Issue: October 2016
October 18, 2016
5 min read

Expertise, education, compassion needed for successful obesity practice

Issue: October 2016
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As the obesity epidemic grows, so too does the need for a structured approach to chronic obesity care. The risk for a variety of health complications, including type 2 diabetes and hypertension, rises with excess weight, according to the CDC. However, many traditional clinics are not equipped to meet the unique needs of a growing patient population.

Patients with obesity, experts argue, will benefit most from an obesity medicine practice that includes a caring, knowledgeable staff, proper patient and physical resources, community partnerships and an atmosphere that motivates patients to meet their health goals.

“The need for this kind of practice is borne out of the fact that, in general, people want to be healthy,” Elena A. Christofides, MD, FACE, CEO of Endocrinology Associates Inc. in Columbus, Ohio, told Endocrine Today. “People want to be more fit; they are trying. They’re looking for resources and accessing an unprecedented amount of data online, and it’s just not working. There is a need to develop an expertise, both clinically as well as in the public domain, in order for us to move this needle.”

‘Limitations and logistics’

Proper access for patients with excess weight must be a key consideration in the setup of any successful obesity medicine practice, experts said.

Elena A. Christofides

The obesity module developed by the American Association of Clinical Endocrinologists includes recommendations on how to prepare clinicians’ offices for obesity medicine. Suggestions include having appropriately sized furniture, wide doors and passageways, an accurate platform scale and appropriately sized blood pressure cuffs, examination gowns and wheelchairs, among other considerations.

“Dealing with a population that has excess weight and obesity, they’re going to be less mobile; they may be less fit; they may require special equipment,” Christofides said. “The most important thing, logistically, is understanding the weight limits of your clinic equipment and the accessibility of your clinic.”

Calibrated equipment, including scales that go up to 800 lb, an accurate, freestanding stadiometer, hydraulic exam tables and fitness equipment, such as a treadmill or stationary stairs, should all be standard in an obesity clinic, Christofides said. Location, she added, must also be taken into consideration.

“If you have a parking lot that is miles away from your door because you’re at a gigantic, multispecialty practice, that’s not something that a patient who has physical limitations from excess weight is going to be able to [navigate],” Christofides said. “The limitations and logistics are ones that people who don’t carry excess weight are never going to consider as being a limitation. You have to see your clinic through the eyes of somebody who might have a BMI of 50, 60 or 70 kg/m².”

Staff training

For patients with obesity, accessibility extends beyond clinic equipment, furniture and location, Charles Billington, MD, FTOS, an endocrinologist and weight-management specialist with University of Minnesota Health, and a past president of The Obesity Society, told Endocrine Today.

“We don’t want people to feel uncomfortable,” Billington said. “It’s important that people be able to get into the clinic. Similarly, when they are greeted by desk staff or nurses, that should be a friendly encounter as well. They should be treated as though they have a medical problem.”

Front-desk clerks, receptionists, nurses and nurses’ aides are often interacting with patients much more than the clinician, Christofides said. Those staff members, she noted, must reflect the clinic’s commitment to the patient population.

“There has to be compassion,” she said. “There has to be understanding. They don’t have to know what you know. They don’t have to know the answer to everything the patient might ask. They do have to know that the patients are in it for themselves; they have valid questions and needs. Educating staff to shut their biases down is probably harder than educating them on anything they need to know.”

The way questions are asked in the clinic setting matters, Billington said, and any staff training must address the use of “respectful language.”

“What I encourage everyone on our team to do is to ask, ‘How long have you had weight? How long have you had these challenges?’” Billington said. “We’re looking for opportunities, not saying what is ‘bad’ or ‘good.’ We have to engage [the patient’s] willingness to make some changes, and they will only do that if they feel like they are respected.”

Christofides will often simulate a patient exchange with her staff.

Charles Billington

“When I do my education with my staff, I will ask them questions,” she said. “I will say, ‘Why did you eat that? That’s not healthy.’ And they’ll start defending their actions, and I’ll say, ‘Stop. I just trapped you, deliberately.’”

Those questions, Christofides said, are biased in nature, setting up an encounter where the patient feels judged.

“When we do that [exchange] ... it finally drives the point home,” she said. “So, when patients say things like that, [staff members] can say, ‘Stop judging yourselves for your food choices.’ This is not about ‘good’ and ‘bad.’ This is about a food choice. How do we ensure that those choices are working toward a positive goal for you?”


Cost, coverage and coding

Obesity medicine predominantly involves counseling, Christofides said, and that requires different visit notes and coding.

“Your notes have to be able to reflect the counseling component, and the billing has to reflect the counseling component because there are different codes for that,” she said. “In addition, billing and coding in obesity management works really well for group visits. Some practices may find it difficult to be financially viable just doing one-on-one obesity counseling and management. They need to think about how they can set up their office to be a group-visit setup, or have group visits and follow a model that has proven to be more successful from the patient’s viewpoint.”

Many weight-control practices struggle with individuals not returning for follow-up appointments, Billington said, often due to cost or a lack of insurance coverage.

According to the Medicare national coverage determination for the treatment of obesity, nonsurgical services in connection with the treatment of obesity are covered when such services are “an integral and necessary part of a course of treatment” for medical conditions, such as hypothyroidism, Cushing’s disease, diabetes and hypertension. Medicare also covers intensive behavior therapy for obesity and bariatric surgery when guidelines have been met for each.

“My practice, at least, is to just straight up code for morbid obesity,” Billington said. “Now, it’s possible that my position leads to folks not getting covered. It’s an area of frustration for me.”

Community partnerships

Obesity medicine specialists should look for opportunities to work with local businesses and organizations that can help patients with obesity better meet their goals, Christofides said.

“If you can find a gym you can partner with, that’s great,” she said. “If you can find a gym that will help evaluate your patients and design plans for them, that’s ideal. You don’t have to offer everything in your office. You can add something as a component to be a complete package.”

Partnerships can extend beyond gyms and fitness centers, said Christofides, who also offers cooking classes as an option for patients through a local commercial kitchen.

“How do we make cooking enjoyable for everybody, and make it easy and enjoyable and cheap?” she said. “These are ways to present yourself as an authority figure on this topic, to branch out your expertise in managing this lifelong for the patients. And it doesn’t have to be you. You can contract with someone to do it, but you should be capable of providing complete lifestyle education for the patients.” – by Regina Schaffer

Disclosure: Billington reports consulting for EnteroMedics, Novo Nordisk and OptumHealth. Christofides reports no relevant financial disclosures.