Joe Kim (CCO): Thank you so much, Dr Desai, for joining us for this interview today. Before we start, if you could just tell us about yourself as well as about your practice, that would be a great way for us to begin.

Dr Sejal Desai (Tula Medical Weight Loss & Wellness): Sure. Thank you for having me. My name is Sejal Desai. I am a Board-certified obesity medicine physician in Houston, Texas, and I was family medicine for about 20-plus years, and got additional Board certification in obesity medicine about 10 years ago, and I created my practice called Tula Medical Weight Loss and Wellness in Houston.

My practice is really aimed at helping patients achieve sustainable weight loss and better metabolic health. I take it personalized, comprehensive, and evidence-based approach, focusing on all the lifestyle factors as well as medications, chronic medical conditions. The goal is to really provide a judgment-free supportive environment where patients really just feel empowered and informed on their weight loss journey.

Joe Kim: I know a few years ago we had the opportunity to work on an obesity quality improvement initiative, and part of that involved your interventions of supporting these patients along their obesity care journey. Can you tell us more about what it means to support these patients as well as to provide them with these kinds of resources?

Dr Desai: Sure. Yeah. I thought that it was a really great intervention and very eye-opening. Even for me as an obesity medicine physician who has been doing this for such a long time, I think all our patients are on a lifelong journey because obesity is a chronic disease and patients need ongoing support even outside of medical visits. It really got me thinking on how I can help support my patients on a daily basis, a weekly basis, just over their lifetime.

I started offering support groups and additional patient resources because I saw that need for ongoing support and we started off with having chat groups that patients can lean into and discuss all of the different things going on in their lifestyle, chat groups that were related to nutrition, physical activities, sleep, stress, just things that can help patients talk about how they are feeling in a non-judgmental environment and get accountability and emotional support.

Joe Kim: In terms of the chat groups, that sounds very interesting. Let us talk through the structure, the format, the logistics. Were these chats scheduled or were they asynchronous, happening all the time? Tell us a little bit more about how they actually functioned.

Dr Desai: Yes, they are asynchronous. We have several different groups, and each group is based on a different lifestyle factor. There is a group for nutrition, a group for physical activity, a group for sleep, a group for stress reduction, and a group for non-scale victories.

This is for patients only that are in my practice, and they can choose to join any or all of them, and it basically functions as any other chat group. You can post in there at any time.

I have a moderator helping me, and I am in there as well and we are making sure patients are posting appropriate content, but they are able to post in there their struggles, their wins, if they have questions. They are able to post any time of the day and other patients who opt in to these groups, they can give their information as well. We get to learn from each other, which I think is so incredibly important because I learn from my patients all the time. It is a great way for me to give out information. Here is a great app that I heard about that you guys may like. Here is something that happened with a patient that I thought was really interesting and might help other patients.

Of course, it has to be confidential. I cannot give any patient health information per se, but in a confidential factor, I give also lots of examples of things that other patients are struggling with and patients are able to ask questions and get information, and that is how most of those work.

That fifth one called the non-scale victories, that one is more for me encouraging patients to post their non-scale victories because it is a big goal of mine to help patients not focus solely on the scale and focus on other factors that are improving, thinking about their health or how they are feeling or just little things. I slept great yesterday, that was a great non-scale victory for someone. Just these small things, helping to keep them motivated and helping them learn that this is a long-term journey and that we are all in this together, and then others chime in and say, yay, great job. I know you have been struggling with that. And so it really helps with that accountability and support as well.

Joe Kim: Yeah, it sounds like it is a great way to keep that momentum going as you mentioned. I would also imagine given the diversity of patients who might join such a group, that there is always that risk that someone might post something that could be considered either medical misinformation or perhaps even considered bad advice. Did you encounter situations like that? And if so, how did you navigate those?

Dr Desai: Yes. That does happen occasionally. Patients get so excited about telling each other how they are handling that situation. This is why I really do have a moderator making sure of a lot of these things. If someone posts something that is any type of medical advice, that is 1 of my rules.

I do have some ground rules, and 1 of them is you cannot post medical advice. Sometimes they do not even realize that that is what they are doing, but my moderator picks up on it, lets me know, and then I do let them know that we are not giving medical advice in this group and it is just shared experiences.

Then I am able to delete that comment on my end. Most of the time, I just rephrased it in a way that is not so much medical advice, but just giving information. There are some rules that patients do have to follow. Of course, medical advice is one, no judgment or shaming, that is a big one.

