40: A Private Practice Obesity Medicine Doc Shares Her Specialty

Session 40

Dr. Alexandra Sowa is a private practice Internal Medicine physician who specializes in Obesity Medicine. She talks about the specialty with us in the podcast.

This is a specialty that is relatively new but very important, In the United States and around the world, obesity is becoming more of a problem. But here in the U.S., obesity and being overweight affect two-thirds of our population. Our guest today is trying to change that as an Obesity Medicine specialist.

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[01:17] Interest in Obesity Medicine

Not having any idea what it was, Dr. Sowa first got interested in it when she was sixteen years old. It wasn't a specialty then but she was part of one of those scholar med invitationals in Washington, D.C. A speaker named Dr. Pamela Peeke gave an amazing speech about prevention and the role it plays in good medicine. She remembers walking away from that event wanting to go into public health. She knew it was she was meant to do. She wanted to prevent the disease.

So in college where she went to John Hopkins and took a double major in public health and writing. But she struggled with the idea of doing traditional public health on a mass scale or the med school. Until she decided she wanted to get into medical school and do prevention. But it wasn't a thing when she was applying but it was always something that she carried with her. So when she finally found Obesity Medicine in the middle of her internal medicine residency, that was it! She wants to manage disease and prevent it from progressing to the main diseases we think of in internal medicine like hypertension, diabetes, sleep apnea, and osteoarthritis, cholesterol problems. She wanted to get to the cause of it.

[03:17] Traits that Lead to Becoming a Good Obesity Medicine Doc

Alexandra cites compassion and openness as important traits to becoming a good obesity medicine doctor. There is an intense amount of stigma around treating, managing, being a person who carries excess weight.

"You need to be aware of how difficult it can be to be a patient who is overweight."

She uses the word obese and she's proud to proclaim that she's an obesity medicine doctor. You need to know that comes with many years of beating yourself up with how much you weigh and people treating you differently. Doctors, even a lot of times, are vocal about hating that population of people.

So again, you have to be compassionate and be willing to be open to understanding that it is a disease. It's multi-factorial. It's not a lack of will power that leads someone to have excess weight. Additionally since it's not a well-established field, you have to be cowboy. It wasn't until 2011 that The American Board of Obesity Medicine was formed and formalized. And it got streamlined under a board process. So there aren't many specialists

You have to be risk-taker. Think outside the box. Carve your own path in that regard. Another foundation to any specialty is just being really good at your primary training. Alexandra is an internist and she believes you still need to be a really good generalist to be a good specialist.

"You still need to be a really good generalist to be a good specialist."

Meanwhile as Alexandra was still going through her training, another specialty that was pulling her was Endocrinology. She thought she was going to be an endocrinologist. She thought managing obesity and the diseases comes along with it. And the only pathway is endocrine. Sometimes she would wish to have a little more training in it so she won't have to refer to an endocrinologist. But she's still happy she did her formal training.

[06:07] Types of Patients and Running a Private Practice

Alexandra sees a lot of patients with diabetes. Most doctors don't know there is a way to manage most people who are Type II diabetics with diet. She also sees people with fatty liver or joint pains and sleep apnea. All these problems are related to excess weight. She see overweight people to morbid obesity. She also sees people with normal weight but have metabolic abnormalities like really low HDL's and high LDL's. They are pre-diabetics and they just want to know what they can do to prevent the progression of the disease.

Alexandra decided to run private practice since she likes the idea of ownership of her practice and her patients. She likes the autonomy and being able to create her own schedule. She's able to create the relationships with patients she wants. And she felt that in her previous practice, there was just that focus on the bottom line. She had to see a lot of patients per hour. 

"In obesity medicine, you just can't do it effectively in a 20-minute slot. So you sacrifice what you're offering to patients."

There are five FDA-approved medications for long-term use in weight loss. And if you offer a 20-minute slot, you can write a prescription in 20 minutes. But you can't do much of the really important work and the counseling. You can't have a personalized discussion about diet and exercise. You can't talk about all of the things that go into how and why you're eating a certain way. Or what their goals are. You can't do that effectively, kindly, and compassionately in twenty minutes. So she decided to go on her own and practice medicine the way she wanted it. And the only way to do it is to do your own practice.

[09:20] Gaining Knowledge of Nutrition

One of the biggest complaints about physicians is they don't know enough about nutrition and diet. Alexandra says this wasn't taught enough in medicine. In residency, you're taught to check the BMI and tell them to eat less and exercise more. There was one clinic that was focusing on nutrition and it was within the bariatrics clinic. And this was the only exposure she got.

