The Wonder Drug We Don't Know How to Use

I’m a resident physician finishing seven years of training. I can run a cardiac arrest, manage an ICU, and help someone survive the worst day of their life. Next month I start outpatient practice—and I’m not sure I’ve been prepared for it.

That’s not an accident. It’s an incentive problem.

Hospitals employ residents. Hospitals profit from inpatient care. So we’re trained, overwhelmingly, for the work that fills beds—not the work that keeps them empty.

The mismatch hit me this week watching a story I’ll see a hundred more times: A patient starts Ozempic, loses weight fast, feels hopeful—then hits the parts our system has no plan for. Weakness. Constipation. A plateau. A pharmacy shortage. An insurance denial. A month off the medication. Hunger roars back. Weight returns. Shame follows.

The drug worked. American medicine didn’t.

GLP-1 drugs—Ozempic, Wegovy, Mounjaro—are among the most effective treatments we’ve ever had for obesity. Up to 20% weight loss, results that used to require surgery. But they’re also a stress test for a system that claims to value prevention but doesn’t train for it, pay for it, or organize around it.

Remarkable drugs demand more than a prescription. GLP-1s change appetite, routines, and—if we’re careless—muscle and function. “Eat less” becomes “eat worse”: less protein, accelerated muscle loss, especially in older adults. We know what protects people: strength training and adequate nutrition. In practice, that work gets a single chart note—“counseled on diet and exercise”—and we move on.

That line is a confession masquerading as care.

In the hospital, the work is legible. Shock has protocols. Sepsis has bundles. You intervene, the numbers change. In primary care, a “visit” is diabetes plus hypertension plus obesity plus knee pain, wrapped in prior authorizations and a payment system that rewards rescuing people but not keeping them well. Training mirrors this. Outpatient clinic is what you squeeze between “real” rotations. The skill you actually need—helping someone stay healthy across years—is the one you never get reps on.

Here’s the irony everyone knows but nobody fixes: sustainable health care means keeping people out of hospitals. That’s where the savings are. But hospitals don’t capture those savings—insurers and employers do, years later. So we keep training for what hospitals bill for, and prevention stays someone else’s problem.

GLP-1s make this contradiction visible. They hand us a genuine chance to change trajectories, and we fumble it with 15-minute visits, no dietitian, and a chart note that says we counseled when we didn’t. Patients stop because of side effects, cost, or coverage gaps. Weight returns. That’s not moral failure—it’s biology meeting a system that never planned for what happens next.

If these drugs are now central to primary care, the work around them needs to be treated that way. Train it like we train cardiac arrest. Reimburse it like it matters. Build teams—dietitians, therapists, coaches—and actually pay them to show up.

Right now we have the opposite: a miracle drug in a system that still treats the long game as someone else’s job.

I didn’t go into medicine to stabilize people we could have helped sooner. The drugs are ready. The question is whether we are.