Creating Bariatric Surgery Advocates: Why it is Critical to Educate Primary Care Physicians

by Christopher Still, DO, FACN, FACP

Dr. Still is Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity Research Institute, Geisinger Medical Center, Danville, Pennsylvania. Dr. Still is also a board member of the Obesity Action Coalition, Tampa, Florida.

This article contains a complimentary physician handout. To downloadable PDF of of this handout click HERE.

Funding: There was no funding for the preparation of this article.

Financial disclosure: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2011;8(11):16–18

Abstract

Bariatric surgery is an effective “tool” for weight loss that resolves many obesity-related comorbidities. However, despite the fact that nearly nine million patients are affected by severe obesity, less than one percent of eligible patients are referred for bariatric surgery. This demonstrates to the bariatric community that there is a great opportunity to educate and partner with primary care physicians on the significant benefits and safety of bariatric surgery. This article provides practical information on educating and communicating with local primary care physicians in the hopes of providing partnerships, not only for increased referral volumes, but also for appropriate comprehensive pre and postoperative care.

Why communicate?
There is a disconnect between primary care physicians (PCPs) and patients when it comes to bariatric surgery. Communication between the bariatric surgery community and PCPs is more important than ever. PCPs are busy and discussing options for weight-loss with their patients is uncomfortable, time consuming, not reimbursable, and, often times, not a high priority. In addition, healthcare reform is taking us in a direction mandating greater PCP involvement in all aspects of patient care. As experts in the weight loss field, we need to educate PCPs about bariatric surgery and thereby serve as advocates for patients who need information about these life-saving procedures.

A recent national survey found that only one out of 10 adults with severe or morbid obesity say they have had bariatric surgery recommended by their primary care physician.[1] This survey, sponsored by the Obesity Action Coalition (OAC) and Ethicon Endo-Surgery, polled 400 adults in the United States with a BMI≥35kg/m2 and 252 adults in the United States who reported undergoing bariatric surgery at some point in the past.[1] Nearly 500 physicians practicing in the United States were also surveyed.[1] The survey found that among patients affected by obesity who discussed their weight with a healthcare provider, seven out of 10 surgery patients and more than half of individuals affected by obesity believe they initiated the first conversation regarding their weight.[1] Physicians, however, believe that about one in five patients on average initiate the first conversation.[1] These findings clearly show a disconnect that the bariatric community can help to address.

The bariatric community has a great opportunity to let PCPs know that patients affected by obesity want to talk about weight-loss options. Many PCPs may tend to underestimate patients’ receptiveness to weight conversations. Six out of 10 physicians believe most individuals affected by obesity have been too embarrassed to discuss their weight with a healthcare professional; however, more than four out of five adults affected by obesity report not being too embarrassed to discuss their weight with a healthcare provider.1 Furthermore, among bariatric surgery patients whose healthcare provider suggested surgery, nine out of 10 felt positive feelings (e.g., excited, relieved, happy) as a result of their suggestion.[1] Patients trust their PCPs and rely on them for health information. They are more likely to act when their PCP advises them to do something, and it is the responsibility of the bariatric professional to ensure that PCPs have all the information they need regarding treatment of obesity.

What to communicate
Now that we have established the importance of communicating with PCPs, the question remains: What needs to be communicated? To answer this question, ask yourself the following: What do I know as a bariatric professional that PCPs in my community may not? Remember, it is not about what you want to tell PCPs, rather it is about what they need to know and what their patients affected by obesity need to hear.

A professional in any medical practice wants to relate to his or her patient in a way that makes the patient comfortable. A PCP may be uneasy bringing up bariatric surgery because of uncertainty of the patient’s reaction. Therefore, I believe it is most important that PCPs know that patients eligible for bariatric surgery are often knowledgeable, engaged, and would welcome a discussion about their weight-loss options. The national survey1 found that both individuals affected by obesity who considered bariatric surgery, as well as patients who have already opted for surgery, spent an average of three years researching their options. In my experience, these patients are aware that surgery is an option, conducting the research themselves, and want their physicians to start the discussion. In addition, the vast majority of patients who have had bariatric surgery are pleased with their decision: nearly nine out of 10 patients (89 percent) believe life has changed for the better as a result of their bariatric surgery.1 A similar proportion of patients (86 percent) wish they had their surgery sooner.[1] This information will encourage PCPs to initiate the bariatric surgery conversation with patients and provide them with tools to have an efficient and effective discussion.

It can be easy to forget to share the “basics” with PCPs because we, as bariatric professionals, know the basics so well. It is important to remember that some PCPs were not taught the basics of bariatric surgery in medical school, so the information they have may be from personal experience and the media, which we know may be filled with misinformation. I recommend sharing the latest data by procedure, in a format that clearly displays the benefits and risks of each. Try using a one-page illustration, similar to the Comparison of Procedures chart (see Physician Handout). We must also convey a sense of urgency about the obesity epidemic. Sharing local statistics on how obesity rates are rapidly rising creates a compelling call to action. Again, back to the basics: share the National Institutes of Health (NIH) guidelines for bariatric surgery with PCPs and provide them with BMI calculators for their patients.

