Obesity-related healthcare costs approach $117 billion a year in the United States. We can expect future increases, too, since 16.4 percent of United States children are obese and 31.6 percent
are overweight. Many factors contribute to the obesity epidemic: extended television viewing and computer use; reduced physical activity programs at schools; zoning practices that promote driving among home, work, and recreation; the increase in serving sizes of prepared foods.
Obese individuals will likely turn to their physicians first for guidance in weight reduction. However, in a recent Harris Interactive survey, most of the 290 primary care physician respondents felt inadequately trained to discuss weight management issues. Subsequently, only two out of five obese patients were diagnosed as obese by their physicians. The geometric rise of bariatric surgeries performed in the United States from 16,800 cases in 1992 to an estimated 205,000 cases in 2007 points to the severe limitations of behavioral, dietary, and pharmacological treatment options for obesity. Both patient and physician are left feeling frustrated, helpless, and hopeless.
Dr. Kay Nelsen, Curriculum Director for the UC Davis Family Medicine Residency, asked me to develop a weight management clinic. I was reluctant given the challenges of attempting to modify behavior patterns that existed for decades and receive daily reinforcement from segments of the food industry. As with most of the surveyed physicians, I had limited exposure during my medical school and residency training in weight management and thought my expertise in weight management was lacking. Yet, I recognized the opportunity to spare my residents from a similar mindset.
Dr. Nelsen and our clinic manager Angela Gandolfo gave me extremely wide latitude in designing the clinic. I begin with a group orientation to discuss the patient-centered model. For most patients, this is a foreign concept–the patient will dictate the terms and pace of treatment, not the physician.
I tell patients that I will provide a maximum of 49.9% of the effort, but they must provide the majority, no matter how small the difference. I ask them to complete the following statement: “Losing weight will enable me to do (fill in the blank), something that I currently am unable to do.” The responses have included: play with my grandchildren, increase my energy, reduce the number of diabetic/hypertensive medications, feel better about myself, be a more healthful role model for my children. I emphasized that the function of the clinic is not weight reduction, but rather equipping patients with lifelong skills to position themselves to be their own primary healthcare providers.
After I outline the patient-centered model to the group, I ask if anyone is interested in scheduling an individual appointment. I have had a few instances where the patient has declared that this is the stupidest concept he has ever heard and thought the orientation was a waste of time. Some wanted a personal trainer, a referral to bariatric surgery, a line of prepared meals, or a physician who would actually “do something” other than make the patient do the majority of the work. For these patients, I agree with their assessment; this clinic is not in alignment with their priorities and trying to convince them otherwise would not be patient-centered.
For the patients who are willing to pursue the patient-centered approach, I meet with them individually and offer the option of walking during our appointments. I have had the luxury of having 45-60 minute appointments, far from the norm of 15-20 minutes for most primary care providers. I incorporated the walking component because I wanted to walk figuratively and literally by my patients’ side as they embark on a journey of becoming the primary provider for their health. And, I tell the patient, the worst outcome from these visits will be that they will get 20 minutes of physical activity for that day.
I set up the clinic in this manner to teach patients, but also to teach our residents to become advocates in addition to healers. I am trying to teach our residents the value of having the patient be the lead for chronic conditions, and the benefits of having the patients speak uninterrupted. Walking outside of the clinic minimizes the confines of the exam room where silence deafens and pushes participants towards goals rather than showing them paths. Once outside, silence between the patient and physician is transformed into contemplation and reflection.
After the conclusion of the appointment, I review the dynamics of a patient-centered approach to weight management with my residents. Then, I discuss the environmental triggers for obesity and submit to the residents that they may do the most good for their obese patients by serving on school boards or city planning commissions. I encourage them to walk their minds outside of the examination room for solutions to the obesity epidemic.
Dr. Ronald Fong, M.D., M.P.H. is director of the Family Medicine Residency Network at the UC Davis School of Medicine.