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Anyone done this? How's it worked out. Or am I misunderstanding somethings here about the process, but this is what I've come to understand from attendings in my program.
Getting obesity certified to bill as a consultant?
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What a dumb profession we've become. We're literally now consulting other doctors for fat patients. It's absolutely hilarious.
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In the US consultation fees are a thing of the past.
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You dont need to be certified in anything to bill a consult. Also obesity 'certification' is nonsense.
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CPT® Code - Office or Other Outpatient Consultations 99242-99245 - Codify by AAPC
The Current Procedural Terminology (CPT) code range for Office or Other Outpatient Consultations 99242-99245 is a medical code set maintained by the American Medical Association.
www.aapc.com
these "office consultation" codes exist but do not pay significantly differently than the standard 9920X and 9921X
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we dont need to consult other doctors (except bariatric surgeon perhaps after all else has been done)
we need to consult exercise fitness trainers.
i have one of those obesity certifications through the CME pathway so i could have a focused curriculum to learn more that I did not really learn back in GIM (i was in the primary care track in residency). Although the residents clinic i was in was a bona fide "PCMH," there was hardly anything about obesity. anyway i dont think ill be paying money for that piece of paper again...
but the best success I have found for patients (who are motivated... most are not) is give them a pedometer, spam their emails "have you gotten to 10,000 steps per day ion average yet? if not why do you keep emailing me and why I do keep replying to you at midnight?," and then I spam their emails asking them for food diaries or pictures of what they eat.
the motivated ones drop a fair bit of weight this way. once the snowball starts rolling and they pick up momentum, then that's when they want to keep up the exercise.
but the biggest hurdle I foudn to getting the snowball rolling is UNHELPFUL FAMILY MEMBERS
"why are you eating so little??!?! UNHEALTHY SKIN AND BONES. Now eat that big mac and finish those fries!"
"why you exercise so much? it's bad for your joints!"
"why is that quack doctor telling you to eat less? you need to keep up your strength!"
so on so forth...
my angle is I need to get some peoples OSA better. CPAP adherence rates are dismal. dental applianecs usually haev a bit of out of pocket cost that no one wants to pay. Surgery is not always effecetive. Inspire is limited access at tertiary care centers.
when patients ask me about how to "naturally get their OSA better," I tell them about weight loss and playing the didgeridoo (Australian RCT showed professional didgeridoo players can improve their OSA)
they balk at this. I say hey you asked me for natural. You didn't say "pokemon center instant cure" for obesity and OSA.
addendum: I am cognizant how older patients have joint issues and have safety issues being outside walking for 1-2 hours a day for those steps. hence i tell everyone who is elderly, frail, or younger with agoraphobia or motivation issues that you can totally watch TV / stream something but you must be walking around your home at a brisk pace while you do this. I tell patients this counts as exercise. i mean it's no gym high intensity heart rate increased beyond anaerobic t hreshold but better than sitting on one's rear end. if one finds this "weird" then I guess staying obese but being "not weird" is more important.
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People have low tolerance for discomfort. But also I think we do have to acknowledge that our current world does not make it easy to encourage health life decisions.
I can tell you my first year as a fellow made me borderline regain some of my med school weight. I just had no energy due to all of the coverage I was doing to work out.
I imagine that a 40 year old working woman with a job, needing to clean the house, and take care of 1-3 kids probably is in the same boat. No energy, too much to do, not enough sleep, etc.
So I think it's complicated.
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While I agree with the obesity medicine tenets (I always tell patients its not their willpower and don't feel bad. It's the ghrelin/leptin imbalance, the disordered dopamine reward system, and all the terrible processed food chemicals messing up their neurotransmitters) and I do empathize (i.e. put myself in their shoes) with the patients and express caring and understanding for their struggles, I also find the whole "we need an RCT before we do anything" to reflect the "medical inertia" as a whole in our profession.
we don't need RCTs to employ the American Heart Association's recommendation of 150 minutes of moderate intensity exercise once per week. Doing 10,000 steps a day (even while watching TV with that kind of low intensity steps) blows that benchmark out of the water.
