prevailing “philosophy” of the clinic, generally demands a steep learning curve.  This is of particular relevance when patients need to be supported in medical and/or surgical treatments for obesity. Thus, for example, patients undergoing bariatric surgery have very specific psychological and nutritional challenges to deal with that may go well beyond the expertise of a psychologist or dietitian who has not worked in this setting before. Fortunately, there are now an increasing number of educational resources offered to allied health professionals entering this field.  One such example is the Certified Bariatric Educator program offered by Obesity Canada, which is open to all licensed allied health professionals (this program is currently being updated to line up with the new Canadian Clinical Practice Guidelines and should… Read More »

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Setting Up An Obesity Program: Medical Expertise and Leadership

Now that we’ve looked at some of the issues around gathering administrative support for setting up an obesity program, we must turn our attention to the next key step, i.e. finding personnel to staff the program. This of course starts with finding appropriate leadership for the program – be it medical or surgical.  Today, thanks to the proliferation of bariatric surgery, finding surgical leadership for a bariatric program is in many ways far less challenging than finding medical leadership. Indeed no one would today consider hiring a bariatric surgeon who has never performed such operations to run a program. Bariatric procedures are now increasingly listed in many licensing catalogues for general abdominal surgery. There are also an increasing number of surgical bariatric centres, which regularly train residents and fellows. Thus, finding a trained bariatric surgeon to establish and lead a bariatric surgery program is rather straightforward.  In contrast, finding experienced and qualified medical leadership for an obesity centre is far more challenging. For one, while you would require a surgeon to have performed a certain number of bariatric procedures (hopefully in the hundreds) before claiming expertise in the area, no such requirements exist for other health professionals.  Thus, there is currently no accepted pathway or minimal requirement that would stop any medical professional who takes an interest in this field from setting up their own “weight-management” program.  As in my case, when I embarked on running my first obesity clinic two decades ago, I had no specific training or experience in obesity medicine – in fact the term “obesity medicine” was not even around yet. All I had was a bunch of, what I then thought were, good ideas, an interest in the field, and strong administrative support to do something in this area.  My story is by no means unusual. Most of my colleagues in this field had little, if any, formal training in obesity medicine and had little more than good intentions and a lot of hope and determination when they set out to work in this area. Many were guided by their own personal “weight-loss-success” stories, their strong interest in “preventive medicine”, or simply their fascination with healthy eating and/or exercise. Few had ever worked in an actual obesity program. Even fewer had completed a formal fellowship or had any kind of training or certification in this field.  Given that there is no accepted pathway to obesity medicine,… Read More »

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Administration: Managing Expectations and Collegial Support

A final word on gaining administrative support for setting up an obesity program relates to the issue of managing expectations and ensuring support from colleagues in other disciplines.  As much as I have seen administrators get enthusiastic about setting up an obesity program, I have also seen them get overly optimistic about the outcomes, both in terms of health impacts and earnings (private) or savings (public). The reality is that our current obesity treatments, although much better than doing nothing, are far from “magical”. Like everyone else, administrators’ expectations have often been anchored to the rather unrealistic anecdotal before-and-after pictures touted by the commercial weight-loss industry or the overly-hyped “success” stories that are regularly celebrated in public media. This problem is even more serious, in cases, where an administrator has apparently “conquered” their own obesity and believes to have found the “cure”. Convincing them that these anecdotal outcome are not typical and can generally not be achieved in serious obesity programs can prove quite challenging. Many find it hard to believe that, based on the best evidence we have, the average more or less “sustainable” weight loss that can be achieved in lifestyle or behavioural programs focussing on diet and exercise (even with good psychological support) is roughly in the 3-5% range. Thus, a 200 lb patient who ends up at 190 lbs at 2-5 years after entering the program, is pretty much exactly where you’d expect them to be! While even this rather modest change in body weight can have important health benefits (e.g. reducing the risk for diabetes by about 75% in people with pre-diabetes), it is not very impressive when you are expecting to see people lose 50 or even 100s of pounds. Even with the addition of medications (where available), average sustainable (with continued treatment) weight loss is only in the 5-15% range (bringing your 200 lb patient down to perhaps 180 lbs). In fact, even with bariatric surgery, the average long-term weight loss is in the 20-30% range (still leaving your patient at around 150 lbs). If administrators, like most patients are hoping for a 50% weight loss, they are likely to be deeply disappointed.  This is not to pooh-pooh the benefits of an obesity program – indeed, even with just a “lifestyle” program, you may well achieve significant improvements in health despite rather modest change in body weight (if any). Indeed, even just preventing… Read More »

