September 3 - September 16, 2002 Issue

By Deborah Borfitz

Call it "cosmetic psychiatry." Bill Dudney, MD, does.

The 53-year old Tampa psychiatrist has built a medical practice exclusively for overweight people whose primary goal is to look better. "They are diet and exercise failures," Dudney said. "By the time they come to me, they've tried it all."

Everything, that is, except what he has to offer: medical management.

Dudney is of the school that views food addictions as manageable with drugs including appetite suppressants, anti-depressants, diuretics and thyroid medications, as well as nutritional supplementation with vitamins and, sometimes, liquid protein. Such treatment methods are common among the 50 or so other bariatric (weight loss) physicians in the state. Half of them belong to the Florida Society of Bariatric Physicians, which Dudney founded in 1997. He currently serves as executive advisor.

Few of the estimated 600 bariatricians nationwide also are psychiatarists. That makes Dudney as unique as his concierge-style practice. His medical clinic imposes no pricey up-front membership fee and therefore is not exclusive to the country club set. It also doesn't limit the number of patients it sees. But weight control services are paid for entirely out-of-pocket and patients enjoy the perk of anytime access to the doctor.
The practice also upholds an unusually high degree of confidentiality and privacy, which patients demand. "Some patients don't even tell their husband or primary-care physician that they're coming here," Dudney said. "It's an easy fit with the business part of the practice. Self-pay means no forms and no copies going to other doctors."

Making the Switch

Bariatrics is a medical specialty Dudney happened upon during his residency at a Navy rehab center in San Francisco. Initially, he treated only alcoholism and drug addiction among sailors, celebrities and government big wigs, he said.

Then the Navy started having problems with overweight sailors who found it difficult to climb ladders or fit through tight spaces aboard ship. "These were older sailors with the most skills," Dudney said. "The Navy wanted to save them rather than discharge them. It put them in the treatment center with the alcoholics and drug addicts and it worked pretty well."

He later went into private practice in Macon, GA, home to Charter Medical, which ran the world's largest private psychiatric hospital. "They added an addiction component to their hospital and I tried to help people who were overweight," Dudney noted.

Not a Good Mix

"At one point in my career, a hospital where I was chief of psychiatry (Columbus Medical Center, Columbus, GA) bought another hospital nearby that had an inpatient eating disorders unit," he continued. "The bulk of the patients has neither clear-cut anorexia nor bulimia. They were just overweight and depressed about it. Inpatient treatment was not the most appropriate treatment setting. They needed to be treated on an outpatient basis."

Unfortunately, insurance companies would "only pay if the case was written up in such a way that it appeared the patient needed hospitalization," Dudney explained. "That's when I started trying to treat over-weight patients as part of my outpatient psychiatric program."

It' didn't' work. "The weight control patients and psychiatric patients didn't mix well in the waiting room and the weight control patients didn't like being seen in a psychiatric clinic," he said. "So, in 1992, I separated the weight control and psychiatric practices. There were two separate corporations, locations, staff and marketing plans."

The second professional corporation, called Medical Weight Management, consisted entirely of private pay patients, while the first continued to rely on insurance reimbursement.

Eventually, Columbus Medical Center decided it wanted to employ its admitting physicians. Dudney responded by offering to sell the hospital his psychiatric practice, but declined to be an employee. A clause in the sale stated that the weight control business was not part of the psychiatric business and therefore not covered by the hospital's non-compete clause.

"The hospital agreed to buy the psychiatric practice only, but wanted me to go out of state so we wouldn't be competing," Dudney said. "I agreed not to practice in Georgia for two years. That's when we moved to Florida. My wife, Lisa, is from Florida and we wanted to move here anyway."

Mostly Middle-class, Middle-aged Women

Upon his 1995 arrival in Tampa, Dudney opened up his psychiatric practice specializing exclusively in weight control. He has seen thousands of patients since then shed pounds and gain a better self-image. The bigger challenge for patients, he said, has been keeping the weight off. Some patients end up returning two or even three times for treatment.

"Two-thirds of patients don't gain the weight back or gain it back so slowly they're not upset about it," he said. "They may come back five years later, but with less weight to lose and a shorter length of treatment. The two factors that predict success are compulsive (regular and structured) exercise and a change in eating lifestyle."

Active patients of Medical Weight Management number 150 at any one time and are seeking to lose between 25 and 65 pounds. Most are between the ages of 35 and 65 and female. Between 5-10 percent suffer from bulimia. Most are medically stable and "100 percent cosmetically concerned," Dudney stressed. "This is really an upper middle class practice, but we have some patients who have to scrape it together to see me."
People who are "extremely obese" - more than 100 pounds over their ideal body weight - aren't among his patients. "They tend to be hopeless and make psychological adjustments to the social consequences of being very much overweight," Dudney noted. "They're in denial or block out their own body perception, so they no longer seek help." Such patients tend to end up visiting their family doctor, however, for weight-related medical problems like diabetes and hypertension.

