I make no secret of the fact that I did a LOT of research on a great deal of Mexican (and American) doctors before making a decision on my own surgery and I think that because of that I receive a number of private messages asking how to research these doctors. I researched the dirt and the good information on all the docs I was considering. I had a bit of an advantage as I volunteer in Nogales, Mexico for a trauma surgeon. He helped me to a great deal of my own research and he was able to find out things I might not have known how to find myself. He taught me quite a bit about researching Mexican doctors.

I decided to start a thread that will give some starting points on researching doctors. I'm not saying my way is the best way, I am saying this is how I did it. I have learned a few things along the way so I'm going to post this for newbies considering surgery in Mexico.

The first post will be an explanation of what I was looking for and why. The next post will be a checklist you can print out and use as you call various doctors if you wish. It will help you organize the information because I promise you the more information you receive, the more confusing it will all be. You will go on information overload.

RESEARCHING MEXICAN DOCTORS 101

Surgery in Mexico is handled a bit different from the US. In the US you will receive a bill from each physician. The surgeon, anesthesiologist, internal medicine doctor, assistant surgeon, radiologist, etc. That is not how it works in Mexico. In Mexico you pay the surgeon for a “package” banding procedure. He pays all the other doctors.

In the US (for example) the anesthesiologists contract with the hospital and their agreements are with the hospital, not the surgeon. The surgeon does not always get to hand pick the doctor putting you to sleep.

People tend to assume the most important doctor in the operating room is the surgeon. Not so. It’s the anesthesiologist that keeps you ALIVE during surgery. HE is focusing on your breathing, your circulation, your heart, everything. The surgeon is focused on one thing, the surgery. In this case I tend to agree with the way Mexico does things. Do you want the surgeon you trust to pick the anesthesiologist or the hospital’s administrative contract folks, the folks paid to get the best deals? The surgeon is responsible for your surgery overall, he WANTS you to have the best person putting you to sleep. His reputation depends on it. His reputation means his entire career. Without a good reputation they have nothing.

So in Mexico the surgeon hires the anesthesiologist, not the hospital contract office people. This is an example of why it is a “package” cost in Mexico vs. individual bills in the US from all the various medical providers.

Which surgeon?

Avoid choosing a doctor that nobody has heard of before. There is little need to do that. Why take the risk? Doctors throughout the world have discovered that banding is easy and it has the potential to be extremely profitable. Many physicians are getting in the business, so there are a lot of inexperienced surgeons around. You really want someone that is very experienced. After a bariatric surgeon has done around 250 bands they are typically very confident in the procedure and aftercare. By that time they have seen every strange and bizarre anatomical problem, every odd issue that happens under fluoroscope during fills, etc. So you want to find someone that has done at least 250 bands.

Now, does that mean that someone who has done 3000 bands is better than someone that has done 500 bands? No, not really. Think about it, were you any better at washing dishes the 500th time you did the task vs. the 3000th time? Probably not. Either you get it or you don't. The same concept applies here.

Experience

How long has your doctor been doing bands? No, not how long he has been doing bariatric surgery but how long he’s been doing bands? That is the question you want to ask. Someone can do 4000 lap procedures but that does not mean he has done 4000 bands. A doctor can do 4000 lap procedures and they might all be gastric bypass or removing someones gallbladder. That is not what we are looking for; we are looking for someone very experienced in banding issues. We have different needs and requirements than folks who had bypass and the technique is extremely different for various procedures. There is a learning curve to each procedure and with each procedure the doctors becomes more skilled and faster at the technique. Do you want to be a part of the learning curve or do you want someone very experienced?

Skill

Skill, I think we should discuss skill a bit. Banding is the easiest surgical bariatric procedure to do. Yes, there is a learning curve but after the learning curve it is without a doubt the easiest procedure to do. That is why so many new doctors what a piece of the action.

Can your potential doctor do the hard stuff too? Can they do gastric bypass? Gastric sleeves? Duodenal switch (DS)? Can they do revisions such as bypass to banding? Many bypass procedures fail and the patient regains their weight. Banding them is not easy at all. Revisions are difficult. Would you rather have a surgeon that only does the easiest surgical bariatric procedure? Banding? Or do you want a doctor that is capable of doing the difficult and tricky procedures as well as banding? MOST doctors do not do all the tricky procedures, they just don't have the training, skill, or experience so they stick with the more simple procedure, banding. My personal preference is to have someone that can do it all, even the hard and tricky procedures. Some don't care, they just want a band and they are sure it will be okay. If you want a doctor that can do it all then ask about other procedures. Don't ask IF they can do the tricky and complicated procedures; ask how many they have done.

This brings up another issue. How many bands has a doctor really done? I know of two off the top of my head that have done less than 200 bands but one claims over 1000 bands on his website and another claims over 2000 on his website. Doctors are people like everyone else and some of them are less than honest. They know that if a patient is researching they are looking for someone experienced. If they told the truth that they have done less than 200 bands they know full well nobody will go to them. So they inflate the numbers so they appear far more experienced than they are. This is not just Mexico; this is with the US and other countries as well.

