Introduction
Metabolic Medicine and Bariatric Medicine involve the care of patients with a wide range of long-term conditions, which require considerable expertise. Some of the conditions are very common; examples are metabolic syndrome, obesity, lipid disorders, osteoporosis and diabetes. Others are rare and include inherited disorders of the metabolism. Metabolic Medicine encompasses the assessment of patients with such disorders and the use of laboratory methods for diagnosing and monitoring such conditions and their treatment.
Bariatric medicine is the branch of medicine that specifically deals with the causes, prevention and treatment of obesity and its complications. With the growing epidemic of diabetes and obesity in Canada and the development of new therapeutics available to treat these conditions, there is a need to rigorously train physicians in this discipline to enhance their ability to provide expert care and understand emerging therapeutics.
The Bariatric Medical and Surgical Clinic at Saint Joseph’s Hospital is a center of excellence (BCoE) that provides comprehensive patient-centred care for obese patients. Referrals are received from the Ontario Bariatric Registry Portal. Patients go through a thorough assessment program that includes an orientation session and appointments with a bariatric nurse, psychologist and/or social worker and registered dietitian. Patients are asses for medical treatment of obesity and/or consideration for bariatric surgery. Two internists in the clinic see patients before surgery to assess surgical risk, and fitness for surgery and optimize medical conditions. The clinic is unique in the sense that it provides collaborative care within a multidisciplinary team.
Clinical Care
We provide evidence-based medical and surgical treatment to obese patients through a multidisciplinary approach. We have been designated by the Ministry of Health of Ontario as a Bariatric Center of Excellence (BCoE) and have been running since 2008. Our team is composed of internists, metabolic medicine specialists, bariatric surgeons, dietitians, psychologists, social workers, diabetic nurse educators, bariatric nurses and a manager. Our medical program offers different treatment options combinations (dietary changes, CBT, meal replacement programs, pharmacotherapy). Our surgeons perform over 700 surgeries yearly, mostly malabsorptive (gastric bypass and duodenal switch) but also revisions. The clinic is unique in the sense that provides collaborative care within a multidisciplinary team and fellows are encouraged to participate in our multidisciplinary meetings.
Education
We offer a competency-based training program. Training in bariatric and metabolic medicine will allow fellows to assess obese patients, decide on optimal treatment, complete a comprehensive pre-operative assessment, follow up with patients after medical-surgical programs and deal with postoperative medical complications. The program is based mainly on outpatient medical weight loss clinics, bariatric surgery clinics, and diabetes, lipids and calcium disorder clinics. We also encourage our fellows to spend a short time at our bariatric ward, to attend 2-3 surgeries and post-operative surgical follow-ups clinic. Residents and fellows are encouraged to tailor their training to their needs and carrier goals and are encouraged to attend and present at national and international conferences. The fellowship is available to trainees that have completed training in family medicine, internal medicine and internal medicine subspecialty.
Research
Residents and Fellows are encouraged to participate in research projects and attend our quarterly research team meeting. We have numerous ongoing research projects and fellows will have the opportunity to work with renowned researchers from McMaster University.
Certification outcome
The successful completion of the fellowship will grant a Fellowship McMaster Certification.
Entry Requirements
The fellowship program is designed for current residents or recent graduates of internal medicine, surgery and family medicine programs. Recent graduates are required to submit an application form and comply with McMaster University Postgraduate Medical Education requirements for residents and fellows.
Residents enrolled in the programs of general internal medicine, medicine subspecialties and/or family medicine may participate in this training program with the approval of their Program Director.
Applications Deadline
The deadline for application submission is July 31st annually.
Goals of training
Upon the completion of training the trainee is expected to be competent in the following:
- Practicing weight-related history-taking and physical examination skills.
- Understanding the health risks and complications of obesity.
- Identifying differential diagnoses of obesity.
- Managing weight-related co-morbidities including diabetes, HTN, OSA, dyslipidemia, fatty liver, NASH, etc.
- Implementing evidence-based principles of obesity treatment including behavioural and medical interventions.
- Learn indications of bariatric surgery (NIH guidelines) and types of surgeries including laparoscopic adjustable gastric band, roux-en-y gastric bypass, duodenal switch and novel experimental surgeries (SIPS, SADI).
- Understanding the preoperative assessment of the bariatric surgical candidate including cardiac/pulmonary risk assessment and bariatric surgery-specific risk assessment tools.
- Understanding the postoperative course of the bariatric surgical patient.
- Understand physiological changes secondary to bariatric surgery and success rates in terms of weight loss and resolution of comorbidities.
- Managing the short/long-term complications including nutritional deficiencies, nesidioblastosis, etc.