This is support groups. We want to help each other. I really have not had anybody do anything like that. Everybody has been so kind so far and has been wonderful.

Of course, I do not allow any promotion of any unverified treatments or products or anything like that. Nobody has tried to do that either yet. It is just a really respectful community, and I really encourage that respect.

Then of course, confidentiality is key, that everything that is said here stays here. It does not go beyond here as well. We want to keep the space positive, inclusive, and really a place that can be beneficial for everyone.

Joe Kim: In that type of virtual environment, do you find that there are patients who are willing to be vulnerable and share some really sensitive topics or stories? Or do you find that it tends to just focus more on the encouragement and the positive?

Dr Desai: Yeah, great question. I think there is a little bit of all of it because everybody is so different. I have some patients who are just very positive, focusing on all the positive stuff, and I have some patients who are being very incredibly vulnerable and I think it is wonderful to have that as well and I encourage that as well because we all have vulnerabilities.

One of the things that I have issues with, with social media is that it can just be a place of all the good. There is not a lot of bad stuff being posted. The days where your hair is a mess and you do not have any makeup on and you are just lounging around and cannot get out of bed, noone is posting that. I think patients can get very depressed thinking everybody is doing so great except for me.

In this group, this is a group where I encourage that if you are struggling, let us know that you are struggling because a lot of times, so many others are having the same struggles that you are having. I do actually have patients posting their vulnerabilities, and as more patients post, then others get more encouraged to do so.

There are a lot of people on there that just do not post it all. They just want to hear what others are saying and listen. They say they are getting a lot out of it, but I have never seen them post, and that is okay also.

At first, I did change on that a little bit because at first I said, “Well, this is a place I want everyone to post and be involved and it does not work unless you post and be involved.” But you know what? I went back on that and I said, I want it to be a safe space. If you do not feel comfortable posting, that is absolutely okay. You can still attend, you can still listen and you can still get the information, and maybe in the future they might feel more comfortable posting.

Joe Kim: Speaking of challenges, for you as the one organizing and running these chat groups and engaging the patients and keeping that momentum going, what have been the challenges that you have either experienced or have faced and had to work through as you have implemented this intervention and as you have worked with the patients through this kind of channel?

Dr Desai: Yes. As with anything, there are always challenges, which can be great learning opportunities too. There were several. Initially, I felt like I started off a little too big and had too many groups. Then I dialed it down a little bit and gave just those 5 different areas where people can sign up.

I think it is better to start smaller and scale up rather than do too much because there's also only 1 of me. That was the other thing, is I was trying to do it all. I was trying to be the moderator and post and listen to everyone and make sure that I am on there every day and checking these things, and it just became too much for me to do as 1 person alone. I did not hire somebody new.

Actually, my manager is the one who is the moderator in these groups. She was the one who was very excited about doing these groups. She is involved in other chat groups online and feels that they are very beneficial. So she has been a fantastic moderator. I did hand over that part to her, so I do not have to log in every single day to make sure everybody is following the rules.

I think that was a big thing because with so many other things in my practice, because my practice is a smaller boutique practice and I feel like I am doing all of it. One of the biggest lessons I learned is just get help, and getting her help has been just tremendous in making these groups successful.

Joe Kim: As you think about the future and think about the sustainability of the groups that you already have as well as growth and the practice and those other dimensions, where do you see things going and what do you think might be some factors or some things that you might change in the coming years?

Dr Desai: Yeah. I do have lots of visions for this growing. One of my biggest commitments to my patients is to help them feel supported, heard, empowered, and I cannot do that in 1 office visit. I do see my patients about once a month, but in 1 office visit once a month where we are trying to talk about their medications and their lifestyle, the personal stuff, the one-on-one stuff, I cannot get to a lot of these different things.

I really do want there to be a lot more interaction and support in many different ways and collaboration in many different ways. I do want to incorporate larger groups and maybe even have different groups where we are opening it up to everyone, not just the patients in the group per se, but also just opening it up to other people who are on this journey and need support.

There is 1 thing that I started recently and that is a live online talk that I do every Thursday at noon, and that is open to the public. It is completely free. It is through an app, it’s called Goodself. Goodself is a free social media app with vetted experts. I am on there every Thursday giving a talk live and you can join live and ask questions. Anyone can join that, anyone can do that. I really want to do more of that type of work. And those talks are then recorded. If you cannot join live, then they can watch the recorded version afterwards.

