Stay Off My Operating Table

From Engineer to Family Doctor: Dr Kerry Reller - A Journey into Metabolic Health and Insurance-Based Medicine 169

• Dr. Philip Ovadia • Episode 169

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While most physicians receive only two weeks of nutrition education focused mainly on vitamin deficiencies, Dr. Reller's early exposure to nutrition came from her mother's college nutrition background, which helped shape her eventual path toward metabolic health despite traditional medical training.

Dr. Kerry Reller, a board-certified family and obesity medicine physician, shares her transition from electrical engineering to medicine and her approach to incorporating metabolic health principles into a traditional insurance-based practice. She explains how she navigates insurance requirements while still providing comprehensive care, including longer appointment times and detailed lab work analysis. The discussion highlights the challenges of working within the traditional medical system while addressing root causes of metabolic dysfunction. Dr. Reller emphasizes the importance of taking time to understand patient habits, from coffee additives to daily routines, that impact metabolic health. She addresses the concerning rise in childhood metabolic issues, sharing personal experiences as both a physician and parent dealing with school nutrition challenges. The conversation explores the barriers preventing more doctors from adopting metabolic health approaches, including limited awareness and medical education focused primarily on medication-based solutions rather than prevention.

NOTABLE QUOTE

"If I don't take the time to ask these questions, I mean, I probe and I probe. I'm like, what is it? Something is going on that you're doing on a daily basis that is affecting you and making you have poorer metabolic health. So let's find out what it is."

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Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings

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Speaker 1:

Thanks for joining us folks. It's the Stay Off my Operating Table podcast. You knew that because you clicked on that podcast and that's why we're listening. This is Dr Philip Ovedia's show. Phil, tell us about our guest.

Speaker 2:

Yeah, great to have Dr Kerry Reller with us today. Kerry and I met a while ago I'll say, lose track of time a couple of months ago at, I believe it was the Metabolic Health Summit meeting, and it turns out that Carrie and I live fairly close to each other in the great state of Florida and was really excited to connect with a local physician who is interested in metabolic health, and so I was excited to get her on. I got to go on Carrie's podcast a while back and now we are flipping the table so we can get Carrie's story out there. Carrie, why don't you go ahead and give a little bit of your background to our audience, and then we'll talk about all the exciting stuff that you're up to?

Speaker 3:

Okay, thank you so much, first of all for having me on your podcast. I'm honored to be here. Yeah, my name is Dr Keri Ruller. I am a board certified family and obesity medicine doctor in Clearwater in Palm Harbor, florida, so not too far from you, and I did have the pleasure of meeting you at the Metabolic Health Conference back in January.

Speaker 3:

I originally actually was an engineer in electrical engineering and I was going to go into like biomedical engineering, thinking I would be creating the next device that you would probably be using on your patients, right. But you know, things kind of changed when I went into the workforce and I wanted to do something more. I wanted to work directly with people, have more engagement in helping them live better, happier, healthier lives. Somewhere along the way I decided to go and get my pre-medical requirements and go to med school. It wasn't completely out of the blue, although some people might think that, but so my father is also a physician, so I kind of had medicine in the family a little bit. So it's not a total surprise that I went and did that. But I did have to get the pre medical, pre medical requirements and do that. But eventually, you know, I found myself going and I did med school and everything in residency and I ended up choosing family medicine because I was very interested in sports and exercise and so that was kind of how I fell into family medicine. And then, when I was finishing my residency, my dad, who's an allergist, convinced me to move back home to Florida because I did my training in Maryland and kind of work with him and learn allergy and asthma and then kind of start my own family medicine practice. So I went ahead and did that. I worked under him for a few years and you know it was really something was missing.

Speaker 3:

I think all along, like I did my senior project and exercise and the wellness of physicians and you know how they did in managing our own health. Because I think sometimes physicians and when we're in our training we kind of let ourselves go in order to help other people, so we're getting unhealthy while we're in our training. We kind of let ourselves go in order to help other people, so we're getting unhealthy while we're helping others. So it was one thing that really kind of bothered me. But I, you know, did my best in residency and stuff.

Speaker 3:

So I think along the pathway with learning and doing primary care, something was missing, right, I'm looking at all these patients every other patient I'm diagnosing with prediabetes, diabetes and I was like what's going on, right? So how can I better help these people? To prevent them? I learned in med school to give them a medicine. Do this, you know, it's really.

Speaker 3:

The lack of preventative care is exactly, you know, what we always talk about in the metabolic health space, even though I'm in preventative medicine, right? So there's something amiss in that situation. I don't know what the deal was, but I was like Googling or something during the pandemic and I came across obesity medicine, and that's when I started to, you know, realize that there's more to this. There is definitely a problem, not just related to, you know, the lack of training in nutrition and exercise and fitness and things like that, but also just other things like where was our education coming from? Was I learning all these drugs that I had to memorize and I was not a memorizer and just giving everybody medicine and saying that's it. I know obesity medicine. We, you know, do learn a lot of similar things to metabolic health, and I think that kind of got me on that pathway of learning about that.