Length of Training
This training program is not time-based but competency-based. Training is flexible to accommodate the fellow’s career goals according to his/her baseline knowledge and skills.
This training program is self-directed, trainees are encouraged to set up their schedules and clinics according to their interests and educational needs.
| Fellowship Training Sheet | |||
| Mandatory
sessions/consults |
Estimated hours | ||
| 1 | Medical WL Program | ||
| Initial Medical Assessment | 25 | 25 | |
| Follow-ups | 10 | 10 | |
| 2 | Dietary Assessment – Dietary Prescription | 10 | 10 |
| 3 | Exercise Prescription | 5 | 5 |
| 4 | Psychological Assessment | 5 | 5 |
| 5 | CBT group | 2 | 4 |
| 6 | Preoperative medical consult | ||
| Bariatric Surgery Preoperative Assessment | 25 | 25 | |
| Redo Bariatric Preoperative Assessment | 6 | 6 | |
| Multidisciplinary Meeting | 8 | 8 | |
| 7 | Preoperative Surgical Consult | 10 | 10 |
| 8 | Surgery Orientation Class | 1 | 3 |
| 9 | OR | ||
| Bypass | 1 | 2 | |
| Sleeve | 1 | 2 | |
| Duodenal Switch | 1 | 4 | |
| 10 | Bariatric Ward | 2 weeks | 50 |
| 11 | Postoperative Medical follow up | ||
| Medication reassessment post-op | 5 | 3 | |
| Hypoglycemia | 2 | 2 | |
| Orthostatic Hypotension | 2 | 2 | |
| Pregnancy | 2 | 2 | |
| Nutritional Deficiencies (Iron, A, D, etc.) | 10 | 10 | |
| Regular Follow up (6-9-12 months) | 10 | 10 | |
| 12 | Post Operative Surgical Follow up | 10 | 10 |
| 13 | Conference (choose from major ones) | 1 | |
| CON (www.obesity network.ca) | |||
| ABSM (www.asbp.org) | |||
| TOS (www.obesity.org) | |||
| IFSO (www.ifso.com) | |||
| ASBP (www.asmbs.org) | |||
| CABPS (www.cabps.ca) | |||
| Other (Obesity Summit Cleveland) | |||
| 14 | Research – Publication | TBA | |
| 15 | Other | TBA | |
| Educational (M&M rounds, educational session) | 1 | 10 | |
| Administrative | |||
| Total Mandatory hours: | 218 | ||
| Total Elective Hours: | 282 | ||
| Total hours: | 500 | ||
Curriculum highlights
Training will be delivered in the ambulatory setting with inpatient consultations as required. The main objective of the training is to provide clinical training in several overlapping areas of medicine with a focus on obesity, diabetes, lipid disorders, bone health and nutrition. A formal academic curriculum will be developed that will consist of clinical sessions, lectures, journal clubs, group discussions, clinical research and multidisciplinary clinical team meetings.
Obesity (80%)
- Causes of obesity (genetic, behavioural, environmental, pharmacologic and endocrine)
- Complications of obesity (OSA, HTN, heart disease, coronary artery disease, stroke, diabetes, fatty liver, metabolic syndrome, PCOS, psychiatric illness)
- Non-pharmacologic treatment
- Dietary recommendations (low-calorie diet, very low-calorie diet, ketogenic diet, low-fat diet, balance deficient diet, Canada Food Guide) and contraindications
- Physical Activity and Exercise prescription
- Behavioural modification
- Behavioural and cognitive therapies
- Other therapies
- Pharmacologic treatment (antidepressants, anti-psychotics, diabetic medications and anti-hypertensive medication)
- Surgical treatment
- Candidate selection
- Surgical procedures (LapBand, gastric sleeve, roux en y gastric bypass, duodenal switch and others)
- Follow up post-surgery
- Short and long term Surgical Complications
Diabetes (15%)
- Role of nutrition, exercise, pharmacological management
- Monitoring and prevention of complications
- Management of complications (retinopathy, nephropathy, PDV)
Bone Health
- Disorders of calcium metabolism including disorders of vitamin D and parathyroid.
- Osteopenia and osteoporosis
- Prevention, diagnosis and management
Lipid Disorders
- Diagnosis of lipid disorders
- Management and monitoring of lipid disorders
Lifestyle
- A healthy diet and recommended physical activity to preserve good health and prevent diseases associated with obesity
Supervision & Feedback
The trainee will have a supervisor who will review his/her work regularly. Details of clinical exposure and attendance to meetings and lectures will be recorded in a resident logbook. Supervisors’ evaluations will be used as evidence of satisfactory progress.