CHAPTER 1
What to Look for in a Weight Management Doctor
I wrote this section to primarily make the reader aware of what to look for when attempting to find a weight management medicine doctor. When I was in my residency, more than a couple of my supervisors told me I was crazy to open up a clinic dedicated 100 percent to weight management medicine. One or two of them had tried to add weight management to their clinics and were unsuccessful. Of course, upon further questioning it became evident that the "weight loss clinics" they had opened were little more than giving the patient a reduced calorie program and an appetite suppressant. If the patient was experiencing low and slow weight loss the answer was to exercise more and eat less. Did these doctors attempt to find an underlying cause for the weight gain? If they had I would not have felt the need to write this book, and they might have actually had a successful weight management clinic.
Their prediction was that I would be out of business in less than two years. They said I was competing against the commercial weight management centers that had deep pockets for advertising. I told them I had no competition because there was only one "me" out there. Unless those commercial weight management centers were planning on cloning me, I felt as though no one was doing weight management the way I felt it should be done. After over a decade, I have proved all of them wrong. Not to say there have not been ups and downs. But in my community I have always been the physician to come see for fast, safe weight management as well as Bio-Identical Hormone Replacement Therapy.
In Florida, I spent most of my career on the East coast of the state and after around five years I felt as though if I could make it work there I could make it work in other places. I opened up additional clinics in the state. I hired and trained Nurse Practitioners that could render the type of care that needed to be given. I basically duplicated the program I created on the east coast of Florida. The only difference was that it was not going to be me that the patient would see each time they came in. The majority of the time it would be a nurse practitioner that the patient would see. After a year and a half I decided to close these clinics. The patients just did not seem to do as well as they had in the past. The patient and doctor referrals for the programs were not what they should have been as compared to the original east coast location; where I was seeing patients on a regular basis using the same programs that were being offered at the other clinics. For the life of me, I could not figure out how to make those other clinics work.
It became apparent that what I did when I was the one seeing my patients was intangible and difficult, if not impossible to duplicate. Not to mention the fact that when the patient reads the clinic is owned by Dr. Lance Ashworth they wanted to see Dr. Ashworth, not a different doctor, a nurse practitioner, or a physician's assistant. This is not to say that these types of practitioners could not be successful. What it does say is that doing weight management part-time or allocating the patient contact to someone else may be what prevents the patients from being successful. There is an element of expectation present when a person walks in the door of a weight management medicine clinic.
If a clinic is not successful it may be that the doctor is attempting to see the weight management patients in the same way they see their regular internal medicine or family practice patients. The name of the game these days in a managed care environment and a tough economy is how many patients can the doctor see in an hour? This will not work in weight management medicine. Patients in a weight management program need extra time to simply talk about how they felt that week. This may be how they felt mentally instead of strictly physically. There may be nothing to actually treat in the strict sense of the word at that particular visit. The patient may simply need a motivational, hunger, or exercise tip.
Patients who are seeing someone for weight management expect to be motivated long after any diagnoses related to gaining weight have been diagnosed and treatment began. It seems that patients can feel when a doctor really cares about them and why that doctor is sitting in front of them. Attempting to cram these patients through the door and see as many as possible will not be successful for very long. My patients get to know me as well as I know them. I became acutely aware of this when patients would ask me what was wrong or why I looked so stressed out. A strong relationship of trust and mutual respect needs to be developed. It is as if the patient should want to lose weight for all the correct medical and personal reasons, but also for the doctor. Being capable of fostering this type of relationship is difficult to teach a doctor, they either can do it or they cannot. Motivating patients, putting them at ease, or relieving their stress is something that comes natural to a physician or it does not.
The amazing part of all of this is that the patients can feel it. I believe it is because they have usually been through a lot. By that I mean everything from multiple programs and treatment styles, to straight out abuse from the people around them. Sadly, the worst abuse is often from those closest to them, like their husband, wife, or parents. They have been ignored, thought of as lazy, physically abused, and in the process have had their self-confidence destroyed. It takes a certain type of doctor to be able to relate to these patients and earn their trust. That is what I tell every patient. I am their personal weight management doctor and we are a team.
I put this in the book for you, the reader, to help you find a doctor that will help you lose weight. When this may be your "last-ditch effort", it needs to be the correct type of health practitioner. They will either be cut out for the job or not. A lot of that is dependent on their personality. A lot depends on their ability to be able to treat each patient differently according to their needs. It takes a bit of common sense. There is no cookie cutter way of doing weight management. The future of medical weight management, the paradigm shift I would like to see is one where every patient is looked at as a whole: the entire array of symptoms, the patient's personality, and lab results need to come together as a whole. Nothing is taken alone and looked at individually to direct an entire treatment protocol. The future of weight management medicine is figuring out why the patient gained the weight, not just treating the diseases the excess weight is causing. Physicians need to come out of the safety of the "medical box" and treat underlying disorders that may be making weight management impossible. As you read through the different disorders think about how you feel, the medications you take, and attempt to find yourself in these pages. Be prepared to take what you learn and share the information with your doctor. There is treatment available. Being overweight or obese is not a death sentence or a lifelong condition. Knowledge is power. Unfortunately common sense is not that common in the medical community. Read on and let the knowledge empower you to help your doctor help you.
CHAPTER 2
What to Look for at your First Visit
Before jumping right in, I thought it would be a good idea to go through a typical Initial Consult. I am including this because of the sheer number of so called "physician managed weight loss clinics" people are exposed to. This book helps you understand what to look for when a doctor or even a commercial weight management center gets you into the consultation room or "hot seat," whichever applies, and begins to talk about how they will help you lose weight. There are certain subjects and key words that these people should mention, or questions that need to be asked of you that will be the signal that you are in the right place. I also suggest questions that you can ask that will validate that you are in the right place. Go in with confidence. They are lucky to have you in their establishment. You put them on the hot seat and see if they truly know what they are doing.