Speaker 3:

And then, you know, more recently, as I attended that conference with you. It was just, like you know, mind blowing to me and I've been constantly learning and researching and I know you've had several of the guests on the podcast your podcast that spoke at that conference and they're, you know, I'm following and learning and reading all more about these things, so I wouldn't say it fell into my lap. I've always had a health, you know, journey as well, a little different than some other people's. But I think that you know my, my role in this space is becoming pretty important because I'm really trying to focus on the patients who need help and to prevent that disease before me. Just hey, here's your medicine, it's over, you know. So that's kind of a roundabout way of kind of how I got to a little bit, to where I am. I'll just stop there and see if you have any questions.

Speaker 2:

Yeah, no, that's excellent and you know, kind of getting a relatively fresh perspective right on this to someone who's kind of new to the area will be great. But I wanted to go back a little bit. The interesting tidbit you mentioned about studying, doing a thesis or something around physicians health what did you learn about how good physicians are at keeping themselves healthy?

Speaker 3:

Yeah, great question. So it was basically are we following those exercise guidelines? So 150 minutes of moderate intensity activity and then or 75 of more, I guess, high intensity activity and then the two days per week of weight training. And I did query my residents and fellows and the attendings and nobody's meeting those guidelines. It was like one or two people out of everybody that we asked and it's that's pretty sad, right, and I think we're all quite busy during that timeline. But even the tendings, who aren't doing quite as much as you know residents, and they're still not meeting those guidelines. So not good outcomes really.

Speaker 2:

Yeah, no, and some of the statistics that I've seen and come across suggest that, you know, physicians are really not any healthier than the rest of the population, any healthier than the rest of the population. And it kind of brings up the question, right, if we can't keep ourselves healthy, what chance do we have at keeping our patients healthy? And obviously, like you said, a lot that goes into that. But it should be a concern to the patients and to the physicians because, you know, like I said, it doesn't really speak well if the physicians can't take care of themselves.

Speaker 2:

You mentioned that you kind of, you know, dove into the specialty of obesity medicine. Talk a little bit about what you started to learn, you know, in that environment, at those conferences that you know you said there's a fair amount of overlap with what metabolic health and I guess you know you went to the metabolic health conference because of maybe that overlap. But maybe talk about some of the overlap and then some of the differences that you found between the obesity medicine kind of world and the metabolic health world between the obesity medicine kind of world and the metabolic health world?

Speaker 3:

Yeah, that's a really good question. So there's also lifestyle medicine. So lifestyle medicine tends to have a very plant-based approach and we all talk about the same thing sleep, exercise, nutrition, stress management and lifestyles focusing on that nutrition, more plant-based approach. So I'm not board certified in that and I we've had discussions about that and I think even on my podcast I had a vegan cardiologist right after I had you on my podcast, but so that's one distinction between that. And then, as far as for obesity medicine versus general metabolic health, I think the big difference is medication usage.

Speaker 3:

In obesity medicine and I mean I think that you know I practice both ways there's a role for the medications and I think they do really help patients make these choices. But in general, you know we're talking about like the same pillars of making sure all these things are helping to improve our metabolic health. Looking at metabolic markers that are all at risk for cardiovascular disease, for Alzheimer's disease, for you know all these diseases that are somewhat preventable, right? So anything that's related to weight or obesity is usually going to be improved by improving your overall metabolic health, and I mean obviously a lot of this like circles around insulin resistance and diabetes. So I think that's a big crossover. But the bigger thing I think with metabolic health is you're really trying to implement those lifestyle changes with not necessarily using medications at times, whereas in obesity medicine you know that we believe, or there's a lot of belief, that they play a larger role, right, whether it may be, you know, metformin to help you make yourselves more insulin sensitive, or you know contrave, which is a combined medication with naltrexone bupropion, which helps with an addiction type personality. That may be something that isn't, you know, thinking in the metabolic health space but could really help someone with those kind of issues with I don't know if you want to call it food addiction that would be a whole nother topic that I'm not an expert in, but that's a role for that medication.

Speaker 3:

And then the other types of medication like Q-Cymia, which is an appetite suppressant of phentermine combined with topiramate, which is, you know, actually an anti-seizure drug, has also been used for a while. And then, clearly in the new day and age you can't leave out you know the GLP-1, gip agonists, which are definitely a huge topic now and you know I have mixed feelings about because you know I want my patients to do. You know the lifestyle part and all the studies with those medications are all shown the benefit with the lifestyle part. Right, it's hard to balance of who's the right person for what, but really I'm there kind of to support the patient. But I think the biggest difference is the medication portion. I would say yeah, yeah.

Speaker 2:

So you're there, kind of you know, on the front lines, right in a family practice environment, and you're seeing these patients Talk about you know how you do start to balance that. Right, you know we have the medications and you know, because of our environment, right, they're all over television, they're being advertised, they're being pushed heavily. I'm sure a lot of people come in saying, you know, I just want the medicine. Right, I've been told that this medicine is going to fix my problem. I've seen the celebrity that you know lost all the weight doing, you know, doing this medicine. And you know how do you kind of approach that discussion around. You know it's not all about the medicine, or maybe the medicine isn't. You know it's not all about the medicine or maybe the medicine isn't. You know the right thing in all situations.

