Postdischarge Issues with Postbariatric Surgery

Participants:

Renay D. Tyler, MSN, ACNP, CNSN

T his Roundtable explores posthospital issues for bariatric patients. There is often a constellation of providers who are involved in the care of bariatric patients once they leave the hospital. With that comes an inherent amount of disconnection among providers, even with the most streamlined of care models. This is magnified by the complex needs of weight-loss surgery patients, and requires team-oriented solutions.

—Renay D. Tyler, MSN, ACNP, CNSN

Associate Editor

Renay Tyler: I think one of the first issues to appreciate is the complexity of the needs of these patients and to ask if there is one person or a single entity that should ultimately be coordinating the patient's overall care when they leave the hospital.

Trish Walters-Salas: I'd like to begin the discussion on that point. I am board certified in case management. In our practice, I find that having one person, such as myself, coordinate the care across the many specialty physicians of these patients works so much better. Of course, we do not have an extremely large practice. Currently, we have approximately 175 patients in our program, and, as they need specialty visits, I help facilitate and coordinate scheduling these for them. When possible, I will do reminder phone calls; mainly, I try to arrange for patients to be where they need to be when they need to be.

Michael Bloch: I would echo those comments—obviously there are many people involved in the comanagement of patients after discharge, but when there is too much shared responsibility sometimes things can fall through the cracks. Probably different centers in different regions are going to have different people who take ultimate responsibility for making sure things happen appropriately, but I think it is important to formally designate where “the buck stops,” so to speak, and with whom ultimate responsibility for coordinating care should rest.

Kathryn McFadden: I would add—as a psychologist and due to the fact that my original background was in nursing—that I lean toward coordinating with a focus on the nurse as my primary person with whom to communicate. I find that nurses generally are very available, and they also seem to take a holistic approach in terms of patient care. Therefore, I often will look to the nurse for this type of help and assistance.

Robin Blackstone: What about the role of the surgeon in coordinating care afterward? After the initial postoperative visit, I do not really know if there is a role for them in coordinating care. That being said, I do think there is a role for the bariologist or primary care physician, nurse practitioner, registered dietician, and exercise physiologist, as they are the team members who really need to have further contact and ongoing work with the patient. The patient needs to get value out of each and every visit, and these team members have more to offer during the long-term follow-up of the patient. The surgeon should be supportive of these roles and work with the team to make sure the follow-up program is easily available to the patient.

Renay Tyler: I think that the key word here is “team” and, critically, who makes up that team. Is the team composed of postsurgical personnel? Is it those persons on the bariatric surgery team who accept responsibility for handoffs and knowing what is happening when the patient goes home to the community again? Or should the team be defined by a broader group of caregivers, to include someone from internal medicine, the person who referred the patient, and the psychologist who saw the patient preoperatively and perhaps is not even in the bariatric practice? I think understanding where the buck stops is helped by defining who is to be on the team and knowing what is its composition, as Dr. Bloch has said.

Laurie McGinley: I agree with the previous comment about case management being a good way to facilitate follow-up. At my practice, and I have a fairly moderate-to-large practice, I am the one who generally oversees that patients come in at proper intervals to have their laboratory work done. We do communicate with their referring physician, internist, and cardiologist. I copy notes to every provider involved with that patient when I see them come back and at certain points postoperatively. I believe that our surgeons feel very responsible for the health of these patients, every one, and they do not want to just “cut them loose.” Therefore, we encourage the Roux-en-Y patients to follow-up every 3 months during the first year and then minimally once a year thereafter for their lifetime. For band patients, follow-up is tailored according to need. For example, because we are seeing nutritional deficiencies and issues with adjustable gastric bands, we schedule a great deal of follow-up for these patients. We do not just perform the surgery and release the patient.

Michael Bloch: I would agree with those comments. I think that if you are going to take a team approach, there needs to be a person who is setting protocols, making sure that everybody is on the same page in that team, and I think in many settings—that person probably should be the primary bariatric surgeon. Obviously, there are other models that might work. That does not mean that the surgeon has to be involved in the day-to-day care of that patient. In terms of really managing the team, however, I think it makes a lot of sense. The primary bariatric surgeon is who the patient looks to as their physician and who the community often looks to as the person who is heading that team.

