Starting a Bariatric Surgery Practice from Scratch

Abstract

This is the season when graduating fellows and trainees start their practice. For those who trained in Advanced Gastrointestinal Minimally Invasive Surgery and Bariatric Fellowships, an oft-asked question is how to start a bariatric surgery program. This is a loaded question and the philosophical response is usually “why do you need to start one”? In other words, is this something you absolutely want? Is this something your hospital wants and want to commit resources to? If both are true, you are in a good starting place.

The most ideal situation is to join an established program and work with existing practices. In this way, you adopt the culture of a mature program while introducing your own methods to create a fresh blend of best practices. However, not all new surgeons have this option and, at times, are blocked from performing bariatric surgery by covenant or by exclusionary policies. This is often difficult to overcome especially when the new entrant is outnumbered or outmaneuvered by established groups. In these instances, the only real way to start a practice is to form new alliances, either by working at a more welcoming hospital and group, or starting afresh.

Each practice environment will have its uniqueness including malpractice policies (cost and tail coverage) and practice performance evaluations, but there are foundational competencies any new entrant should look for when starting a bariatric surgery practice. The ultimate goal is to attain the minimum number of cases and gain accreditation or reaccreditation as a Centers of Excellence (COE) through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), keeping in mind that each insurance payer will likely require additional documentation to approve your practice as a bariatric center for clients. These are suggestions to gauge the possibilities: 1.

Floor nursing and facility: The nurses need to care and share in the excitement. Educate up-front and allow frequent phone calls to you in the early experience. Circle back after a few cases and debrief. When you see the patients in the office, give follow-up to the floor nursing staff. Eventually, encourage certification through the ASMBS-certified bariatric nurse route. Regarding the facility, floors that are accustomed to performing orthopedic and spine surgery usually have the setup to help bariatric surgical patients such as wider doors, easy access bathrooms, physical therapy, lifts, and so on. If I had to choose between nursing and good facility, I would choose nursing. Nursing leadership that is passionate about this patient group without judgment can make the difference between success and failure. I have visited other practices where the facilities were functional but not “five-star.” Nevertheless, all the physical shortcomings are quickly forgotten after witnessing the support that comes from all the nursing and staff.

Anesthesia willingness: You cannot take a patient to the operating room (OR) without anesthesiology. Start speaking to them about this. Gauge the level of willingness, handling of high body mass index (BMI) patients, obstructive apnea protocols, and any prior experience. Include discussions about bad experiences in the past that may taint your efforts. Lectures and discussions with the anesthesiology team are a good place to start. Find out the barriers to their buy-in. They want details of blood pressure cuff sizes, OR table capabilities, thromboembolic risk mitigation, airway issues, and case duration. From my personal experience, the more you understand what is important in anesthesia and you can converse in language that conveys your understanding, you stand a better chance. If they feel a patient needs to go to the intensive care unit after an uncomplicated surgery, allow it. In introducing a new procedure to anesthesiology, it is not a matter of how valid any objections are, but whether they trust you as a surgeon colleague. I recall my early days operating on a high BMI nonbariatric patient who lost airway due to an undiagnosed vocal cord polyp. I was at the bedside helping and then quickly provided a surgical airway. From then on, I could do no wrong with my anesthesiology colleagues.

Data collection: You can offer the best bariatric surgery services in the world but, without data, it will only be known to you alone. Without data on 30-day readmissions, complications, short and long range outcomes, reoperations, ongoing process improvement projects, you will not be able to report your experiences to MBSAQIP, any insurance payer, or to your hospital and to your patients. From the beginning, this information needs to be captured preferably in MBSAQIP format so you will be in good stead for COE application. A designated data personnel conversant in healthcare language is a necessary investment by the hospital. In hospitals already with other data collection systems (i.e., stroke, chest pain, and transplant), initially sharing such a personnel is a feasible option, but the amount of information upkeep will quickly loom as patient volumes increase. The data personnel should be supported by the hospital as COE designation is usually ascribed to the hospital and not the individual surgical group.

Radiology services: In everything we do, it is necessary to do a “what if” analysis. In addition to postsurgery examinations if you choose it, there are times you will need to perform additional imaging or even radiologic intervention. What are your options? Will the procedure tables or the scanning machines sustain a patient above a certain weight? What services are available on weekends? Are the radiologists shared between several hospitals making them scarce on weekends and nights? The robustness of radiology services should not rule out bariatric surgery, but there should be contingency plans. Before we had a scanner that can accommodate any one >500 pounds (227 kg), we had an agreement to transfer the patient to another hospital with such capabilities and bring the patient back. Just know the options.