Of course, the bariatric professional community knows that weight loss is secondary to the profound medical benefits of bariatric surgery.2 Although this is first and foremost in our minds, this may not be the case among those in the PCP community. It is most important to share the latest comorbidity resolution data by procedure type with PCPs.[2]

The national survey also found that among individuals affected by obesity, the top perceived drawback of bariatric surgery is the fear that it is dangerous (59 percent).[1] As bariatric professionals, we know that this is not the case: bariatric surgery is as safe as gall bladder surgery.[3,4] We must stress the safety of surgery because patients need this information to make informed decisions about their health, and they need to hear it from their PCPs.

Last, but not least, let PCPs know that working with a bariatric program is not as difficult as one might think. All healthcare professionals are strapped for time and they will be more likely to make a referral knowing that the bariatric program has processes in place to make the partnership as seamless as possible for both the PCP and the patient. Outline in detail how your program will work with the PCP and patient throughout the process, including aftercare. Something I often hear from PCPs is that they are the ones who have to care for the patient after surgery, particularly after the first year. Make sure PCPs know the long-term support system you have for patients; they need to know about your nutrition, psychological, and peer-support programs in addition to your screening criteria. Along these same lines, give PCPs the insurance information their patients will be asking for when seeking bariatric surgery. Many have the misconception there is little or no coverage, and therefore; they may not bother offering it as an option. Be specific. Provide coverage information for Medicare as well as commercial insurance and Medicaid coverage in your state. Include information on large employers in the area who offer bariatric surgery coverage to their employees. Finally, help them understand that your program has experts who handle the entire insurance process on behalf of the patient.

How to communicate: Relationships + Resources = Referrals
To effectively communicate with PCPs you must focus on 1) building trust through relationships and 2) making referring easy through available resources. Relationship building requires taking the time to meet with PCPs often. I recommend conducting grand rounds and/or in-person meet-and-greets several times a year. Also keep in mind that medical society meetings and continuing medical education (CME) conferences offer opportunities to meet with PCPs. In addition, take the initiative to schedule an informal meeting over breakfast or lunch with the PCPs in your community. Identify one PCP that you have worked well with in the past to become your champion and bring him or her along to join the discussion. Also, consider bringing one of your post-surgery patients who can provide PCPs with his or her unique perspective. I have seen success by scheduling a one-hour lunch time meeting where the visiting bariatric team provides lunch and the PCP team is able to drop in as their schedule permits. This makes for an informal environment where more members of the PCP team have access to your information.

In addition to building relationships, you must provide clear, concise resources consistently throughout time. In my experience, I have found it is best to communicate in person, over the phone, or via snail mail. Most importantly, communicate often. Be the first person to share the latest data, news, and trends on obesity with PCPs.

To begin a relationship with a PCP, send an introductory letter. Follow up with a packet of information including the basics discussed previously, safety and efficacy data, NIH guidelines, BMI calculators, obesity statistics, and insurance coverage information. The algorithm for referral (see Physcian Handout), created by Dr. John Pilcher of New Dimensions Medical and Surgical Weight Loss, San Antonio, Texas, is another great resource to share with PCPs.

And it is not just about the PCP. Consider targeting other specialties, such as OB/GYNs, endocrinologists, pulmonologists, orthopods, and cardiologists. We all know that accessing the physician can be a challenge. Nurses and mid-level providers are influential with both the practice and the patient and are more easily accessible and often times have longer conversations with patients during appointments.

After a referral, send a personalized thank you note, and do not forget the importance of continued communication post referral. It is best practice to send a letter to the PCP after every visit with his or her patients. Showing them the progress their patients are making after surgery (e.g., off certain medications, reduction in BMI, and resolved or  improved comorbidities) is invaluable. As many practices move toward electronic medical records, there is software available that makes this process automatic, and it is a great investment when considering the results this act of trust-building can yield.

For better or for worse, the likelihood that prospective bariatric surgery patients will continue to depend on PCP referrals, especially as healthcare reform shapes “medical home” or “healthcare quarterbacks” type programs, will not change and may actually require greater PCP involvement. This creates a great window of opportunity to cultivate a strong partnership and referral base among PCPs. If bariatric programs will embrace these aforementioned concepts by investing and allocating resources now, greater number of referrals will ensue. Concise, regular follow-up information regarding patient’s status, semi-annual educational newsletters, “timely tips” or “fast facts” about your program’s offerings, and the assurance that your program is available for ALL aspects of the bariatric care of their patient, both before and after the surgery, will help educate and garner long-term referrals of the most appropriate patients.

References
1.    Bariatric Surgery Study: Patient Data Summary Sheet. Harris Interactive Inc. April 2011.
2.    Buchwald H, Avider Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–1737.
3.    DeMaria EJ, Pate V, Warthen M, et al. Baseline data from American Society for Metabolic and Bariatric Surgery-designated bariatric surgery centers of excellence using the bariatric outcomes longitudinal database, surgery for obesity and related diseases. Surg Obes Relat Dis. 2010;6(4):347–355. Epub 2010 Jan 4.
4.    Dolan JP, Diggs BS, Sheppard BC et al. The national mortality burden and significant factors associated with open and laparoscopic cholecystectomy: 1997–2006. J Gastrointest Surg. 2009;13:2292–2301.

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