Speaker 3:

Yeah, no, I definitely agree. So I will, you know, see a patient and you know I give a little bit extra time than the average physician, I would say, you know. So that's one thing. I have a new patient appointment which might be 30 minutes versus someone who's doing doing in 15 or 20. And then, if they take, they fill out an intake questionnaire and if it asks about weight and their trajectory of weight over time, and you know issues that may be associated with that and what they've done before, haven't done or tried or anything like that, and that really brings up the conversation, right, so I don't have to be the one asking about weight or saying, hey, you better lose weight, you know. So that really helps, I think, to, I guess, set the stage for everything. And then, you know, of course, there's going to be a patient who is coming in just for the medicine. So I'll give an example Basically, I had a patient who, you know, bmi of 23, wants to lose 20 pounds or, sorry, 10 pounds, and she, you know, wanted our opinion on this and I'm like you know this is I believe that you want to feel better, look better, be a little bit healthier, but you're not.

Speaker 3:

This is not my you know cup of tea. This is not something that I'm going to work with you because I don't. I think you're healthy, I don't think you need a medication to do this and you can do this outside. Yeah, I'm not going to be the doctor for you for that, and that's fine. And then we have another patient who really just wants to come in and do the medicine and not be part of our program. So I'll explain that more as well. And you know, I'm like you know I write, I go through all this insurance stuff. I have to say that you're going to be part of these lifestyle modification programs to get your medicine, and that's what I believe in. And if you don't want to be a part of that, then I don't want to be the physician writing this medicine, because you're not going to be getting the whole treatment that I think that you need in order to be healthier and be properly managed on this medicine. So I will just say I don't think I'm the right fit for you. I will happy to see you as primary care, but if you want to get, you know, just a medicine and that's it, I think we're not a good fit, and then there'll be someone who has tried everything possibly under the sun, who has a BMI over 40, who you know has really struggled their entire life with weight.

Speaker 3:

I might do some genetic testing right, make sure nothing is being missed from a genetic standpoint of obesity. And you know that's I will say that's a little bit rare but I have had to do that. And then you know they might be the right candidate for weight. They might need help with that food chatter, that noise, that feeling of fullness and satiety that they're just constantly hungry. Clearly, you know I'm going to ask you know a food history of what they're actually eating and doing? But if that's all there, you know I may be okay and they're coming to me for you know help and maybe the medicine. Then I might say, okay, you're a, you might be a good candidate for this.

Speaker 3:

This is, you know what we're going to do, but I'm going to monitor you at least monthly. I'm going to offer you a health coach. I'm going to do your body composition. You know we're going to do all these other things in company with it. I'm not just prescribing the medicine and letting you walk away, and I think that's a big difference than I don't know about other areas, but our area is a huge med spa type here's your medicine, see you later, kind of thing, and I think that's a real disservice to the patients.

Speaker 1:

Phil, I'm interested in how you've got to look back on your life, but if these GLP-1 drugs have been available for you 10 years ago, how would you have responded to it?

Speaker 2:

Yeah, that's a great question, you know. I think, and you know, we did have other options, right? Kerry mentioned a few of the other medications that have been approved for obesity for longer periods of time. I think I always had a little bit of a skepticism right of the you know, the drug solving the problem approach and you know one of the interesting things as a heart surgeon is, you know, one of the previous, what was supposed to be a blockbuster miracle drug for obesity, fen-phen. If you remember that one of the major side effects that led to it ultimately being pulled off the market was heart valve problems. And so I saw that as a heart surgeon and that probably, you know, did serve to bias me against the medical approach to obesity. And you know, I don't know for sure what I would have done, you know, like I said 10 years ago, if GLP-1s came out for obesity then. But I think I did have some skepticism that probably would have kept me away from them.

Speaker 3:

You know, I mean, they were available for diabetes, right?

Speaker 2:

Yeah, yeah, they were available for diabetes, but no one was thinking about them for obesity back then. And you know, I guess you know as much as I struggled with obesity throughout my life. I was always trying to do the work right. It just turned out I was trying to do the wrong type of work and when I started doing the right type of work around it, lo and behold, it worked and I've been able to stick with it.

Speaker 3:

Yeah, I think that you know, obviously very commendable. And then I mean you could have had bariatric surgery too, right, like we do sometimes partner with the surgeons for the patients that are who want or have our candidates for that as well. So that's definitely. I didn't mention that. When we're comparing to, you know, just kind of over the metabolic health versus obesity medicine, I don't think that while that changes the metabolic health for bariatric, having bariatric surgery can be very helpful and everybody's, you know the markers do improve and even ghrelin goes down and everything. So there's good evidence for that. I'm referring to gastric bypass or not, the lap band. The lap band nobody does anymore. It doesn't have, you know, the metabolic we're going to have metabolic improvements but it doesn't have the other overall ghrelin and everything improving.

Speaker 1:

Why do they not do the lap band anymore.

Speaker 3:

I ask because I have a good friend who's effective and effectivity of it and the, the, I think, the complications sometimes like people end up having to get it removed. I mean every, almost everybody. There's one guy who I knew has had a lap band who's been still successful and gets it tightened, but they usually are ended up taking them out for most people, so they're not really doing that. And plus the bypass and the new one with the duodenal switch is like way more effective and people do pretty well with it.

Speaker 1:

Yeah.

Speaker 3:

But to speak on what you had said about you were doing all the wrong things. I mean there's. You know I've been a little bit lucky in that I've always loved physical activity and exercise right. So throughout my life I've had that going. But there were definitely periods where my weight went up. So I lived abroad, in London in college and I was eating bread, I was eating cheese, drinking alcohol, not moving at all compared to what I normally move, and I gained so much weight. I came back my parents made me join Weight Watchers. I lost a lot of weight and I did well.

