Questions for your surgeon and their groups:

At the bottom of the page, I give reasons why you need to research your doctors because the health care system is not what people think. Here is just one reason why you should check out the bariatric surgeon: Bariatric Surgeon’s license suspended

Find out who your insurance company contracts with and get that list. Go to every seminar for every doctor. Doctors put on these information seminars for one reason: to sell their view/version/healthcare groups’ idea of the surgery. The seminar is pretty much the same in every group amongst all the groups in the area. Think of the doctor like a car dealer: they’re there to sell you their own particular version. Each bypass is the same as each sleeve is the same. Doctors pretty much do the same surgery the same way. So choose the surgery FIRST, choose the aftercare, nutrition, follow up, and support group SECOND, and the surgeon LAST.

Find a doctor who does bypass and sleeve & ask them how many of each surgery have they done as the primary, then backup. Ask if they teach the surgery to any other doctors. Find out how you can verify the number, as some can “fudge” those numbers.

Its their skill you want, forget whether or not you like them. You need someone who can get the job done first. It doesn’t matter how slick they are, they have to be good at what they do. If you get a sleeve, it doesn’t matter, because unless something really strange happens (like with mine), everything is the same and you don’t need the doctor after the first year.

Ask for references from good AND bad. If the doctor won’t give bad ones to you or won’t give you the names of those who’ve had negative experiences, what does that tell you? They have all had them, but if the doctor can’t work with people after a bad experience, what does that say about their skill, resourcefulness, abilities? Any one can stick a tube down the throat and cut away the excess stomach, which is basically what happens in a sleeve. If they have problems, how they deal with them, recognize them, who they refer to, THAT is where skill is. Get at least 5 MAJOR issues people, not just “I couldn’t eat that far out after 2 months”, I mean at over 1 year, a sleeve developed a leak, reflux, how did the doctor deal with that and how did the STAFF deal with it.

Make sure that the references you get are NOT from the same hospital group that your doctor works with. Make sure it is someone who has no ties, either from work or personally, to the doctor and/or the hospital or hospital group they work for or with. That includes buddies that they used to know, work for, or clean their houses.

Talk to references in PERSON or on the phone, because any one can have multiple email addresses and give you different accounts, but still be the SAME person.

Google your doctor for not just patient reports but lawsuits, complaints, disciplinary actions.

Ask when and why a doctor won’t do surgery? The superobese? Heart issues? What will the surgeon not take?

One person, Farzad Mostashari, asked the best question: “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?”

I found not all doctors’ offices are up to date and not everything they do is based on research or science. Below are some reasons why – and support this argument:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1123314/>Physicians’ and patients’ choices in evidence based practice
Medical student don’t consider basing decisions on the best available evidence.
They lose their autonomy if decisions are based on science.
Evidence Based Medicine.

“How long does it take for a new treatment for a given disease to make its way into routine patient care — after it’s been proven to be more effective than the previous standard? About 17 years, according to the Institute of Medicine. That huge lag time between the reaching of conclusive evidence for a new protocol and its inclusion into ordinary practice is one big reason that protocols in many practices are obsolete or incomplete, the IOM claims — with only half of today’s patients with many common diseases receiving adequate care.”

Doctors resist basing treatment on science.
Trends in medicine going to science basis.
How do you feel about Evidence Based Medicine
Evidence based reports
Making Evidence-Based Medicine Doable in Everyday Practice
Chart

GENERAL:
* What percentage of the surgeon’s bariatric surgeries are performed laparoscopically versus open?
* What would be some of the criteria for open surgery?
* What would be indications for conversion to open surgery from a planned lap surgery?
* Who covers for the surgeon when they are gone or out of town?
* What is the follow up care plan for support before and after surgery?
* Do you allow participative care or do you have a paternalistic style?
* Do you have people with and without complications who I can speak with in regards to how your surgery & pre/post care is?
* What websites do you recommend for learning about all options and support?
* Obesityhelp.com does have an area where your information is sent to the surgeon. Do you require approval on publishment?
* Do you agree with this or have you ever participated in this or does the center/group you are with does this?
* Should you retire (or be close to retiring), who will take over my care?
(As doctors age, worries about their ability grows: see Docs health.
* Can I choose my surgeon?
* How many surgeries has the surgeon done?
* What are his/her specific complication rates and how do they calculate them? (Do they keep a database?) leak? – pulmonary embolism? – death? – others?
* Who are the members of the team and how will they be involved in your care?
* Are dietitians available for follow-up? How long have you been without a dietician at any time during the program, and what was the reason for that?
* Is there a support group?
* Is there a bariatric nurse? What is their specific experience? How recent is it?
* Is the hospital equipped specifically for the care of the weight loss surgery patients?
* How is the staff in the hospital trained to care for you?
* What is the educational program?
* Who is available to answer questions after I go home?
* Are the surgeons members of the ASMBS?
* How long have they been doing bariatric surgery and how long have you been doing that?
* Do you exclusively do bariatric surgery?