Trish Walters-Salas: We are working with an adolescent population, and we use the same team approach. Our teens are really good at text messaging. I know this may sound a bit different, but what I do is communicate with our young patients through text messaging as frequently as necessary, sometimes several times in a single day. Teens are seen in clinic at frequent intervals. We do not and would not cut them loose because they are teenagers and subject to teenage behaviors. They are in a difficult position, because they need our oversight and are at a stage of normal development where it may not be wise to trust a teenager will follow through.

Renay Tyler: So you send text messages to the patient?

Trish Walters-Salas: Yes, and I ask them specific questions. If they run into an issue or concern, they will text me. Usually, the text message is surrounded by a problem that has just arisen. I will get a text, for example, saying, “I just overate and I threw up. What do I do?” Then, at that point, I can call and talk to them. Teens are really into the latest technologies. We have a Facebook site through which they can communicate with us or each other. However, most of the time, communication to me occurs via text messaging. We have team meetings every 2 weeks to discuss any problems or issues that have come up. For those patients with problems, I let the whole team know what is happening. Again, we are working with teenagers, who are a very different population than adults.

Kathryn McFadden: I want to respond to the question about who is responsible for the needs of the bariatric patient postsurgery. Should the surgeon be involved? Of course, my answer to that is, yes. I think surgeons are a very important part of the treatment team. I am looking at this from a psychological perspective, because the patient has made a life-changing decision to allow the surgeons to operate on them and to change their life forever. I think that is why the surgeon is important. Patients look often to their surgeon with respect and also want to have his or her knowledge and to get the surgeon's feedback in reference to their progress. As a consequence, I think that before, during, and after the operation, surgeons are just as important as any treatment member who is involved in this truly life-altering experience for patients.

Renay Tyler: I agree. In the bariatric surgery community these patients are their patients for life. Let's explore the indistinct line between a surgical issue and then what becomes an ongoing medical issue that requires continued follow-up. Examples are glucose control and hypertension management as patients lose weight, endocrine-related issues such as bone density, etc.

Robin Blackstone: I think it is important, really key, to have a practice with an integrated team. The question I have for everyone here is what is your actual percent follow-up at one year? I think all of us are experiencing that the percent follow-up is not as high as we would like, and maybe there is something wrong with the way we are approaching it. In our model, we have integrated primary care folks with us. They are very important in long-term follow-up, and the surgeon is always there and sees them occasionally. But, to be honest with you, most of the follow-up after the first 90 days or so is really done by the integrated team that the patient has known from the beginning and is comfortable with. We were always hoping that this would translate into a higher amount of postoperative follow-up.

At 1 year, we are still hanging in at around 80% of patients, but by 3 years our numbers have dropped dramatically. By 5 years, our percentage follow-up is far less than 10%, which is true for almost everybody, as far as I can tell. To me, the long-term issues are really important, because I think we are seeing malnutrition, maladaption, and weight regain as well as other issues with patients, even though we have tried to create a sort of medical home for them.

Renay Tyler: Is there a heightened role for case management in that follow-up?

Robin Blackstone: We have long advocated for a more case management approach and tried to get our insurance payers and partners in that regard to be more involved with the patient, keeping them on track and within the program. I think what happens in our situation is that people migrate their insurance from one company to another, or sometimes they have just changed addresses, or chosen a different primary care doctor who may or may not be that “plugged in.” By that time, they are a normal-weight patient and the primary care physician may not really understand the issues involved with that patient's long-term care. I think there is a kind of disconnect right now between our objectives and goals and the way that we are trying to do this against the actual facts and reality of long-term follow-up.

Michael Bloch: I think those numbers are quite representative of what has been seen around the country, and I think part of the problem is that as you make the handoff from acute care to a chronic care model, many patients and their primary care physicians think that they have another medical home for those problems—with the primary care doctor. Integrating those primary care doctors, the ones who are generally going to be following up with these patients on a regular basis, is critically important, and it is not easy to do. In fact, it is really hard, especially as people change from one primary to another and change insurance plans and other things in their lives.

We have to recognize that those follow-up numbers are real and that every type of model that is out there has the same poor follow-up at 3 years. So, perhaps we need to be looking at different types of community-based models and having sort of a one-stop shopping center where that patient comes to get all their postbariatric chronic care.