Speaker 3:

But during that time I mean I remember going to Subway I think it was during the Biggest Loser probably and getting a vegetarian sub because I thought I was supposed to not eat the protein. So I get like a big Diet Coke and a veggie sub and go running and go swimming and you know I was just in thinner but not as strong as I think I normally would be. And I remember trying to think about going out play soccer and I couldn't even kick the ball across the field. It was just crazy. I was thinner but not stronger. So I don't even know I never did labs back then but I wonder how healthy, you know, I might've been at the time just thinking I was healthy, eating like Subway bread, I don't know. But so anyway, I just wanted to share that as well.

Speaker 1:

You know, it's always a much more powerful message when somebody has suffered themselves and has and then it said, oh, I tried that, it didn't work. I mean, you know, part of the reason Phil has so much credibility is he's an actual heart doctor. But I think really bigger than that is the fact that he struggled with obesity his entire life. So when he says, hey look, folks, I tried all these things, it didn't work, this is what worked. I know it from personal experience and from what I see when I'm working on somebody that carries a tremendous amount of authority. I have no authority in this area, partly because I have no education, but I've never struggled with my weight. Now I can talk about problems with adrenal failure, I can talk about that from inside, what that feels, but I can't talk about this thing. That's what's the percentage, bill? 40% of our population is obese, 80%.

Speaker 3:

I think it's a third have overweight or obesity.

Speaker 2:

Yeah, I think we're right around that, but rapidly approaching. I think it's projected to hit 50% by the end of this decade in terms of the percentage of adults that are obese or overweight. And of course, the rise in this in childhood is even scarier, and that actually would be a good topic because you are a family physician, you treat across the spectrum of ages and I don't know how much pediatric stuff you do, but you know I'm imagining you certainly see teenagers that are struggling with this and metabolic disease in general. Maybe talk a little bit about that.

Speaker 3:

Yeah, I don't see that many kids, but I do have kids and I can tell you a lot about that. But I do have a couple weight management patients that are in, like our teenagers. So I think the biggest thing that we're seeing is that, you know, people are kids, I'm sorry are coming in with, like fatty liver disease. People are kids, I'm sorry are coming in with, like fatty liver disease, diabetes, even elevated cholesterol, at such young ages. And being a parent, I can see exactly why it's happening. Okay Cause, let me just give you an example.

Speaker 3:

My kids play these sports right. They're supposed to be going out there having fun. Right After the sports. When I was a kid, we got some orange slices and, you know, some water. Maybe now they are getting pre like bags full of things, of course a sugary drink, like a token, clementine, some sort of carbohydrate thing, and sometimes even candy or a granola bar that is full of sugar, and I think I mean pretzels and things like that. It's just like you burn two calories and not that I'm thinking of calories and calorie out with exercise, but you burn like almost nothing, and then you're rewarded for participating with all of this food. So it's a very difficult thing to be dealing with.

Speaker 3:

And going into schools and trying to educate and talk about it is definitely something that I'm interested in doing and some other colleagues have been doing.

Speaker 3:

But I mean I don't see as many kids in general, but we're a little bit older population where my office is. But I think that you know, as a parent I really can speak to a lot and I've spoke to other parents. For instance, my kids are in an after school program and they one day gave us this picture of all the snacks that are available for afterschool care and I'm like that's so nice that you guys are providing snacks, but could we please try to find something healthier? And you know they said it has to be like packaged or whatever. And I'm like you know what, there's not great options, but there are better options. And pretty much I was ghosted from this whole situation and I even had other doctor parents involved and you know they just kind of shut it all down. It was very sad. So basically I'm supposed to just have my kids not have that snack and yet provide additional snack for them so they don't eat the junk. I mean it's like Oreos chips.

Speaker 2:

My suggestions of beef sticks as snacks for the kids' activities never goes over pretty well, but my kids don't like them, we're going to keep working at it.

Speaker 3:

Yeah, yeah, I mean I have offered that and I do try to do my best as well, but it is very difficult. Even the lunches available for purchase are not very healthy or balanced and it's a huge frustration. And you know I can see it in other kids as they get older. I can the juice, the soda. It's. That's a huge thing and if you know, if not bringing that in and eliminating that, it's just step one.

Speaker 3:

My husband grew up in orange juice. I did not. You know those kind of things. I am like no more for not drinking this. No more orange juice. I did not. You know those kinds of things. I am like no more for not drinking this. No more orange juice. I'm seeing, like some other family members, when they bring the soda in, it just doesn't. It's not a good situation. You know, we're constantly trying to educate and without creating a problem is where I find the hard line to draw there of, you know, not creating a eating disorder, if you will, from educating enough or creating a complex about that. But it is difficult with the kids I'm.

Speaker 1:

I grew up earlier than either of you did and I'm trying to think back. You know Little League days and YMCA basketball. I was on a swim team and I don't remember our snacks being particularly what I would know would be healthy. Now Seems like we were snacking on the same junk, but I grew up in a time. I mean there were 800 kids in my high school and there were two who I would say were probably more than a little overweight. I know there were two because it was so exceedingly rare. You know they were just clearly obviously overweight, huge exceptions to the rule two out of 800. And I I assure you there's no way that any group of 800 kids randomly selected, has only two who are obese today. I mean, it's one thing when we've spent decades eating poorly and not exercising and all the things that we've done. I'm just I'm overwhelmed that young kids, but it's happening so fast.