But when she had found this field, she sought out board certified experts. She was lucky enough to get to rotate with a well-renowned doctor, the godfather of the field. He started doing research back 25 years ago and has been a pioneer in making the field. So it was an eye-opening experience for her being able to work with him and being exposed to his clinic. That's when she started to realize that it can be in the form of the diet or pharmacology.

The diet piece came in more after residency and as she was working toward her board-certification. She just started reading. And she was reading outside of the traditional textbooks given to her in her internal medicine residency. She attended conferences and made connections with people doing diet modification in ways that blew her mind.

Down at Duke, Alexandra says they have an amazing multi-disciplinary group that does diet in different ways. They have low calorie diet or ketogenic diet (low carbohydrate diet). They also have meal replacement diets. So they tailor-make the plan just for the patient and what works for them.

Because of this, she has become much more in control of the diet plans she creates for patients. She doesn't use nutritionists nearly as much as she did when she started out. She feels like it's something she needed to teach herself so she could have that great relationship with patients. And it's working out really well.

[12:15] A Typical Day

Alexandra believes you have to think about what you want your life to be like. She has made a conscious decision to split some of her time up into boxes. She's a mom of two so two of her days are spent at home. This means some of her office work is done in the mornings. But MWF, she's in the office and comes in at around 8:30AM. She starts seeing patients at 9AM. And in her new practice, she's dedicating 40-60 minutes with each patient that comes in. So she's no longer seeing 20 patients a day.

Aside from seeing patients, she does admin work. She's doing a lot of meal plans and a lot of virtual correspondence with patients. She does coaching along the way. Every two weeks, she would check in with the patient if they're doing well or they're dieting or exercising. It's a nice reminder to patients so they feel that their doctor is invested in this with them.

She's also building up a new practice so there's a lot of learning a new skill set. She's a small business owner now too so there's accounting and lawyers. She has to deal with insurance and stuff. These take up a little bit more of her time now since she's at the start of her business. Nevertheless, she thinks it's a good balance.

[14:48] Talk About Insurance Reimbursement, Taking Calls, and Work-Life Balance

Alexandra admits insurance companies don't reimburse very well. So she has decided to step out of the insurance model so as not to compromise her care for patients right now. But she hopes that as more data come out and as more companies realize that it does make a big difference in ten to twenty years. That if they're able to take 10% body weight off an obese person, they're preventing a slew of diseases. So a lot of money is saved. And maybe they would realize to focus on a specialty. But as of the moment, it's not so great.

"I have made a conscious decision to step outside of the insurance model, just so I don't have to compromise my care."

In terms of taking calls, Alexandra has a partner as an internist and obesity medicine doc, and they're doing 50/50 call. But in obesity medicine, there aren't a lot of emergencies. She does use medications and it's rare that someone has a reaction. Sometimes too, when they're dealing with a specific bariatric population where they just had surgery, that might warrant some urgent follow-up. But it's not something with a very out-of-office hours burden

As to having that perfect balance, Alexandra still doesn't know the answer. But she has a made a few big decisions on prioritizing her family. She also thinks men and women shouldn't be afraid to talk about this. Doctors train for a very long time and females are going to have a baby somewhere along the way. Alexandra had her baby at the end of her third year of internal medicine residency. While being pregnant that year, she decided not to apply for fellowship and to pursue this path.

So the first decision she made was to step outside of training to have a little more control of her hours. She chose a job right out of residency where she didn't have to work five days a week. Her second son is now one year old. So Alexandra made her own hours and decided and when and how much or when to work.

"On one hand, you've got to work a lot owning a business but it's working for myself and that makes me feel it's all worth it."

[18:44] Training for Obesity Medicine

Alexandra stresses the importance of obesity medicine being that two-thirds of our country make up obese people. This is a huge underserved population. That said, Obesity Medicine covers the whole umbrella of anyone treating anybody with excess weight to lose and doing it in a thoughtful and trained manner.

The field of Obesity Medicine includes a variety of specialties including surgeons, pediatricians, internists, family medicine, and OB GYN. So it's not just limited to Internal Medicine. You can actually sit for the boards with any specialty.

To give you a better understanding, Alexandra explains the American Board of Obesity Medicine was founded in 2011. They created a track out of training which means you have to be board-certified in a primary specialty. Then you have to accrue a certain amount of credits and attend conferences over about a two-year period.

Another option is the fellowship. When Alexandra was looking to be certified a few years ago, there were not many fellowships. But the field is now exploding. In New York City for example, the number of fellowships has grown from zero to four.

So in order to get into Obesity Medicine, the first path doesn't require doing a fellowship and the other is to have a fellowship. But she believes a fellowship would be great. It gives you the opportunity to have access to learning from more seasoned mentors.

"The test is pretty hard so you really have to put all of your effort into being a self-learner."

