[jiffypop]

Believe it or not, this is a Q related to my JOB. i work for a medical education company [and i won't torture you with the details]. among other things, we run live meetings with faculty who talk with an audience and there are questions/answers and discussions. and so on and so on [and before anyone jumps on me - this is ACCME-accredited medical education - entirely evidence based].

anyway, i'm going through the Qs asked in a recent meeting that featured about 3 hours of bariatric surgery. and one of the Qs amused me - then surprised me - then annoyed me, and i wanted your reaction to it:

does the patient decide which surgery will be done, or does the doc evaluate the patient and will decide which one is right?

there was no discussion of this Q, so i can't tell you anything about what the group of docs said. How would you prefer that this process go?

[L144S]

my 2cents is that an educated consumer is the best patiant!

know the choices, know the pros and cons of each surgery, short and long term and why or why not a surgery might be best for you and then defer to the DR. AND nothing wrong with getting a second or third opinion to make the best LIFE altering decision that will suit your life!
(did I do ok Jiffy?)

[Brenda549]

With the group of people I know, mostly support groups, coworkers, etc. they became informed of the WLS choices available and they made the choice. For me, my surgeon explained the pros and cons of my surgery choices, and I ultimately chose the surgery.

[ladybugnessa]

while i think the decision should be up to the consumer it needs to be an educated decision and I think input from the surgeon is crucial.

[*stefani*]

Absolutely the patient.

There will be influences of course --- like medical issues and insurance (you could though self pay).

DO NOT LEAVE IT UP TO THE SURGEON!

It is extremely rare that a surgeon will recommend a type of surgery they do not perform. You should know your options all the way.

Dawn

[jillybean720]

110% the patient. The patient is the only one who really knows their own habits and what they can/cannot handle post-op. The patient is the one who has to LIVE with the decision.

That said, I think there should be more educational requirements pre-op, such as quizzes or something. I can't STAND when I talk to someone pre-op and ask what procedure they're having, and I get a response like, "Oh, you know, that Y one." No really, someone said that to me. I think you should be able to draw a diagram of exactly what is going to be done to your insides, be able to explain WHY/HOW the procedure works, be able to list common possible complications and what the course of action should be for each, etc. I think too many people go in with too little information and rely too heavily on their medical team to hold their hand every step of the way. I cringe when I see someone who is MONTHS post-op asking something like how much calcium they should take each day. That sort of info needs to be known BEFORE you have your surgery!

Whew, sorry - bit of a tangent there!

[jiffypop]

thank you, ladies! we all agree - knowing these docs, that Q smacked of 'i know best and YOU, little patient, will be guided by ME!!!'

and Jilly - i absolutely agree with your sentiments, but gotta tell you that there's NO WAY i could draw my re-wired digestive tract, but i CAN describe what's happened to each part of it. and i know that most docs DO tell everyone what to expect and how the surgery works and all that, BUT many people simply don't listen - or take notes or anything. That's one of the many reasons that the Centers of Excellence program was started - so that insurers and everyone would know that docs were providing support and documentation [and this was in addition to the surgical skill and experience, and hospital infrastructure to support bariatric patients]

having said that, i tested an online patient ed tool a few years ago - it had chapters to it, and each chapter had Qs at the end for the pt to answer. if you answered a Q wrong, you'd be directed to the place where it had been discussed for another chance.

and at the end of each chapter there were a a few OTHER Qs, like: do you have more Qs about this? and then after it was all over, the pt had to insert an electronic signature that they'd understood everything. it was interesting. but i haven't heard if it's made it into use.

[nanj]

Unfortunately, I think the insurance decides for a lot of people. I think it should be the patient's choice. I was offered two choices: Rny or lap. Actually, DS was presented as not a good choice! I didn't give it a thought then, but knowing what I know now, they were very foolish to not give that as a viable option. I'm just grateful that I had my insurance had the WLS option at all.

[30and300]

Nancy is right, I think. While it's best to have the freedom to chose what surgery the patient thinks is best for them (afterall, they have to live with it forever), ultimately it comes down to money. If you can't afford it with cash, if your insurance company only covers one thing... what can you do?

[Mama]

Originally Posted by nanj

Unfortunately, I think the insurance decides for a lot of people. I think it should be the patient's choice. I was offered two choices: Rny or lap. Actually, DS was presented as not a good choice! I didn't give it a thought then, but knowing what I know now, they were very foolish to not give that as a viable option. I'm just grateful that I had my insurance had the WLS option at all.

This just makes me sick... the idea that insurance companies getting to make medical decisions is terrifying. But I suppose this is a rant for another time.

