What it takes to build a pediatric weight management program [PODCAST]

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“Amazing pediatricians are back where I was years ago, with their C-suite asking for business plans for the medical side of their adolescent bariatric surgery programs. The reality is corporate health care has infiltrated pediatric health systems, and the C-suite looks at the medical component as a necessary evil to drive adolescent bariatric surgeries. In fact, they are OK with medical treatment failing because it means more adolescent bariatric surgeries. The medical arm is what helps document six months of failed treatment which is a requirement for consideration for bariatric surgery.”

Karla Lester is a pediatrician.

She shares her story and discusses her KevinMD article, “What it takes to build a pediatric weight management program.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show we have Karla Lester. She’s a pediatrician, and her latest KevinMD article is titled “What it takes to build a pediatric weight management program.” Karla, welcome back to the show.

Karla Lester: Thank you for having me. Thanks again for your awesome platform, Dr. Pho.

Kevin Pho: So you’ve been on the show many times, and for those interested in hearing more about Karla and her story, just go to KevinMD.com/podcast and search for Karla Lester. But I want to go straight into your article, titled “What it takes to build a pediatric weight management program.” So walk my audience through it and share the story of why you decided to write it.

Karla Lester: OK, thank you for the opportunity to share, because it’s really timely. I’ve been working on the childhood obesity epidemic for almost 20 years of my career. One of the things I did was start a nonprofit called Teach a Kid to Fish in 2007. I left my practice, and I was really firm that I would not start a weight management program, that it wouldn’t be clinical, that it would be focused specifically on public health, community building, and policy and advocacy.

So what I did was take the framework from our organization. The American Academy of Pediatrics puts out these amazing expert committee recommendations and policy statements. In 2007, the expert committee recommendations came out for how community pediatricians should prevent, assess, and treat childhood obesity, and I used that framework to launch my nonprofit. The treatment arm has a staged approach to treatment recommended, so I created these programs in the community from scratch, from my own funding and from gathering and writing grants.

I first started with stage one, which was working in primary care. I worked with DHHS out of the CDC grant, and we developed Foster Healthy Weight in Youth, Nebraska’s clinical childhood obesity model. We got that out to pediatricians and family docs across the state and did amazing work there. So I’m like, “OK, great, next up.” We needed a multidisciplinary approach, which is stages two to three, so I created that. I worked in the community and did BodyWorks programming, which was an amazing program. My nonprofit got the funding, and we ran it in 20 different sites across the community.

Then, famous last words, “I’m not going to start a clinic.” Well, I get all these calls from school nurses and pediatricians: “What am I going to do with this kid? This kid can’t even walk down two steps without turning, when he’s in first grade. I literally feel like he’s going to have a hypertensive crisis at school. What do we do?” And I’m like, “Well, obviously I’m the pediatrician who’s taking this on as my mission, so here we go.”

So what I did was start to look at what was out there. I looked at different models, and obviously I looked at the one at Children’s in Omaha. My board really wanted a community program where all the hospital systems were contributing, which, I found out after trying that for three years and trying to get everyone around the table, was a complete joke. I don’t want anybody to not have a feasibility meter or a realistic meter. That’s probably not going to happen in any community.

But anyway, I got a grant to work with a health care finance consultant. She was amazing, and she was recommended by other physicians. She and I started looking at a five-year pro forma for what it would take, because these clinics are not typically moneymaking. Then I started working on strategic partnerships and started working with the evidence base for all the components that we need, how many hours of touch points and contact hours they need. It took me literally three straight years of working these partnerships and grants and working with Children’s to finally launch it, and then I was a pediatrician in January 2015. While all the political stuff happened, it was pretty grueling. I incurred a lot of moral injury through that process.

Now I’m on the American Academy of Pediatrics Section on Obesity listserv, and over the last couple of weeks I see this come out on the listserv: “Does anybody have any resources for launching a medical component of a weight management clinic? I’m getting asked by my C-suite for the medical side of the adolescent bariatric surgery program.” And I’m just flooded with almost trauma. I’m like, here I am. I started that journey specifically for the clinic 10 years ago, and there were some amazing things that happened.

But reflecting on it, I want to help people avoid these pitfalls, and I can see they’re already falling for them and starting to jump through the C-suite hoops. They’re chasing their carrots and handing that power, and maybe even their vision, over to these folks. So I was like, “I need to write about this. I need to talk about what it takes and share my journey.” I can’t help everyone avoid all the pitfalls, but I want them to be mindful of what it takes and what you need as a visionary physician to manifest your vision and to be able to stay the course, but also to be willing to let it go if you need to.