Stephen Ritz: I agree with everything that has been said. Obviously, while the immediate bariatric team is important, the further in time the patient is from the surgery, the less likely they are going to access that team. I do not have an easy solution for this. I know that when I served as a consultant to Magellan Health Services, which is a behavioral healthcare company, there was an initiative to involve many primary care doctors with regard to treatment for depression and medication management. I certainly hope that insurance companies would be a part of this mix. While people change insurance fairly frequently, these companies might be in a position to develop some kind of long-term, coordinated effort with primary care doctors, because it would benefit them financially. One example might be to at least monitor patients, to get some sense of how they are doing long-term. Patients may not want to go back to bariatric physicians if they are starting to regain weight because of the embarrassment associated with it, while they might feel more comfortable with primary care doctors to address those kinds of issues. So, I would certainly like to see a community-based effort and maybe even one involving insurance companies in some way.

Kathryn McFadden: I want to just add a comment to what has been stated so far. I think you really cannot ignore the role of the mental health professional in terms of trying to continue to have the patient involved in an active maintenance program. This is going to involve having them participate perhaps in group therapy or a bariatric support group to give them a place where they can go and identify the barriers to and the rewards for their continuing success. In these groups the patient can talk about relapse and what triggers relapse. The patient can work on assessing and enhancing their personal motivation for complying with the treatment program. If we are looking at long-term maintenance and success with weight-loss surgery, and, indeed, we also are looking at a chronic situation, we have to have parameters in play that allow the patient to make changes and sustain these changes. I do think that the role of the mental health professional is critical in this particular area.

Robin Blackstone: I could not agree more. We have an extremely strong support structure where all of our support groups are led by licensed mental health professionals, and we have very strong attendance at support groups. In addition, we have two online groups with very strong participation by patients in their first 6 months after surgery. That being said, we have found a pretty drastic drop-off of patients after that point in time. I agree that support groups are necessary, but, for some reason, patients do not seem to continue to utilize this essentially “free service for life” in terms of interacting with support groups as a vital benefit for them.

The other issue that I think we need to realize and be realistic about is that one of the serious barriers to these patients having an opportunity to do follow-up is that their primary care doctors are often not getting reimbursed to care for them. Once their hypertension and diabetes go away, other than their annual wellness examination they may or may not be covered. It is hard for primary care physicians to decide to follow people that they are not going to be able to charge a fee to see. That is just not practical.

Kathryn McFadden: That is a good point, in that the primary care physician has a role regarding medical treatment; however, they do not necessarily provide the psychological support that a patient might need. There are changes that can occur in terms of behavior, and there are actually stages of changes. There is a theory that addresses this particular area, which focuses on the time after 6 months, exactly what you said a moment ago—when a person starts to enter the maintenance phase, usually from 6 months to 5 years after surgery. If they do not have a continued commitment to sustaining the behaviors that they learned, we can expect a relapse.

Robin Blackstone: Yes, that's true.

Kathryn McFadden: As healthcare providers, we are in the position of trying to find mechanisms to help patients have a continued renewal of their commitment to the behaviors that they have implemented to make the changes to improve their health status.

Robin Blackstone: What do you think about using an Internet-based system? I was very struck hearing about incorporating text messaging into follow-up care.

Kathryn McFadden: I thought it was great, and it would be a good system for people who are savvy as far as the Internet. It is also important to ensure patient confidentiality if this system is used.

Robin Blackstone: We have just started a program where I e-mail patients individually just to check on them, saying, “Hi, how are you? How are you doing? We have not seen you for a couple of months. We would like to know how you are.” It does not cost them anything to just e-mail me back.

Trish Walters-Salas: When I get an e-mail from someone I have not heard from in awhile, it is a mood-lifter; it is a simple way to make people feel like, “Oh they are thinking about me.” I can see where this would work, because people feel we are in a fast-moving society now, and we do not have time to sit down, call people, or send them a letter. People do look at e-mail and respond.

Renay Tyler: Have we done a good job of educating the other healthcare providers that are not necessarily keenly connected with bariatrics? This is important if a patient is several years postsurgery and goes to another primary care provider, and they know the patient has had bariatric surgery. Are they asking key questions regarding supplement compliance and laboratory monitoring?

Laurie McGinley: I work with four bariatric surgeons, and they really strive to educate on a continual basis. We have a large population and are spread out in northern Nevada. We have patients who live 5 hours away. So, we have programs periodically that the surgeons host and provide education to the primary care physicians. I know our surgeons have pulled in Dr. Bloch to help on issues, and he consults with them. Since we refer patients it is helpful to have some type of educational opportunities hosted by surgeons to help disperse the knowledge and to stress what we feel is important to follow postoperatively.

