Bariatric surgeons, physicians, nurses, nutritionists, and other integrated health professionals are on the frontlines of the severe obesity epidemic in this country. But some on the frontlines are also battling what 24 million other Americans are, severe obesity.
Health professionals are not immune from an epidemic that is linked to the rise in diabetes, heart disease, stroke and premature death. However, do patients receiving advice from doctors about obesity treatments hold doctors to a higher standard? Do patients feel they can trust someone recommending bariatric surgery, when the person doing the recommending is perceived to need bariatric surgery themselves? Does it become a case of physician, heal thyself?
“I don't know if it was a problem for the patients. It never came up," said Walter Medlin, MD, FACS, a bariatric surgeon from Billings, Montana, who weighed 305 pounds before he had a sleeve gastrectomy in 2008. "Hopefully, they were more focused on their own weight and health than they were on mine. I make a point of approaching conversations about treatment with a supportive nature. I think how you deliver a message certainly influences how the patient perceives you and the information."
The issue of the weight of health professionals (not bariatric professionals) has come up before. A study published in International Journal of Obesity last November, suggests that healthcare providers perceived to be overweight or obese may be vulnerable to biased attitudes from patients and that their credibility may suffer as a result. The online survey of 358 adults also found patients were less inclined to follow their medical advice than "normal-weight" physicians. These biases and perceptions were present regardless of the patients' own body weight, according to the Yale researchers who conducted the study.
Previous studies suggest physicians also harbor bias against those with obesity, and that bias can start very early. A study published in May 2013 in the journal, Academic Medicine, for more than one-third of medical students hold a high degree of bias toward individuals with obesity, and many are unaware that they have such bias. The study authors state this mind-set may reduce the quality of care to patients with obesity.
As long as he can remember, Dr. Medlin struggled with weight loss, but at six feet tall and 305 pounds, he found an identity being the “big guy,” and was less inclined to identify himself as being an unhealthy person with obesity. However, when his blood pressure became dangerously high, Dr. Medlin came to the decision that he too needed bariatric surgery, the treatment he had performed hundreds of times for so many other people in his exact situation.
Dr. Medlin felt sleeve gastrectomy would be his method of choice, but, like many of his patients, he himself had to overcome barriers to get the procedure. At the time (2008), his health insurance plan did not cover sleeve gastrectomy because it was not a primary bariatric procedure. “If I really wanted to have sleeve I was going to have to pay for the procedure out-of-pocket, which at the time was nearly $20,000 – not an easy choice. But I did it.”
Once how the procedure was going to be paid for was settled, Dr. Medlin’s primary care physician recommended delaying it by two months to reduce his risk of complication due to his high blood pressure, which sat in the upper 140s, most of the time. “As a surgeon I had to make a choice to be the patient and take my doctor's recommendations seriously. I understand how frustrating and disheartening the process can be after you make a difficult decision and then face with delays and hurdles. You just want to get it over with.”
Dr. Medlin turned to James Foote, MD, a friend from residency and a bariatric surgeon in Grand Rapids, Michigan, because he wanted a friend not only experienced in sleeve gastrectomies to do it, but a friend he could always call "in the middle of the night" if he had to, without any hesitation.
In September 2008, Dr. Medlin had the procedure and more than five years later, he maintains a 100-pound weight loss and his blood pressure sits at 120/70 with a single blood pressure medication.
“I didn’t cut corners when it came to my post-surgery program. I logged my food, exercised and attended support group meetings. But as a surgeon I had to be very careful about crossing boundaries with patients. When I attended groups it became ‘The Walt Show,’ with patients hyper focused on my progress or personal goals. I made it a point to attend the group and then exit soon after participating to avoid the attention that being a bariatric surgeon/patient brings.”
Back at work, Dr. Medlin says that he works to find a balance when sharing his personal struggle with weight and his surgical experience with patients. “It’s important to remind ourselves as physicians that it’s about what the patient is feeling – it may not be beneficial to interject with personal experience. But if I do, I make it clear to patients that my journey is my personal journey and what I have experienced and what has been successful for me may not work for them.”