(10,000 steps a day is not an RCT studied benchmark. it was a marketing slogan from a Japanese health ad. but does anyone really need to do a study for logistic regression to find the ideal number steps per day?)
But this "it's complicated" statement is not a very proactive statement. (this is not a personal attack on you. it's just my overall feeling towards how the medical profession as a whole treats obesity.)
We don't need randomize controlled trials. We need one on one motivation and leading by example for our patients
I work 80-90 hours per week (not all is face to face with patients. about 20 horus per week of this is admin/office work). I have standing desks. I am literally hopping and walking in place every day and taking extra time to walk around. If I am in the hospital you bet im taking stairs and taking the long way aroud.
I get about 30,000-40,000 steps per day in my office/hospital literally hopping around like a bunny for about 10-12 hours per day.
I have kids too who need to be tucked in and we need their story time at night.
i get in 30 minutes of HIIT on my treadmill at night on a 12% incline. i have zero time to go to a gym. it's all in my basement.
I have gone "vegetarian on work days" (only because it's easier to get into calorie deficit on a vegetarian diet and its easier to prepare and easier to digest in the middle of a busy day)
I get in an hour of weights on Sunday at night when my kids are asleep and I have my headphones on watching some movies/TV.
I maintain around 11-13% body fat while doing m y 80-90 hours of doctoring work. I have no social life other than my kids (and talking to you all fine people on SDN)
Again this is not to say Im so good why cant others be like me. This is why michael jordan was a bad coach (yes he was a coach for a while). *I am not saying I am michael jordan... I'm just drawing an analogy)
I am just saying it's all doable and the only thing I feel like I have the power to do is to lead by example and work on one patient at a time and focus on those who are receptive to my recommendations. I have gotten some of my patients to buy into this and they are doing well and their OSA, BP, DM etc are getting better. Usually once they build some momentum with exercise, their dopamine reward system kicks in again for exercise.
I used to eat garbage in college, med school, and residency/fellowship and was a 25% body fat individual. after starting my busy attending life work my LDL was hitting 200 and BP entering stage 1 hypertension (AHA 2017). but after taking the obesity CME pathway certification course and getting the proper education, I decided to take my own advice and it has paid off.
I am just trying to do my best to get these basic tenets for my patients.
Addendum: I misremembered (to use an incorrect word from a sports athlete Roger Clemens) that Michael JOrdan was never a coach. I was referring to Magic Johnson being a head coach for a year and not doing well because he expected every player to be as good as he was
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Yes to all of the above. Do good CME, building it into your practice, acquire the right patient panel.
No to Board Certification, No to another fellowship. Just learn it, Just Do it.
Lest we become like Cardiology: a specialty now fraught with some 9 different board certifications (one of each type of study, Echo, NucMed, etc). Absolutely ridiculous.
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much of the Obesity medicine teachings (I took the Columbia course. yes I spent the money. shrugs) focuses more on the "eat less" half of the equation. the literature really is fascinating but it is also depressing in that it pretty much just means that Big Food / Big Pharma / and lobbyists have most of the American population stuck in
The academics are busy getting Pubmed articles and trying to push the next medication. Zepbound tirzepatide is on its way. The data is really good and I am sure it will help the Class 3 obesity patients out who really need that "head start."
mean starting BMi was 38
for the 15mg arm the mean % body weight reduction was about 20%
that's big and that will help patients improve their ASCVD risk, risk of MACE, and most salient to me is help their OSA out
But my experience with semaglutide is that once patients are off of it, theyGAIN THE WEIGHT BACK
The only exceptions are those who use the weight loss meds as a tool and a head start while building good eating habits and sustainable exercise habits.
Hence if we doctors do not focus on the other half of the equation for weight loss (physical activity) or focus more on the nutrition aspect of the "eat less" part, then are we just pawns to help make profits for the business people in the futile cycle that is Big Food and Big pharma?
