- Do I qualify for a surgical or non-surgical bariatric procedure? …
- What type of medical tests do I need before surgery? …
- What risks are involved with the procedure? …
- How quickly can I expect to start losing weight? …
- Is the procedure reversible? …
- How long is the recovery process?
Bariatric sensitivity is a very important part of patient care. What do you emphasize with your staff as the most important aspects of being sensitive to these patients?
Tracy: Bariatric sensitivity is essential to patient care long before the first bariatric surgery is performed. At Scripps La Jolla, we offer ongoing empathy training as part of our nursing orientation. There are many components that I stress in empathy training, including genetic predisposition, refectory response to dieting, and induced discrimination both in society and sadly from the medical professionals as well. I also believe in humanizing the disease. Commonly I will have a patient or two also teach the class as well. Our patients can be great teachers.
What adjustment problems do you see on a regular basis in patients their first few days after surgery?
Tracy: I think the most common postoperative “adjustment” patients experience is anxiety. We often call it the phase of “buyer’s remorse.” This is minimized if patients are well educated prior to surgery. I also believe that it’s extremely beneficial for patients to come to support groups before their surgery. Often patients’ anxiety is because they feel that they are going to fail the surgery. This belief comes from all their failed diets. Reassurance is imperative during this period.
Can you tell us a little bit about your involvement in the ASBS and your feelings on allied health’s role in the organization?
Tracy: I started my career in the mid-1980s. In those days there was no organized allied health section. A group of 10 or 12 of us would meet in the hotel restaurant during the bariatric meeting attended by surgeons. As years passed, allied health attendees began to have some meeting time at each annual meeting. It began by a two or three hour meeting of allied health staff getting together and talking about struggles, ideas, and helpful hints. In those days I knew all the allied health attendees’ names, where they lived, and the surgeon with whom they worked.
I was the first elected chair of ASBS Allied Health in 2000, and continued as chair until June, 2004. Since then we’ve grown into a sophisticated, cohesive section within ASBS with over 1,140 members and have three days of educational opportunities at our annual meetings dedicated to the Allied Health section, as well as our own bylaws, policies, and procedures to support its structure. We also have our own board and a voting seat on the Executive Council of ASBS (fulfilled by the acting Allied Health chair). I am currently on the Allied Health Board as the past chair. I am also the Course Director of the Essentials curriculum for ASBS. I am also the co-chair of Allied Health of IFSO, a role I share with Elizabete Shiraga from Brazil. Allied Health continues to evolve as a respected section within ASBS, and has experienced an enormous amount of growth and development—with a lot more to come in the years ahead.
Where did you study to become a nurse, and how did you become involved in bariatric surgery?
Tracy: I studied nursing at Harbor College in Harbor City, California, where I received my AA degree. I then completed my Bachelors degree at Cal State Dominguez Hills, also in California. I became involved in bariatric surgery in the mid 1980s. The surgeon with whom I was working began bariatric surgery and I assumed the role of aftercare.
Do you believe that nursing students who are entering the field of bariatric surgery are well equipped to treat bariatric patients? If not, why? Do you envision nursing schools offering specialty courses for the field of bariatrics?
Tracy: Unfortunately, even today with the obesity epidemic’s stunning growth, nursing students are not trained adequately in bariatric surgery.
Until bariatric surgery is a recognized specialty, training in nursing schools will not occur. Morbid obesity is such a complex disease physiologically, medically, and psychologically. Morbid obesity affects nearly every organ in the body. Because of this, it warrants and deserves as much or more attention than neurology, cardiovascular surgery, orthopedic surgery, or the numerous other rotations nursing training encompasses.
I do, however, envision nursing schools in the not so distant future offering education on bariatric surgery. As surgical fellowships become more common and the certifications of bariatric programs as Centers of Excellence, so shall—I predict—specialized education in nursing schools. Nothing would thrill me more.
What advice would you give to the nursing student whose plan is to enter the bariatric field?