Dr. Medlin added that having the surgery changed his focus with bariatric patients. "It’s about the long game. I focus less on the scale and more on the long-term quality of life my patients have after surgery. With my patients today it’s more about the vision of how mobile and healthy they will be in their 80s,” he says. “I use to talk about exercise like it was work, now it’s about sustaining mobility and staving off atrophy. We brush our teeth so we can keep them our entire life, exercise is the same – if you want to be mobile at 80 you have to be moving every day at 50.”
Just months after surgery Dr. Medlin and his wife took a trip to Hawaii where he fulfilled a lifelong goal of learning to surf. Dr. Medlin was also successful in getting his insurance plan to cover gastric sleeve procedures as a primary procedure, so others may benefit, whereas he could not. Over the last 10 years, he has performed more than 1,400 gastric bypasses, sleeve gastrectomies, gastric band procedures and revision surgeries.
For Gary Wisner, MD, an orthopedic surgeon in Lodi, California, his obesity was actually a common thread he shared with many of his patients. With a BMI of almost 47, Dr. Wisner had steadily gained weight since his surgical residency days. At his heaviest, he weighed 289 pounds and suffered severe sleep apnea, diabetes and high blood pressure. “I had a lot of guilt over being that heavy and having so many health problems. It wasn’t fair to my family or me. But the truth is, the heavier I got the more patients my practice saw come through the door,” Dr. Wisner says.
According to Dr. Wisner, many of the people who came to see him for joint replacements were suffering from knee and hip deterioration due to their obesity. Most had been turned down by other surgeons unwilling to operate on patients whose weight could potentially cause surgical complications or artificial implants to wear out quickly.
“I made a point of being a doctor that wasn’t judgmental. In fact, I think it became my reputation -- kind of being the guy who knew what it was like to be fat,” says Dr. Wisner. “But, I never pretended that my patients didn’t have a weight problem or ignored their health status.”
Dr. Wisner says that even though he was embarrassed by his own struggle with obesity he felt it was his duty to “raise the red flag” when patients with obesity came to him for joint replacement. “It is my responsibility to talk to them about what they are doing to their bodies. I had to explain the risks of hypertension and stroke, how it could result in complications during surgery and the need for additional surgery down the road,” he said.
But when patients confronted him about his own size, Dr. Wisner had an exit strategy. “When they would say, ‘Doc, come on. You need to do something too.’ I was embarrassed. So I would crack the same joke every time. I’d tell them ‘Just because I don’t practice what I preach doesn’t mean the word isn’t right.’ Then I shake their hand and leave on a laugh.”
In was no laughing matter in 2007 though when Dr. Wisner’s diabetes had gotten out of control. His moment of truth occurred when he was told by his physician that he would soon need insulin injections, in addition to the three oral diabetes medications he was already on. At the time, he was also taking more than 22 prescription medications for high blood pressure, high cholesterol and a variety of obesity-related conditions and ailments.
Though he knew bariatric surgery was his last best chance to become healthy, Dr. Wisner describes an immense sense of embarrassment about his decision to have bariatric surgery, not uncommon among patients, doctors or otherwise. He also was "petrified" that like all his other attempts at weight loss, surgery would fail him too. But soon embarrassment and fear turned to hope and a commitment that this operation that worked so well for many of his patients, would also work for him.
“Several of my orthopedic patients had bariatric surgery and lost incredible amounts of weight over the years. It made a big impression on me because I spent years trying to drop pounds with a number of diets, but could never keep the weight off," said Dr. Wisner. "Surgery wasn't a new concept for me. I had been thinking about it and researching it for years but now was the time to take action so I could be around for my family."