* Latest medical research from http://www.medscape.com/viewarticle/82163 in March 2014 said that the rate of NIDDM (Type II Diabetes) “However, it has become apparent that bariatric procedures do have a significant relapse rate, both in terms of weight loss and type 2 diabetes remission, Dr. Sargsyan said, noting that the 1-year data from the Swedish Obesity Study (SOS) were the first to demonstrate this. The SOS results showed a 72% rate of remission of diabetes 2 years after surgery, which plummeted to 36% at 10 years afterward.” Can you tell me what your statistics are, and how many are lost to follow up at what rate?

COMPLICATIONS:
* What do you define as complications?
* What are the complications that can happen during or right after my surgery?
* What are the complications that can happen 1 year out?
* What are the complications that can happen farther than 1 year out?
* Who takes care of those complications, does the surgeon or another doctor(s)?
* What complications do you send to a gastroenterologist? Who is that doctor(s) and can you check out why and what the relationship is, and if you have a choice, will they work with your GI?
* What are your leak stats (every doctor has them, if they say no, then something isn’t right. How do they deal with them?

For more than a year out, you want to know:
* How up to date is the surgeon on complications that can happen more than a year out?
* How up to date is the surgeon on vitamin research and complications from those?
* How many cases of problems and what types of problems has the managed? Are still managing?
* What tough cases has the surgeon managed?

LOWERING COMPLICATION RISKS:
* What can I do before surgery to lower my risk of complications?
* For which of my medical problems (such as diabetes, heart disease, or high blood pressure) do I need to see which doctor(s) before or after the surgery?
* If I lose weight before surgery, and go maybe just below 40 for BMI, will you still operate?
* What happens if I gain weight while being in the program? What if it is less than 10 pounds? More than 20 pounds?

SUPPORT:
* Can I talk to people who have had weight-loss surgery?
* Can I get a buddy who is a few months ahead of me or someone
* Can I talk to other people who have had complications after surgery?
* Can I talk to other people who have had complications after surgery more than 1 year out?
* Can I talk to other people who have had complications after surgery more than 1 year out who had something other than weight regain?
* What followups do you provide after 1 year out in regards to long term issues with weight loss surgery?
* How far out do your patients get followed?
* Can any of the bloodwork be run by a PCP, and if so, what is the medical basis for return to the office without problems? Is this true for ANY of the surgeries?

VITAMINS:
* What supplements do you recommend I take? (If they says “Flintstones” either find another surgeon or realize that he’s not up to date on the latest studies. Flintstones don’t cut it. See the American Society for Metabolic and Bariatric Surgery guidelines).
* Do you have a list of supplements that are out there?
* How often will you be checking my blood vitamin levels for deficiencies?
* What specific vitamin levels do you check?
* Do you check any other vitamin levels?
* Can I be tested more often if I wish?
* Will I be receiving a copy of the results?
* The stomach produces hydrochloric acid for iron absorption and produces intrinsic factor for vitamin B12 absorption. How will my surgery affect these vitamin levels?
* The duodenum is the major site of iron absorption. How will my surgery affect absorption of this vitamin?
* What other vitamins, minerals, protein, nutrients may be affected by this surgery? What medical rationale is there to take supplements if our vitamin levels are normal?
* What is the basis for the bariatric surgeon’s having someone come back once a year for vitamin deficiencies? Why can’t the PCP run them & interpret them? Do they keep records of return patients for Centers of Excellence? If they say yes, most people have to pay more to see a specialist surgeon when it isn’t needed for THEIR STATS, not for any other reason. My PCP’s have run more bloodwork than my surgeon did and caught more deficiencies: zinc, Vitamin K, Vitamin D, anemia’s, and high copper, for starters.