Tracy: For those nursing students who are fortunate enough to have exposure and therefore desire to work with bariatric surgical patients, I advise them to work at a hospital that recognizes the unique needs of the bariatric patient. These hospitals have specialized units and education through mentorship programs, and are most likely recognized Centers of Excellence.
What can surgeons do to better assist their bariatric staff, and in turn, better assist the bariatric patient?
Tracy: Surgeons can best help the bariatric staff by recognizing their contribution to the program, contributing to ongoing education, and being helpful and approachable when needed. In turn, the staff can be most helpful to the surgeon by being well trained on all aspects both routine and unique to the bariatric patient. We are an extension of the surgeon’s care. Keen assessment skills and accurate reporting and intervention of abnormal findings can make all the difference in the patient’s outcome.
How does the current insurance climate toward bariatric surgery affect you in your job? Have you seen improvements since the Medicare change was announced?
Tracy: Although the current insurance climate is better than years past, it continues to be both frustrating and unfair to those of us working in the field of bariatric surgery, but most importantly to the patients who suffer from the debilitating, life-threatening disease. There are very few—if any—other life-threatening diseases for which insurance companies deny treatment. The delay in treatment often mandated by the mandatory medical weight loss is nothing short of insulting.
What percent follow-up are you able to achieve for postoperative patients three months, six months, and one year up to five years, respectively? What can allied health professionals do to encourage better follow-up rates in patients?
Tracy: Follow-up is extremely important, but often very challenging for the team. Our follow-up rate at one, three, and six months is 98 percent. At one year it is 95 percent. Unfortunately, at five years it drops significantly to a little over 65 percent. Currently, however, we are collecting data for our first 200 laparoscopic gastric bypasses, the first being performed in 1993. Our team has gone to great lengths to find and contact those patients.
Most programs find long-term follow-up a challenge. Some of the things that help is stressing preoperatively that follow-up is a dual responsibility and very important to prevention of potential problems. My philosophy I share with my patients is: Our (meaning our team) responsibility is to be here—your responsibility is to get here!
It’s also important to have adequate staff to fulfill follow-up needs and obligations. Other things that help encourage long-term follow-up are having an 800 number, quarterly newsletters, emails, annual reunions, and retreats. All of those ongoing communications keep the patient connected to the program.
Tracy: All of my work is rewarding. I know that sounds corny, but I mean it. I work long hours but I don’t feel I work hard because I thoroughly love what I do. I think the absolute most rewarding thing is crossing off the comorbidities as resolved. To witness diabetes, sleep apnea, hypertension, and stress incontinence disappear still gives me goose bumps. I also love the one-on-one time with patients.
The most frustrating aspect of my work is that even today we have to defend bariatric surgery to insurance companies and to the public. What other surgical procedure can prolong life and cure so many other diseases? What don’t they get? Why do they choose not to understand?
Tracy: There is no doubt that open bariatric procedures can be performed safely and effectively if done by a well trained, experienced bariatric surgeon. But the laparoscopic approach substantially decreases many complications associated with open abdominal surgery, especially on someone who suffers from morbid obesity. The benefit of getting our patients up a few hours after surgery helps prevent pneumonia, atelectasis, ulcers, deep vein thrombosis, pulmonary embolism, and on and on. Dr. Alan Wittgrove performed the first laparoscopic gastric bypass in the world in 1993. This stirred a real interest for those in the surgical community who were not interested in bariatric surgery before.
Tracy: More time and more days in the week would help me do my job better. There are so many ideas I have to add to the program, but the day-to-day follow-up and patient education is very time-consuming, so my creative side moves at a slower pace than I would like.
Teaching and re-emphasizing the importance of long-term follow-up would best help patients achieve success. Patients need to understand that the disease of morbid obesity is a chronic disease and, like all other chronic diseases, it too needs to be monitored for life. This must be repeated and emphasized by our team members.
