This is a guest post written by Robert Michaelson, MD, PhD, FACS, weight loss surgeon in Washington state and Vice President of Washington Chapter of the American Society for Metabolic and Bariatric Surgery.
I was one of two hundred and twenty six candidates who took the first American Board of Obesity Medicine (ABOM) obesity medicine examination. We were practitioners from across medical disciplines like internal medicine, family medicine, obstetrics and gynecology, pediatrics, endocrinology, surgery, preventative medicine, gastroenterology and sports medicine. Eleven surgeons took the exam; 9 passed and became boarded in obesity medicine (including Dr. Alana Chock, also of Northwest Weight Loss Surgery and myself).
Why did it matter to me?
My interest in ABOM certification certainly stems from my unique background. I earned a PhD in neuroendocrinology before going to medical school. I taught medial physiology at the University of Illinois for 10 years, including the 4 years while I was a med student. I got turned on to surgery because it is physiology in the fast lane. I never imagined that a decade and a half later, fate would connect my two interests. I’ll never forget my first professor in grad school, “the father of comparative physiology”. His name was C. Ladd Prosser – his famous characterization of how the GI tract functions was as a “symphony of the bowels”. In addition to being a consultant on the Manhattan Project, Dr. Prosser discovered nerve cells in the GI tract that coordinate and orchestrate the processing of energy within us. I went on to nourish a tremendous interest in the way nerves and the chemicals they release so precisely regulate our body’s ability to control all of our systems with imperceptible, moment-to-moment corrections to maintain an even keel (homeostasis in doctor terms). We aren’t even remotely aware of the subtlety delicate changes that are being made in insulin secretion, or changes in respiration, and a multitude of other functions which correct for minute deviations in our plotted course.
Sparks flew.
At the 2011 Metabolic and Applied Research Strategy Course (MARS), my two passions–surgery and neuroendocrinology–started to flirt with one-another. Sparks were flying out of my brain. It was my “Eureka” moment and everything clicked. A passion for intellectual stimulation was reignited, and I sunk my teeth into preparing for the ABOM certifying exam.
The MARS course prompted me to start thinking about what we truly need to survive. Oxygen, water, food? Yes, all of the above. But foremost, we need the energy to bring air into our lungs; energy to walk the desert in search of water; energy to hunt and gather. We don’t need to be built like Arnold Schwarzenegger in his glory days to kill a mammoth. All we need is enough muscle, brain power and team work to deliver a fatal blow with a spear in the right place. Because of this, we will sacrifice our muscle mass to preserve energy stores (fat) for our survival. What we thought was relatively unsophisticated tissue – fat – has turned out to be one of the most regulated endocrine glands in the body, which will preserve itself above and beyond all other systems in the body! There are no less than 22 chemicals involved in preserving this life sustaining force. When the body perceives a drop in fat stores, through a decrease in circulating leptin (a hormone produced by fat cells) a cascade of events is initiated leading to the starvation response. This response leads to food-seeking behavior, increased appetite, and increased metabolic efficiency. Our fat mass, can be viewed as HAL from 2001: A Space Odyssey. When we try to lose fat, the fat will defend itself vigorously : “I’m sorry, Dave. I’m afraid I can’t do that. This mission is too important for me to allow you to jeopardize it.”
Obesity is taking an insurmountable toll on humanity, and specifically the United States. We, as a society, cannot financially sustain the costs imposed on a stumbling health care system by corporate giants that do not provide adequate health insurance to their employees; and continue to contribute to the overall demise of our nation’s health. Many business are run with a relatively short-term work-force that has limited if any health care benefits. Their employees will move on to the next purveyor of gluttony and sloth, and on and on; leaving in their path an ailing health care system, and the increasing burden (literally and figuratively) of our nation’s failing health.
So, how does this have anything to do with the ABOM certification exam?
Preparing for this certification wasn’t easy. In fact, I studied harder for this than I did for my ABS recertification. However, it was much more fun. I thoroughly enjoyed learning about the influence our operations have on the endocrine/neuroendocrine milieu that governs our energy balance. It taught me more about the societal, behavioral and cognitive methodologies we can add to our armamentarium to bolster, delay, or perhaps circumvent surgical intervention. I learned about pharmacological tools we have at our disposal to modify appetite and energy balance prior to surgery and possibly in addition to surgical therapy.
We, bariatric surgeons, are a unique subspecies of surgeons.
In our prior lives, we had very tangential relationships with our general surgery patients. They had right upper quadrant or right lower quadrant abdominal pain, and we intervened surgically and did the right thing. They would see us one week later, and our mission was accomplished. Then 2-3 years later while reaching for a box of Rice-a-Roni, your cart bumps another driven by someone who is remotely, vaguely, familiar to you – and you to her – but can’t quite place that face. That is not our life anymore. We have long term relationships with our patients, more akin to those of primary care physicians; we are managing many obesity-related comorbidities with their long term providers.
The point is, our patients come to us battle-weary. They have tried and failed everything out there. Preparing for the ABOM gave me some further awareness of our extended family. We are not in this alone. We, as surgeons often do, think our patients come to us because the rest of the system failed to help them. We need to get over ourselves. Until we can effect substantive change in the manner in which our edible food-like substances are being delivered to us, our families and our patients, we’re going to fight this fight. In the words of Arthur Agatston, we will not win this war against obesity until convenient food becomes healthy and healthy food becomes convenient. As bariatric surgeons, we are but a link in a lengthy chain of providers who are all trying to solve this problem. Preparing for the ABOM certifying examination opened my eyes to just how dedicated so many different disciplines are involved in this battle. I would highly encourage all of my colleagues to prepare for and pass the ABOM. Our patients, and frankly, our world, will benefit from a cohesive approach to this disease.
by Robert Michaelson, MD
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About the ABOM exam: Since the American Board of Obesity Medicine (ABOM) was founded in January 2012, it has sought to further the accreditation of a sub-specialization of medical practice: obesity medicine. Specifically, this sub-specialty requires competency in and a thorough understanding of the treatment of obesity and the genetic, biologic, environmental, social, and behavioral factors that contribute to obesity. The ABOM offers a certification examination to assist physicians in attaining competency in this increasingly important and universally relevant aspect of medical care.
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