Recently I have become interested in the obesity epidemic plaguing our country. I’ve actually been interested in obesity and co-morbid psychiatric illness since residency, but recently my interest has been revived. I read that Medicare is going to be reimbursing health care practitioners for obesity counseling and screening. My initial thought was that this is a positive step in the right direction. But the cynic in me began to wonder–what does obesity counseling exactly consist of? Who will be administering this counseling? Will it be nurses, doctors, nutritionists, or psychologists? What data is available that tells us this will actually work?
Currently, the art of “counseling” is already in danger of becoming an extinct entity, as a result of changing insurance reimbursements, which tend to be better for psychiatrists who prescribe medications rather than psychotherapy. This has influenced the state of psychiatry training programs, which have begun to deemphasize training for therapy, favoring instead a focus on psychopharmacology and biology. This has its pros and cons, as with anything, but has turned psychiatrists partially into pharmacists. I find it unfortunate.
But back to obesity counseling. Usually now, when obese patients see their doctors, they hear a lot of the same information over and over again–that obesity leads to hypertension, diabetes, strokes, heart attacks, shorter life expectancy, and so on. To deal with obesity, patients are told to eat healthier and to start exercising. Well, no kidding! All of this information is now readily available anywhere online and is not news to people. So what makes doctors think that repeating this information will all of a sudden get a patient to lose weight? It doesn’t. Which leads to no change, which in the long run, makes doctors become pessimistic, believing none of their patients will change. So they start treating the diabetes and high blood pressure, ignoring the underlying obesity, and it turns into one big never-ending cycle.
I hope this is not what “obesity counseling” will consist of. I hope that what doctors and other health care practitioners start learning is that motivational interviewing and motivational therapy is the way to get patients to start changing. We have to allow patients to tell us why they want to change, not us tell them why they need to. People only change when they are ready to. We need to start learning how to get patients to get closer to that point. It’s easier said than done.
Christina Girgis is a psychiatrist who blogs at getaheadwithdrg.
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