I was in rheumatology private practice for just under four years as my first few years out of fellowship. During that time, too many of my patients were coming with obesity complicating a facet of their rheumatic disease. The most common example might be osteoarthritis, where excess weight directly applies force to joints like the lower back, hips, and knees, accelerating the disease and worsening outcomes. A less obvious example is when obesity is associated with sleep apnea, in turn exacerbating fibromyalgia. We found that weight loss in these scenarios helped these individuals gain control over their disease when few other interventions had the power to do so.
When I would ask my patients empathetically, “Hey, what have you tried in the past, or what has your primary doctor talked to you about in terms of weight loss?” I was often left with blank stares. Some were referred to nutrition but follow-up would taper off if they went at all. They would ask me what they should do—the worst part is, I’d give them a blank stare right back. My answer was always a bit vague: I could recite exercise guidelines and intake guidelines, but in the end, I didn’t have much else to offer on that front, so I’d point them back to their primary. Ultimately, their weight rarely improved.
A note to primary care physicians: I do not want any of you to read this and think that I’m pointing fingers at you (unless you’re the one who told my patient you “don’t believe in weight loss medications,” as if semaglutide was somehow a superstition or conspiracy theory). The reality these patients live in is a consequence of how our society has stacked the deck against them by what our supermarkets carry, what advertisements for fast/processed food force into our brains at every turn, and the time constraints our exhaustingly busy society forces on us to survive. Addressing this becomes a monumental task for primary care alone to manage, especially when one appreciates how busy one’s schedule has become. Before I moved, primary care doctors in a dense suburban area were booking new patients six months out, and follow-ups were up to six weeks out for routine issues. Talking about weight loss, especially giving it the time and attention it needs, is just near impossible with schedules like that.
It was sometime around my third year of practice that I learned my practice situation was about to forcibly change. Family reasons being what they were, we would ultimately have to move out of the area within the next year. I saw this as an opportunity to expand my practice to help serve my patients better: I wanted to add in obesity medicine training to specifically help my patients with obesity; I wanted a better answer than the disappointing shrug I had always given in the past.
I ended up going through the Obesity Medicine Association for CME, taking one of their content courses that took my metabolism and nutrition education well beyond what I learned in medical school and internal medicine residency. I walked away, lamenting I didn’t get more of this in medical school (there wasn’t one lecture on the proper psycho/social/medical management of obesity).
Now, I’m in my own solo practice but wearing two hats. My primary focus and passion are still rheumatology; however, for those interested rheumatic patients, I also offer weight loss counseling and recommend medical management (only occasionally prescribing when their primary care is in agreement). This hasn’t split the focus of my practice like you might think; it only expanded what I offer patients to serve them better. At the end of the day, aren’t we all trying to serve our patients better?
Today in my practice, patients affected by obesity and, say, late-stage knee osteoarthritis ask me about weight loss and get a different answer than I used to give. It’s no longer the blank stare and helpless shrug; it’s “This is how we can get started and move forward.” Patients have responded incredibly well, and my practice is better for it.
What this comes down to is a question: is there a role for us specialists to be more equipped to address obesity so we can serve our patients better? I’d advocate the answer is yes, there is. No, we all don’t need to get board-certified in obesity medicine or start a side gig as a semaglutide prescription mill, but becoming even a bit more knowledgeable about navigating the rising prevalence and explosion of treatment options is something every patient interaction could benefit from, even if just a little. When obesity has its fingers in congestive heart failure, obstructive sleep apnea, liver disease, psychiatric issues, and to say nothing of endocrine issues—how can we ignore it or defer it somewhere else entirely?
If you practice cardiology, pulmonology, sleep medicine, endocrinology, sports medicine, or even primary care, and you don’t have a good answer when your patient asks you, “Doc, how can I lose weight?” I’d advocate spending a bit of that annual CME money this year towards some of the great obesity material out there (Obesity Medicine Association, for example). There’s a tremendous amount of material out there for all of us to keep up with in our primary specialties alone, no question. But, coming from a busy specialist, time spent on such a powerful issue as obesity will likely enrich your practice as it has mine.
Zachary Fellows is a rheumatologist.
