ACLM Lifestyle Medicine Newsletter

Building a Thriving Lifestyle Medicine Practice in a Fee-for-service World
 By Beth Motley, MD

When we look at the pioneers of Lifestyle Medicine -- our role models -- their road to practice seemed a lengthy journey.  It meant publishing original research, writing a book, getting a spot on the podium, earning celebrity status, and starting a private practice.

Our forefathers left us a wealth of information and a strong foundation upon which to carry forward their work.  In fact, according to Beth Motley MD, if we want to make an impact on our communities, “We do not need more research. We have so much information already; it’s time to start applying it!”

And she is doing just this in her practice.  Equipped with board certifications in Family Medicine and Lifestyle Medicine, she was hired into a traditional Family Medicine role in 2017.  In 2018, she completed more than 3,000 “Lifestyle Medicine” patient encounters while averaging 3.5 clinical days per week and maintaining productivity equal to that of her strictly Family Medicine peers.  

How? She began by visiting a variety of Lifestyle Medicine practices during her training, in order to discover what approaches might be most translatable to her own future practice.  She attended Dr. John McDougall’s 10-day program, participated in Dr. Caldwell Esselstyn's Heart Disease Reversal Program, completed a research and advocacy internship with the Physicians Committee for Responsible Medicine, and spent a few weeks with Dr. Ron Weiss (Ethos Health).  At each stop, she picked up a few ideas, and carried these into her current practice.  

Here are Dr. Motley’s tips for anyone looking to build Lifestyle Medicine into practice:

Utilize your “other certification”

As it currently stands, Lifestyle Medicine certification is offered as an adjunct to those who are already credentialed in one specialty or profession.  As a Family Medicine physician, Dr. Motley practices Lifestyle Medicine in a manner that overlaps with this. This is particularly important for billing, as reimbursement is generally poor for strictly Lifestyle Medicine codes, e.g., obesity counseling.  This approach also allows you to maintain a full schedule while you build up the Lifestyle Medicine side of your practice. When Dr. Motley started out, only about 10 percent of her practice was Lifestyle Medicine. After 18 months, this rose to 80-90 percent, with the majority of patients seeing her for both Family Medicine and Lifestyle Medicine.

Engage in your community

It’s difficult to build up a Lifestyle Medicine practice without first creating some name recognition and demand.  The “Lifestyle Medicine” label is a great start; board certification will pique the interest of both your employer and your community.  Beyond that, offer community talks on Lifestyle Medicine topics, lead grand rounds for other specialties, get to know your potential referral sources (e.g. cardiologists), or consider starting a social media platform to engage your community. Check out Dr. Motley’s Facebook group: Food is Medicine Greenville

Use a Lifestyle Medicine intake form

A thorough pre-visit patient form will help you to obtain relevant information prior to the visit, so that time can instead be spent on counseling and developing a plan.  Include typical medical history, a dive into the patient’s lifestyle, and questions about the patient’s health goals. Check out her form here.

Teach simple concepts in the office

If you intend to have a sustainable practice, do not plan to spend 60 minutes personally educating each patient and answering every question that arises.  Begin to curate a collection of Lifestyle Medicine handouts, and use these to teach simple concepts in the office.  (Here’s her collection.)   For example, if a patient has high cholesterol, Dr. Motley uses one-page chart to visually show where their numbers fall.  Then, she reviews a one-page teaching aid to explain that cholesterol is only found in animal-based foods, and fiber, which helps to reduce our cholesterol, is only found in plants.  If a patient is overweight, she reviews her one-page teaching aid on calorie density. For patient with food addiction behaviors, she may review a one-page infographic on Dr. Greger’s Daily Dozen and discuss refocusing the diet on maximizing wholesome foods, to crowd out the junk food. 

Provide at-home learning activities

This is where the bulk of the learning occurs.  Once the simple concepts are taught in the office, the light bulb is turned on, and the patient is ready to learn more.  For the patient with high cholesterol, at-home learning activities may be to read “Prevent and Reverse Heart Disease” by Caldwell Esselstyn, MD, and begin to explore a plant-based cookbook.  The overweight patient may be directed to the YouTube by Jeff Novick, MS, RD, “Calorie Density: How to Eat More, Weigh Less, and Live Longer” and a “Cooking without Oil” article from T. Colin Campbell’s website.  For the patient with food addiction behaviors, she may recommend Dr. Greger’s Daily Dozen app and “The Pleasure Trap” book by Doug Lisle, PhD, and Alan Goldhamer, DC. The provider is a guide; the majority of the learning is done independently by the patient.  Check out the quarter-page printouts she uses as at-home learning activities.

Bill effectively

The majority of Dr. Motley’s office visits are billed as 99203/99204 for new patients and 99213/99214 for established patients, using standard Family Medicine codes, e.g., hypertension, dyslipidemia.  To be most efficient, she encourages couples to schedule appointments together, which allows for more counseling time. When cancellations leave her extra time, she may bill for time with 99214 (>25 min) and 99215 (>40 min). New Lifestyle Medicine patients have a 35-minute slot, and all other appointments are 17 minutes.

Refer to health coaches and outside programs

For patients who require a higher level of support, refer out.  Dr. Motley has identified three local, independent health coaches that fully comprehend plant-based nutrition.  (If there are three in small city in South Carolina, the land of biscuits and gravy, then there must be at least one in your community!)  She also refers to community programs for exercise, smoking cessation, addiction, etc. Is there is a PCRM Food for Life class in your community?  Or a YMCA with a Silver Sneakers program?  You may be surprised to discover what already exists in your community!  Consider referral to online programs as well, such as Mastering Diabetes

And while you may aspire to start a private practice down the road, or move over to the corporate wellness side of things, or focus your practice on heart disease reversal, those doors are still wide open.  But realize that you can start your Lifestyle Medicine practice now.  Take action using the resources available to you.  You will make a greater impact on your patients, benefit your community and get on the road towards a truly fulfilling career.  No need to wait!