Speaker 2:

And I don't get it. I mean I think we're learning about, you know, I mean there are lots of factors Right it. I mean I think we're learning about, you know, I mean there are lots of factors right. But one of the things we're also learning is sort of the generational factor right here. That parents, you know, your mother in particular, is obese or is having, you know, issues around high blood glucose during the pregnancy. You know that is just really priming the child for obesity, really priming the child for obesity. And then we add on the fact you know that just these obesogenic processed foods are being introduced so early to these children. I mean baby formula, most baby formulations are high carbohydrate, you know, vegetable and seed oils, processed stuff that we're, you know, introducing so early. It's. I think there are lots of things, but we, it's definitely. You know.

Speaker 2:

I saw an interesting meme the other day comparing. You know what I think most people would agree is not great food, right, some of these snack foods or something like you know, white bread, right. But it was comparing the ingredients in those same foods, like in the 1970s, versus the ingredients today. And it's the same food, it's the same package, it's the same name, but the ingredient lists are just completely different. You know the degree of the process, all of these chemical things that have been introduced into it, that you know. You look back, jack, and you say, yeah, I was eating the bag of pretzels, you know, as a snack back then. But it's probably not the same bag of pretzels, you know, in terms of the ingredients, and that was fairly interesting to think about as well. I'm not sure.

Speaker 1:

I'd use the word interesting. It's a little bit. It's alarming, it's.

Speaker 2:

Yeah, alarming, I think is right, kerry, we wanted to talk a little bit about you know you are doing all of this in the context of you know what we kind of call a traditional medical practice. Right, you take insurance, you're dealing with the insurance companies you mentioned a little earlier about you know, having maybe a little longer appointment times than is typical, but talk about some of those challenges that you deal with around doing this in the system as it is.

Speaker 3:

Yeah, that's definitely a great question. It's a challenge, for sure, and sometimes I question why I do it, but somebody needs to help these people who have insurance and need to use it and try to get them healthier, right? The biggest challenge is not knowing when something is covered or not, and me wanting to order, like a more specific test or something, so I will educate the patient. Hey, this may or may not be covered, but guess what? Quest told me it's only going to be $40 total, so we can add on this, so that maybe I can add in a more advanced lipid panel for that, so I can look at some more metabolic markers like the ApoB, the lipoprotein A, the HSCRP, the LP, little a and the particle sizes. Right, if I don't think that's available or they're not willing, then I will just do the standard lipid panel and look at the triglyceride to HDL ratio and work with that. And then you know, I think fasting insulin is something I may or may not do. Sometimes I don't even find it necessary because I get the A1C and it's already high, so I don't. I mean almost, like I said, every other patient, it's prediabetes or diabetes almost every time. And then so lab work, right, that's a little bit of a hiccup, I think, there. The other thing is answering toward their quality measures, which I think is the biggest thing. Right, if I get dinged, if someone has a high blood pressure in my office yet I want to give them time to do some lifestyle modifications in order to improve that blood pressure, right? So I they'll come back and say that their blood pressure was over 140, over 90. And then I get in trouble. So sometimes I will say, okay, we're going to treat this, but guess what? You're going to get off this medication. Right? We're going to go ahead and appease everybody, make sure it's in a safe range, and then we're going to work as best we can to get you off of that medication. And then you know you'll still be in range of a normal thing, so they'll be happy, right?

Speaker 3:

The other one is you know, every diabetic needs a statin. And then if I say someone has high cholesterol, which is almost everybody, then they're, you know, flagging it as they need to be on a statin. And I think everybody knows how you feel about statins. So it's, I'm trying to hold off doing some of these things, trying to educate the patient, or, you know, I guess working with them for the next measure. So maybe I'll say okay, here's your regular lipid profile. Your triglyceride A ratio is not great. Focus on the sugar and carbohydrates. I'm not so worried about this LDL, you know. But then we'll go back and get the advanced lipid panel next time, if that's all still concerning. You know, maybe I'll get the coronary calcium score, which is not covered by insurance. But I've created a handout to give my patients that has all the locations and the costs to get a coronary calcium score so we can look at that as well. Those quality measures that they require are sometimes a little frustrating because I'm not sure I'm in complete support with them. But trying to think of some other examples, because I'm not sure I'm in complete support with them, but trying to think of some other examples. But I think those are the biggest things.

Speaker 3:

And then when I do offer the longer appointment, I feel like I'm getting flagged by some of the insurance companies. Why are you always billing a 992.5? I'm like I spent that much time with them. I have to answer to like those kind of coding things as well. So that makes it a challenge. And then obviously, reimbursement issues, right. So if I'm spending that extra time. There has to be a plan of how we can make a you know, sustainable business, right? So there are some things that I am fortunate that I get to offer the patients In the insurance model.

Speaker 3:

We also have something called remote patient monitoring. It may be the patient taking their blood pressure every day and then we can look at it and have a call once a month to discuss anything or check in with the patient, and we can bill insurance for that. The other thing would be just checking their weight. So I put a lot of patients whose insurance covers it on a scale and check that every. They do that every day and we have a way to get a little reimbursement from that. But also keep track of the patient, keep them accountable, right, give them a little motivation, and I think that's also really helpful.

