Abstract
Background:
Obesity is among the most undertreated chronic diseases in the United States. Inadequate obesity medicine education for medical students and residents is one potential cause of undertreatment. There is currently no original research on subspecialty training in obesity medicine. This study describes obesity medicine fellowship programs to identify areas for preservation or improvement.
Methods:
Online questionnaires were administered to 25 U.S. obesity medicine fellowship program directors compiled from the Obesity Medicine Fellowship Council. Over a 6-month period in 2023, program directors completed online surveys querying four domains: general program operations, fellows’ clinical duties, fellows’ scholarship duties, and faculty duties.
Results:
Twenty-four out of 25 fellowship programs completed the survey. Most programs were of 1-year duration, prioritized outpatient clinical experiences, promoted academic productivity, delivered formal education, and provided mentorship. Areas of heterogeneity included degree of supervision, independent continuity clinic, institutional support, and faculty involvement. Standardization of funding sources and evaluation protocols for fellows and programs were identified as targets for improvement.
Conclusions:
The current state of obesity medicine fellowship training focuses on clinical competency, education, and scholarship with great variety in delivery and implementation. Fellowships would benefit from standardization of financial support. Recommendations for standards require future studies to examine competency outcomes.
Background
Obesity is the most consequential disease of adults and children worldwide. In the United States, 40.3% of adults have obesity, and the prevalence of severe obesity has increased over the past decade. 1 Obesity causes multiple comorbidities including hypertension, type 2 diabetes, dyslipidemia, cardiovascular disease, musculoskeletal disorders, and some cancers. On a societal level, the cost of obesity and consequent chronic diseases was estimated to be $1.7 trillion in 2016. 2 Despite the breadth of burden, obesity remains undertreated. Obesity is a missed diagnosis in 60% of medical appointments, 3 and when diagnosed, only 2% of patients who are eligible for medical management are offered pharmacotherapy. 4
Several factors have been identified as potential causes of undertreatment, with particular focus on the lack of obesity medicine education at all levels of training, beginning with medical school and extending through fellowship.5,6 Medical school curricula commonly omit obesity education entirely, and those who have it dedicate a mere 10 h to obesity education, which fails to prepare students to provide evidence-based obesity treatment once they start residency training. 6 After medical school, the deficiency in obesity education persists. Only 10%–20% of internal medicine and family medicine residencies reported preparedness in the management of patients with obesity.7,8 A cross-sectional survey of family medicine residency programs revealed that few family medicine residents were adequately prepared to manage patients with obesity at the end of their training, especially in topics related to pharmacotherapy and weight stigma. 7 Furthermore, even though 53% of pediatric, internal medicine-pediatrics, and family medicine residency programs recognized the importance of childhood obesity training, only 18% had a formal curriculum. 9 A systematic review on obesity education in medical schools and residencies worldwide highlighted the urgent need for health care professionals to receive adequate education on obesity management to improve patient outcomes. 10 Evidence supports the implementation of obesity medicine training in residency to improve bariatric surgery care. 11 However, perceived barriers to enacting such training include systemic (e.g., lack of time or administrative support), economic (e.g., lack of funding), educational (e.g., lack of faculty expertise), and regulatory (e.g., lack of Accreditation Council for Graduate Medical Education [ACGME] guidance).7,12,13
With the 40% increase in American Board of Obesity Medicine (ABOM)-certified physicians from 2022 to 2023, 14 the growing interest in obesity medicine as a field underlines importance of training future experts and leaders. On the subspecialty level, the number of obesity medicine fellowship programs grew from 25 in 2023 to 31 in 2024. There are now nearly 150 fellowship-trained obesity medicine physicians, 15 and yet there is no research examining obesity medicine education at the subspecialty level. This study describes obesity medicine fellowship programs in the United States for the purpose of identifying needs and gaps for standardization.
Methods
Over a 6-month period in 2023, invitations were sent to program directors of 25 obesity medicine fellowship programs in the United States identified from the Obesity Medicine Fellowship Council (OMFC, omfellowship.org) to request their participation in this online survey. A descriptive, cross-sectional study was conducted via online questionnaires, which were self-administered by respective fellowship program directors.
