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Physician Training in Obesity Management is Long Overdue



sharma-obesity-medical-students1Almost a decade ago, I recall noting to a journalist that most health professionals know about as much about managing obesity as your cab driver – I was not joking!

Unfortunately, not much has changed.

This sorry state of affairs is now discussed by James Colbert and Sushrut Jangi in a Perspectives piece in the New England Journal of Medicine.

As the Colbert and Jangi note,

“Physicians-in-training frequently fail to recognize obesity, are unfamiliar with treatment options, and spend relatively little clinic time treating obesity.”

As I have previously suggested, all physicians-in-training need a rigorous background in the biological and pathophysiological foundations of obesity.

“Once trainees have achieved a solid foundation in the science of obesity, these fundamentals must be applied clinically through mastery of behavioral medicine.”

“Finally, successful management of obesity requires that students learn to function as members of interdisciplinary care teams that include physicians, nurses, medical assistants, social workers, nutritionists, and behavioralists; the earlier such collaborative models are introduced into medical education, the more likely they will be to successfully replace the antiquated model of the solo physician and patient.”

While Colbert and Jangi note the importance of educating physicians in nutrition and motivational interviewing, I would take that this is far too “nutrition-centric” a view of what is needed.

Although, more education in nutrition and physical activity during physician training could certainly not hurt, we need to ultimately move beyond the age-old “eat-less-move-more” paradigm of obesity management. Not only, has this approach failed our patients, it also fails to acknowledge the complex physiology and psychology of obesity.

Thus, I would suggest that even the most knowledgeable “nutrition doctor” will more often than not end up treating the “symptoms” and not the “root cause” of obesity.

So, while I am all for teaching medical students the basics of obesity management (indeed, I would go as far as to fail any trainee, who does not know the fundamentals of energy physiology and the neuroscience of ingestive behaviour), propagating a “lifestyle” approach to obesity management will do little more than reinforce the notion that obesity is simply a matter of motivation and choice.

Health professionals, who still believe that obesity can be conquered simply by teaching and motivating people to eat healthy, are sadly part of the problem rather than part of the solution.

@DrSharma
Edmonton, AB

ResearchBlogging.orgColbert JA, & Jangi S (2013). Training Physicians to Manage Obesity – Back to the Drawing Board. The New England journal of medicine, 369 (15), 1389-1391 PMID: 24106932

 

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9 Comments

  1. Without having a real energy balance (caloric requirement based on measurement of. at least, the metabolic rate), NOBODY, including a well trained physician in the “biological and pathophysiological foundations of obesity”. can really help solving the obesity epidemic.
    See these very promising data and conclusions as we presented at the ECO2013 (European Congress on Obesity) http://www.vitasanas.ch/wp/wp-content/uploads/2013/06/poster-only-eco-liverpool-ok.pdf

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  2. There are many contributing causes for weight gain as you always mention and a large multidisciplinary team that includes a psychologist or other mental health therapist would have the best odds of being helpful.

    Some people have 1-3 lbs a year weight gain related to the common busy/inactive lifestyles and the metabolic changes with age (rather than any significant underlying issues related to weight gain such as grief, mental health issues or mobility issues). For this portion of the public seeing an exercise therapist and dietitian may be adequate to reduce or prevent further weight gain. It is human nature to underestimate what we eat and overestimate how much we exercise. Getting thorough external assessments and customized plans as well as having someone to be accountable to can be helpful and is worth having available for family doctors to refer to.

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  3. I am interested in the idea of eating plenty of fruits, veggies, legumes, and whole grains partly to displace more calorific items, and partly because recent research indicates that diets with enough of such nutrients fasciliate the intestine having a healthier biome which might itself help with reduction in inflammation from bacterial products.