Speaker 3:

And then sometimes I will order a continuous glucometer for a patient. I tell them hey, the cash price is this, go get it, even if insurance doesn't cover it. This can really offer you a lot of information on what's going on. For instance, this week I'm having a guy who's struggling with reactive hypoglycemia, as anyone sees, 5.5. He's not diabetic or pre-diabetic, but he's eating the things that are causing him to crash. So we're taking a really deep dive in that, and I mean it is billable to insurance. I don't know if I'm getting paid yet, but it's a way to, you know, really look at the details of what he's doing so he can learn how to pair different foods, and when I see them, you know I'll suggest a certain book to read or something that might help them as well, and I think that's helpful.

Speaker 3:

And then, as far as, like patients who I'm working with weight, you know we're always really dealing with the comorbidities associated with weight. So it's going to be their blood pressure, their cholesterol, their diabetes, kidney disease, anything like that, and usually we have to make those the billable codes, because the insurance companies don't recognize obesity as a disease. Still, though, the World Health Organization I think I did and think did in 2010. Yeah, you know, billing differently and things like that is important as well. But as far as our weight management, I did kind of move to a membership model. So they're either in those remote patient monitoring things or there is like a monthly membership fee, but with that, you know, we're offering all of these things, and then I they have an app that we give as well, and education on things to help with accountability, support and motivation.

Speaker 3:

And then we also offer health coaching. So there's a lot of companies that partner with the physicians that you can build obesity counseling codes or chronic care management codes and some other codes that can be in reimbursable and the patients really find this beneficial, like they get their own private coach, they get it's televisits and they can get a lot of support and accountability with nutrition, stress, exercise and sleep health. And you know some love it, some don't. They try for a little bit and that's okay. Not all the insurances cover it. So who does I try to send and who doesn't? You know you can have a paid cash but I can't, I can't eat the cost of that, so they sometimes don't. I can't offer that, but at least, like we have some of these other tools to help them with.

Speaker 3:

You know they're getting those lifestyle and habit changes and other than that, if I'm really working closely with them, I'll see them like once a month. And even for the patients who I'm not in weight management for or in my weight management program, I am looking at these labs, being very picky and I'll tell them that and nobody really gets offended, which is wonderful, because I always have the sense that people get offended when you say, oh, you just need to lose weight, and think I'm not saying that. I would never say that. But I'm like I'm getting picky about these labs Because if we stop this problem now, you're going to be healthier down the road. So if I'm seeing an A1C, you know that I don't like that isn't near pre diabetes, but is somewhat higher, and it went up again the next time.

Speaker 3:

What's different? What are you doing in your daily habits that we can fix Sometimes? I'll just be discussing their coffee, right? If it's, what are you putting in the coffee? If it's full of sugar, like creamer with sugar, let's reinvestigate that. Maybe that one thing could be it.

Speaker 3:

I had one patient who was eating an entire bag of green peppermints every single day and gave and got prediabetes and I'm like let's get rid of that and see how you do.

Speaker 3:

And if I don't take the time to ask these questions, I mean I probe and I probe. I'm like what is it? Something is going on that you're doing on a daily basis that is affecting you and making you have poorer metabolic health. So let's find out what it is. Give me a, you know, a food diary, something, and it really makes a difference. They'll come back and lost 10 pounds and you know that's great from one little change I mean, it might be six months later, but it's a big difference sometimes and I think that patients you know really appreciate it as well. So those are some things that we have to that I implement in our office to help with getting a better sense of metabolic health and weight management in an insurance model, which is very difficult, as I'm sure you're aware, which is why everybody's jumping ship, as they should, to direct primary care or direct specialty care.

Speaker 1:

You know, the thing, as I'm listening to you, I'm thinking Carrie doesn't sound like she's nearly as radical as a lot of the folks we we talk to and I love talking with those folks because you know I'm one of those burn it all down kind of people. The thing that it sounds like that you're doing differently, aside from just kind of not having your head up your butt about metabolism, is spending time. I mean that all by itself is so different than the typical experience of a patient going to a primary care physician. Who was it I think it was Brian Linskus we talked to who told us his insurance had him on a model of something like I don't know six or eight patients an hour, just an insane number of patients. And I'm thinking if you didn't practice medicine any differently than the average MD in America, other than just taking some extra time to listen, I think it'd make a huge difference. Now I'm a big fan of the stuff that Phil has taught me, but kudos.

Speaker 3:

Yeah, no, time is definitely a struggle and you know I don't have all the time in the world. But I do get overwhelmed because if they are throwing more than I like, keep make sure they come in for the lab review. You know that's a big thing. Everything is not in green and doesn't. Green doesn't always mean good. If you know, I'm picky about the labs and I want my patients to follow up for the lab review. But if they bring 10 problems to me with the lab review, you know I get a little overwhelmed and I say OK, we'll have to discuss that next time. So there is some of that in counseling and stuff. So you know I can't stay there forever but I do try to listen and give a little more time and help them, you know, realize these small little things that they can change can make a big difference. Yeah, little things that they can change can make a big difference, yeah, what's?