Kevin Pho: So let’s talk about that scenario, that physician you brought up from the listserv. Someone from the C-suite said, “You know, we should have a pediatric weight management program. Make it happen.” Now, you talked about your journey. You mentioned things like pitfalls, moral injury, and a lot of things to look out for that physicians aren’t necessarily trained for. So put yourself in the shoes of that physician who was just asked by the C-suite. What are some red flags that they should look out for?

Karla Lester: I think the number one thing is if you have an executive, an administrator, coming to you as a physician asking you to provide the pro forma. I mean, it was one thing for me to create that. I loved doing that with the health care finance consultant, but I was on my own with my nonprofit, so I wasn’t underneath anybody asking. But these folks, operationally, should have the operational infrastructure and the expertise to run those numbers in their sleep, to launch these clinics. So I think it’s that kind of proving that I don’t like. It’s like they’re putting that burden of proof on you, and it just creates that power divide that I was really a victim to.

First of all, I would ask, what is the vision? I would ask the administrator, “OK, well, what’s your vision? That sounds exciting.” So be excited, because maybe they are a visionary. Maybe they want really good things to happen. I mean, in reality, they want more adolescent bariatric surgeries, and they want more funnel to their contribution margin, and more special studies, more procedures, and more referrals to specialists.

Then the other thing that people don’t want to talk about: They don’t want to talk about contribution margin, but they don’t want to talk about the fact that you have to show insurance companies six months of failed medical intervention and a commitment by the patient and the family in order for an adolescent, and I don’t know what it is for adults, to qualify for bariatric surgery, to even be considered. So I think it’s a little bit, I don’t know, suspicious. I was told, and I mean I was told this by a surgeon, “We only created this clinic, Karla, because we want more bariatric surgery.” Sure, offer bariatric surgery on the first visit.

So I think, what’s the shared vision? And just have red flags up for, maybe, a lack of operational infrastructure to support it, if they’re asking the physician to provide, work on, and present the financials to them.

Kevin Pho: So one of the things that you had mentioned was politics. Tell me how that factored into the path where you tried to start that clinic.

Karla Lester: I had been with my nonprofit, and it was just an exercise in community politics, working with funders, these power plays, chasing carrots, and jumping through hoops. I did a lot of that. I mean, you’re going to have to do that. So there were the community politics around trying to pull the health care systems, and the ups and downs of that. We have two health care systems in Lincoln. We have CHI, and we have Bryan Health, and they’re great health systems. Both of those organizations had supported another physician’s nonprofit, especially CHI, and he had duplicated my mission, actually. So, I mean, it was really hard. I had meetings with them that were promising, and then they just never supported it.

In fact, one time I had pitched a really amazing collaboration with their community benefit department, their foundation, and was asking for sustainable funding, or three to five years of funding, for my nonprofit. Here’s your give, here’s your get, the strategic partnership, to the tune of about $100,000 of support per year, which is not bad for a community hospital and what we’re doing. I never heard anything. Then I reached out to the head of their foundation and said, “Any words? Any feedback?” I had had a great meeting with the head of their hospital. And he said, “You know, it’s been a really tough decision, but we want you to know that we’re really committed to your mission, Karla, and we’re going to give you a check for $750.” I mean, that’s literally the level of support. So I was like, “Keep the check. Keep the check.” This person was not involved, actually, in those meetings, and he was just wholly embarrassed at that. But anyway, that’s literally the level of politics. You have to write 10 grants to get one in the community.

Then none of them wanted Children’s involved in the community, so it was kind of not going to happen, where the health systems would all work together. That worked out well for me, because I was able to work with Children’s, so they expanded their clinic to Lincoln. I was able to identify the need, and then there were the politics of putting all the pieces together, because there are so many pieces that go into a clinic like that. You need at least 26 to 75 hours of comprehensive behavioral intervention within a six- to 12-month period to show significant reduction in BMI and comorbidities in children and adolescents. That’s all the goal tracking, monitoring, education, expertise, behavioral support, and family-based intervention.

So how do you do that? You can’t get it in the clinic when they’re coming every two to three months. So I created a whole Energy Fitness program and worked with the university, with the psychology department, specifically a child health researcher, Dr. Tim Nelson, who is amazing and has NIH grants and everything. We created a whole database and a whole Energy Fitness program and looked at all these measures, not just BMI and weight.

Then Children’s CEOs, who I had been working with, realized this was their lane. They don’t want to supplant; they can be additive and fill gaps, which I agree with. It’s a really amazing marketing opportunity and partnering opportunity that they don’t have and that I had and brought to the table, along with a lot of vision I brought. Once they realized that, their CEO stepped up. With my health care finance consultant, I presented to Children’s leadership team a proposal to support the expansion of their HEROES program to the Lincoln community in its entirety. And then I heard nothing. Then they call back and say, “Oh, we’re going to support it, Karla. I hope you’re excited.” So of course I’m thrilled. I’m like, “Three years of grueling hell, no.” And then I put down the phone, and I actually was crying. Of course, they want me to be the pediatrician for it.

