An Interview…Discussing Obesity, Bariatric Surgery, and the Betsy Lehman Report with George L. Blackburn, MD

You place a high level of importance on the multidisciplinary team and mention that this is an important part of the Betsy Lehman Report. Why is it so important to have a multidisciplinary care team within bariatric surgery?
Severe obesity is a multifaceted disease; thus the treatment needs to be multidimensional. Staff that make up a multidisciplinary care team use the expertise in their respective fields to provide input and evaluate and manage the patient throughout the surgery and follow-up period. More information about our multidisciplinary team can be found at www.BIDMC.Harvard.edu/WLS.

Where did you study to become a surgeon, and what was your path to bariatric surgery?
I studied to become a surgeon at Boston City Hospital, Harvard Division, under Dr. William V. McDermott, Jr., and at Deaconess Hospital, Harvard Medical School, under Dr. Neil Sedwick. My career track was critical care medicine. I established the first surgical ICU at Deaconess Hospital. I also have a PhD in Nutritional Biochemistry from MIT, and established the first Nutrition Support Service at Boston City Hospital and then Deaconess Hospital. I performed the first gastric bypass for weight loss surgery in New England in 1973.

What was the atmosphere in the medical community with regard to gastric bypass operations when you began them?
The year would have been 1973. It was really a pioneering time in this field. When Dr. Edward E. Mason introduced the surgery, it was originally used to treat ulcer disease. Mason noted the effect that the surgery had on weight loss, and his insight took us in that direction using a highly disciplined, comprehensive research program that progressed from animal research to high risk patients. Gastric bypass surgery has now become the most widely used method for treating obesity.

How many operations have you performed in your career?
I performed 2,000 within a unit that did 4,000. I started 35 years ago, under the mentorship of Ed Mason, and performed the first gastric bypass surgery in Massachusetts.

How was obesity viewed then as opposed to now?
Obesity was not part of medical education at that time. What was known about both medical and surgical treatment was misdirected; the focus was on the elimination of all excess body weight. The physiology and metabolism of obesity were essentially unknown. The study of obesity was a byproduct of other research interests, as in the case of Dr. Mason. It was not until the discovery of leptin by the Rockefeller group in 1994 that we began to build a scientific foundation.

To what do you attribute the growth of obesity in our population?
We clearly live in an obesogenic environment that is toxic for individuals with severe obesity. The challenge is daunting for people who not only fight against the excess calories in larger portion sizes, but also the decreased physical activity in the lifestyles of many of us. Most importantly, we now know that people are fighting multiple biological impulses that drive hunger and satiety, leading to an energy imbalance. The population shift of 20 pounds over the past two decades can be explained by a 10-percent (200 calories per day) increase in energy intake.

What are you most proud of in your distinguished academic and surgical career?
Using evidence-based methods to develop recommendations for best practices, and making the switch in weight loss surgery from jejunoileal (JI) bypass to gastric bypass. I am also proud of developing a multidisciplinary team and fellowship training in the field of nutrition and obesity medicine and surgery.

How would you characterize the current state of funding for obesity research, and specifically bariatric surgery?
At the very time when we have the science and technology to improve the treatment of obesity, we have inadequate funding. What is troubling is that without appropriate funding, we may be missing the opportunity for much needed further development and progress in the areas of prevention and treatment.

Do you have a stance on the conversation revolving around open versus laparoscopic surgery? Are you a proponent of one over the other?
The evidence base points to laparoscopic surgery as our treatment of choice. Research and treatment can now be directed to improvements in laparoscopic surgery, natural orifice transluminal surgery (NOTES), and other endoscopic approaches, such as prosthetic indwelling endoluminal sleeves.
Another priority is to investigate the mechanisms of action of the various procedures.

What would you say, or what advice would you give, to the medical students who plan to enter bariatric surgery?
I would applaud them—not only will they have a satisfying career helping severely disabled people improve their physical and mental wellbeing, but given the current obesity epidemic, they will be also be doing a major service to society.

