Part 2: A Proposal: Designating Qualified Bariatric Aftercare Programs and Providers to Aid in Long-term Bariatric Patient Followup

by Eric J. DeMaria, MD

Dr. DeMaria is from New Hope Wellness Center, Raleigh, North Carolina.

Bariatric Times. 2011;8(10):26

I have heard the same question over and over again from patients during my 20 years in the field bariatric surgery—“Why isn’t there a bariatric primary care provider I can see?” I have sat in on focus groups with bariatric surgery patients discussing how they feel about their long-term postsurgical care. Inevitably, as they delve into the issues of how to obtain long-term care after bariatric surgery, one of the participants, often in frustration, will ask this same question.

The answer—surgeons are specialists. We typically do not provide life-long or primary care to our patients but rather focus on our procedures and on periprocedural care. Sure, we have strong feelings about the long-term care of our surgical patients, and we want them to do well. But do we prioritize the long-term care aspects of bariatric surgery? To gain some insight into how we prioritize our efforts, let’s ask ourselves the following questions about how bariatric surgeons spend their time each day: 1) Do we prioritize long-term, follow-up visits above seeing new surgical candidates? 2) Do we carve out time in our days to spend hours caring for long-term patients? To some extent, we do prioritize and spend time caring for long-term patients, but most well-established bariatric surgeons (with hundreds or even thousands of follow up patients) fill their days with surgery and new evaluations while hiring others to provide the long-term care. As we get busier and busier, accumulating more patients for which we are responsible, most of us shift a large portion of this long-term care burden to others, such as physician extenders and registered dietitians.
I believe patients could benefit greatly from a partnership between medical and bariatric specialties that strives to provide safe, long-term care to our patients. Plus, the reality is that most of our patients already have a “regular doctor” for their primary care and consider us to be specialists, as we are defined by the payers. I am reminded of the old joke, “What do you call the physician who graduates last in his class?” The answer, “doctor.” If we do nothing to identify doctors with special knowledge and skill, the public may not find those who possess these attributes.

One implication of the “specialist” label is that patients often pay more out of pocket for our services. It is often a financial decision for our patients to visit their primary care physician (PCP) for a nominal out-of-pocket fee versus a larger sum for the bariatric surgery specialist. That is one of the reasons patients will call the office with many questions—a phone call is free. In today’s economy, people will drive across town to save 20 cents on a gallon on gasoline when they need to fill a 10-gallon tank. Do we really believe that people will spend $70 for a specialist’s visit copay when they believe they think they can get acceptable care from their regular doctor and save the $50 difference?

This diatribe is not meant to offend colleagues. Our specialty is arguably of the highest value in our society’s ongoing battle against the obesity epidemic. By performing bariatric surgery, we seek to convert patients suffering from the serious life-threatening disease of morbid obesity, into nonobese, healthier persons. Our patients typically get better, not sicker, over time. They absolutely need long-term care, but generally, that care is to provide surveillance for issues that might arise rather than providing further interventions. Why do we return people to better overall health, yet believe that only bariatric surgeons are capable of providing the basics of long-term care for this much healthier population? The term wellness care more aptly describes the care that most patients who have undergone bariatric surgery need long term.

I have nothing negative to say about our medical bariatrician colleagues, except that there are too few of them to really solve the numbers challenges I described in Part 1 of this installment. Furthermore, they, like us, seek to treat obesity, not provide routine wellness care. While some patients struggle with weight-related issues following their bariatric surgery, most do not, and some require surveillance for complications rather than weight-related interventions. Nutritional issues are the primary area of concern followed by detection of complications, such as marginal ulceration, band slippage, and internal hernia. Medical bariatricians, dietitians, and psychologists trained in treating eating behavior disorders play an important role in the subset of patients identified to be struggling with their weight loss or weight regain after surgery.

Unfortunately, many of us (and I include myself in this category) have actually undermined the credibility of our primary care colleagues with their bariatric surgery patients. For instance, I thought I was protecting my patients by advising them to call my office if they had concerns or doubts about any recommendations from their PCP. For example, our preoperative group is educated about medicines they should not take after surgery, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and products containing aspirin, which are sold over the counter under many different product names. I believe that gastric bypass patients should not take these medications due to the risk of marginal ulceration. Over the years, I have told patients to call if they were prescribed a new medication to be certain it was ok for them to take. We would look it up and figure out, for example, that Goody’s powder contains a bunch of powdered aspirin.

