Changing Perceptions: Obesity as a Disease, Focus on Collaboration and Long-Term Management “For Better, For Worse”
A Message from Dr. Kelvin Higa
Kelvin Higa, MD, FACS, is Clinical Professor of Surgery, University of California, San Francisco, Fresno, California, and Director, Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California. He is also a past president of the American Society for Metabolic and Bariatric Surgery (2007-2008) and President-Elect for the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).
What an honor it is to be this month’s guest editor of Bariatric Times! I know this is only because Dr. Raul Rosenthal is devoting so much time to the American Society for Metabolic and Bariatric Surgery (ASMBS). And what a great job he is doing! In fact, reflecting on the changes since I was President: 2007-2008, it’s a completely different organization. The ASMBS is the undisputed champion of the world for advocating for the ethical and unbiased treatment of the disease of obesity and metabolic syndrome. Through the tireless work of many individuals, such as Raul, our specialty has matured greatly. Yet, we have a long way to go before society, third-party payers, and our medical community accept this disease as a chronic, multifactorial disorder. There is no better illustration of this attitude than the “non-covered benefit” or the “one procedure per lifetime” clause built into many insurance contracts.
“…so long as you both shall live” What is missing? It’s not because the ASMBS is not representing us or fighting for the ideals, rather I think a large part of the problem is our own attitude toward the treatment of this disease. Sure, before surgery, patients are victims of their disease and we are advocates for treatment (as long as it involves a procedure), but what happens when times get tough? What happens to patients if they do not succeed or they have a complication from a procedure many years later? We often label them as “non-compliant.” They are told to go back to their original surgeon. They are orphans, or worse, treated like a “one-night-stand.” Of course, we are often treated as such by our patients who rarely follow up and are often non-compliant. But the fact remains, every failure, every complication is not born by the individual surgeon, it is a responsibility of all of ours who practice this specialty. We have an obligation to care by not only advocating for the primary treatment of this disease, but also for patients who have already had surgery. It’s a marriage—for better, for worse…
Bariatric/metabolic surgery: marriage or one-night stand? Dr. Lee Kaplan said it best in one of my courses on revisional surgery: WWOD—What would the oncologist do? Brilliant! As I was trying to figure out why we have not gained traction with respect to more widespread acceptance of our interventions, despite the great body of evidence available today, it occurred to me we might have a public relations issue. And it’s our fault—not the ASMBS. The oncologist designs a treatment plan, based not solely on an intervention, but rather a truly multidisciplinary plan that may include surgery yet doesn’t have to. The oncologist is not disappointed by not having personally cured the patient, but rather satisfied with long-term remission. The oncologist doesn’t institute random protocols unless part of a study and reports their data. The oncologist isn’t seen as pushing chemotherapy, so much as fighting a disease—cancer. The oncologist knows when no further intervention is appropriate but is still willing to care for his/her patient. Cancer treatment is universally covered, expensive, and results are often suboptimal. Treatment failures are blamed on the disease, not the oncologist or intervention. We still have a PR problem.
Changing perceptions. For the past several years, my group and hospital have a “no-refusal policy” In other words, no transfer from another hospital or ER would be refused on any bariatric surgery patient for emergency or tertiary care for any reason, be it financial or complexity, regardless of the primary surgeon. This year I made it a point to visit every ER in my geographic area with one message: “We will take any bariatric surgical patient—period.” I was surprised by their reaction. They thought I was there to garnish more referrals. Instead, they were relieved because I could solve one of their problems: the unassigned bariatric patients that the general surgeon on call did not have the training or knowledge to care for. This was a step forward. For years, most of us were trying to educate the world as to what we were doing. Our PR problem isn’t the “what”—it’s the “WHY.” WWOD.
Revisional bariatric/metabolic surgery. Although my interest in revisional bariatric surgery began around the same time my as interest in bariatric surgery (20 years ago), it wasn’t until recently that I had institutional support to host an international consensus conference on revisional bariatric/metabolic interventions (RBMI). Through the generosity of the Fresno Heart and Surgical Hospital and Community Medical Centers, Dr. Eric DeMaria and I directed the The First International Consensus Meeting on Revisional Bariatric/Metabolic Interventions (ICC-RBMI). The objective of the ICC-RBMI was to study, interpret, and discuss available evidence in order to develop and publish expert consensus on the following topics:
• Identifying appropriate candidates for RBMI
• Identifying interventions that provide benefit for patients and under what circumstances
• Define next steps in order to obtain and evaluate collective data regarding RBMI
• Explain what evidence is lacking in the scientific literature and what work needs to be done in order to address these deficiencies
• Discuss nomenclature for various procedures/interventions in RBMI
Over 30 international experts participated in the presentations and discussions. Based on the paucity of available data, little consensus was obtained on most topics. The heterogeneity and complexity of the problem makes it virtually impossible to design or fund randomized trials, so it was unanimously agreed that we should establish standards for each procedure and outcomes from RBMI should be mandatorily submitted to a registry. All agreed to participate in the second meeting early next year.
Collaboaration for long-term disease management. Our specialty has come a long way, yet we have a long way to go. My generation of general surgeons looked at each patient as an operation. What bariatric/metabolic surgery has taught us is that we need to go beyond our individual silos of episodic interventions, to collaborate in multidisciplinary team models and to look at long-term disease management as the only viable solution to the health care issues we face today. Someday everyone will be asking: WWBSD—what would the bariatric surgeon do?
Kelvin Higa, MD, FACS