Trish Walters-Salas: In the beginning of the summer, we had a reunion of all our patients and families; we had a tremendous attendance, including patients whom we had not seen in a while. We sent invitations to everyone. The event was an opportunity to sit down and chat with them to reconnect. The questions we asked to those we had lost to follow-up were, “Where are you going for your healthcare? Are you having your vitamin levels monitored? Are you taking your vitamins? Are you exercising? Are you keeping up with things, and are you having any issues?” So the reunion had a double purpose, to reconnect with them and to revisit some of their health issues. We had a great time, and we plan to do this annually.

Stephen Ritz: You asked the question, Renay, have we done enough in terms of education? As a mental health professional of behavioral healthcare, it is hard for me to answer that, because I have an independent practice. While I have been involved with this for a long time, I am not part of a program. From the point of view of a person who is on the outside looking in, I would venture to say probably not enough has been done in terms of education. I would say that because people do not typically lose as much weight as they would like long-term, and people regain weight long-term. What that says to me is that somewhere within that system, whatever it includes, there is not enough structure, there is not enough accessibility, and there is not enough opportunity and creativity to keep people connected to whatever medical systems they need to be more successful long-term.

Michael Bloch: I would certainly agree. I spend a lot of time educating primary care physicians, and I think we have made the care of bariatric patients seem too complicated. I believe that it is very difficult for a primary care physician, or a patient for that matter, to go to one place where there is a very distilled set of recommendations for what they need to know or to do in terms of chronic care—even just for simple things, like psychological counseling and what labs are needed, what supplements their patient needs to be taking. Obviously, all of that is just a place to start. Each of these behaviors and activities need to be individualized, and I think that is one of the frustrations that primary care physicians have, in that there is really no one place, no one resource from which they are able to retrieve the information they need in summary form—one they can have on their wall or that a patient can bring in to show them and say, “Hey, doc, am I not supposed to get these things done for me every year?”

I think bringing in a multidisciplinary team to do education sometimes makes it seem more difficult than it is, that you need to have seven different doctors involved in a patient's care. Sometimes you do, but many times you do not. Some of these chronic issues can just be taken care of by a primary care physician if we can really distill some recommendations down for them.

Robin Blackstone: About 4 years ago, we felt the same way—that a lot of times it was just that the primary care doctor was not aware of what they needed to do. So, in every single summary, from the first postoperative visit, which is done in our practice about 10 days after surgery, every single time, we decided to send a letter summarizing the course of care on that patient. We also sent a separate attachment that said, “In the ongoing care of this patient with an adjustable gastric band, you will need to look for the following.” These adjustments are now part of our regular care, and we feel it gives the primary care doctors a foundation of what to do, what not to do, when to contact us, and what to do for the annual visit, so that they know what those things actually are. Ideally, we had hoped that that information would either be scanned into the patient's record or placed in the chart so that when that patient goes back for follow-up, there would be some recommendations right there for that particular individual which was based on the procedure they had received and the course of care they went through in regards to their procedure. I cannot say at this point whether the approach has had any impact or not, because we have not studied it.

Michael Bloch: It sounds like a great intervention.

Robin Blackstone: Well, in terms of trying, yes. I am not sure it is actually intervening, but at least we are trying.

Michael Bloch: One of the things that oftentimes centers try to do is maintain such a tight program that they keep everything or a lot to themselves with a patient coming back to them, and they do not disseminate enough information as life continues for the patient. We have to recognize the reality that many of these patients, despite our best efforts, are going to be lost to follow-up from that center of excellence, and, as much as we can, we need to get their information out to whomever they are going to see next. It benefits everybody.

Renay Tyler: There is an obesity medicine certification examination that has been proposed. Has anybody heard about this?

Michael Bloch: Yes. We have a colleague who has even done a related board certification process. I am not sure if it is the same examination to which you are referring. I think there are a couple of different ones out there.

Robin Blackstone: Yes, this is a new effort that has been piloted by The Obesity Society. The American Society for Metabolic and Bariatric Surgery (ASMBS) is supporting their idea of getting a bariologist-type certification, similar to cardiology, the cardiothoracic surgeon model. Bruce Wolf, who is the president-elect of our society, is working on the committee to put together a certification exam and certification process. They have been having meetings for about 6 to 8 months, I believe. I do not know when this process is estimated to be completed, but I do know they want to have a very scientifically based and thorough certification program. This is important so that those internists and primary care physicians who are interested in caring for obese patients or postoperative obese patients could have a quality baseline education available in regards to being certified.