GASTRIC BYPASS:
* How small will my pouch be? Do you have a standard measurement, or do you use “anatomical landmarks?”
* What about medications after surgery? I take _____.
* How will surgery impact the absorption rate and effectiveness of this medication(s)?
* I have diabetes/ high blood pressure/ other co-morbidity. I know that gastric bypass often, but not always, dramatically reduces or even eliminates these problems. How closely will you monitor these conditions after surgery, and how will we know when or if my medications should be changed or stopped?
* Will you coordinate with my other health care team members on about the issues?
* Is it possible for my pouch to stretch back out?
* If so, what can I do to prevent it?
* What foods should I or should I not eat? What about drinks?

SLEEVE:
* Sleeves have anywhere from an 8-10% chance of getting reflux/GERD if you didn’t have it before the surgery. Those who are converted to bypass do better. If your surgeon isn’t sticking with you, what happens to your care?

BARIATRIC SURGERIES IN GENERAL:
* I’ve heard diarrhea and gas are a common side effects. Is this true and is there anything I can do to prevent them?
* What do you think is a realistic goal weight for me to achieve and maintain?
* How rapidly do you expect me to lose weight? 10 pounds a month? 30? How wide a range is “normal?”
* Can I expect plateaus? When can I expect them? What do you recommend when I have them?
* How long can I expect weight loss to continue after surgery? Will it ever again become very difficult or impossible to lose weight?
* How hard will I have to work to maintain my weight loss after 18 months, in 2-3 years?
* How hard will I have to work to maintain my weight loss in 2-3 years?
* This is a lot of information to take in all at once. What do you consider are the most important things I need to keep in mind before having surgery?
What does the surgeon do for me afterwards? If I need another surgery that requires a general surgeon, will he or she perform it?

WOMEN:
* What about pregnancy and birth control after surgery?
* Do you dismiss patients that become pregnant before the 12 to 18 month cut off recommended before trying to get pregnant.
* What do you recommend when someone gets pregnant before that time?
* What do you recommend when someone gets pregnant after that time?

OBESITY RELATED DISEASES:
* What are the most common resolution or improvement in percentages of the following issues after surgery?
* Diabetes
* Hypertension/high blood pressure
* Hyperlipidemia
* Obstructive sleep apnea
* Infertility

CLOTHING:
* Do you have a system set up for recycling of clothes or does a support group have regular exchanges or who works with setting up help for when rapid weight loss occurs and what clothes to wear?
* When should I start buying new clothes?

FOOD:
* How do you work with patients who have problems with food?
* What do you suggest for portion control?

THE REASON WHY THE QUESTIONS YOU ASK BEFORE CHOOSING A SURGEON AND PROGRAM ARE SO VERY IMPORTANT:
You are choosing more than a surgeon: you are choosing a support team and a physicians philosophy! Choose wisely and carefully. While it is easy to deal with patients who have no problems, if a surgeon or group does not have experience with problems, and you turn up with those, what happens then?

* Why did you get into this field?
* What methods do you use to keep up with changes in this field?
* Doing the same surgery (or 2 to 3 surgeries) would appear to get boring. How do you stay “fresh” or “enjoy the job”?

PAIN:
* What is the surgeon’s philosophy on pain?

LEAKS:
* When you do the fluoroscopy leak test, do you use barium or a water soluble product? If they use barium and it leaks, you will have barium in your abdominal category. This is dangerous! Barium is not absorbed so it would require surgical removal. The potential for infection is there.

SURGEON’S STAFF:
* What are they like?
* Who are they, what are their titles, and what are they responsible for in terms of when I would need them?
* How easy are they to reach?
* What is the average time of responses to people: before, after, and more than one year out?
* Do you see someone else besides the surgeon at any point?
* Can I speak to them?
* What are they like, what is their practice like, their philosophy on working with patients?
* Why did they get into this field?

INSURANCE:
* How well does your office work with the insurance to getting my surgery approved?
* What is the time frame for my specific surgery type with my insurance?
* Do you get any of this paperwork done before hand?
* What kind of response can I expect if it is denied?
* How do you work through that and how long of a process does that take?

AVAILABILITY:
How soon is the surgeon available? Who is the first assistant or surgical assistant? Is it another doctor? What happens if that doctor is not available?

NUTRITIONAL ADVICE:
* Do you recommend one diet only or can you deal with, have experience in, other dietary issues: celiac, dairy intolerance, other food intolerances, reflux, etc.?
* How much experience, and who with, what types of populations, does your nutritionist have with bariatric surgeries both before and after? How did they get their experience?

OFFICE CONCERNS:
* If I have a compliment or concern, who do we talk to?
* Do you retaliate if someone has a problem? Have you ever retaliated against someone for a problem?

