Tuesday, May 15, 2007

Reticence and reversibility

We were trying to decide between RNY and MGB alternatives for our bariatric surgery, and while we'd heard the arguments for MGB, we hadn't really gotten a fair shake at hearing RNY's side. In all our extensive research, the few RNY doctors we'd heard had only been vague or spoken in anecdotes and speculation; they didn't talk like scientists at all. So we scheduled an appointment with the RNY surgeon, Dr. Spaulding, at Fletcher Allen Health Care in Burlington, in hopes she'd give us her side. After all, we have to choose a surgery before we can seriously begin the process of qualifying for it and getting it.

Between the time we scheduled it and the appointment, they instituted a new program where new arrivals in the bariatric program had a "pre-first-visit visit" in which they sat in front of a dull slideshow that covered the basics, and then got insulted by nurses for a little bit. This is very helpful for most people who, apparently, go to hospitals and doctors without even looking up what their condition means or what the surgery they're considering actually is. Not so helpful for us, as it turns out, since they cancelled our doctor visit in favor of this. We didn't learn anything we didn't know, and weren't able to get any of our questions answered. We wasted half a day of sick leave and several dollars in gas and parking for nothing.

When we complained, they set us up an appointment with Dr. Spaulding for this morning. We went in and got told right off that we'd be seeing a nutritionist and a psychologist to prescreen us for the procedure before we could talk to Dr. Spaulding. It was futile to point out that we weren't on the track for any procedure, we were just trying to get some answers. We were on the conveyor belt and there was no way to get anywhere other than down the assembly line.

So we sat through these post-pre-meeting pre-meetings, which we had to do separately because "that's how we do it", before we could finally talk to Dr. Spaulding. She was friendly and personable, but she also insisted on starting at the beginning, explaining everything in detail except for the bit we said we wanted to talk about: why RNY over MGB? But finally, going into our third hour there (not counting the hour drive each way) we were finally getting to the actual point of the meeting.

Her reasons for RNY over MGB: "Oh, I wouldn't recommend MGB." She added, "I know someone who did those for a while, but he stopped right away." When pressed, she suggested that there wasn't enough data on MGB to determine what its risks were (though she also claimed that they were greater) -- which is not true, they've been doing MGBs for 10+ years and have done thousands of them. Pretty much the same non-answer I have always gotten from RNY doctors which sounds suspiciously like what, in the non-scientific lay world, really means "I am against anything I haven't bothered to learn about yet." You expect that from used car salesmen, but you expect doctors to have a scientist's mindset, to base things on evidence and proof.

I didn't let it rest. We had spent two whole mornings on this and I didn't want to come away without the answer again. I pressed the issue. Her response was that I would have to schedule another appointment, as she had to be moving on.

I can understand that she only has so much time set aside for us and that her next patients don't deserve to be kept waiting. But we explicitly said our whole purpose in coming to see her (both times) was to ask this question. We said it when setting up the appointments, and then first thing when we got there, and first thing when she came in. Now she wants it to be yet another appointment.

And when we talked to the person who schedules appointments, she had no way to do so that wasn't the next step on the assembly line. Merely to come to another appointment would require us to again visit the nutritionist, who would in turn demand detailed day-by-day food logs with calorie counts. It would also be a meeting not with the doctor, but with the nurse who had berated us while providing no answers at our first pre-meeting-meeting. In other words, it would be yet another opportunity to not get answers, while being treated like an interchangeable part.

But in talking more about this, we've come to the conclusion that her answer was all the answer we really need. I don't just mean that the way we were treated is a clear answer that "we will not get a surgery here" -- that goes without saying. I mean that her lack of a good answer, compounded upon all the other lacks of a good answer, and stacked up next to the scientific research we've seen (though I have to read more of that more closely), is an answer.

More to the point, the clincher of the deal is reversibility. RNY is not really reversible -- it's been done, sure, but it's not usually possible and you shouldn't count on it. That means if you get cancer and need chemotherapy, you're screwed. Chemotherapy will make you need more nutrients than your RNY-altered stomach can supply, and you'll starve to death if you go on it, period.

There are other reasons you might need a reversal, but that's the big one. MGB is reversible and also revisable -- if you're losing weight too slow or too fast it can be adjusted, though naturally you don't want an extra surgery if you can help it. But if you need it, the option is there, and that's something the RNY people can't touch.

Settling on MGB also settles the open vs. laparoscopic question since MGBs are only done laparoscopically. It also settles the question of where to have it: the only place that offers them to people my size is High Point Regional Health System in North Carolina. Now we have to work out the logistics of how to get there to do this, for both of us (done at separate times), including followup appointments. We have to start the annoyingly repetitive and unnecessary six-consecutive-month medically supervised weight loss plan Cigna requires.

And, biggest of all, we have to work out how this will get paid for. Getting Cigna to cover a completely medically necessary surgery with an in-plan doctor locally is a challenge. Getting them to cover a surgery they classify (for no reason we can determine) as "experimental", with a doctor in NC who may or may not be considered "in-plan" on our plan, is going to be a bitch. High Point won't bill them, either; we have to get pre-approval and then pay for it ourselves (to the tune of $17,000 each) and hope Cigna comes through after. If it ends up being considered in-plan, and they pay, it'll cover almost all of it (except our travel costs, of course), but if it doesn't, we may have to shoulder 20%, which is more than $10,000 between us. Where I'm going to make that money appear from is a good question.

But at least we have settled finally what direction we're going, so now it's just a matter of overcoming all those obstacles.


MightyFrog said...

"You expect that from used car salesmen, but you expect doctors to have a scientist's mindset, to base things on evidence and proof."

I used to proofread Controlled Clinical Trials, a journal that provides some interesting insight into doctors' attitudes towards evidence. One of the industry buzzwords since the 1970s has been "evidence-based medicine." A surprising number of medical and surgical treatments are based on proof which would seem incomplete and flimsy to a chemist or engineer. Often, this is for good reason: double-blind, placebo-controlled trials are too dangerous to test every kind of treatment. More than this, many physicians contend that evidence-based medicine "treats populations, not individuals," i.e., ignores cases where an unusual treatment could be the right one for a patient and refuses to acknowledge therapies which show promise, but no definitive results.

None of this is meant to excuse the doctor you met with, incidentally; that just sounds like garden-variety medical arrogance. :)

Hawthorn Thistleberry said...

Comparative sstudy of laparascopic RNY vs MGB shows a strong conclusion. "Both LRYGBP and LMGBP are effective for morbid obesity with similar results for resolution of metabolic syndrome and improvement of quality of life. LMGBP is a simpler and safer procedure that has no disadvantage compared with LRYGBP at 2 years of follow-up." Wham. Science wins. (Note, this study wwas not done by "MGB people", it was a tthird party study.)