Speaker 1:

I realize I'm asking you to generalize in a situation where that might not be possible at all, but is there a common response from your patients where they are revealing a level of ignorance about health, taking care of themselves that shows up again and again, patient after patient, that those of us who've been immersed in the metabolic health world just kind of take for granted? It's, oh my God, I forget that people by and large don't know this.

Speaker 3:

Yeah, no, I think that's very true. I mean, there's still I think it's a generational thing too because I have a lot of older patients who may be baby boomers or whatever, and they still want. They just want the medicine sometimes, and there's several that aren't, but they're the exception, right. So I have some older generation ones that are an exception to the rule, but a lot of them they don't. They just I've asked this.

Speaker 3:

Some people with you know pretty decent bad diabetes. You know what if we did this or the other? They're not. There's some that are just not interested. So there's that. Then you know, there's definitely everybody's still afraid of fat and they all think the LDL is the worst thing in the world and they all think it's all about saturated fat all the time. So there's definitely education there and that is a hard one to get around. I think for everybody, the biggest thing, right, like fat that we consume is not the fat that is on our body, like they're not the same thing, and that's the biggest thing that I think I wouldn't say. I even still take it for granted, it's still in the back of my head. You know, I ate snack.

Speaker 3:

Wasn't that weird you mentioned it before, but I don't think that I think that's the biggest thing. And then I mean the fact that some people really don't want to change or they think that they can still include a lot of ultra processed food in the diet rather than trying to make that less. Ultra processed food is just not, I don't know, sustainable. So there's a lot of education there. What are you eating Like? These things are not good and you really need to focus on eating.

Speaker 3:

You know whole foods and that's a difficult conversation to typically, you know I'm not seeing too many with financial relationship difficulties with the food I've had a few recently but I think that they can at least feel like they can go to the store and purchase what they want, because we're not in like a food desert or anything, and that would make it a whole different world, I think. But I mean, I've had a patient who was doing weight management. She didn't have a kitchen, she had a microwave and a mini fridge and that was very difficult. But I mean, typically, you know it's the same thing, I think, is the saturated fat and the LDL myth. And then you know, not realizing what they're eating. You know it's just the food supply. Trusting in the government, trusting in the food supply, believing everything that politicians you know say, and things like that, having so much faith in that when really we've been misled for so long.

Speaker 1:

I think one of the most powerful statements I heard that kind of shook me loose from my stupor about diet was it's not fat that makes you fat. It's not fat that makes you fat. You know very simple phrase. Because intuitively, if somebody says, oh, all this fat is what's making you fat, it makes sense Sure, oh, I shouldn't eat things with fat. I need to eat lettuce and diet Doritos and diet Coke and diet. Oh, what's that candy that I just cannot resist? There's a little candy corn. I tell my daughter-in-law do not, under any circumstances, allow me anywhere in a room where there's candy corn, because I'm helpless against it. I'm going down a road I don't need to go down.

Speaker 2:

Yeah, it is interesting to hear that perspective right, because obviously you know we have moved well past that, but it is just still so prevalent and you're right, it's the big one that I still hear as well, and it's the one that is really one of the most challenging to get people to change their minds on or at least be open to consider. Right, because it's really presented and it's been presented this way for 50 years as a non-controversial fact, right, that saturated fat is bad for your health, it's going to make you fat, it's going to give you heart disease. It wasn't, you know, we think this. It really has been presented as a well established, you know fact and and we know the reality that it's not. But that's the big one and that leads to so much more right about this discussion.

Speaker 3:

So you really got to start at that one yeah, our nutrition training, as everybody knows, in medical school is not much and it's been funded by. You know, our med school is funded by some other things other than who it probably should be funded by and there's no nutrition class brought to you by Frito-Lay and Coca-Cola.

Speaker 1:

Yeah, how much nutrition training did you get?

Speaker 3:

I think we got two weeks and it focused mostly on vitamin deficiencies. So it was basically rote memorization for me and, you know, not my cup of tea, but I think you know, over the years my mom did some nutrition I think. I don't think she's a dietician or anything, but she did nutrition in college or something. So I didn't grow up on white bread, I grew up on whole wheat bread and healthier cereals until she let us buy whatever we wanted. In high school we didn't have juice, but I remember Gatorade in high school. I mean we were playing lots of soccer and things like that.

Speaker 3:

So as far as medical nutrition, I mean really I, you know either, had it in my knowledge base from growing up, but you know it. Like I said, it was flawed as well, like I was duped by that as well when I was counting points and things like that, and I you know. But the biggest thing now is, you know, I'm seeking out the education myself so I can teach my patients and if you've really got to find a doctor, that's going to do that so they know something. And I think lifestyle medicine, obesity medicine, we're definitely on the right path. Everybody's getting better educated. So I think that's good, but you know you got to go out of your way to do it, you know.

Speaker 2:

Yeah, what are some of those challenges that you see for that? You know, what do you think the barriers are that prevent more doctors from doing this Right Cause I mean, all doctors you know have good intentions and want to stay educated Right, and you know have good intentions and want to stay educated right, and you know we do the things that we think are keeping us educated. But, like you said, it really does take some extra effort that you had to do that, I had to do that, so many of us have done. But what are some of the barriers that you see to doing that? Why don't more physicians do that?