OTHER QUESTIONS:
* If I choose a surgery and you don’t feel it is right for me, would you still do the surgery?
* Do you perform revisions? If so, how many and for what time frame, as in 3 this year, 1 the year before last?
* Do you have any licensing issues or malpractice claims pending? Do you have any outstanding or former complaints with the state board of medicine?
* How many long term, long standing issues do you currently cover over 1 year out and can you give me 3-5 examples of protocols?

SPECIFIC TO THE HAMPTON ROADS AREA OF VIRGINIA, BUT MAY ALSO BE TRUE IN YOUR AREA:
* Do you notify patients that in the Hampton Roads Va area, if they lose their bariatric surgeon, they will not have care in the area?
* Do you notify patients that after 1 year after a sleeve gastrectomy, they can be dropped with no care in the area?
* Do you do this or have you done this?
* Do you tell sleeve patients they don’t need a surgeon? Have you ever done so? If so, what medical literature supports this?
* How many complications related to nutrition have you diagnosed out after 1 year?
* If you only see a patient 1 time a year, how would you catch this?
* What types of continuing education do you take in terms of complications and food issues after surgery?
* Have you ever had a patient refuse to be weighed? If so, what did you do? (refusing a medical test is allowed by law)
* Have you dismissed a patient for not following orders?
* Can a medical test be refused and you still get treatment? Is that guarenteed in writing?
* If we request medical basis for a test, do you provide it?
* Have you dismissed patients for ability to pay, and is that guarenteed anywhere in writing?
* What written treatment care plans do you provide?
* What are your guidelines for compliance and non compliance when it comes to obeying a doctors’ orders, even if those doctors’ orders conflict with medical research or is just an opinion of the doctor that does not have a basis in fact/research?
* Do you or have you ever dismissed a patient when compliant?

“If a patient is competent to consent to an operation, the patient is competent to refuse consent as well”, writes Dr. George Annas in The ACLU Guide to Patients’ Rights. “A person is not incompetent simply because the person refuses treatment or disagrees with the physician. If this were so, the entire doctrine of informed consent would collapse into a right to agree with your doctor.

* Is any of my health information used for purposes or medical research papers?
* If I am in a database for the ASMBS, do you alert patients of that?
* Will you get my express permission for any studies or any of my data being used in another other program but the one I sign up for here?
* Are you aware that, by law, retaliation for HIPAA violations is illegal? Yes or no.
* What rebates are available for any “program fees”?
* What if I choose other exercise choices than your center provides or want to investigate options on my own, am I still required to pay?
* Can we choose or switch doctors?
* Even if a doctor is correct in a diagnoses, does this mean they have the right and/or authority to make medical decisions on behalf of a non emergent patient under any circumstances?
* Can patients be removed for non compliance when a patient must accept the “opinion” of that doctor vs. a patient potentially having facts of medical references/peer reviewed literature and/or other doctors who disagree?
* What happens when there are differing opinions between a patients’ doctors? Do you agree that those people should be dropped from care when one doctor states one direction and another doctor states another direction? No matter what, this scenario requires that the patient lose at least one area of care to satisfy another, and potentially both.

Questions from ProPublica, Dollars for Docs – check to see what doctors in your area are on this list of taking $$$ from drug companies:
https://projects.propublica.org/docdollars/payments/checklist/9850920
“Questions you might want to ask your healthcare professional”
* What are the specific circumstances of this payment?
* What is your current relationship with this drug or device company?
* What drugs or devices have you prescribed me or may prescribe to me or others, that are manufactured by companies you’ve taken payments from?
* Are there non-drug or different device alternatives that I may want to consider first?
* Are there less expensive generic alternatives to the drugs you have prescribed or can another device or not device at all work?
http://www.propublica.org/article/lawsuits-say-pharma-illegally-paid-doctors-to-push-their-drugs.”

Reasons to check your docs:

I think these links sum up a lot of good information. There isn’t a lot of reporting to the official governmental oversight groups. This means you need to do your homework.
Hospitals drop the ball on physician oversight
DEA’s Failure to Provide Information to the National Practitioner Data Bank (leaves citizens hanging)
Physician Accountability

Conflicts of Interest

$ for docs
Docs mints millionaires
Doctor says
‘Maybe I am a pervert. I honestly don’t know’

Doctors dine on drug companies dimes

‘In a raft of federal whistleblower lawsuits, former employees and the government contend that the firms have used fees as rewards for high-prescribing physicians. The companies have each paid hundreds of millions or more to settle the suits.’

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