Antidepressants One Culprit

Over the past decade, Dudney said he has seen "an increased percentage of weight gain that seems to be related to taking serotonin-based antidepressants like Zoloft, Paxil, Prozac, and Celexa. These patients are on a high milligram dose or have been on the antidepressant for many years. Two of the complications are weight gain and sexual dysfunction, the latter of which overlaps into weight and self-esteem issues."

The practice averages 250 patient-visits per month, with the majority coming in every two weeks, according to Dudney. "But some come in once a week and a few women from a condo nearby who have nothing to do visit three times a week." Patients who must make a long drive to the office often request a longer interval-up to four weeks between visits.

The fee for the first month of treatment is $250, regardless of the number of visits, Dudney said. In each of the next six months, the fee is $190, dropping to $150 monthly thereafter.

The initial work-up includes a baseline body fat percentage measurement, estimate of baseline metabolic rate, nutritional counseling as needed, a full laboratory blood panel, and a medical interview and examination by Dudney. The return visits are for weigh-in, physical check-up and medication adjustment.

Dudney usually tapers down or discontinues any serotonin-type antidepressants patients are taking. "If they need a mood-stabilizing agent, I'll switch them over to a drug with a different mechanism of action." Appetite suppressants may also be prescribed, as allowed by special rules written by the Florida Board of Medicine-with Dudney's assistance-in the aftermath of the phen-fen scare. Vitamins are dispensed for free.
Medical Weight Management does not provide hypnosis, biofeedback, or psychotherapy for weight control, as all three, in Dr. Dudney's experience, have proven ineffective.

Some patients require psychiatric counseling on weight-related issues and receive it elsewhere while being treated by Medical Weight Management. But patients who have medical problems must have them handled by their primary-care physicians before Dudney will treat their weight problem. Anorexics are excluded from the program due to their medical frailty.

"Lisa has background in psychiatric social work and helps me make the differential diagnosis between cosmetic weight loss and eating disorder," Dudney said. "Normal weight bulimics may successfully hide their condition until many months into treatment. They come into treatment whe her husband to know she throws up all the time. Sometimes, it's a mother of 40 afraid n they're experiencing a difficult change, like a woman getting married who doesn't want of passing on the condition to her teenage daughter."

Lots of Marketing

The majority of patients refer themselves to Dudney's program. "We do a lot of direct marketing with newspaper ads within our market area," he said. The marketing slogan is, "When diet and exercise are not enough, medical weight management may help."

"A website also was added a year ago, at the urging of my daughter," Dudney continued. "Since then, practice volume has been up 20 percent, but headaches have been way down. There are fewer calls from people wanting to know what we do. And we're spending less patient visit time explaining what the practice is all about."

Managing incoming call volume is important to the practice. "There's just me, Lisa (the nutritional counselor) and an office manager," Dudney said.

There is no shortage of potential callers. Currently, 56 percent of all adults are over-weight, according to Dudney. "That a 61 percent increase in the last decade…despite the 'trendiness' of being fit. Fast foods get most of the blame, in my opinion."

Many of the for-profit weight loss clinics that popped up in Florida in the mid-1990s have disappeared, he added. There now are some clinics that offer herbal supplements and liquid protein diets. Medical Weight Management has "dozens" of competitors, including chains like Weight Watchers and Jenny Craig.

Practice revenues, Dudney said, are "less than a psychiatrist would get with a busy hospital practice, but similar to what an office-based practice makes." Only a tiny fraction of it is attributable to sales of liquid protein, the only product the practice sells.

One of Dudney's long-term goals is to get involved in clinical research. "There are many new drugs in the pipeline that target obesity. Participating in research would give me experience with a drug as early as possible."

A shorter-term goal is to assist the Florida Society of Bariatric Physicians in convincing the state legislature to give physicians more latitude in how they prescribe selective serotonin reuptake inhibitors. Currently, doctors are forbidden from using such drugs unless they're FDA-approved for weight loss. That limits their ability to prescribe off-label medications and drug combinations. And off-label prescribing lies at the heart of what medicine is all about, Dudney said.

One key reason his practice has succeeded where others have failed boils down to marketing, he stressed. Dudney runs a simple newspaper ad once a week, inviting readers to contact Medical Weight Management for an information packet about the practice. "My marketing budget is $3,000-$4,000 a month. To keep up patient flow, you can't let up with marketing."

It also didn't hurt that his Tampa clinic was glowingly featured on ABC's Prime Time Live in 1998, during the height of the fen-phen scare. "There were several high-level bad outcome cases in Florida and Prime Time 'secret shopped' several weight loss clinics to show how things can go wrong. After they did me, they said I had followed all the rules and used my practice as an example of how to do it right."

Central Florida Medical Business - September 2002, pgs 9-10