And then crickets after that. Then more of the politics and more of the hoop jumping, and it’s like, “Oh, you’re going to have to be an independent contractor. We’re not going to have you as an employed physician. Oh, you’re going to have to cover your own malpractice. Oh, by the way, your small nonprofit is going to have to support the entirety of all the community programs.” So more grant writing, to the tune of, I supported $100,000 in cash from grants from the AAP, the Community Health Endowment, a community foundation, and other donors to get all of this going. And I just kept saying, “Oh my gosh.” The pressure.

Anyway, I think I obviously had an extraordinary case, but those are some of the pitfalls, if you recognize them early: that you’re going to have to do a lot of the hoop jumping, there’s this power divide, they’re not respecting your time and your expertise, and they don’t have a shared vision, and especially a shared vision to sustain it. These executives, these administrators, have to back up the clinic, because that didn’t happen.

Kevin Pho: So who did you turn to for advice? Because a lot of these skills of running a nonprofit aren’t necessarily innate to physicians. Who did you turn to for advice?

Karla Lester: Well, I had an awesome board of directors, and I worked really closely with my health department. Actually, my strongest and closest mentor was Charlotte Burke. She’s actually an RD, but she was head of health promotion and outreach at our health department, and she’s just an incredible thinker. She’s my go-to person. But I had an awesome board, and I listened. I knew nothing about starting a nonprofit. I learned along the way.

I remember leaving my practice, and then my first day of Teach a Kid to Fish, where I had an office from the Lincoln Lancaster County Medical Society, and my husband and I had invested $15,000, and I wasn’t getting paid, and I had no staff, but I had a good board. I just remember thinking, “WTF have I gotten myself into?” It’s me and Google. So I would meet with somebody in the community, and they’d say, “Meet with these 10 people.” Then I’d meet with those 10 people, and each of them would say, “Meet with these 10 people.” And I just listened. I’m a good listener. I just listened, and I built up so much trust, and I developed a strategic plan with the entire community. I really highlighted, elevated, and amplified people’s work. But the thing I think I learned best is manifesting your vision through community partnerships and a shared vision, and working with those kinds of key stakeholders.

Kevin Pho: We’re talking to Karla Lester. She’s a pediatrician, and her latest KevinMD article is titled “What it takes to build a pediatric weight management program.” Karla, if you were to do this journey all over again, is there anything that you would do differently?

Karla Lester: Yeah, I’d be willing to walk away. I think you’ve got to have an out if you’re a physician. The other thing is I would probably not have worked with health systems. I would have thought of it in a completely different way. I would have changed things up. I wouldn’t have felt like that was my only chance. I wouldn’t have jumped through the hoops, I mean, someone who would have. But I think I would have spoken up for myself.

My attorney, when I finally got it going and we had a launch date, I said to him, “They’re not even giving me a contract, and they’re not even providing a template for a contract, and they said I have to cover my malpractice insurance.” And he said, “Hey, Karla, do you realize that you don’t have to do this? You don’t have to do this. You don’t have to be the pediatrician for the clinic. Maybe your role was to get all of this going.” And I was like, “No, I need to do it, because this is what I want to do. Nobody else could do it.” I mean, it’s true. But even so, I would have been willing to just go back and negotiate and say, “Listen, you’re going to need to cover the cost of this community programming, and if you don’t share that vision, then this deal is off.” And I would have walked away. I think that’s the number one thing.

And also, just be really aware of what I call the operational red flags. If they’re depending on you as a physician, again, to create those pro formas, to not partner with you, and they’re not coming to you with the vision, no, I wouldn’t do it.

Kevin Pho: My final question: What are some of the take-home messages that you want to leave with the KevinMD audience?

Karla Lester: Well, I want to say there are so many ways that you can manifest your vision, and you don’t have to depend on anyone else to, in the end, manifest your vision. I understand we’re all stuck in these kinds of paradigms of how we think things have to work, and sometimes that is true. I mean, if you want to get paid, you need to work with health care systems. But be willing to just really be open, and also to protect yourself. And first, really don’t get so involved in overfunctioning and fixing and solving things. You can show up and tend to the causes in your life, but you’re not there to fix and solve. And really, when we lose track, like I did, of our internal capacity to be able to say, “I need to go, I need to leave,” that’s a huge red flag. So I think just be willing to walk away.

Kevin Pho: Thank you so much again for coming back on the show and sharing your story, time, and insight.

Karla Lester: Thank you.

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