Good Questions to Ask Bariatric Doctors
…Including the Reasons Why These Are Important
These questions are written as if you are asking them to your surgeon or you are asking them to the surgeon’s staff regarding the surgeon or the program. There is nothing magic about these questions; they are simply my thoughts about what I would want to know if I were having an operation of this type.
1. What was your training and are you a member of the American Society for Metabolic and Bariatric Surgery and the American College of Surgeons?
This question covers more territory than it may seem. Being a member of the American College means the surgeon became board certified and passed other requirements and oral and written exams to become a “fellow” of the college. The ASMBS is the only professional society strictly devoted to the disease of morbid obesity and the surgical treatment there of. If the surgeon is at all interested in Bariatric Surgery, he or she should be a member and regularly attend the conferences. So this question gives you a lot of background.
2. How long have you been doing Bariatric Surgery?
There are many articles now that show how technically advanced a Laparoscopic Gastric Bypass operation is and how there is a “learning curve” to such operations. Some try to talk around this type of questions by discussing how many laparoscopic operations they have done or how many operations in general they have done. Although there is some cross-over, it is important to be rather specific.
3. What are your outcomes and how long have you been keeping your data and statistics?
Outcomes in the field of medicine are very important and often not recorded from various programs. Also, it is the outcomes results at two years and even five years and longer that is important. Some programs discuss results in a general way, in that they talk about what some of us have published in the medical literature without saying what “their program” has done. The danger with this is not everyone does the operation the same way, and not every program has the same philosophy. If the program doesn’t know the results of say 50% or 75% or 80% of their patients’ weight loss at three or five years then what is a prospective patient going to expect from that program as far as their individual results? There is a program is San Diego, for example, that quotes: “Long-term success rate of 99 percent since the program’s inception-patients maintain a 70 percent loss of excess body weight”. This type of reporting is harmful to patients in that NO program can achieve those results but people expect that the program will tell the truth!
4. Are you a Surgical Review Corporation / American Society for Bariatric Surgery (SRC / ASBS) “Center of Excellence”?
There are many “Centers of Excellence” (COE) nowadays. Many insurance companies have designated their COE but the SRC / ASBS is an independent review of the program and their commitment to following outcomes. This certification includes an on site evaluation. Many of the insurance companies issue a COE designation if a hospital or program will accept their reimbursement schedule rather than the designation being tied to quality indicators. I believe that the SRC / ASBS designation of Bariatric Center of Excellence will become the standard and the others will fade away. Even though a program has the “COE” designation it does not mean they have been keeping their data for more than about a year (since the SRC system is new it could not require longer data submission). The designation is important now because it means the center has passed certain minimum standards but the designation will gain even more impact as they years go by. Refer to questions 3 and 4 as well.
5. What are your specific complication rates for leak, DVT, stricture, bleeding and infection? What is your mortality rate?
Many programs will give global comments related to the medical literature just as they do for outcomes. To keep all the data, the program or surgeon needs to have a database and the personnel to enter the data. This takes time, an interest in maintaining a high level of care, personnel and resources. With an operation as complex as bariatric surgery, it is important to try to keep complication rates low and experience certainly helps, but 1% complication rate is ridiculous to quote. What you as a patient want to know is that the program keeps their statistics in an honest and realistic fashion. For example: we have looked at our first 1000 cases to fully evaluate OUR complications with the operation done the way we do it at our facility. Programs should quote their rates and not the “national rates”.
6. What are the components of the program?
All programs showed to have a multidisciplinary approach to the disease of Morbid Obesity and to the surgical treatment to maximize patients’ potential success. They should have all the components of the SRC / ASBS Center of Excellence including specialized nursing care and training, exercise coordinator, support groups run by health care professionals, and psychological evaluation and support. The issue of support groups run by health care professionals is important because often non-professional “facilitators” will overstep their bounds and give medical advice and this can be dangerous. This is the same with advice given over the internet via patient chat groups. Though these groups can be quite supportive and offer benefit to some, the risk may be there when medical issues are inevitably discussed.
7. How far away is help if I need it in the hospital or soon after?
Though most operations go well, in bariatric surgery we operate on patients who are at risk because of their health state and the operation is complex. The risk of significant / life threatening complications is highest in the first week or so after the operation. If complications do occur, they may need emergent action. It is nice to know your surgeon is in the same city as your operation and that emergency care can be given at any hour, day or night. There are discussions now about this type of surgery being done in an “out patient” setting or in “surgi-centers”. You would have to decide for yourself if the emergent care is at a level which you feel comfortable. For example, is there an ACLS trained physicians available at all times (24 hours a day in the facility). Does the hospital have specialized training for urgent needs? Who cares for you if your surgeon is not available?
8. Does the program offer all bariatric procedures?
Though a program does not need to do all operations and may feel more comfortable doing only one operation, they should still discuss all options in a relatively “non-biased” fashion. For someone to only push a Banding operation, for example, without offering any insight or opinion on the Gastric Bypass (or visa versa) would not be offering true informed consent to the prospective patient. If only one operation is done it might also be good to know why only one is done. Did the surgeon have too many complications with another operation? Is there some sort of industry support that may influence the choice? These are fair questions to ask.
9. What is the data about the endoscopic pouch reduction?
We covered our thought about the pouch reduction issue in another section. There are several different “platforms” or techniques available and different technology is used for various approaches. It is very important that the surgeon have a lot of revision experience. There is a rather special mind-set that a surgeon needs to have to work through the complexities of failed or poor results. Since these are more or less unusual cases, the surgeon needs to have experience in treating patients with a number of different modalities. “If all you have is a hammer, all the world looks like a nail.” If the surgeon has never done a revision of a major operation then they may have a very biased look on what a patient might need. Add to this the factor of industry support and unfortunately, some surgeons allow their treatments to be guided by their pocketbook. Read our section on revisions if that applies to your condition for a better understanding.
Those are a few of the questions we think every patient should at least think about when they are considering Bariatric Surgery. Check back from time to time as we will add more as the occasion arises.