Renay Tyler: Currently there are nine member societies that are contributing to this, including the American Society of Parenteral Nutrition, The Obesity Society, American Association of Clinical Endocrinologists, and of course the ASMBS. So, it is a pretty well-rounded group that is cooperatively working at this.

Robin Blackstone: Interestingly, this effort has a little different focus than the bariatrician certification that currently exists, because the focus contains a lot more, if you will, of education around the whole continuum of care and how to care for postbariatric patients. I think this new endeavor is going to go a long way to help us resolve the educational issues that we have concerning ongoing care.

Renay Tyler: Looking back at some of the barriers that we talked about earlier with mobility and patients disconnecting with programs, do you believe there is a role for healthcare reform in all this? Do you think there are opportunities where we may have better options and better coverage for some of these things that we have talked about, such as case management and transition of care between entities?

Kathryn McFadden: I could speculate on an answer—that I would hope mental health would have more parity with medical treatment in terms of helping patients, because a lot of the time psychological and psychosocial aspects of recovery are ignored, and I believe that if those areas are not addressed, the patient is more likely to relapse. So, we will just have to see what the new healthcare reforms offer.

Michael Bloch: I think there is certainly some potential for having delivery models that are going to be more efficient. I am not sure that I have seen anything that is necessarily going to make that happen which strictly pertains to the bariatric world. However, I think if you can begin to move the system away from a “fee for service” approach and more toward one of coordination of care—many of the services that are currently provided as almost add-on services that are not necessarily reimbursed will potentially be reimbursed. If payment for providing and coordinating care can be bundled, I think we will see a lot more enthusiasm on the part of providers to offer those services.

I also think one of the other great potential opportunities is to make insurers more responsible for certain aspects of care coordination. For one thing, they should provide a framework where these patients can remain on the same insurance plan even if they move or change jobs. There are also other educational tools and resources that 3rd party payers can help supply. Certainly, we see this in vertically integrated delivery systems, where the insurance provider is much more involved in the delivery and the organization of some of this care. There is a lot of potential for that type of integration, but I am not sure that necessarily any of it is going to happen any time in the near future.

Renay Tyler: Some insurance companies provide coverage for home health visits and some do not. In the absence of parity and equity across the board in what patients do receive, what do we do for our patients who do not have coverage for home health or psychological follow up versus the ones that do?

Trish Walters-Salas: I previously worked for an insurance company as a case manager. When managing a case, you do have the ability to weigh the cost and benefit of getting extra services for a patient. So, now, for most of our patients, the first thing I tell them is to get a case manager with their insurance carrier. Just call and tell the insurance company that you need a case manager to help coordinate your many health issues. Once this has been done I can speak directly to that person. I have not had any problems getting the patient's healthcare needs addressed whenever I explain how it will save the company money in the long-term. This is an option for people to consider, that they just need to present the cost savings and benefits to a person who sees the whole picture. If a patient is denied services, there is the option of appealing. In the appeal, the best way to approach the company is, again, to show the cost benefit. It's appropriate to say, “This is going to save you money and also help restore the patient's health, which is supposed to be the objective.” That is a positive leverage that people can use.

Kathryn McFadden: I would like to respond to your question about those individuals who do not have outpatient home visits with follow-up treatment. As a psychologist, what you can offer patients is a list of community resources that hopefully are going to be free, because sometimes people do not have the insurance for this type of mental health benefit. You could follow up with the patient and find out what support groups are in the area. Often, there are bariatric support groups that you could recommend to your patient as an option.

There also are Internet bariatric support groups. As a healthcare provider, you want to be aware of which groups you would want to refer patients to—resources that are complimentary to your treatment structure. Then there could be other options, such as Overeaters Anonymous, and as long as any particular program and attendance at that program are congruent with your bariatric program structure it could be another referral source.

Renay Tyler: Since we do not have total control over where each of our patients are able to have or continue follow-up, how do we manage the communication with community resources?