Dr. Wisner turned to bariatric surgeon John Morton, MD from Stanford University, who performed a gastric bypass that led to weight loss of about 120 pounds. And remember those 22 prescription medications he was taking before surgery? Today he's down to one pill a day for blood pressure, and he thinks he may be able to eliminate the need for that soon.
Even though he was experiencing so much success, Dr. Wisner kept the surgery a secret, not wanting patients, colleagues, or even extended family and friends
“As a doctor you are supposed to be a figure head of healthy living, so I didn’t want to be a poster child for surgery – successful or not. However, not telling patients about my procedure was a great moral dilemma that I dealt with each and every day. I was advocating for patients to have bariatric surgery, but not disclosing my own.”
David Sarwer, PhD, professor of Psychology in Psychiatry and Surgery at the Perelman School of Medicine at the University of Pennsylvania, says that among the general public and even within the medical community there are still a range of positive and negative perceptions about obesity and bariatric surgery.
“For many healthcare professionals who have bariatric surgery, they may feel that the stakes are higher for them to succeed. It may leave them feeling like a walking billboard, which can add another layer of pressure and anxiety that affects their decision making process before surgery and impact their lifestyle and behaviors after surgery," Dr. Sarwer said.
Dr. Wisner reconsidered his decision about keep his surgery a secret after about a year because his "health had been completely transformed." Discussing it wasn't a routine part of his interaction with patients, but he would no longer hide the fact that he himself had surgery.
Nor does he hide the fact that about a year ago he started to regain some of his weight -- about 20 pounds. "I had dilated the top of my pouch. I no longer had the sensation of fullness that came after my bypass. I was eating more and gaining weight."
Dr. Morton recommended and performed an endoscopic revision to restore the pouch this month and Dr. Wisner has already lost 14 pounds and his satiety has increased. Today, Dr. Wisner has no regrets and is very comfortable discussing his weight loss journey, and finds no shame in the fact that he is a doctor who needed help.
Pam Davis, RN, BSN, CBN, the bariatric program director at TriStar Centennial Center for the Treatment of Obesity in Nashville, says their program is “very fortunate” to have so many healthcare professionals on staff who have had bariatric surgery, including herself, who understand the journey of being a bariatric surgery patients.
“During seminars, support groups and even in the office I think patients appreciate that we can say ‘I’ve sat in that chair wondering if it was the right decision, I’ve laid in the hospital room worrying if I wouldn’t lose a single pound. I’ve felt like giving up sometimes'”, said Davis who is the Immediate-Past Chairman of the Obesity Action Coalition (OAC). "Sharing these concerns can help some patients who appreciate camaraderie and I think it gives our recommendations a greater air of legitimacy."
Pam had her laparoscopic gastric bypass in 2001at TriStar Centennial Center. Prior to this time, she tells of a lifetime struggle with obesity along with high blood pressure and acid reflux. Before surgery, she weighed more than 300 pounds. Today, 13 years later, she has maintained weight loss of more than 160 pounds.
“I believe my experience as a patient and a nurse allows me to assist patients in setting realistic, personalized goals. I make mistakes as a patient and eat things I shouldn’t, and I share that with patients. I am responsible for my health. I try to help my patients become accountable to themselves, not to others like their nurses or surgeon – they have to commit to the program for themselves and set their own goals beyond what the scale says,” Davis said.
Many health professionals face the same struggles of those they treat. A medical degree does not inoculate someone from diseases like obesity and type 2 diabetes. However, when healthcare professionals themselves become patients, it can lead to greater empathy and understanding of those they treat in the office, the surgical suite or hospital and send a powerful message to other medical professionals.
"Sharing with patients that you’ve had bariatric surgery or discussing your own struggles with obesity may help patients achieve greater understanding and reduce the stigma they may have felt or experienced their whole lives about obesity and bariatric surgery," Dr. Sarwer commented. "When health professionals have bariatric surgery, it also sends an important message to the medical community at large. Primary care and other medical specialties need to make obesity a priority and discuss appropriate treatments, including bariatric surgery, with patients without judgment.”