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, it should be no surprise that doctors enter this field from a wide range of backgrounds. We have family doctors, general internists, endocrinologists, diabetologists, gastroenterologists, preventive cardiologists, pulmonologists, nephrologists (e.g. myself) and even gynaecologists leading obesity programs. I have also seen obesity programs led by dietitians, psychologists, exercise physiologists, nurses and even pharmacists. 

In my personal experience, given the complexity and heterogeneity of the patient population, generalists (e.g. family doctors or general internists) may be far better suited to run an obesity clinic than specialists. While patients with obesity present with a wide range of health problems affecting both mental and physical health (virtually every organ system can be involved), specialists tend to pay inordinate attention to their area of expertise. Thus, I have seen endocrinologists reduce obesity to a thyroid or diabetes problem, while ignoring musculoskeletal pain or depression. I have seen gastroenterologists focus on fatty livers and reflux disease, while showing less enthusiasm for PTSD or urinary incontinence. I have seen preventive cardiologists micromanage blood pressure and lipid profiles, whilst ignoring binge eating disorder or chronic pain. But I have also seen dietitians turn obesity into simply a nutrition problem and exercise physiologists largely focus on getting people to be more active whilst paying little attention to their actual mental or physical health. 

While all of these problems exist and obviously will need to be dealt with, I tend to see family docs and general internists do a far better job of taking a holistic view of the problem than most specialists. Thus, for instance, while my colleagues from family medicine have few qualms about starting a patient on medications for their depression or ADHD or helping them deal with their anxiety, insomnia or chronic pain, I often find my specialist colleagues obsess about optimising blood pressure or glucose control while largely ignoring the “real” issues. 

Fortunately, we now have an increasing number of educational and certification programs dealing with the breadth and scope of obesity medicine. Examples include the American Board of Obesity Medicine Diplomate Program (open to all doctors who have completed residency training in the US or Canada) or the World Obesity Federations SCOPE Program, open to all health professionals. Moreover, we are starting to see a number of new obesity fellowship programs pop up around the globe, which I am sure will, over time, increase the number of trained and qualified obesity personnel with true leadership potential. 

In the meantime, I can only celebrate the fact that more and more younger colleagues are deciding to dedicate themselves to this exciting and fast developing field of medicine. Recently, I was truly delighted to hear that well over 1400 doctors are currently poised to sit for the next round of ABOM exams. There are now thousands of health professionals who have taken the SCOPE seminars. This bodes well for the field and should go a long way towards making it easier and easier to find qualified medical personnel to lead obesity programs in the future. 

Berlin, D