Do you believe that surgery residents who are entering the field of bariatric surgery are well equipped to treat bariatric patients? If not, why?
Looking back at where we have gone since the 1970s, when obesity was not part of the curriculum and bariatric surgery was still in its beginning stages, today’s residents are much better equipped. Second-year students at Harvard are exposed to the study of nutrition and obesity, and then in their third year, they have the option of a track that enables them to participate in a year-long clinical clerkship that follows patients from the assessment and preoperative workup through the first postoperative year. The skill level and background knowledge they gain in this area now is something of which we are very proud. The development of the skills lab—which teaches through a combination of models, simulators, and other technologies—provides a great incentive for our students to elect surgery as their career. They should take every opportunity to learn from those who specialize in this field by attending programs like Patient Safety in Obesity Surgery: Implementing Accreditation Standards and Best Practices, which will be held at the Harvard Conference Center on September 11–13, 2008.

How would you characterize the current state of insurance coverage for bariatric surgery?
It’s sad to say, but at this time, it’s an irregular and inefficient system. Denial of insurance coverage affects 25 percent of the patients who present for treatment. This is highly inappropriate given the guidelines established by the Centers for Medicare and Medicaid Services (CMS), the American College of Surgeons (ACS), the American Society for Metabolic and Bariatric Surgery (ASMBS), and others. This is an area that should evolve, and those providing care should unite and push for progress in this area.

Do you believe that two separate bariatric surgery credentialing systems will be an obstacle to patient access to proper care?
No, I do not foresee this being an issue, but it would be nice to have a single system.

As more and more bariatric centers pop up as stand-alone institutions and within hospitals across the nation, what critical goals and variables do you believe must be considered in this evaluation process of all bariatric treatment centers and surgeons?
We have just completed our update of the Betsy Lehman Report, which was published in 2004. The 2007 version serves as a resource for the evaluation of these treatment centers and programs. The summary of evidence-based guidelines focuses on surgical care; multidisciplinary evaluation and treatment; behavioral and psychological care; adolescent surgery; anesthetic perioperative care and pain management; nursing perioperative care; informed consent; policy and access (coding and reimbursement); specialized facilities and resources; data collection; and endoscopic interventions. You can find the Betsy Lehman Report by going to www.mass.gov and searching for “Betsy Lehman Report.”

What are your thoughts on the role of the bariatric surgery program manager or coordinator?
Without a doubt, the program manager is the key to safety and efficiency. A higher level of care will be provided because the specialists within the multidisciplinary team are able to focus their energies solely on treating the patient.

You place a high level of importance on the multidisciplinary team and mention that this is an important part of the Betsy Lehman Report. Why is it so important to have a multidisciplinary care team within bariatric surgery?
Severe obesity is a multifaceted disease; thus the treatment needs to be multidimensional. Staff that make up a multidisciplinary care team use the expertise in their respective fields to provide input and evaluate and manage the patient throughout the surgery and follow-up period. More information about our multidisciplinary team can be found at www.BIDMC.Harvard.edu/WLS.

What fields/areas are included in a multidisciplinary care team for bariatric surgery?
The multidisciplinary care team should comprise medical, surgical, anesthetic, psychiatric, nursing, physical therapy, and nutritional professionals. A clinical program manager is also needed to pull everything together, allowing the other members of the team to focus on their respective specialties.

Do you think preoperative weight loss is beneficial? Does the Betsy Lehman Report have recommendations for this? Who on the multidisciplinary team addresses this issue?
Research shows that a preoperative weight loss of greater than or equal to five percent is related to decreased operative time, which may reduce a patient’s surgical risk. A weight loss of 5 to 10 percent of initial body weight, especially in patients with BMI greater than or equal to 50, is recommended by the Betsy Lehman Report. The two members of the team who are most involved with preoperative weight loss are the psychological and nutritional professionals. With that said, all of the members of the multidisciplinary team play a role in helping the patient progress from preoperative to postoperative on the safest, healthiest track possible, so all may play a role in encouraging the patient to lose the preoperative weight.

Category: Interviews, Past Articles