Dietitian/nutrition: Every hospital has dietitian and nutrition services. The nutrition services team members always appreciate involvement in decision-making so involve them early. Most postsurgery nutrition counseling are too brief, at the bedside, with no great way to ascertain information retention. It is best practice to have all your nutrition counseling before surgery in any adult-learning format you like, followed by brief refreshers after surgery.

Operating room: ORs become the stage where all your work finally comes to fruition. When you are done with your fellowship, your skills are undoubtedly in the top quartile of your peers. For the sake of discussion, assume you have competent staff who have done well in other operations but have not seen a bariatric operation. It is normal to be wary of new experiences because it stems from fear of appearing incompetent or having a bad outcome. Your twofold job as the surgeon leading the operation is to establish competency and manage emotions. Competency means preparing. In your mind, know your operation and run it over and over again in your head. Dr. Raul Rosenthal from the Cleveland Clinic Florida calls it “mental conditioning.” Having sutures and staplers ready without sending people out to hunt and gather material during the case (mise en place) helps the operations flow. Showing key parts by video to the staff helps crystallize technical concepts. Most OR staff love learning new skills, so educating them helps engagement. Initially, go to the OR early and help with the setup and do not complain if things are not to your liking. Remember about gaining trust from the anesthesiologists? Same with the OR team. If they feel a certain positioning is better and it does not change the operation, allow it. For you as the surgeon, do the “what if” analysis. Suppose you find a staple line leak when you test it, are you prepared to oversew or redo the anastomosis? If the abdominal fat is too voluminous for you to perform a certain step, what options do you have? If the stapler misfires, do you have a plan? (Just my personal observation: opening the patient does not always make things easier.) What about the emotions of the team? Remember the cause of fear is likely the risk of failure or appearing incompetent. I have a saying, and most mentors have some version of it: “Don't worry. Whatever we break, I can fix it.” And even if you do not have a quick fix in your mind, you offer a “safety net” for your OR team who are doing the operations for the first time. It takes courage on your part and resolve not to take out your frustrations on the team. To show the team how you can calmly control a crisis no matter who is at fault is your ultimate test as a surgeon. The alternative is to blame someone or for a split second roll your eyes (i.e., signaling that someone failed or is incompetent), and watch how quickly all your preparatory work vaporizes. My colleague, and Associate Editor for Bariatric Surgical Practice and Patient Care, would say, “At the end, everyone in the OR needs to have had a good day.”

Medical team: When we first started our practice, we followed our patients for everything including skin rashes and dental problems. As the practice grew, we were able to bring in a medical team to help manage the nonsurgical issues and even manage hypertension. If this is not your infrastructure, partner with a primary care medicine team who can help manage these problems. Call and speak to them often about vitamin therapy, supplements, injection therapy, and laboratory studies. You can send an order set along with the patients to present during their follow-up with the primary care team. You will need a lot of this information for your outcomes database. Go visit the primary care team and explain the operations and post-surgery concerns. When a patient needs to be readmitted, it probably does not matter whose service the patient goes to as long as everyone knows there is seamless information exchange and care coordination. Take nothing for granted. There are plenty of surgeons who have little understanding of bariatric surgical procedures, so why would you assume nonsurgeons would know any more?

Office staff: Your office staff will make you look good or bring you disrepute. The office staff willing to speak with patients and fill the gaps that are not in any one person's job description can only enhance the patient's experience and care. If a prescription was not given to the patient upon discharge, is the choice to send the patient back to the hospital to pick it up or have your office generate another one? If the patient left a cane in the hospital, does your staff instruct the patient to call the hospital or do they try to locate it for him or her? The patient has some numbness of the left hand in the ulnar distribution, does your office say it is not what you do or do they say come in and be seen and then determine next steps? Does your office staff stigmatize the person with high BMI or make off-colored comments about heavy patients, and to make matters worse, not realize that the patient had not yet hung up the phone.

Hopefully, it is clear that all obstacles are surmountable, but you need to be strategic and deliberate about your approach. The new entrant has to do the hard work and there is little room to traffic half-hearted efforts. One can never prepare for every possible scenario and even if you do not seem to have every last detail in place, at some point you need to do your first cases and test the system, debrief and make adjustments. All this can easily take 6 to 8 months to start, so be prepared for it. If it takes longer to get started, you probably do not have enough support or momentum to start your program without a different approach.