    That said, I think that the failures of physician training for obesity is part of a much larger attitude in med school about what physicians do when things are not going right from their perspectives. Three examples: we are fortunate enough now to have a geriatric physician for my husband’s parents who is knowledgeable about quality of life measures. Did she know these from physician training? No. She knows them because she was first a nurse for a number of years. The physicians who helped at the end with my parents knew nothing about how to manage quality of life. We had to seek out information from nurses, PTs, OTs and others, and usually the physician did not even give any guidance on how and where to contact those experts. The same thing happened to me when a surgical follow-up complication by an advanced glaucoma surgeon cost me most of that eye’s vision. Both he and my ophthalmologist just told me to work on living with it, giving no leads to information and no sheets of tips and tricks for coping with the problems of low vision, glare, reduced field, and mismatched eyes. Some of that just does take time, like having my brain now learning to mostly ignore the bad eye, but most of what needs to be learned is better not learned without guidance because there are ways to ease experiences and facilitate learning and adjustments.

    To me these things seem to be systemic of the SAME problem, a failure of medical schools to teach what to do when things do not go the way the physicians hope they will go combined with a Puritanical tendency to unconsciously blame victims. Physicians need to be taught to better respect the types of expertise taught to other types of medical experts, and in relation to the neglected areas such as obesity to which society foolishly assigns moral blame there need to be areas or expertise which are like OTs or PTs or Pulmonary Techs who can teach the techniques and guide people to further help, sort of Energy Balance Techs.

    More radical might be a different gateway to becoming a physician by favoring medical school applicants who were previously experts in the life needs of patients such as nurses, PTs, OTs, etc. My glaucoma surgeon was considered technically adroit but from experience I can honestly claim that he forgot there was a person attached to the eye, and I think that a very similar situation happens with obesity. Physicians see the obesity but fail to see the patient and to realize that what is happening is a complex situation in which more guidance and help beyond simple spread sheets is often needed, both for those who are obese and those who are trying to avoid slipping over into it.

    In paleontology there is the Red Queen Hypothesis with its name taken from the _Alice in Wonderland_ line (paraphrased here) that one has to keep running as fast as possible to stay in the same place. That Red Queen problem is normal for many aspects of life including weight management for either extreme no matter the cause (and I know from friends that the public and too many physicians over simplify the opposite problem, too, just as incorrectly expecting anorexia in the genetically thin as others incorrectly expect laziness and gluttony with all who are overweight even those with overweight on both sides of the family like my cousin). Such a difficult problem and wide spread problem DESERVES to have its own supportive medical specialty as well as physician specialty, and somehow physicians need to better recognize the expertise of other medical professions and utilize them more to help patients.

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  4. It is amazing how often the same old approach gets repackaged as new and different. I think this is your second post in a week about people who are promoting an approach that is based on “eat less move more” and calling it a fundamental change or paradigm shift. The fact that the people promoting the change truly believe it is new and different is the saddest part.

    I was particularly dismayed by this sentence in the last paragraph: “One of the goals of health care reform is to start rewarding clinicians for keeping patients healthy, rather than reimbursing them on the basis of the services they provide or the procedures they perform.” I hope they’re not thinking that it would be helpful to provide financial incentives to physicians whose patients lose weight or who do more weight loss counseling. The relationship between physicians and obese patients is fraught enough as it is.

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  5. Hi Arya: Congratulations on bringing to the fore our greatest treatment handicap in the treatment of N. America’s greatest epidemic…OBESITY (as described by Colbert & Jangi!). Ignorance is partly a result of medicine’s belief that there is no adequate treatment (beyond Sx) for Obesity, and thus it is unwilling to “waste” any time on the subject. Also our colleagues have not been able to grasp the chronic nature of obesity, and thus naively believe that once excess weight is lost that no further special care should be needed (unlike diabetes & other chronic diseases). Your help is desperately needed in guiding Edmonton’s PCN to at least a beginning by establishing training/treatment centres in the PCN. (One PCN is trying to put together a program under the guidance of an RN untrained in the treatment of Obesity using methods proven not to work.) It would be useful to have a discussion, perhaps around the time of your presentation in Atlanta and share some ideas about what could be done if we pool our resources. I will be available there from Nov 13to 16. How about a meal together?
    Doug A

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