I want to do more things like that open to the public. I may perhaps create a Facebook group. There is so many different Facebook groups out there. Create online courses that are made available in certain areas where we can dive deep into liver health, or menopause, or sleep health or something along those lines that patients can take a course for me and do it at their leisure at their time. I think that all of this can help.

I also would love to collaborate bringing on more specialists and therapists and dieticians and different people in the field, and collaborate with them to make content that is available to everyone, not just the patients in my practice.

Joe Kim: Yeah, it sounds really exciting to think about the potential as well as the opportunities. As you think about other clinicians and various practice settings who might hear about this idea of supporting patients through chat groups and such, what advice would you have for those who might be interested in doing either something similar or trying to replicate what you have done?

Dr Desai: Yes. The first thing I would say is keep it small and keep it simple to start. And you can always change as you grow and it will change. I feel like with all of these things, I am constantly changing to do things that work for my patients, but it is easier if you start small and keep it simple to begin with. Maybe a private chat group, a monthly Zoom call, or weekly email check-ins, something that is small and obviously HIPAA-compliant.

I think setting clear expectations from the beginning is really important too. Really think about it. What is it that you are wanting to achieve? Who is your target audience? How do you want to really get that message and information out? How are you going to be able to sustain that? Do you have the staff, and who exactly is going to do what? Setting those clear expectations ahead of time is so important.

And being consistent as well, just holding yourself up to a better standard. If you are doing weekly Q&A sessions, make sure that you are doing those. Do not make plans that are unrealistic or set goals that are unrealistic. Make sure you have the time to be able to do that. Establish the ground rules from the beginning so everybody understands those rules, and then there is not as much of a need to reprimand or delete chats and things like that. I think establishing those ground rules and fostering just a supportive judgment-free space can really prevent a lot of misinformation from spreading.

I think that is important. Also 1 thing I have not done that I would encourage people to look into is really using technology more that we have and including things like AI.I think that AI can certainly help in so many different ways, and it becomes a little challenging because in our field, we have to find things that are obviously HIPAA-compliant as well. I have not been able to just say, let us just create a WhatsApp group. I do not know how to do that yet, because that to me does not seem very HIPAA-compliant. Finding that is more challenging, but I think there are still ways that AI technology could help with this, perhaps there are platforms that AI could be a moderator or generate questions.

I think there is a lot of possibility out there for AI. It is 1 of my future goals, and just things that I feel that I need to become more educated in as well.

Joe Kim: Yeah, it is a great point about just even generating ideas and coming up with topics and maybe themes and things to talk about with the patients. Speaking of things like AI and other tools and resources, are there either specific platforms or things that you have found to be very helpful, whether it is on the technology side, on the administrative side, on the technical and logistical side? Across any of those areas, have you found things that have really helped you?

Dr Desai: Yes. Many things. I have gone through many things in the process as well, but there are a few that I absolutely love and have helped so much. One is definitely my newsletter platform. There is several out there like MailChimp. I use Constant Contact, and that has really helped me just keep my patients on there as well as others that enter my website or other ways they found out about it. It is a great way to get out all of this information, and just good information to patients.

I do send out newsletters periodically. I do not want to overburden anybody, but I use Constant Contact to help me create those newsletters and then send that out, so that has been great.

For my administrative things, I am a big fan of Google Forms and Typeform, and there's just Google Sheets, keeping everything organized on Google Workspace, which is HIPAA-compliant and can keep our practice organized. I even have virtual assistants who can help, and these platforms can be shared virtually. Virtual assistants have been a great help in my practice as well.

I use Canva so much. I am in love with Canva. It helps me create so much content. I have this big artistic side, I feel like, that I never really got to use as much in medicine, and I loved it. I love to create my own content, and I love to create my own flyers and emails and brochures and information, and just even handouts for patients. I have truly loved Canva for that. It makes it so easy and simple.

I use Zoom as a platform for certain webinars and things that I do, just free of charge for patients. I use Zoom for that. My electronic medical records, I use Elation Health, and that helps me with my televisits and also these group visits.

Then I use a platform called Bodysite. Bodysite helps me, this is where my chat groups are. It is a HIPAA-compliant platform as well, and they offer lots of different plans and different things, tools that they have for patients. They have different plans that patients can get through emails and you can customize. They have templates, and you can customize those plans. They have the chat groups, where I have my chat groups or through their as well. Those are the things that I am using right now.

Joe Kim: Thank you. It sounds like there is a lot of great resources, and thanks for being so specific with those examples. In addition to the chat groups, you had mentioned your weekly presentations where people can also interact with you virtually. Are there other weekly meetings or other meetings that you hold, whether it is weekly or on any other regular basis, that allows for more of that real-time synchronous type of interaction?