Then again most doctors I know are woefully out of shape so it's no wonder why this half of the equation is not being targeted more. One has to walk the walk in order to talk the talk.
For the record my peak VO2 is 31ml/kg/min (I have a CPET machine after all) . I am definitely no elite athlete (those people push 40 or higher) but ill take my improvements as they come
The academics are busy getting Pubmed articles and trying to push the next medication. Zepbound tirzepatide is on its way. The data is really good and I am sure it will help the Class 3 obesity patients out who really need that "head start."
mean starting BMi was 38
for the 15mg arm the mean % body weight reduction was about 20%
that's big and that will help patients improve their ASCVD risk, risk of MACE, and most salient to me is help their OSA out
But my experience with semaglutide is that once patients are off of it, theyGAIN THE WEIGHT BACK
The only exceptions are those who use the weight loss meds as a tool and a head start while building good eating habits and sustainable exercise habits.
Hence if we doctors do not focus on the other half of the equation for weight loss (physical activity) or focus more on the nutrition aspect of the "eat less" part, then are we just pawns to help make profits for the business people in the futile cycle that is Big Food and Big pharma?
Then again most doctors I know are woefully out of shape so it's no wonder why this half of the equation is not being targeted more. One has to walk the walk in order to talk the talk.
For the record my peak VO2 is 31ml/kg/min (I have a CPET machine after all) . I am definitely no elite athlete (those people push 40 or higher) but ill take my improvements as they come
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tbh i was asking more in the vein of IM docs billing more so it makes sense financially to do it, because lets be honest, you're telling the same things to these people as a fm doc is, but if you can bill more for it, why not.
But someone dm'd me saying you can't so that's that.
but it's also interesting why is there an obesity board? ABOM does not need to be a thing.
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Because it’s a lifelong chronic medication…if you stop someone’s statins wouldn’t you expect their cholesterol to go back to what it was before they were treated? It’s the same principle…really…chronic medication…have to take it for the rest of your life…not ready to do that? It’s not the medication for you.
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Then don’t join.
And consult codes for most insurances isn’t covered since cms doesn't cover consult codes…you have to use new pt codes…have for at least 8 years now.
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Because we (doctors) are a stupid bunch.
We insist on creating boards for everything in order to elevate our prestige and justify our existence. We then complain about having to take said boards and engaging in the MOC.
What's worse is if we make the BC mandatory for practicing that type of medicine (obesity, addiction, chronic pain . . . pick your favorite category), then we create a perceived physician "shortage".
The medical system deals with that by circumventing us; they hire a bunch of NPs to do the same job for half the cost (I mean after all, does it really require 15 years of education and training to prescribe Ozempic to some fat ****?)
It's a vicious, self-destructing cycle that we doctors can't seem to get out of.
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we've had this conversation in another thread before and have the same philosophical disagreement
we both agree that statins in DM and statins in CAD/PAD/CVA have great benefits from reducing aSCVD and that is not disputable by the evidence.
but this "chronic lifelong medication. if you stop someone's statins it is going back" only holds true if the UNDERLYING cause is not addressed.
many patients are elderly and frail and cannot work out like a young person to get fit and low body fat %.
I get that. I am empathetic to them. I keep them on meds to keep them out of the hospital.
I do not apply this "less meds more exercise" approach to someone with uncontrolled DM, CAD, etc...
but I do still try to get them to get in their AHA recommended 150 minutes of moderate intensity exercise per week.
I'm trying to open up pulm rehab at some point in my office
i could also use that gym equipment for some patients who might want to get in some exercise for non pulmonary workout reasons.
But for someone who is fitter (and no age discriminration here) why not work on the root cause?
many people who get fit and lose that body fat % treat their
this is the same concept as the surgeon's touting "bariatric surgery is the surgical cure for diabetes."
Well getting fit and dropping that weight (which is easier for a BMI 30 than a BMI 50 I will grant that. But the medical providers have to really emphasize this aspect more of the lifestyle modifications) is the NATURAL cure for diabetes.