Nevertheless, The Obesity Society and the Obesity Medicine Association have fantastic, ongoing lectures and conferences. You get to have access to new content. They're also creating their own journals. Alexandra recommends learning and soaking everything you can so you just grow with the field as it grows.

[22:30] Working with Primary Care and Other Specialties and Special Opportunities

When asked what she would have wished for primary care physicians to know about the obese and overweight population is that it's not a lack of willpower. She says this is the number one misconception that makes patients so disappointed in the healthcare system.

They've been told what to do traditionally, but it isn't working for them and their bodies. She explains that obesity, excess weight, or metabolic disease is multi-factorial and it goes all the way back to how much your mom gained during pregnancy, the kind of birth you had, etc. It's not just calories in and calories out. And so she encourages the doctors and medical students out there.

"It's not as simple as this traditional model that we've always learned. It's complex and there are new ways of tackling it."

Alexandra adds that you should try not to be close-minded. She believes words like diet doctor, medication, or diet has gotten a bad rap or connotation. People roll their eyes and think it's a fast fix and not true. She adds everyone is different and everyone should be treated in a different manner.

Other specialties she works the closest with include Endocrine and Bariatric Surgeons. Also, in her field outside of Obesity Medicine, because of her interest in training in nutrition, other specialties include gastroenterology. She sees and treats patients who have IBD and help them to manage bowel disease with specific diets and ways of eating and looking food as medicine.

In terms of special opportunities outside of clinical medicine, Alexandra sees this as a great area to write for education. Not every person has to go see an obesity medicine doctor. A lot of people can make some of the changes of the tools they have on their own. So anyone interested in writing or doing Facebook live video. She sees a huge opportunity for people to connect with the public at large with the information that the specialty provides people with.

[26:27] What She Wished She Knew About Obesity Medicine and the Most and Least Liked about the Field

Alexandra wished she had been more aggressive in creating research content within the field and connecting with mentors. It actually took her a while to find other people who were in the field. She realized out of her training now that people are happy to connect and they're happy to help you, especially in this field because they're so passionate about it and they want to see it continue to grow at the rate it has.

"People are happy to connect and people are happy to help you."

What she likes most about her specialty is the ability to change other people's lives. She has helped people who for years, have not been able to take off a single pound or worse. Or she has helped those who have gained and gained weight when nutritional medical system has failed them. They come to her and they start losing weight for the first time in their lives. They've taken off their medications and they cry for joy when they come back to see her. It's the first time someone treated their obesity as a disease. Treating that way, they're able to co-manage all their other diseases and reverse some. This is something very profound. In fact, her patient sent her a valentine's day card saying it was the best valentine's day present one can have. That year, she lost 50 pounds.

Conversely, what she likes the least is you can't fix everyone. So it's hard work. It takes time. And it's emotional and complex. Alexandra's dad is a hand surgeon. When he takes someone for surgery, he knows he's going to be able to fix them. If not, he manages expectations. But this is not the same with obesity medicine. You can't guarantee what everyone would become when they come to you.

"We're just here to make you a little bit healthier, and the weight that comes off is bonus."

This is how she approaches every patient. But she knows some people can still be disappointed. It's tough. There is no fast fix. It's hard work on all fronts. And this can be disappointing.

[29:24] Major Changes in the Field and Some Final Words of Wisdom

In terms of major changes she sees coming in the field, we're going to see novel treatments. This field of understanding that gut microbiome is really going to change obesity medicine. So there's a lot of fascinating basic research that is going to translate quickly into clinical medicine. She hopes that in her career it goes from five medications to a hundred. And that they can really target them into each individual patient.

If she had to do it all over again, she would still do it.. Lastly, she leaves some medical students with some pieces of advice. Listen to that little voice inside of your head that led you into medicine in the first place. She didn't even know this existed but there was something in her since she was sixteen that said she wanted to prevent disease. Her greatest motivator was to prevent disease and her getting to this now is fulfilling.

Follow your guts and think outside of the box. It's easy to become so inundated by the routine and all the years of schooling you need to do. Although important, it can be exhausting. You don't get to use the other side of your brain. So think outside of the box. There are opportunities outside of the traditional academia. You can carve out a little niche and patients will be so thankful.

"When the right patients find you, they're so thankful that you were there because you'll be offering something different."

[33:16] Last Thoughts

Check out Dr. Alexandra Sowa's website www.alexandrasowamd.com. Hopefully, this episode has helped you. Maybe this opened up your eyes to the specialty that you've probably never heard of before. This is the very goal of this podcast. If you know someone who can come to this podcast, just shoot me an email at ryan@medicalschoolhq.net

Links:

MedEd Media

The American Board of Obesity Medicine

The Obesity Society

Obesity Medicine Association