Thursday, August 18, 2022
Today’s Guest Post comes from my colleague Michael Crotty, MD, a family doctor in Dublin, Ireland.
I believe we are on the cusp of a new dawn where the vast majority of bariatric care will be provided in primary care with family physicians taking a leading role.
Obesity is a chronic, progressive disease that impacts every organ and system in the human body. It requires an individualised, bio-psycho-social approach which incorporates screening, early diagnosis and evidence based treatment. We must shift away from solely focusing on primary prevention to also provide treatment and support to those living with overweight and obesity. This is in addition to the ongoing management of the potential medical complications and co-morbidities. There is, undoubtably, work to be done to change the narrative around obesity in society. We must continue to reduce the weight bias and stigma that persists in healthcare and primary care is no different.
As family doctors, we are perfectly positioned to support patients who live with obesity. If we are adequately resourced, we have the capacity to see the large volumes of patients for whom excess weight may affect health. Primary care is not only a more convenient setting for our patients but it also offers significant savings from a healthcare economics perspective when compared to hospital based care. In many countries, primary care clinicians have invested heavily in healthcare informatics/IT and have been at the forefront of adopting hybrid models of care. These advancements have been realised on a day to day basis during the COVID19 pandemic. There is an opportunity to offer a blend of traditional, in-person and virtual consultations to patients living with obesity. The advantages offered are immense and can potentially remove some of the barriers to care that have existed in the past.
As GPs, we know our patients in the context of their family and their community. We treat them across their lifespan. This provides an opportunity to screen those at higher risk ( with knowledge of family history, medical history and medications etc) and to facilitate early intervention. We are skilled in managing chronic diseases and offer the continuity of care and frequent review that is needed to manage a long term, progressive medical issue like obesity. We are innovators and can be at the forefront of adopting new treatments as they become available.
We are experts in communication, behavioural support and brief intervention – the foundation of medical weight management. We are the last true generalists. We do not view our patients living in a vacuum or through the narrow lens of one disease but see them as individuals with unique experiences, skills and challenges. We spend our day managing multi-morbidity. What is best for the
heart may not suit the kidneys, what is best for mental health may not be best for weight – it is up to us to integrate these competing challenges and collaborate with our patients to find what is most appropriate and acceptable to them. Putting the person at the centre of the decision making process is vital and we do this every day in our practice. Although we are directed by guidelines and evidence, we must adjust our treatment plan based on the bespoke needs and values of our patient. We are already treating people for weight related complications and co-morbidities which will undoubtably be lessened if we can also manage the underlying cause.
In primary care we spend our day constantly shifting gears, (in my case this is assuming I have had enough coffee) and transition between discussions about psychological, functional or metabolic health. This is one of the most vital skills when managing a medical condition that can affect every facet of health. Over many years treating our patients, we develop a rapport and trust. This helps us appreciate when it may be acceptable, with permission, to start a conversation about weight. If they feel a discussion is not appropriate at that time, we know that we will certainly meet them again and have made it clear that we are available to help.
It is implausible to think of every patient with hypertension or asthma being seen by a specialist for treatment. Our hospital system does not have the capacity. The skills of my esteemed colleagues are better applied to patients living with the most complex and severe illnesses. There will always be a place for specialist multidisciplinary medical and surgical bariatric care but why must patients languish on long waiting lists developing more severe complications when we can start treatment and intervene earlier in primary care – Obesity should be treated like all other chronic diseases. With safe, effective treatments and a shift in our approach towards pharmacotherapy with an adjunct of behavioural intervention we will be less reliant on the conventional MDT approach. We are already prescribing identical treatments for other indications with great success.
With adequate funding for treatments, training and an appropriate referral pathway there is an army of healthcare practitioners in primary care who are sufficiently caffeinated, ready, willing and able to treat the chronic disease of obesity.
Michael Crotty, MD
Dublin, IE
About the author: Dr Michael Crotty is a General Practitioner who specialises in Bariatric Medicine. He is a member of the Clinical Advisory Group of the Irish National Clinical Programme for Obesity and co-chair of the Adult Weight Management Subgroup. He was awarded a SCOPE National Fellowship by the World Obesity Federation. Michael is the co-founder and clinical lead of the “My Best Weight” medical weight management clinic in Dublin, Ireland. www.mybestweight.ie
