Total Bariatric Care

by Eric J. Demaria, MD

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

This column is dedicated to providing updates and commentary on a wide range of topics within the specialty of bariatric surgery

This month’s topic: Aftercare: Are We Providing Value to Our Patients?

Bariatric Times. 2011;8(6):36–37

I am excited to be writing a new column for Bariatric Times. As a new columnist, I thought it would be appropriate to start with a controversial question: Are you providing lifelong value to your patients? I do not claim to have the answers, but I have spent some time speaking with focus groups of patients to seek their insight regarding long-term care. The challenges I raise in this column come from those sessions.

Bariatric surgeons are part of a medical specialty with a long history of solving problems via innovation, and we have fought for a neglected segment of our population that needed us to advocate for them. However, by definition, bariatric surgeons suffer from a credibility problem with the public. We are surgeons and we get paid to operate on people. The more patients come forward for surgery, the more we get paid. We spend money to convince people they should have surgery. One litmus test of what we believe is the question of aftercare. Are we dedicated to the idea of providing lifelong healthcare for our patients? Or are we really more focused on getting new patients to sign up for surgery? Many of our support groups are focused on the idea of bringing in patients who have had surgery to talk to “newbies” so that they are not afraid of the decision to have surgery. But wait! Aren’t support groups supposed to provide value to our postoperative patients? We think we hide the agenda to recruit new patients to surgery, but believe me, our patients know we are using them to do it. The most common explanation I have heard from patients who stopped attending support groups was that they did not feel it was worth their while because the focus of the groups was either on recruiting new candidates or on the very early postoperative challenges patients face. In the background, there is always that question of credibility; since we get paid better when we perform operations, isn’t performing more operations our priority? A patient I know recently proclaimed, “I wish there was a bariatric primary care specialist that I could see!”
Many of our patients eventually stop coming back to see us. It is easy to blame the patients for failing to come back, and perhaps it is their fault. We do not really know why most patients fail to return. Is it relocation, changes in insurance coverage, embarrassment or avoidance of blame when things are not going well, or no sense of need for those who are doing well? The answer is probably a mixture of these and other explanations, but with large data collection efforts providing follow-up data on fewer than half of those patients undergoing bariatric surgery combined with the likelihood that as many as 20 percent or more of the more than 200,000 surgeries performed each year result in eventual failure by some definition, we bariatric surgeons certainly have a significant problem unless we seek to improve follow up.
I suggest that the aftercare issue comes down to our patients’ perception of value. Allow me to illustrate with a personal story. I watch my 17-year-old son try to make it financially on the wages he receives from working his part-time job. It is his responsibility to put gas in his car, and if he cannot, then he must ride the school bus. With gas topping $4 per gallon, there are weeks that his entire paycheck goes into his gas tank. He’s a minimum-wage employee, fortunate to have a job as many of the jobs usually reserved for high school kids where we live have been scooped up by unemployed adults desperate for work. As I see the economics of life through his struggling perspective, I have gained a better understanding of the realities of healthcare economics. Insurance co-payments continue to rise for those of us who provide specialist care for many plans. For my son, and other minimum-wage employees, a $50 co-pay is an eight-hour day’s take-home pay. Not long ago, I took my son to the orthopedic surgeon and saw, through his eyes, the opulence of the physician’s waiting room as we plopped down $50 cash for a visit with the doctor that lasted less than five minutes—a day of wages exchanged for five minutes of a physician’s time. Do our patients agree we are worth so much to them?

There are many challenges in the problem of obtaining follow up. Our specialty better resembles primary care than a surgical practice, as we have the responsibility of providing lifelong aftercare. Transplant programs have that responsibility, but they have medical doctors doing most of the long-term care. Cancer surgeons are aided both by the too-frequently poor prognosis of their patients and the medical oncologists. After bariatric surgery, our patients have improved life expectancy, not less. The numbers who need aftercare are staggering. With 200,000-plus new postoperative patients each year in the United States (and we are still treating less than 2% of the eligible population each year), we already have millions of patients who need knowledgeable aftercare providers. Surgeons generally put limited resources into providing long-term care for their patients, preferring to spend their dollars on bringing in more new patients who might sign up for a procedure. As for the hospitals that now employ many of us, do they understand the commitment and resources needed to provide this aftercare? The ones I have known certainly do not. They view bariatric surgery as a procedure-focused revenue stream, not as a lifetime care challenge.

So let me ask you, and believe me I am not immune from having to confront these same questions on a very personal level, are we really providing value to our patients when they come back for long-term follow-up appointments? Do our patients really understand that their annual check-up can help detect complications that can develop silently after bariatric surgery and are easily diagnosed and treated if detected early? If you, like some surgeons I know, believe that the long-term visit is about everyone feeling good, doing a victory dance, getting a hug or a heart-felt thanks from Mrs. Smith five years after her surgery, I respectfully suggest that you will only see Mrs. Smith when she has disposable income and the time to sit in your waiting room while you prioritize seeing your new patients above her hug. And she probably will not make the mistake of coming back too many years in a row before she decides to spend her time and money on other priorities.

One of the greatest challenges for our industry is to demonstrate long-term value to our patients. We have to shift our focus and figure out how to provide total bariatric care, for all people who need it and on a lifelong basis. Our care needs to be affordable so that patients can receive it. Although universal benefit status for bariatric surgery must continue to be our objective, it is not just so that all patients can receive surgical treatment, but so that all who have had surgical treatment can receive lifelong aftercare. We need an improved system of aftercare as much as our patients need one. Only then are we likely to capture the long-term outcomes of our patients we need in order to demonstrate the value of our treatment. Poor aftercare risks turning the tide of public opinion against bariatric surgery if growing numbers of patients become dissatisfied with their results. No amount of marketing is likely to reverse a negative public opinion should the public grow to believe that bariatric surgery provides a nondurable fix for obesity. Our approach to aftercare is broken and it will get worse as we create hundreds of thousands of new post-opperative patients each year unless we pursue more creative solutions now.

Finally, I encourage you to consider surveying your patients about their aftercare experiences with your practice, or, better yet, have someone independent come in and meet with small focus groups of patients to learn their perspectives. All of us need to listen to our patients’ feedback with an open mind. I believe that a first step in solving the follow-up issues in bariatric surgery is for each of us to take this on as our own problem and explore local solutions for our own programs. After every follow-up encounter, ask yourself if you provided value to your patient that was worth his or her time and expense. Or maybe you should try asking your patient. We might gain some credibility in their eyes just for asking.

Category: Past Articles, Total Bariatric Care