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Administrators: Space and Attitude

In my experience, administrators tend to often underestimate the amount of outpatient space needed to run an obesity clinic. Given the larger size of these patients, there is need for larger seating, larger scales, larger exam tables, and wider doorways (not to mention the critical importance of floor-mounted toilets!). This means larger waiting rooms, larger exam rooms, larger changing booths, larger rooms for group sessions, etc. Add to this, the additional time needs for patients to dress and undress and move between rooms, it should be no surprise that an obesity clinic will take up at least 50% more space than a regular clinic to see the same number of patients per unit time.  And while we’re on the topic of space, let us consider the physical location of the clinic in terms of accessibility including distance from parking or public transportation. Having to walk a few hundred metres, navigating ramps, long hallways, or even stairs may prove physically exhausting or almost impossible for patients with severe obesity and mobility issues.  At this point it may be appropriate to put in a plug for an exciting project on designing a bariatric-friendly hospital, championed by my colleague Mary Forhan in a partnership between Alberta Health Services and Obesity Canada at the Medicine Hat regional hospital in Alberta.  Key findings from this project, that would make an in-hospital encounter far more safe, efficient, and pleasant for both patients and staff include mandatory education of all staff on weight-bias and respectful interactions, better understanding of the unique needs of people living with obesity, access to and knowledge in the use of bariatric equipment and supplies, and the need to respectfully communicate patients’ needs to other departments (e.g. diagnostics, wards, etc.). As a learning from this project, Obesity Canada is currently working on finalizing a simple labelling system that would readily indicate the weight capacity of all hospital or clinic furniture and equipment. Finally, when it comes to naming the program, I recommend avoiding the use of the word “weight” (as in “Weight-Loss Clinic”, “Clinic for Healthy Weights”, “Weight Wise”, etc.), as a key tenet of obesity management is to improve the overall health of the patient and not just focus on changing numbers on the scale. This is why I much prefer the terms “Obesity”, “Metabolic”, or even “Bariatric”, as used in a clinical context.  These terms will also help differentiate your centre from commercial… Read More »

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Educating Administrators

While we’re on the topic of harnessing the enthusiastic support from administrators for an obesity program, it is important to consider that administrators, like most people, have little experience in thinking of obesity as a chronic disease nor fully appreciate the complexity of its causes or the need for multi-modal treatment pathways. While, given the clear unmet need,  one may well succeed in convincing administrators of the need for setting up an obesity program, they may not be thinking beyond “educational” interventions focussed on promoting “healthy lifestyles”.  In fact, their idea of an obesity program may be limited to providing dietary or exercise counselling, whether to individuals or groups, in the hope that this will be enough to help patients reduce their weight.  At the other end of the spectrum, administrators may be gung ho about bariatric surgery (perhaps hoping for a new income stream), little recognising that such a program requires far more than simply hiring surgeons and giving them sufficient OR time. They may in fact be surprised that such a program involves medical management, psychologists, dietitians, and nurses, not to mention the considerable space and infrastructure required for intake, pre-surgical assessment and management as well as extended follow-up. In addition, there is almost never consideration or plan for post-surgical abdominoplasties or body contouring surgery.  Lately, with the increasing availability of effective anti-obesity medications, the boundaries between “medical” and “surgical” programs is fast eroding, as these medications, and thus medical management, is proving to be an integral part of pre- and post-surgical care. Thus, today, obesity programs must plan to integrate both conservative medical as well as pre- and post-surgical management of patients (even if the actual surgery may be performed elsewhere). Thus, a key step in gaining administrative support for setting up an obesity program, is ensuring that they fully understand the nature of obesity and the complex needs of these patients, so that they plan for the provision of what is required. Simply hiring a dietitian and an exercise specialist does not constitute an obesity program, nor does simply performing a few bariatric surgeries on anyone willing to pay for them.  @DrSharmaBerlin, D

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