Thursday, April 5, 2012

To treat or not to treat obesity? That is the question!


When a patient visits a doctor, the expectation is that the doctor will provide the community standard of care for the patient’s ailment(s). There is, of course, sometimes a divergence of medical opinion regarding what is that standard, but as long as the doctor’s actions are within reasonably acceptable guidelines the doctor will generally not be held liable for such care if it fails.  Furthermore, if the doctor fails to suggest or provide standard treatment, that could create a liability for the doctor. For example, if a patient presents with a fasting blood sugar above 200, it will be inappropriate for the doctor to ignore such finding and not suggest further evaluation and treatment for diabetes. Equally, if a patient presents with cholesterol of 500, blood pressure of 180/100, or an irregular fast growing black mole with a hair growing out of it, etc., it could be construed as malpractice if the doctor did not address these potentially life-threatening problems.

Yet, when it comes to obesity there seems to be a lack of congruence. Obesity often is accompanied by serious illness or leads to it. Obese patients have a far higher incidence of diabetes, heart disease, stroke, etc. Yet, other than the use of bariatric surgery, there has been relatively little attempt to treat it by the medical establishment.

Recently, a company that helps doctors implement weight loss programs for their patients ran an advertisement campaign that read as follows:

“I spent more time learning about malaria in medical school then I did about obesity.  I have yet to see a patient with malaria."

The obvious reference here is to the fact that the doctor most likely has seen many patients with a body mass index of at least 30 which is what defines obesity and yet received little to no training during medical school (and thereafter) on how to treat it. 

On the other hand, a Northwest Indiana hospital in 2011 ran a billboard advertisement that read “Obesity is a disease. Not a decision.” The hospital faced a major backlash from people who were outraged at the suggestion that obesity is anything but the result of poor decisions.

So which is it? Is obesity a disease that requires treatment or the result of individual irresponsibility?

Medicare, the Centers for Disease Control (CDC), and the World Health Organization (WHO) all define obesity as a disease. In fact, in 2012, Medicare began reimbursing for Intensive Behavioral Therapy for Obesity (IBTO), an obesity counseling program consisting of up to 22 sessions that can only be provided by a primary care practitioner operating in a primary care center.

The problem with IBTO is twofold. First, Medicare chose to pay on average only $27 for sessions lasting up to 15 minutes. Extrapolated to an hourly rate of $108, which is far less than what the typical primary care practitioner earns in one hour, this lowly wage is hardly an inducement for a primary care practitioner to implement IBTO in practice. Second, even if the doctor was inclined to look past such a reward for effort, most doctors as the ad above suggested have meager to little training in counseling patients to lose weight. Counseling is an art form that takes practice and experience. 

It requires the patient to realize that change is needed and to embrace the steps needed to accomplish real change, incremental or otherwise. The first rule of motivational interviewing is to resist the righting reflex. This is the instinct that doctors develop starting in medical school and continue to develop throughout their careers which is to gather facts, identify the problem, and then just tell the patient what to do.

Obesity counseling begs for a different approach. It requires patience, giving time for the patient to absorb, engage, and take action. It requires teaching a patient about good nutrition, proper physical activity, proper management of stress, and how to achieve fitful sleep. Doctors are typically not good coaches in that regard. They come. They diagnose. They conquer.


Furthermore, even if a doctor is naturally good at counseling, he or she must have the proper knowledge to impart. Most doctors do not possess knowledge in the nutritional sciences. Nutrition isn’t taught even today in most medical schools (only 15 states mandate it be taught), and there is scant time for doctors to learn it after formal training ends in the midst of trying to master all the diseases they encounter on a regular basis. Most doctors cannot afford to even hire a nutritionist because Medicare typically does not pay for nutritional services other than for diabetics and patients with end-stage kidney disease. So what’s a doctor to do? It is quite a quagmire with no easy solution.

Since it’s the introduction of the IBTO in January 2012, I have not heard of a single doctor’s office providing the service. I even went through multiple pages of Google search and could still not find a single reference to a doctor’s office providing the service.  It’s not surprising. Again, it doesn’t pay well and it requires specialized knowledge and skills sorely lacking in most doctors. 

However, getting back to our discussion as to what the standard of care a doctor is obligated to provide, the question I pose is if a primary doctor can ever be held liable for failure to provide IBTO to his or her obese patient(s) who due to their untreated obesity go on to develop more serious consequences?
I’ve discussed this with some other doctors and I’ve gotten a mixed response. Some say, yes, the doctor could be held liable because treatment is available and a doctor is obligated to advise the patient as much. Others say, no, because doctors are not responsible to provide treatment that they are not comfortable with providing. It remains a hypothetical question for the moment.

My perspective is that primary care doctors should make the effort to develop the requisite skills necessary to provide IBTO and thereby make my question a moot point. In the meantime, there is good news in South Florida because MDPrevent provides IBTO and continues to schedule qualified patients for the no-cost service.  Let’s hope that other doctors follow our lead soon.

3 comments:

  1. Its good to know that there are such health care initiatives and research taken by the doctors. Great job. primary care doctors South FL

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