Speaker 3:

I think that's an excellent question and I believe that everybody is trying to help. You know everyone as well. I honestly think it may be lack of awareness that it exists. You know, I didn't know it exists. I was in residency and I believe there was someone doing obesity medicine there, but I had no idea, was not exposed to it, and I was like how did I not know this existed? This is I wanted to do sports medicine. It's like adjacent to that in my opinion, which is why I think I love it so much. But I just find that is maybe they just don't aware, but I think it's becoming more aware like the number of people board certified in obesity medicine has increased crazy in the last couple years. I don't know if it's just because of the GLP one thing, though, so that's you know. I because of the GLP-1 thing, though, so that's you know.

Speaker 3:

I don't know if it's a fortunate or unfortunate thing, I don't know, but at least I think we're all learning that there's a lot of disease that is associated with weight and weight needs to be treated as a disease, and I think that's an important thing, right. But I don't know. Perhaps it's also because there's no track in you know residency or med school that talks about it. I think that's bad. So how do we get patients or not patients, doctors to do it? More is, I think, just educate that it exists. You know I don't like more there.

Speaker 3:

I will say that AFP, the American Academy of Family Physicians, has had a lot of more CME training. I noticed on obesity lately, so that's good. I will say that I think it's like I said. I think geared a lot with more CME training. I noticed on obesity lately, so that's good. I will say that I think it's like I said. I think geared a lot with the medications, though. So I don't know, I think I think doctors are going to need to do this. I think the more people are coming on board and part of the Florida obesity society, which is brand new, and we actually have a like a CME thing series, like for the next three thursdays. So I was hoping to network and see who's you know involved with that.

Speaker 3:

But I I do think it's getting better, but I'm not sure it's going to be in a role in that wish. We would want to see which is more prevention rather than just treating with medication. So I do have a concern with that. But I I mean I guess that's part of my thing, like getting the word out there, that there you have to do your own CME. You know, I'm not even I don't even get CME for some of the stuff that I do. I'm reading books. I read your book, by the way, and I, you know, I've read Steve Finney's book and just lots of Robert Lustig, and you know all these people that you have on your podcast probably read their books and listen to their podcast and I have to go out of my way to educate myself on this and I think it's important. So I guess getting the word out will be the next step. Maybe that's what we need to do.

Speaker 1:

We're doing our best.

Speaker 2:

I mean, I do think awareness is a big part of this right and it's kind of ironic right. I stumbled into this at a you know conference, at a Society of Thoracic Surgeons conference, but it wasn't really the main conference, you know content, it was just the guest speaker happened to be Gary Taubes, and you know that's what kind of set me off on my exploration of metabolic health. But you know, for the most part we just don't get exposed to this. Most physicians do not know that any of this really exists. It is just outside the bubble, outside the sphere, and you know, unless you happen to be looking for it. You know, and that's the story we've heard over and over from the physicians we've had on this program. You know they were looking for it or one of their patients, you know, found it and shoved it down their throat, right, because even a lot of physicians, you know the patient, comes and they say look at the success I've had doing this. And you know the physician's just too busy to really notice or think about it. But for a few physicians it wakes them up, it triggers something and they go, start looking.

Speaker 2:

You know, and I think, unfortunately, you know, one of the biggest problems we have in medicine these days is curiosity is discouraged in many ways. It's kind of programmed out of us. You know, thinking back to medical school, right, it's all about follow the guidelines and memorize these, memorize these facts and don't really think about, you know, whether or not that it might be true, or whether there might be other facts, whether there might be other facts out there. Really, just, it's all sort of discouraged in medicine these days. So I certainly congratulate you for being curious and doing this and thinking about these other things and just trying to think about different ways to help your patients.

Speaker 3:

I appreciate that. You know I was going to say we didn't really mention functional medicine, but I think partnering with doctors you know the functional medicine providers or you know some are doctors, some are the alternative type doctor I think that's shows a lot too. I remember when I walked in that conference with all the vendors and stuff they're like you use insurance, what this was like. Totally crazy for me even to be there for that. They were so confused. But a lot of you know the functional doctors out there, you know have a lot of offering too and I think maybe partnering with them like I've tried to do a little bit myself is very helpful too, because I think they have a lot to offer, a different role. I mean, you know I've thought of doing some of that myself, but time. So I think that would be a helpful way to also educate, get the word out as to you know.

Speaker 2:

Yeah, certainly All right. Yeah, this has been a great discussion, Very interesting, different perspective than we've gotten previously. So glad I ran into you at that conference and that we've been able to talk and stay in touch since then. For people that want to find more about what you're doing and find your practice, let them know how to do that.

Speaker 3:

Yeah, it's a call Clearwater Family Medicine and Allergy and we're in Clearwater and Palm Harbor. Our website is wwwcfmahealth and phone number 727-446-1097. And on Instagram, Clearwater Family Medicine and yeah, you can find me there and I'm sure you'll put all the rest in the show notes and things like that. Thank you so much for having me on. This was a lot of fun talking to you guys about everything in the, you know, insurance based world and whatnot. Thank you.

Speaker 1:

We appreciate you For Dr Philip Ovadia and Dr Keri Roller. This has been Stay Off my Operating Table. All the contact information that you heard here will be in the show notes. We'll talk to you next time.

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Dr. Philip Ovadia

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Jack Heald

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