diabetes as a surgical disease.

[Veneficus]

Do people who engage in sports or dangerous recreational activities deserve medical care? They are making a choice that results in harm.

Why should joe tax payer have to pay for somebody who is a jobless 3rd generation welfare abuser sports injuries. When that energy could have been better spent on getting a job and being a productive member of society

Im not saying to judge as that is a personal thought. Im talking about using a point system like many. many other medical prodecures are scored on.

Transplant systems have this down and for a reason.

What if they were playing that sport to keep fit while they went to school in order to get a job?

You know part of the transplant selection is whether or not the person has the money for follow up care?

You may also be the best choice for recipient in the world on moral/social grounds, but if the HLA doesn't match, then it will go to a less desirable candidate.

There is also the reality that in the US, if you have money, you will go to the top of the list regardless of alcoholism or anything else.

 

[DrankTheKoolaid]

It is a flawed system without a doubt. But with limited resources I think we can do better then what is in place.

 

[Veneficus]

It is a flawed system without a doubt. But with limited resources I think we can do better then what is in place.

With that, I agree.

 

[Aidey]

In regards to the "why should we pay for X" arguments.

I believe everyone deserves healthcare within reason. I very firmly believe that non-medical interventions should be exhausted before medical interventions are performed. I also firmly believe that the most appropriate medical care is the care that has the highest chance of permanently fixing the problem. If drunk Joe Idiot wrecks his motorcycle and breaks his leg, there is no non-medical intervention to attempt and surgery is going to offer the most permanent fix. There are non-medical interventions that can be used in obesity, HTN and diabetes. Honestly, it wouldn't surprise me if the amount of behavior modification therapy and diet education needed to truly change the behavior of a obese person would be more expensive than the surgery to fix the guy's leg.

So from my point of view it isn't about not paying for anything, it is about paying for the most appropriate option. Just because we pay for surgery for a broken leg doesn't mean that NOT paying for bariatric surgery is treating it differently.

 

[mycrofft]

Long-term ( after a few years) Roux-n-Y and banding patients' weight loss profiles nearly equalize. Banding has a slower weight loss and is overall healthier except the little matter of a foreign object clamped around your stomach which can result in erosion, slippage, and too many adjustments (adding and subtracting saline from the collar's sleeve). Roux-n-Y has a faster decrease, but there are malabsorption issues and other self-image things like diarrhea, flatulence, and the very high percentage of patients consequently needing a cholecystectomy.

My family has morbid obesity as a multi-generational issue, and some of the comments here are just plain ignorant. I'm chalking them up to ignorance, otherwise the terms insensitive, simplistic, callow and callous come to mind. I learned a lot from going through this process with my spouse and it has re-colored my perceptions of many medico-social issues.

 

[mycrofft]

Speaking of diabetes as a surgical disease, where are these gene therapy and stem cell magic cures, especially for Type I patients?

 

[Dwindlin]

I think the failure rate would be proportional to the post surgical care including lifestyle modifications.

I am not fool enough to think a bypass surgery is going to be a one shot solution to obesity to replace lifestyle modification.

Just like I don't think HTN cocktails and statins are going to solve cadiovascular diseases.

And there-in lies the rub. If lifestyle modification worked we wouldn't need the surgeries in the first place. The problem is many who get these surgeries believe it is a magic bullet that requires nothing of them, hence they change nothing and eventually relapse. Honestly the ones who are successful with the surgery would have likely succeeded without it, albeit a little slower.

 

[Veneficus]

And there-in lies the rub. If lifestyle modification worked we wouldn't need the surgeries in the first place.

I think the point of the article was to consder these surgeries as a jump off point to lifestyle modification.

The problem is many who get these surgeries believe it is a magic bullet that requires nothing of them,

Not only do I think this is true of many surgeries, I have an anecdote.

I once pulled a 58 year old suffering from chest pain out of a rollercoaster car. His significant history? Heart transplant 1 year prior. He died... That day...After a helicopter ride...

 

[mycrofft]

And there-in lies the rub. If lifestyle modification worked we wouldn't need the surgeries in the first place. The problem is many who get these surgeries believe it is a magic bullet that requires nothing of them, hence they change nothing and eventually relapse. Honestly the ones who are successful with the surgery would have likely succeeded without it, albeit a little slower.

(Red letter accent added by mycrofft)

A prerequisite for a responsible surgeon is to force the patient to lose some weight, quite a bit of weight, by "conventional" means before taking them on as a client.

People who have undergone bariatric surgery are supposed to be indoctrinated that the surgery is serious, and only a leg-up on a modified lifestyle. Troubles arise because...
1. Patients relapse (see below).
2. Patients aren't screened (too much profit margin) for addictions, lack of maturity, mental illness
3. Significant others/family don't support the change in habits after the surgery has healed.

Not all patients totally relapse, most slide down to a certain plateau then slowly rise to anther one, generally below their max and either a lot healthier or a lot closer to healthy than before.

 

[Veneficus]

People who have undergone bariatric surgery are supposed to be indoctrinated that the surgery is serious, and only a leg-up on a modified lifestyle

I can tell you that not only do surgeons not think that way, they are taught that sugery is curative.

By the very nature of effecting gross changes in the body, it lends to the misconception that if it looks fixed, it is fixed.

As one of my soapbox issues, surgery and medicine are not seperate disciplines. We teach it as seperate, we set up the systemas seperate, but it is a flawed perception for the convenience of doctors.

If you notice, most surgeons qualify people for surgery, some still take part in post op care of a patient, but after that they are immediately turfed to a medical discipline. Who more often than not, tries to manage the patient as a pathology not only independant of other systems, but independant of social and economic realities as well.

Not only that, but the idea of "evidence based guidlines" actually promotes one size fits all and narrowmindedness and tunnel vision in providers.

In my experience, with the exception of a few odd primary care providers I have met, only intensivists seem to consider this global vision of a patient.(obviously out of necessity) But I have also noticed that new physicians who do consider it actually gravitate towards anesthesia and intensive care as a specialty.

Which means from a practical point, the only people actually considering the total organism as a whole are the ones who only see people who are near death. (even if they are inducing it)

With each new subspecialty, scale, protocol, and chart, medicine walks further and further away from global consideration of the body.

The details and solutions are too complex to discuss here. But suffice to say, sending people to an army of hyperspecialized ancilary providers is not the answer.

 

[mycrofft]

Vene, re the above, I largely agree wholeheartedly, and also feel the plethora of liposuction and "lap banding" billboards (!?!?) out to be banned.
The surgeon my wife went with has a sort of "boot camp" or steeplechase his prospective pt's have to clear before he even works them up for anesthesia. However, as you say, after healing, the surgeon's role is over and then who takes care? (Many of our primary care MD's are basically triageurs and referrer/gatekeepers for their respective medical systems and insurance companies).