I think it is ultimately the decision of the patient - but there should be much guidance from a trusted doctor. And, obviously, a patient can't just demand a certain surgery and expect to get it. There are, afterall, medical criteria which must be met etc. etc.

[jillybean720]

I get the insurance issues, I really do. But I've seen many people get the procedure they wanted come **** or high water. Me, I spent 6 months doing the required supervised diet program with my PCP. I started in July, so I was done in December. In early December, my employer announced we would be switching insurance plans effective January 1. Guess what - the new plan didn't cover ANY WLS. I practically begged and pleaded and searched tirelessly for loopholes, but it wasn't happening.

I didn't give up. I went home and printed out a job application for Starbucks. They offer health insurance to part-time employees, and that insurance covers WLS (including the DS). They are not the only employer to do this, but since I happen to live in the area of the country with the highest concentration of Starbucks restaurants per capita...I figured I could handle working 65 hours a week for 6 months or so to get the surgery I really wanted for the rest of my life.

I ended up not having to do that because I had another option that most people probably don't have - I married my fiance and got on his insurance, which covers the surgery. But for anyone married, definitely check your spouse's insurance as well. Even if it is a more expensive insurance plan, you only have to be on it for a year, and it sure is undoubtedly cheaper than paying for the surgery.

There are also medical loans that many people use; I've also seen people take loans from their 401k plans, second mortgages on their homes, beg and borrow from family...and then go have the surgery in Mexico where it's much cheaper than in the US.

Maybe I'm a bit naive in my young age to think this, but I truly believe most people can find a way if they are willing to look and work hard enough. MOST people - I know there are always exceptions, but I do think too many people just shrug and say, "oh well, my insurance only covers XYZ," without even looking any further. This is the REST OF MY LIFE - I was not willing to settle for a procedure I did not think was the absolute best choice for me. Haven't we all, as morbidly obese individuals, had to settle for enough in life already?

[worthylady]

I truly believe that the patient should make the decision about what best suites their needs. I certainly believe that the surgeon should provide their best professional advise in the interest of their patient. I also, believe that ethically the surgeon is obligated to refuse to perform surgery if either surgery no matter which type puts the patient at risk. I made the best choice to suit my lifestyle and would bring me the most success and I would hope others have that same opportunity.

[Wannabenormal]

Wow... I find more and more interesting dialog here! I work for a hospital and the type of insurance they have is you MUST enroll in a 12 month program (the whole program is monitored by an RN who tracks your progress and makes suggestions on how to proceed, more exercise, less food intake, etc.)
The bariatric surgeon that is affiliated with the hospital is frustrated because there are probably a 100 people who qualify for the surgical options available. Me, I've decided to have the RNY and have read tons of information about the pros and cons. But since the program strictly says you must complete the 12 month program and have proven to have attempted 10% weight loss THEN you can qualify for the surgery. I've been told that even insurances that are not as strict are becoming more so --- but I don't know how true that is -- but even so. The stigma is you can just diet, exercise, and push away from the table and lose all the weight you want. They don't take into account the health issues that immediate surgery would solve.

The surgeon I spoke to had lots of information on all the available surgical options (they of course have favorites) Some like the lap-band, other the RNY --- but ultimately they ask you what you feel prepared to do. My concerns are and continue to be -- diabetes -- my mother has it and my father had it. It runs on my mother's side of the family and it's just a matter of time before I have it. Already I'm pre-diabetic. So with the RNY that would cease or perhaps be kept under control with diet alone.

If the surgeon is worth anything at all, it's a decision you, the doctor and family members make together --- it's a life altering change for everyone.

[missangelaks]

I happen to agree with Jilly...not an uncommon occurrence, Jill. The thing is that in the long run, it's the patient's choice.

My ins. company didn’t cover WLS until 2007 and only had one Dr. in the area that performed them but HE DIDN’T TAKE MY INS! GGRRRRRR!! It took me 3 years to convince my Ins. and their Dr. that RNY was my best option...3 years! I knew THAT was the surgery I wanted. I knew that it was the right choice for me. I didn't want the DS, too dangerous...I didn't want the Lap Band, not effective enough for my needs...I wanted the RNY and fought for it! Sometimes, that's what it takes.

AND I agree that there should be some kind of testing involved. People should know how to recognize complications and when to seek help.

Angela

[preetyladyserenity]

For me it was different since in my country I got to do it for free in the government hospital of my country. So the band is no longer done in the government hospital (they think it's outdated. No offense to band-havers - my dad has one and he loves it) and the other two operations done had criteria. It was either gastric sleeve or gastric bypass for me and my surgeon told me that he saw the gastric sleeve as the best option regarding my age.

So I just let him do it... Of course I did get the pros and cons of both operations but the final decision was not mine but rather his.