The survey instrument was composed of 42 questions addressing four domains: general program operations, fellows’ clinical duties, fellows’ scholarship duties, and faculty duties (Supplementary Appendix). It included multiple-choice and numeric text questions. The survey was not validated, and it was constructed based on metrics followed by the ACGME, a literature review of current knowledge and knowledge gaps in obesity medicine subspecialty education, input from subject matter experts, and consensus on survey objectives from the OMFC. Survey was piloted with a sample representative of the study population (e.g., program directors of nonobesity medicine fellowships) prior to dissemination.
Data were collected via Qualtrics™. Continuous variables were reported as mean ± standard deviation. Analysis was conducted within Qualtrics.
Results
Twenty-four out of 25 (96% of fellowship programs) responded and completed the survey. Programs included 21 adult obesity medicine fellowships, one combined obesity medicine/endobariatric fellowship, one pregnancy obesity medicine fellowship, and two pediatric obesity medicine fellowships. All results are presented in Table 1.
Results of Fellowship Program Survey (n = 24)
Philanthropy was defined as a onetime, recurrent, or sustained financial support from an external source; endowment was defined as a specific long-term fund or investment.
Referred specifically to registered nurse (RN) or licensed practical nurse (LPN) to distinguish from nurse practitioner.
A Clinical Competency Committee was defined according to the ACGME as a designated committee that synthesizes quantitative and qualitative assessments regarding an individual fellow’s performance.
A Program Evaluation Committee was defined according to the ACGME as a designated committee that identifies outstanding features of the program and areas that could be improved.
ABOM, American Board of Obesity Medicine; ACGME, Accreditation Council for Graduate Medical Education; APD, associate program director; CME, continuous medical education; DEA, Drug Enforcement Administration; FMG, foreign medical graduates; PD, program director; SD, standard deviation.
General program operations
At time of survey administration, 25 obesity medicine fellowship programs had been certified by the OMFC and 24 were active programs. The first fellowship program was established in 1993, and 13 programs have been added since 2020 (Fig. 1). Most programs (92%) were 1 year in duration, one program’s duration was 1 or 2 years depending on track, and one program was 2 years in duration. Half of the programs had historically made modifications to their fellowship to accommodate a personal or professional circumstance (e.g., maternity leave, medical leave, delayed visa, specific fellow’s interest). Most were housed within the department of internal medicine, endocrinology, or gastroenterology, with a minority within pediatrics, surgery, or obstetrics and gynecology, respectively. Fellows were commonly appointed as instructor or clinical fellow. Thirteen programs (54%) accepted applications from foreign medical graduates, with four programs having responded, “to be determined,” and of the 13 programs, five accepted J1 visas, four accepted H1B visas, two responded “no visa required,” and three stated “to be determined.”
Growth of Obesity Medicine Fellowship in the United States.
Programs were funded through a variety of revenue sources such as clinical revenue (63%), institution sponsorship (54%), clinical or research grants (42%), philanthropy (21%), or endowments (13%). Philanthropy was defined as a onetime, recurrent, or sustained financial support from an external source; endowment was defined as a specific long-term fund or investment. All programs had registered dietitian-nutritionists and multidisciplinary teams of different compositions. Most programs (92%) had an administrative assistant, who was often shared with another intra-institutional program.
Fellows were typically provided with dedicated workspace, compensated time-off, and an educational stipend or reimbursement. Most programs covered conference-related costs (87.5%), with responses ranging from $1500 to $4000 per year, and two (8%) programs reported full funding of all expenses for two conferences per year. Four (17%) programs set a continuous medical education or professional allowance per year. Most programs formally delineated fellows’ clinical or administrative responsibilities (88%), competence-based goals or objectives (79%), and program aims (63%), whereas 50% of programs formally delineated faculty’s clinical or administrative responsibilities.
Twenty (83%) programs formally elicited bidirectional feedback. Most programs (83%) also had protocols to formally evaluate fellows, but fewer (63%) had protocols for fellows to evaluate faculty. A minority of programs had a Clinical Competency Committee (25%) or a Program Evaluation Committee (38%), as defined by the ACGME.