Right from the start I must say that I never try to talk anyone into starting my weight management program. I simply present what I am able to do and see if the patient and I are compatible. You should not feel pressure or feel like you are being subjected to tactics to get you to start a weight management program. As a matter of fact, I have flat-out told people they are not ready and told them to return when they are absolutely sick of being overweight. I tell them this because if they are a little bit "ok" being overweight, when the rubber meets the road and the newness of the weight management program wears off, they will feel a whole lot more "ok" being overweight. Just like I tell you that there are certain words you need to be looking for, I also look for certain people when they enter my clinic. I try to determine if this is going to be a person that is going to give it their all or someone who is going to give up when the going gets tough.
One of the major obstacles the general public perceives when they think about seeing a doctor for weight management is the money needed to get the job done. The reality is that people end up saving money when they are on a low calorie or very low calorie program. When one looks at the economic environment we are in it is especially important to address the misconception that reducing weight is expensive. The USDA has done many studies looking at the cost of food and the cost of food while on a weight management program and utilizing medically manufactured shakes to supplement nutrition. When the USDA has taken into account the food bought for in home consumption as well as eating out, the results have consistently shown that the person actually saves money while reducing weight and becoming healthier. This is not rocket science and I feel as though if a person really wants to lose weight they will come in having done the math and should be ready to start the process of getting healthy.
If you feel like you are walking into a weight loss clinic with the feel of a gym or fitness center type of atmosphere where high pressure sales tactics are being used just walk out. Or better yet turn the tables and ask them a question: "I'm really feeling pressured to start treatment here and it makes me feel uncomfortable, are you trying to make me feel this way?" Do not let anyone pressure you into starting a weight management program. You will know if a clinic feels right. Go with your gut feeling.
I have never used contracts that lock a person into paying a certain amount over a period of time. Patients pay for a month of weight management at the beginning of each month. If a patient finishes a month and still needs to lose more weight, then they will pay for another month. If something occurs in their life or the person just loses the will to continue the weight management program, I refund the amount paid for the month less any services or products received by the patient. There is no magic wand that will make a person stick to a weight management program. If a clinic or fitness center attempts to lock you into a contract over a specified length of time, run. They should not need a contract. If they are successful at helping people lose weight they should not require a contract to keep you in the program. Most importantly, it is vital to have a medical professional treating you. Avoid the programs that are approved by doctors or created by doctors. You do not want an establishment where you never see these elusive doctors. Most of these places change management and front office staff like the changing of the weather. They have you take a handful of pills and give you a diet they copied out of some physician's or dietitian's book that is supposed to apply to EVERYONE.
Before everyone out there with a degree other that of an MD or DO gets all bent out of shape let me explain myself. Professionals with these degrees have the training, experience and responsibility to know which symptoms, physical exam findings and lab tests to perform and subsequently interpret that will enable a timely diagnosis as to why the patient gains weight so easily. A question you should feel comfortable asking, and one that should apply to any weight management medicine program is: "What is it that makes your program successful in helping people lose weight?" With the large numbers of individuals in this country being overweight, if a clinic is successful you should have heard about it if the doctor has been around over five years. Most of my patients are word of mouth referrals from previous patients. Before seeing me the patient fills out a questionnaire that I look at which lists their medicines and health conditions and includes many questions on eating and exercise patterns. Everyone is different and requires discussions of different topics and issues. When deciding on a primary care doctor it is very important to find one that is proactive in terms of their patient's weight and body fat percent. Doctors understand, or should understand that gaining weight can cause diabetes. When a trend of weight gain begins, the doctor should focus on the weight. Focusing on the weight is not simply telling the person to stop eating so much, exercise more, and proceeding to write a prescription appetite suppressant medication. So if this is not how a weight management program should start then what is, you may ask an appropriate starting point?
I have always strongly believed that any good first step is for the doctor to order some blood work. Some of the blood work I typically order is not in the standard lab profile, but I am alarmed that some of the common lab work I require has recently been dismissed and removed as necessary in making crucial diagnoses. The treatment of conditions such as Type II Diabetes and Hypothyroidism absolutely require common sense! With obesity causing so many diseases it should be no surprise that I consider all aspects of a person's health profile critical. The doctor needs to take the medical history, the physical exam, the labs and everything else that goes into uncovering a diagnosis. A doctor should never depend on one lab value and make any determination of a person's health without taking all that has been mentioned above into consideration also. This type of medicine, where we look at the person as a whole is starting to be referred to as "Functional Medicine". A doctor needs to be ready to spend 30 to 45 minutes at an initial consult making sure the patient feels comfortable and trusts the doctor. If this doctor is not their primary care doctor it is probably just another program of many the patient has tried and they are more than just a little skeptical. It is our jobs as weight management medicine doctors to put this skepticism to rest, to put you at ease and assure you that you are in the right place.
Laboratory Test Guide
Since one of the goals of this book is to teach the reader what to ask of their doctor, I feel it necessary to give a brief explanation of what some of the more common lab tests really mean in laymen's terms. In order to discover what may be at fault for your weight gain the best place to start is to help you understand the labs that uncover these six disorders. The best way to use these terms would be to have a copy of your lab work in front of you prior to leaving for your doctor's office and go down the list looking for explanations of the results that are of interest. You will learn what is of interest and what disorders apply to you by the end of this book. Something worth mentioning is that the values below are not a complete list. Not to worry though, I describe many of the other pertinent labs as I write about the disorders later on in the book. The bold print is how the lab will be written on your lab results.