Keeping support groups informative and interesting helps keep patients coming, which leads to long-term success. Informative newsletters, retreats, health tip emails, and follow-up appointments are all efforts that give patients tools for success; doing all of this keeps their toolbox full.
From an allied health perspective, what critical goals and variables are important in establishing and evaluating for Centers of Excellence?
Tracy: A well trained multidisciplinary team is imperative and should be critically evaluated. I also believe an important component of that team is specialized nursing training for hospital staff. This is a critical aspect that contributes to good or bad outcomes. Any delay in complication recognition can be detrimental to the patient. A true Center of Excellence puts the patient in the best hands possible from all aspects.
Tracy: I believe that bariatric nursing will expand and become recognized as the specialty it deserves to be. A big step in the accomplishment of this objective is the formulation of bariatric nursing certification by the ASBS under the director of Bill Gourash, NP, and his devoted, hardworking committee. The first certification exam will take place at our next annual conference in San Diego on June 27, 2007.
We’ve come a long way in caring for the obese patient. What areas do you still see that need to be addressed from a nursing standpoint?
Tracy: We need to strive for bariatric surgical nursing to be a specialty much like that of a critical care nurse, cardiac nurse, or transplant nurse. We are getting there!
Tracy: I love hiking in the mountains, and scuba diving and snorkeling in warm waters. The ocean and mountains give me a sense of balance and wellbeing. I also enjoy weight training and I love tennis.
Tracy: My workday varies. Some days are solely dedicated to follow-up; other days are postoperative classes and seeing patients a week after surgery. Other days include hospital education. Our support groups are on Tuesday nights and some Saturdays, and I facilitate those as well.
Answers to Common Bariatric Surgery Questions with Dr. Amy Somerset, DMC Bariatric Surgeon
Questions About Candidacy and Type of Bariatric Surgery
The first step in having weight loss surgery is finding out more about the procedure itself. Here are some questions you can ask your surgeon. They will help you get a sense of whether you want to have bariatric surgery.
Questions About the Surgeon’s Experience
An important factor in the success of your weight loss surgery is the surgeon’s expertise. Studies show the more experienced the surgeon, the lower is the rate of complications after bariatric procedures. You can ask your surgeon the following questions to learn more about their experience.
Questions About the Surgery and Recovery
Oftentimes, the thing that causes the most anxiety in people having weight loss surgery is the procedure itself. It is a good idea to be mentally prepared and know what to expect. Here are some questions to ask your bariatric surgeon about the surgery.
Two days per week I evaluate patients in the office and provide their preoperative and postoperative care. The remaining three days per week are spent performing operations and procedures.
When you first come out of training, you will likely be employed by a private group or hospital system, as nowadays it is very difficult to simply open your own practice. As a first year employee you can expect to make somewhere in the $200k range.
Unfortunately, dealing with health insurance companies can be quite challenging. They can make it difficult to help patients at times because their rules regarding who can and cannot undergo the operations are quite strict. Also, as a surgeon you are expected to take a certain number of nights and weekends “on call”, which means you have to be available to deal with problems that may arise during these “off hour” periods. Lastly, the amount of money insurance companies pay the surgeon for his/her work can vary and the physician has little control over how much they are paid for a given operation.
I personally take six weeks off per year. As a surgeon in private practice, you only make money when you operate, so the more time you take off, the less you make.
You must go to a four year college or university, followed by four years of medical school (although there are some combined college and medical school programs that will allow you to finish faster than eight years), followed by a general surgical residency which could range from five to seven years depending on whether or not you take the option of doing a couple of years of medical research during your residency training. Then you would ideally enter a bariatric surgery fellowship, which typically is one or two years long. You do not have to do a fellowship, but the odds of you getting the position you desire without one are lower.
FAQ
What is the most common complication of bariatric surgery?
What makes you a good candidate for weight loss surgery?
What criteria must be met for bariatric surgery?
What tests are done before bariatric surgery?