But in seeking to protect my patients by telling them to call the office, I have planted a significant doubt in their minds that they cannot trust their regular doctors.

I believe it is time to change the paradigm and embrace those among our primary care colleagues who are interested in providing quality aftercare to bariatric surgery patients.

This is an opportunity for our professional society, the American Society for Metabolic and Bariatric Surgery (ASMBS). Let’s admit that we cannot meet our own expectations for long-term care as we operate on hundreds of thousands of patients each year, and let’s start a pilot program to train the primary care workforce, both physicians and extenders, to help us. The ASMBS already has a mechanism in place to easily test the waters. An essential mission of ASMBS is education and one way they provide this is by offering Continuing Medical Education (CME) credit for its education events. I believe that PCP education programs should cover the “basics” of bariatric surgery care, parallel to the ASMBS Essentials Course offered by the Society for many years, but with less attention to the technical aspects of bariatric surgery and more focus on the long-term needs of the patient population. ASMBS as an organization also has an avenue by which it can logistically provide a formal process for designation of PCP physicians who successfully complete the knowledge and skill acquisition requirements. The Surgical Review Corporation (SRC) could independently administer an assessment and award the designation of Qualified Bariatric Aftercare (QBA)  for practices or individual providers. I do not believe a process for expensive site visits would be necessary. An added benefit of involving SRC would be to bring QBA providers in to help solve the problem of collecting accurate, long-term data in the Bariatric Outcomes Longitudinal Database (BOLD). A number of practices already involve their patients’ regular physicians in obtaining the data BOLD requires. Expanding the scope would allow QBA providers to directly enter data as users into BOLD, assuring that they had the necessary understanding of the process and could provide quality control for accuracy and verification efforts. Not to mention, this might allow us to obtain more long-term data.

Space does not allow for a full discussion in the level of detail needed to work through this potential solution. For example, I have no idea how our PCP colleagues would view seeking the QBA designation I am proposing. However, even PCPs work in a competitive environment in our heavily populated areas so designation may be viewed as a differentiating factor that will help them attract patients. If only one percent of the estimated 400,000 plus PCPs in the United States were willing to pursue the QBA designation, it would already double our long-term care workforce. ASMBS and SRC could jointly identify QBA centers for the public, allowing our patients whom we have an obligation to protect, to identify physicians in their communities who have a better understanding of bariatric surgery aftercare than their peers.

Implications for patients seeking providers with the QBA designation would include being able to find providers who support them as postsurgical patients rather than being hostile (as some physicians are toward bariatric patients even to this day). Yes, although less than past decades, hostility toward our patients still exists among some of our medical (and surgical) colleagues who are critical of a patient’s personal decision to have bariatric surgery. Some of our medical and surgical colleagues even blame the patients for whatever happens to them after surgery. It is likely that QBA providers, armed with more education about patient management and the outcomes of bariatric surgery, would evolve into better allies in the battle against the obesity epidemic, as their fears of the complexity and unknowns of our specialty are replaced by knowledge and understanding of what we do.

This is an opinion column and my goal is to stimulate discussion among bariatric surgery specialists as to how we can better provide safe care for our postsurgery patients long term. I believe that the ASMBS can enact these changes if they hear that their membership is behind this type of solution.

I encourage all members of the bariatric team to debate, discuss, and provide your feedback to the ASMBS leadership. We clearly have an obligation to our patients to provide quality bariatric aftercare. If not through this solution, then we need to propose and get behind other ideas. Make no mistake, we can not leave the current state of affairs unchanged. There is too much at stake, particularly the public’s sense of confidence in our system of care for patients who have undergone bariatric surgery. Thousands of “orphaned” patients with recurrence of obesity-related comorbidities experiencing long-term complications (like osteoporosis, for example) will inevitably destroy the public’s growing confidence in bariatric surgery as a solution to the obesity epidemic.

Category: Past Articles, Total Bariatric Care