Dr Desai: Now I have a hybrid practice where I see patients in person and I still see them virtually. This I changed over to a few months ago. Before that, I was fully virtual. When I was fully virtual, I did have monthly meetings with my patients where it was a question-and-answer. I presented a topic related to health and wellness, and then we had a question-and-answer session. I did that about once a month, different times during the week.

One of the challenges I had with that was just getting patients to show up to those meetings, and it is very difficult. We are all busy, we all have so much going on in our lives, and it was hard. I would get maybe 2 or 3 sometimes patients showing up, and it was very difficult just to have a meaningful conversations, support group, all of that with just 2 or 3 people showing up. I think that also had to do with the fact that it was only 1 of me and I could only do 1 session. I was only doing 1 session per month.

Even when I tried to do 1 every couple of weeks, I still felt like I did not have the engagement in person. So many people wanted the recorded version afterwards. They just were having a hard time showing up in person. So far, that is still 1 of my struggles and challenges. I would love to still go back to that.

My other big goal is, now that I am in the office, is to invite patients in and do more of in-person support groups as well where we are together in person.

I love the virtual telemedicine and virtual platforms that we have was a silver lining from COVID, but I really have missed that in-person connection with my patients. I think a lot of people are missing that actual social connection, which is such a big part of our overall health. For that reason, I really am wanting to create these in-person groups where we meet at least in person, and I want to open that up to the community at large as well as my patients.

That is something that is in development. I have been going through some different iterations on those types of things, so it is still in the works.

Joe Kim: That is great to hear. Just as we wrap up this discussion and think about all the lessons you have learned with the chat groups and the discussions from those, what would you say have been some examples of things that patients have shared with you, or have shared in the groups that have really demonstrated like, “Hey, this is a very effective intervention, it has led to meaningful outcomes.” Can you provide us with some of those?

Dr Desai: There has been so many. I feel like we have these wins all the time. One of the recent ones, I have a patient, she is about in her early 50s, and she was one of the quiet ones on the group. Every time we were meeting in our monthly meetings, she was struggling with a lot of frustration and anxiety, and stress over the fact that she was not losing weight the way that she wanted to at the levels that she wanted to. We always discussed realistic weight loss, but she had been very quiet on these groups for a long time.

Recently when I met up with her, she shared with me that listening to all these other people posting, she started understanding that she was actually doing really well. She was putting a lot of unrealistic expectations on herself because she was comparing herself to someone in her life who was on a different journey. Everybody is on their own journey. She started realizing that when she started paying attention to how she was feeling and all of these non-scale victories that these other patients were sharing, she realized she had so many of her own non-scale victories. It started changing her whole mindset about her weight and her health.

Now when I see her, I just am talking to a completely different person. I can tell just in her voice that she just has so much hope and positivity. I love that, changing that perspective has helped her do that.

One of the other things I can share is I had a patient who was struggling with losing weight, and we always work on a comprehensive approach. I am telling my patients, it is more than just diet and exercise. It is more than what you are putting in your body. There are so many other factors. Sometimes they have to hear that from other people to understand that, I think. In our chat group, which is focused on sleep health, lots of patients are posting about their struggles with sleep, but also their successes.

This patient who had totally been ignoring her sleep issue, started realizing through that chat group that, yeah, I am also doing that and not getting the bed sleep. Yes, I am also doing that. Yes, I am also doing that. Maybe I do need to change my sleep habits. She started changing her sleep habits, which made such a huge impact in her weight journey, and she started noticing the effects and noticing fat levels decreasing as her sleep started improving. That really happened because that came from other patients. It came from me, but she did not listen to me as much as she listened to others, her peers.

I think it is a fantastic way to do that because in social media, which is where people are listening to other people, sometimes it is not the best advice, but at least this is advice from other patients about what they are doing, but we are also making sure that they are not saying something that is totally off the charts or something that could be very detrimental to patients.

I love that, that they are learning from each other too.

Joe Kim: Those are some great stories. Well, thanks so much for taking the time and for sharing your experience about improving obesity care. As we get ready to wrap up, anything else that you would like to mention?

Dr Desai: I think the biggest thing is for all providers who are helping patients lose weight, just understand that obesity is a chronic disease. It is a lifelong journey. We need to help our patients manage this disease. We want to do it in an engaging way and in an evidence-based way to help them improve their long-term health outcomes, and help them with sustainable weight loss in a safe and effective manner.