Fellows’ duties
Fellows’ duties encompassed clinical, scholarship, didactic, and administrative responsibilities. Most of fellowship time was spent on clinical care, followed by scholarship activities, formal didactics, and administrative tasks. The core of all programs rested in an outpatient setting with most of the time (65.3%) spent in obesity medicine clinic, followed by surgery (7.8%), nutrition (4.5%), and endobariatric gastroenterology (3.6%). While most of these experiences were outpatient clinic, endobariatric gastroenterology, which is the subspecialty within gastroenterology dedicated to endoscopic procedures for obesity treatment (e.g., intragastric balloon, sleeve gastroplasty), encompassed time spent in the procedure room as well as clinic. About 9.5% of outpatient time occurred in other clinic experiences: endocrine, sleep medicine, hepatology, general internal medicine, and lifestyle medicine. Programs reported a mean of 6.2 clinic sessions per week, with one clinic session defined as a 4-h period (e.g., 8 am to 12 pm). Six programs included inpatient obesity training. Almost half (45.8%) of the programs had multiple outpatient or inpatient sites. Fellows were given on-call duties in nine (38%) programs, ranging from attending coverage to afterhours pager. Most programs (79%) allowed fellows to moonlight in their licensed discipline outside of obesity medicine.
Outpatient clinic experience consisted of attending clinics and, for 14 programs, fellows’ independent continuity clinic. In attending clinic, fellows were provided direct supervision, indirect supervision, or oversight, as defined by ACGME. Programs gave more direct supervision (62 ± 36%) than indirect (21 ± 24%) or oversight (8 ± 21%) in the first half of the year but with wide variation. Supervision shifted to a more even distribution of direct (41 ± 37%) and indirect (40 ± 35%) supervision in the second half of the year. In attending clinics, 9 (38%) programs had fellows bill for the encounters, 12 (50%) programs had the attendings bill, and 3 (13%) programs allowed either fellows or attendings to submit billing.
Fourteen programs (58%) had established fellows’ independent continuity clinic in which fellows were permitted to manage patients and bill encounters without attending supervision. Of these, eight (57%) programs opened independent fellows’ clinic within 6 months of fellowship start, five (36%) programs opened at 3–6 months, and one (7%) program started after 6 months. In 12 (88%) programs, the fellows billed for the encounters.
Nineteen (79%) programs delineated requirements for academic productivity. Fellows engaged in several scholarly activities including conferences (96%), original research (83%), publications (83%), quality improvement or safety projects (71%), creation of didactic tools (50%), innovations in patient care (42%), and service on professional committees (17%). All programs offered educational activities specified as conferences (100%), formal didactics (83%), journal club (75%), and medical student or resident education (75%). Additional activities included fellows’ lectures and presentations, weekly clinical conference, monthly interdisciplinary meetings, board review questions, and divisional grand rounds. Fellows attended a mean of two conferences per year. In almost all programs, fellows were expected to sit for the ABOM examination, which was typically encouraged to be taken after fellowship completion.
Faculty duties
Fellowship programs were commonly led by one program director, with three programs having had two program directors. About half had one or more associate program directors. Program directors were given a mean of 9.8% full-time equivalent protected time and spent a mean of 8.1 h per week on several tasks. In most programs, administrative tasks, teaching or scholarly activity, fellow recruitment or selection, evaluation or promotion of fellows, disciplinary action, supervision of patient care, and securing financial support were all responsibilities delineated to the program director.
Programs had a mean of 4.6 core faculty members who spent 3.8 h per week on administrative tasks, supervision of patient care, teaching or scholarly activity, evaluation or promotion of fellows, and fellow recruitment or selection. In the setting of supervising patient care, attendings in 17 (71.8%) programs did not make changes to their clinic schedule, while attendings in 13 (54.2%) programs closed their clinic or scheduled fewer patients to allow time for supervision.
Discussion
This descriptive study of obesity medicine fellowships in the United States is the first to report the current state of obesity medicine education at the subspecialty level. Broadly, the surveyed fellowships were 1-year clinical immersion programs with secondary aims of education and academic productivity. All programs provided multidisciplinary experiences and mentorship to achieve these goals. Implementation varied in supervision levels, fellows’ independent clinic, secondary clinics, scholarship opportunities, institutional support, and faculty involvement.
While heterogeneity among programs may have evolved to accommodate the diverse backgrounds, needs, and goals of trainees, standardization is important to ensure equal competency among graduated fellows across the United States. Obesity medicine fellows are drawn from multiple specialties (e.g., internal medicine, pediatrics, family medicine, preventive medicine) and may require different levels and types of engagement to meet obesity medicine competency. Additionally, because obesity impacts all other fields in medicine, fellowships should maintain the flexibility to tailor their programs to their trainees.