Kathryn McFadden: I would like to respond. I thought Laurie McGinley made a realistic point a little bit earlier that some patients could be 5 or more hours away from their treatment program, so they are long-distance commuters for that care. I think as a healthcare provider, you want to know the geographical location of your patient and any barriers they may have to accessing care. Fortunately, as healthcare professionals, we have access to the Internet and we can identify people or treatment facilities or self-help groups that are available within that patient's particular area, in order to can give them the resources they need. We are not going to always be able to do this, but it is something that I try to do within my practice. If I find someone lives in a rural area, I try to identify what types of support systems are available for them.

Laurie McGinley: I have providers that will call me. For example, Elko, Nevada, is about 5 hours away, and if a primary care physician (PCP) has a question they will pick up the phone and call me. I am in the office Monday through Friday, so if there is something I need to relay to the surgeon, I can get ahold of him. I oftentimes facilitate care over the phone. You know, they (the PCP) will pick up the phone or they will e-mail me or sometimes send me a letter in the mail with questions. I think there is that open door, as long as the patient allows release of the information to the PCP and vice versa, which they do.

Renay Tyler: Do most of you work in systems where there is an automated distribution of operative notes, discharge summaries, and lab values to key providers of the patient's care?

Laurie McGinley: We have an electronic system for charting that is very helpful. We also have a method of zeta faxing electronically from our electronic medical record (EMR). After I am done with a note, I click on the provider or providers I want to send it to. I can route labs and follow-up tests to them. We do share a lot of our information, and I think that improves the follow-up care for the patient.

Wendy Feretto: For those patients that live in rural areas, this is where case management can be a key component. They can figure out which providers to get the proper information to and the surgeon's information, so that they can get the proper documentation back and communicate among all the different members of the team.

Trish Walters-Salas: That is exactly what I was going to say, that we have patients who come from south Texas, which is often an 8-hour drive from Houston. I usually pick up the phone and call their primary care physician after we have seen the patient, to give them information about our assessment; then I will fax them their lab values. We have an electronic medical record program that generates a letter to the physician, too, but I go ahead and make the phone call ahead of time, because I do not know how long it takes for that letter to get generated from the record. As the case manager, it is easier for me to access either the nurse or the physician. I just tell them I am a case manager calling about their patient, and they usually take the call.

Stephen Ritz: I do not know how to answer the question that you asked, but I have been thinking about what people have been saying, and I guess there is something that concerns me. I do not know how to move forward with this, but we are making, possibly, a lot of assumptions here, regarding what is best for the patient in terms of coordinated care. In the short run, I think that we do an okay enough job with coordinating care.

I am much more concerned about the long-term and as to whether case management or something else is the answer, I am certainly open to those and other options. The way people talk about this is, “I am having weight-loss surgery.” They do not say, “I am having weight-loss maintenance surgery.” There are so many factors involved with what helps folks to be more successful, and I do not presume to know all the variables that are going to keep people connected to care systems. The data supports that the majority of these patients do not have psychological or emotional problems that are driving their obesity. That is just the reality. What that means is that there are lifestyle variables that drive what causes weight regain, whether it is driving by fast-food restaurants or the like.

I am not sure that we are doing a coordinated enough job in figuring out, for instance, what patients think are going to be the most effective variables long-term to help them stay connected. Similarly, what are we doing about patients that do regain this weight and feel too embarrassed to go and see the bariatric professionals, no matter how much case management is involved? What are we doing about folks that are living in rural communities? What are the sociocultural factors that may drive nonadherence, which is a big issue? I know I am speaking about a lot of different things here, but we are thinking about issues from our paradigm, and I am not sure that is always the most effective paradigm from which to be thinking.

Renay Tyler: I would agree wholeheartedly. We do the initial transfer of care, or handoff, and communication pretty well. It is long-term care that we really need to look at. How can we develop better connectivity from a communications standpoint with clinical resources and information technology tools?

Robin Blackstone: I have been listening to everybody talk about this, and I was actually just talking with one of our advanced practice nurses in our group this morning about long-term issues. We are all passionate about this. We all are in 100%. We want to do the long-term care. We want patients to be healthy long-term on follow-up and be able to realize the amazing lives that they have.

But life still happens to all of our patients, and life stressors have variable impact. For instance, we believe that some of the weight regain is triggered not so much by the fast-food places, which they are not used to going to anymore, but by their mother dying and having to go and care for her, or by their kids getting in trouble at school or with the law, or their spouse divorcing them, or because they lose their job. All of a sudden, their ability to cope with that kind of stress causes them to revert to old habits. In people that have not really adopted exercise as part of their postoperative regimen, it is really hard to cope with the increase of even several hundred calories a day. They just put the weight back on, and then they begin to feel that they are failures.