Patients complain all the time doctors are just pill pushes and suspect we are in cahoots with big pharma.
I'd prefer to work on the natural methods first and if unscucessful then rely on the meds
Alternatively if a patient is on meds, im trying to get them off if possible through natural means of improving weight
the analogy I often give patients is your garden is getting overrun with weeds. are you gonna just keep spray pesticides forever? are you gonna want to get in there down and dirty and pull those weeds out?
a common analogous pulmonary issue are patients with bronchiectasis and NTM-LD or Pseudomonas infection.
too many other pulmonologists do NOT do the bare basics of pulmonary hygiene.
they just give nonstop antibioticcs every time there is a flare and if NTM is diagnosed, automatically go onto RIF/ AZI / EMB and patients never quite clear it over time. Then go onto ALIS.. and never quite clear the disease ?
why? the fundamental pillars of GERD management, microaspiration prevention (bed wedge pillow, h ospital bed, dysphagia evaluation), and pulmonary hygiene with nebulized saline, flutter valves, and chest vests were not properly enforced or educated ?
why? if patient were resistant (I don't see why. the alternative is one year + of antibiotics) . I can only assume "too much paperwork, not doing it" by other community pulmonologist.
my whole thing about managing my patients is medications and treatments are TOOLS. THey will help the patient. But what about that commonly said phrase "an ounce of prevention is worth a pound of cure?"
exactly. That is what I am trying to do for my patients. I have to wonder if anyone who disagrees with my approach believes in that aphorism or just "pretends to do so?" Moreover, if you do disagree with my approach, get a cheap amazon biometric scale and tell me what your body fat % is. I rest my case.
Addendum: I never ever body shame my patients. I care nothing about "cancel culture." Those people can go do something to themselves. But I never want any of my patients to be feel put down because not only is that not nice, that INTERFERES with their motivation to get weight management done. I am always sweet and nice to patients (and irritated and annoyed on the inside) because it's easier to get something done with honey than spice.
Addendum: to show that I "walk the walk" when I "talk the talk" (and also due to my arrogance... though all of us doctors are arrogant to some degree. that's how we all got to where we are in life. though I do try to be nice and sweet on the outside to everyone), I am posting my body fat %. I am a little higher now since I measured this nadir value. hence why I changed to vegetarian diet on non-weight days to get into a calorie deficit easier. I also posted my CPET trends. An athlete I am not.. but I am working on the HIIT every day to try to reach my maximum potential
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It isn't. Make the time or be out of shape and sick.
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I don't disagree that we need to do better.
God knows I need to lose 10-15 pounds before I get back to 15% body fat and my peak bench.
That being said my ability to tolerate protein shakes, chicken breast and brocolli lyfe might probably be less if I had a kid who wants chicken nuggets three times a day.
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we can only do our best.
but the pedestal should not be elite athlete for our patients or ourselves.
reducing visceral fat and waist circumference Women: > 88 cm (35 inches), Men: > 102 cm (40 inches) should be the primary goal for us to tell patients. after all, we are physicians and not exercise fitness trainers.
my personal goal is to become a "recreational athlete" because I was always a "nerd" and a "dork" growing up. that's just me
but i wear my pedometer on me when seeing patients and I am always bringing it up. for those who are interseted in a step count regimen, i get their emails and tell them share me your steps. share me your steps. why aren't you sharing me your steps? share me your steps. If these patients like to email me at odd hours to ask me about something they read online, you bet I am emailing them at all hours "show me your steps show me your steps."
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I am not sure that someone aiming for an extra certification to distinguish themselves or their practice is stupid.
What makes doctors stupid is the lack of financial, business, management education that allowed members of our profession to be subjugated by Pharma/Hospital Systems/Insurance - to the point that a primary care doc isn't given more than 15 minutes by their employer to properly address a subject like obesity with a patient.
It's not a 'shortage' that drives hiring of NPs - it's that they're cheap compared to an MD. They'll be hired for that reason whether or not a 'shortage' exists.