Table 2 offers future directions for investigators, program leaders, or professional societies to consider in the evolution of obesity medicine fellowship education. Five areas of strength were consistently reported among fellowships: diverse patient care experiences, interdisciplinary clinical teams, formalized education, and scholarship opportunities. Optimizing the clinical experience is crucial to high-quality patient care, but future studies should investigate the relationship between competency and time spent in each clinical activity to determine what exposure levels, and in which activities, establish minimum competency and mastery. Based on the mean number of clinical sessions per week and mean number of days off, fellows spent 1190 h in clinical care as part of a one-year fellowship. For comparison, mastery of Roux-en-Y gastric bypass is considered achieved at a threshold of about 500 surgeries averaging 1 h each.16,17
Future Directions for the Assessment and Development of Obesity Medicine Fellowships
Three areas were identified as crucial targets for improvement given the evolving needs in the field: evaluation of fellows’ clinical competency, evaluation of programs, and sources of funding. Evaluation protocols may be adopted from ACGME guidelines. 18 Funding is a primary barrier. Obesity medicine has historically been a marginalized subspecialty with little institutional support, and our data found that this challenge persisted, with only half of fellowship programs having had institutional sponsorship. Funding for current fellowships have been sustainable through the OMFC’s model of diversification through departmental funds, grants, and billing for fellows’ services. 19 However, such stakeholder buy-in is crucial to secure for the future of the field.
This descriptive study is limited by participant recall in which data were collected via self-administered surveys and thus susceptible to availability bias or varied interpretations. Additionally, the survey was not statistically validated. Other areas of interest, including occupations after fellowship graduation and future earning potentials, were outside the scope of this survey. Future directions should include such objectives as well as evaluation of program fulfillment of competency domains set forth by the Obesity Medicine Education Collaborative. 20
Overall, current fellowships have individually developed strong foundations for the training of physicians in the subspecialty of obesity medicine, but the field would likely benefit from standardization across programs. This descriptive study is the first step toward standardization informed by data on the current state of obesity medicine fellowships. Further studies should examine the competencies achieved from such fellowships and professional development thereafter with the goal of developing outcome-informed standards for subspecialty obesity education.
Conclusions
Obesity is the defining disease of our generation. Society must prioritize obesity as a disease, patients must have equitable access to safe and effective therapies, and providers must be trained to meet the needs of the population and the individual. Although obesity medicine fellowships have been established in the United States for over 15 years, most programs launched recently, highlighting the growing demand and interest in this field. Specialized obesity expertise is essential to meet the complex and rapidly evolving landscape in obesity care. Fellowships must be optimized to cultivate leaders who will drive progress in obesity medicine.
Footnotes
Acknowledgments
Thank you to the members of the OMFC for their participation.
Authors’ Contributions
B.G.T. contributed to conceptualization, methodology, investigation, data curation, formal analysis, writing—original draft, writing—review and editing, and supervision. P.C. and C.B. contributed to data curation and writing—review and editing. S.L.S. contributed to conceptualization and writing—review and editing. W.S.B. and G.S. contributed to conceptualization, supervision, and writing—review and editing.
Data Availability
The datasets used or analyzed during the current study are available from the corresponding author upon reasonable request.
Ethics Approval and Consent to Participate
Ethical approval has been waived (exempted) by Weill Cornell Institutional Review Board. Prior to completing surveys, respondents provided informed consent electronically. This study was conducted in accordance with the ethical principles of the Declaration of Helsinki.
Author Disclosure Statement
B.G.T. reports consulting/advisor fees from Lilly, Novo Nordisk, and Skye Bioscience. W.S.B. receives consulting/advisor fees from Novo, Eli Lilly, Boehringer Ingelheim, and Abbott. G.S. is a consultant for Novo Nordisk, Rhythm, and Eli Lilly and receives research grant support from Eli Lilly and is on the speaker’s bureau for Rhythm and Novo Nordisk. All other authors report no conflicts of interest.
Funding Information
P.C. and C.B. were funded by the University of Chicago Jeff Metcalf Internship Program.
Abbreviations Used
References
Supplementary Material
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