The prevalence of obesity in the United States from 2018 was estimated at greater than 35% for men and >40% for women. The obese state is associated with cardiovascular disease, type 2 diabetes, obstructive sleep apnea, nonalcoholic fatty liver disease, cancer, polycystic ovarian syndrome, gallstones, and disability.1 A recent meta-analysis by Kim and Basu in Value Health, estimated medical costs attributable to obesity at approximately $1,900 annually per person, amounting to $149.4 billion nationally in preventable or modifiable healthcare spending. Primary care physicians are the first in line for prevention and treatment of obesity, necessitating adequate training to handle this complex and prevalent condition. Prior studies have assessed primary care physicians’ comfort, ability and desire to care for patients with obesity, often suggesting suboptimal treatment.2 The U.S. Preventive Services Task Force (USPSTF) and several medical organizations have released practice guidelines covering the evaluation and management of obesity in the primary care setting, recommending screening adults for obesity and referral to intensive, multicomponent behavioral interventions.1
Despite the magnitude of the health condition and several clinical practice guidelines, training of primary care residents to manage obesity remains inadequate. A survey of 25 residency programs completed in 2016 found that minimal time was dedicated to obesity and nutrition training.3 Out of an average of 255 hours of didactic teaching annually, fewer than three hours were spent on obesity-related topics. Furthermore, only four of the 25 programs provided instruction on the use of obesity specific guidelines.3 A recent survey of 219 senior residents from primary care residency programs revealed only 14% of respondents participated in a rotation that incorporated instruction on obesity counseling.4
Given the disparity between need and treatment for obesity, it is incumbent upon primary care residency training programs to equip trainees with the knowledge and skills required to care for this patient population. Incorporation of obesity medicine specific competencies and milestones into the curriculum will ensure a minimum standard of education and training for residents. In order to ensure residents enrolled in the internal medicine residency program at the Zucker School of Medicine at Hofstra/Northwell (ZSOM) receive obesity management training, a resident Obesity Medicine Continuity Clinic was created.
Providing dedicated training in obesity medicine increases resident physician self-efficacy and adherence to guidelines and fosters a more positive attitude towards obesity counseling. Providing lectures has been demonstrated to improve residents’ attitudes and clinical practice behaviors towards obesity care, although lectures did not lead to improved knowledge of obesity medicine or improved outcomes of obese patients treated in residency clinics.5 Therefore, our approach to obesity medicine training of primary care residents included both didactic sessions and clinical experience. This paper outlines the program, the goals, and the metrics used to gauge success.
Setting and Participants
The internal medicine residency program at Hofstra Northwell School of Medicine follows a traditional “X+Y” model for scheduling inpatient and ambulatory care blocks. The schedule incorporates a rolling four-week inpatient block followed by a one-week ambulatory continuity clinic over three years. The Division of General Internal Medicine and the Section of Obesity Medicine at ZSOM designed and implemented a subspecialty training program utilizing the repeated ambulatory block. The program incorporated the six Accreditation Council for Graduate Medical Education core competencies as they pertain to obesity medicine. The intention was to achieve trainee improvement in obesity medicine knowledge, attitude towards treatment of the obese patient, comfort level in discussing the topic with patients, and a clinical skill set including interview techniques, clinical decision making and ease of facility with relaying key behavioral changes.
The obesity clinic pilot involved second year residents (PGY-2) working in the Improving Patient Access, Care, and Cost through Training (IMPACcT) clinic, funded by the Health Resources and Services Administration. The IMPACcT clinic was designed to train internal medicine residents, pharmacy students, medical students and physician assistant students to deliver team-based care that included attending physicians, pharmacists and social workers. Patients with BMI ≥30 and an interest in actively managing obesity could be referred from general internal medicine residency continuity clinics.
A total of five PGY-2 residents applied for and were accepted to replace their traditional ambulatory continuity clinic with the IMPACcT clinic. During each IMPACcT week, each resident staffed the obesity clinic for one 3.5-hour session on Tuesday afternoon every fifth week for the entire academic year. A board certified obesity medicine physician and obesity medicine fellows precepted each clinic. Allotment times were 60 minutes for new consultations and 30 minutes for follow-up visits. Each visit started with the resident interviewing and examining the patients, followed by precepting with the attending.
Curricular objectives included the following: 1) physical exam skills, 2) appreciation of the treatment modalities and specialty referral, and 3) developing and sharpening counseling skills including interviewing and dissemination of behavior change techniques, problem solving and joint decision making with patients. Each session began with 30 minutes of didactic and case-based learning. The didactic sessions covered essential elements such as the approach, assessment, evaluation, and treatment of the obese patient.
The program will be assessed using resident feedback via the end of year program survey. A survey prior to academic year 2020-21 on attitudes and knowledge towards obesity medicine was conducted and will be repeated at the end of the year. This included a self-reported assessment of knowledge of obesity medicine topics, comfort in discussing relevant issues with patients, improvement in clinical decision making, and perceived ability to transfer these skills back to their general medicine clinic. The Division of General Internal Medicine leadership will evaluate the program on its ability to maintain patient continuity, appropriate referrals and clinical outcomes.
Our obesity clinic expanded upon the traditional “X+Y” block model of internal medicine residency training programs, specifically incorporating the subspecialty clinic into the outpatient weeks of the second post graduate year. This ensured both didactic and experiential learning. Participating residents reported that they were able to apply what they learned in obesity clinic seamlessly into their general medicine clinics, including primary care management of patients with obesity and behavioral change techniques for all patients.
Other approaches to curriculum development may be more appropriate for different settings. For example, a dedicated four-week block rotation in obesity medicine may be feasible for centers without ambulatory blocks. This approach would follow similar subspecialty elective models for primary care residencies. Such an elective block would allow ample time for evaluation and initial treatment of obesity but not for longitudinal follow-up and relationship building which are part of intensive treatment models better mimicking the primary care setting.
Challenges exist when embedding and implementing a teaching program in obesity medicine. There are financial hindrances to managing a subspecialty resident clinic. In some states, managed Medicaid insurers do not consider obesity medicine to be a subspecialty and consequently do not cover services. Many residency clinic patients are insured by Medicaid or are uninsured. In these settings, the funding for a clinic would have to come from an external source such as an academic department, hospital administration, or philanthropy. Many standard-of-care obesity treatments are not, moreover, covered by insurance. These include newer medications and referrals to registered dietitians, with the exception of patients with additional underlying conditions such as diabetes mellitus or renal failure.
Finally, maintenance of continuity is challenging in the obesity clinic. Patients often had many challenging social determinants of health and suffered from high no show rates. This has a potentially negative effect on patient outcomes and can deny the resident the experience of longitudinal treatment of a chronic illness. We tried to alleviate this issue through frequent follow-ups, reminder calls, access to a patient portal for communication, and adding additional patient visit opportunities with a registered dietitian for patients requiring more frequent supervision.
In our experience, an obesity medicine continuity clinic can provide the needed training for residents. With support and collaboration from residency directors and obesity medicine physicians, evaluation metrics and a robust curriculum can be developed. This will ensure competence when trainees are caring for this patient population.