Most obesity medicine specialists never see what happens to a patient under anesthesia. Jessica Duncan, MD, did — for nearly a decade — before pivoting to obesity medicine and becoming chief medical officer at Ivim Health. The operating room (OR) shaped how she thinks about risk, adherence, and the conversations clinicians across specialties are still afraid to have. Medscape Medical News spoke with Duncan about what carried over.

What did you observe in the OR about patients with obesity that informed your later practice?

The first thing was a better understanding of obesity as a disease. I knew this — but I truly understood by watching the physiology in real time, across body systems, in my anesthesia patients.

The other thing, which was actually outside the OR was the pre-op conversation. Anesthesia requires a current weight. So many patients who had been avoiding any conversation about their weight got on the scale a few minutes before I walked in. And they wanted to talk to me about it. They’d say, “My doctor told me to walk 10,000 steps a day. I’m already doing that. I don’t know what else to do.” When you don’t feel you have the tools to solve a problem, avoidance is the coping strategy. Sometimes one person, at the right moment, asking the right question, is what a patient needs. That’s a big part of why I do what I do now.

What did you observe about how patients with obesity are managed in the OR, and how has that influenced your counseling in obesity medicine?

Obesity, like any disease, was part of every decision the team made — even when no one named it out loud. Positioning injuries, for example, are a higher risk for a patient with obesity and the team worked together to be sure a patient was protected, and risk was minimized when they were asleep. The anesthetic itself reflects the same calculus — obesity changes how the heart pumps, airway management, drug distribution, recovery — and it was my job to make the adjustments and keep patients safe.

But what I felt more often, and what shaped me, was a sort of frustration. I knew, for some, that obesity had contributed to the condition that brought them to surgery. I’d think, we have done a disservice to this patient. Nobody treated the disease that drove them here.

Also, anesthesia is a trust exercise compressed into fifteen pre-op minutes. I’d meet someone, and within minutes I’d have to earn enough of their trust to take them to surgery, put them to sleep, and bring them back safely. Chronic disease care is the same exercise stretched over years. The foundation is the same — make sure they feel like they have a partner.

The American Society of Anesthesiologists has issued guidance on holding GLP-1s before procedures, saying patients don’t need to stop the medications before surgery. Having worked in both anesthesia and obesity medicine, how do you think about that decision?

Both sides are missing something.

When GLP-1s first hit the market, I heard others ask, why don’t they just stop the medication? They’re only using it for weight loss anyway. Nobody talks that way about antihypertensives or antidepressants. Because GLP-1s were coded culturally as optional, or cosmetic, the framing got loose. These are medications treating a chronic disease. Pausing them isn’t trivial — food noise comes back and you may give up ground that took months to gain.

The obesity medicine side has its own blind spot. The risk for aspiration is real. Anesthesiologists are managing a stack of risks at once, and a GLP-1 is one more thing to manage. We owe our anesthesia colleagues more credit and more conversation.

Essentially, you’re trading one risk for another. Taking the medication carries perioperative risk. So does sending an uncontrolled metabolic disease into an OR. Neither risk is the only one that counts.

How do you approach counseling patients about long-term risk on a first GLP-1 visit?

I’m deliberate about not bringing urgency into a first visit. Patients with obesity have spent years, often decades, being told their disease is urgent in ways designed to scare them. They’ve been weighed, lectured, and shamed. If I lead with the catastrophic version of the future, I am repeating a pattern that hasn’t worked for them.

So I meet the patient where they are. The long-term risk picture comes in, but over time and in context. I would rather a patient stay in care for years than scare them into a 6-month sprint they abandon.

I have seen the end of the road. I’ve taken care of patients in the OR whose obesity had been ignored for decades, stacking comorbidities into surgical cases that didn’t have to happen. That shapes how I think about long-term risk. It also taught me that fear is not a treatment plan.

Adherence is often described as the central problem in obesity medicine. Do you see it that way?

Adherence is a problem. But it’s not the central problem and calling it that puts the responsibility back on the patient. The central problem is that we haven’t treated obesity like a disease. We’ve treated it like a moral failing dressed up as a medical condition, and we’ve designed care plans the same way — short-term fixes, generic advice, no plan for the long term.

When I see adherence break down, my first question is not “what’s wrong with this patient.” It’s “what’s wrong with the plan I made.” Did I miss that they have a baby who isn’t sleeping? Did I prescribe a lifestyle that doesn’t fit their life? Adherence problems are often plan problems.

Most people don’t engage with abstract long-term risk. They engage with how their body feels today. The patients who stay engaged, who change something — they are the ones who feel different. Their knees hurt less. Their food noise is quieter. So with GLP-1 patients, I anchor on what’s tangible. That’s how people metabolize risk: through experience, not through statistics.

If you could change one thing about how clinicians across specialties — including surgeons, hospitalists, and primary care — approach patients with obesity, what would it be?

We have to stop being afraid to talk about it.

Think about the diseases we’re not afraid to talk about. Blood pressure creeping up — your doctor flags it, suggests changes, follows up. Sleep apnea — anesthesiologists screen for it routinely. We counsel on smoking cessation.

Obesity is in the same category clinically. It’s a disease. It’s a risk factor for cancers, heart disease, diabetes, joint disease, sleep disorders, and surgical complications. But it sits in a different psychological category for many clinicians, and so it’s avoided. Clinicians are afraid they don’t know what to say. They carry their own bias. Some part of them thinks the patient should be able to fix it themselves. So they say nothing. And when a clinician says nothing, the patient hears that the disease isn’t worth treating.

I want clinicians across specialties to treat obesity the way they treat blood pressure. We won’t get it right every time. But the cost of staying silent is far greater and we owe it to our patients to try and learn how to do it well.

No reported disclosures.