In our data, we have identified that less than 25% of people have true psychopathology issues, but I do not think that is even the important part. The important part is that patients go out and experience their lives and their ability to cope with the stress of events—they do not have good coping backup. They do not have good support for that. Their primary doctors are doing the very best they can, and many of them are dedicated physicians. But they do not have the passion and focus around this disease that we do. So I think that is part of the disconnect.

Stephen Ritz: I have a concern, and I do not know the word to use. Pathologizing is not the right word, but it is certainly about identifying the patient as the one who is primarily responsible for not being able to manage their life stressor and then using food in some way to manage their response. While I agree that that happens, and that it happens postsurgery, it most certainly happens presurgery as well. What I see presurgically with the evaluations that I have done is that so much of the weight gain is driven by what or who is responsible for deciding what a person eats. It is often not the person themselves but could be anything from television ads, fast-food restaurants, or work schedules—it could be so many different things. My concern is that we are not doing a good enough job educating patients, not just about how to cope with life, but with the variety of forces that fly beneath the radar and influence people's eating habits. So, I agree with Dr. Blackstone that we need to make sure that folks are prepared for the inevitable events that life brings—that life does happen, and there are going to be things that are challenges to cope with, and that there are so many variables that drive what a person puts in their body that are not necessarily stress-driven.

Michael Bloch: I think if we can summarize the things I have been hearing, the sort of fundamental tension in building these models is that everybody is suggesting that the most effective models are going to be very flexible and very patient centered. But, of course, those also are the most difficult models to build and to use. I think there is a fundamental tension between doing that and what we tend currently to do in centers of excellence, which is to have a practitioner-based model, one that is very efficient for us. I am not suggesting I have any of the answers, but I do think that people throw the term of being “patient-centered” around a great deal. However, most of these programs really are not patient centered. In my opinion, they are designed around what works best for the providers and sometimes what works best for the insurance companies, rather than necessarily what may work best for the patient. More flexible, truly patient-centered approaches can be really, really tough and really expensive and time consuming to put in place.

Renay Tyler: There are certainly conflicting forces that surround these issues. With the paradigms that are currently in place, improving this area of care will be difficult but not insurmountable.

Kathryn McFadden: I think the one thing we have to always remember is that obesity is a chronic condition, and I think we want our patients to understand this fact. I thought it was a good point when it said that “life happens.” What we want to do as practitioners is to try to provide people with coping strategies, to have them do rehearsals about what they would do if this or that particular situation occurred. We want to try to prepare our patients for the future, and that includes future problems that they could incur, and try to help them develop coping strategies before they ever even come upon the problem.

Trish Walters-Salas: I would like to see all of us do more prevention teaching, along with the work that we do, and we can focus on the total family. We are trying to focus on the schools, because we are, again, a program at a pediatric hospital. Churches can also be involved as part of community resources. I am speaking about our program, when I say we need to get out into our community more, be more visible and do more preventative teaching. You were talking about teaching coping strategies. I think we need to teach not only those but teach healthier lifestyles, get the community to set up safe places for the kids to play so that they are not in front of the TV all the time. I feel strongly about teaching obesity prevention.

Laurie McGinley: I agree with what Dr. McFadden and Trish Walters-Salas just added. As a clinical nurse specialist, I feel strongly that we have a lot of education in our background, and that we provide ongoing patient and family education on various topics that support patients within their environments. We took people through a supermarket and involved the whole family, helping them with life skills as far as making better choices and providing them that education. It is amazing who does not know how to read a label on packaging for food, so I do think that we need to provide that as a community service to help promote better eating habits. I would like to voice one concern about the use of texting to convey information to the young patients. I wonder about the privacy issues, and the liabilities that may ensue if we are not keeping some form of documentation of these messages and passing of information. It's great that we have these electronic advances, but one must be careful about confidentiality and potential legal issues.

Stephen Ritz: I want to thank everyone for their suggestions and Dr. Blackstone for the idea about e-mailing patients. It is always useful for me to learn other creative ways to try to reach patients and think differently myself. I thought the ideas about text messaging and Facebook were also interesting and intriguing.

Renay Tyler: I am going to bring the conversation to a close on that positive note. I want to thank each one of you for participating. This has been an informative discussion, and I know it will be helpful to our readers.