One doctor combines his stats with that of another. He has done about 100 bands yet his partner has done over 1000 bands so he claims he has done 1200 bands. It simply isn't true.

So read the boards, see the patients that are posting. If someone has done 2000 bands they are going to have patients posting. If they don't, question the numbers.

Patient Coordinators

If you post that you are looking for a band surgeon the patient coordinators are going to come out posting non stop. These are people that are paid to get you to go to their employer. Some of them have been banded and some have not. They will tell you anything you want to hear to talk you into going to their doctor as they usually get anywhere from $300 to $500 for referring you. I am not downing patient coordinators in general. The people I do not like are the people that lie about it. They do not tell you they are making a commission off of your surgery and that is the prime reason they are pushing you to go to one doctor and one only.

If you suspect someone is a patient coordinator do a search of their posts. If the majority of them are pushing a specific doctor vs. giving general advice and thoughts on a topic, it is probably a coordinator. We even caught one coordinator coming up with various screen names so that people would think her doctor has more patients than he does. When people disagree with her she comes up with a new identity, pretends she is another patient, and posts. People think this doctor has more patients and bottom line, he does not.

Believe NOTHING on line. Believe NOTHING that anyone tells you. Verify everything for yourself. I do not care who tells you something, verify the information for yourself. Verify the doctor's credentials, location, years of experience, number of ACTUAL bands, everything. Ask the doctor how many of each brand of band he has placed and then call the band manufacturer and ask if they have actually sold that many bands to that given doctor. One doctor claims to have done 2500 Inamed bands but Inamed disagrees. They have sold him well under 500 bands. One needs to be certified to purchase bands from Inamed. The only place doctors and hospitals can obtain bands is directly through the company.

Booking Agencies

This is another area of consideration. Do you want to deal with a booking agency? Some do, some don't. It comes down to personal preference. Booking agencies are paid to advertise for several doctors, they contact the potential patients, they schedule surgery, and they let the doctor know who is coming, for what procedure, and when. They deal with all the issues before and after surgery. Do you want to deal with a booking agency or do you want to deal with the doctor's office directly? Again, there is no right or wrong answer, it is personal preference. Personally, I want to deal directly with my doctor's office. I don't want to deal with a booking agency, some are quite good, and some are not. Just make sure you are dealing with a quality agency.

Where in Mexico?

Now you need to think about if you want surgery near the border or deeper into Mexico. This is something that is purely preference. Some people want to make a mini vacation out of their surgical trip and others do not. Some want to go to Monterrey for a few days ahead of surgery and have a little fun. Others (like me) want to be close to the border. If something happened I wanted to be close to the US. Again, it is a matter of personal preference.

Hospital or clinic?

This is another issue of personal preference. Some people do not mind, others do. Some clinics are absolutely fine and perfectly safe and clean. I preferred a hospital vs. a clinic and the reason is potential complications. Let's be realistic, we are fat. Fat people carry more risk for complications such as heart problems, throwing blood clots, etc. If you have a serious complication in a clinic you will need to be transported to a hospital. Life in Mexico is not like life in the US. In the US if you have a problem in a US surgical center they dial 911 and you are at a hospital within minutes. That is not the case in Mexico. Yes, they do have emergency services but it is not similar to the US. They will get to you when they can. That is not immediate. For that reason I personally preferred a hospital. The risk for banding complications is quite low but it does happen. If it did happen I wanted to already be in a hospital.

Price

What about price? Many make the mistake of shopping by price and quite frankly there are times in life that you really do get what you pay for. Cheaper is not always better. Keep in mind that with Inamed and Johnson & Johnson bands the cost to the doctor is $2000 per band. That's what the doctors in Mexico pay for the band. If the doctor is really cheap he is cutting corners somewhere or... he is so bad that the only patients he gets are people shopping for price vs. surgeon skill. There is also little need to go to the most expensive doctor. Expensive does not mean skilled, it means expensive.

Patient Testimonials

Patient testimonials are critical to read. Go to www.obesityhelp.com and research your doctor. OH makes it very difficult to research Mexican doctors, they make it quite simple to research US doctors. For Mexican doctors you need to research by specific name vs. US doctors you can research by geographical location. There should be plenty of patient testimonials. If there are not, that might be a problem. See what the trends are. There will always be patients that no matter what is done they will never be happy so if there are 0.001% of testimonials that are not great, look at the overall picture. If people are happy they will say so if they are taking the time to write a testimonial. Just make sure to read the opinions of a LOT of patients and not just a few.

Talking to people on line is a great way to get an idea of doctors. But talking to a few people and feeling that they did well during surgery and that's your research, that is just dead wrong. You need to read at least 100 patient testimonials or talk to at least 100 people about their surgery.

Do a www.LapBandTalk.com search on the name of the doctor you are looking at. Read it all. Do not ignore the bad, read it. If you have questions send the author a private message. There are two doctors I can think of that have the absolute worst reputations in Mexico yet people are unwilling to take the time to do a search on their doctor and they are surprised after they announce they are going to Dr. "X" and people are shocked. People will try to warn them and tell them they are not going to a skilled surgeon but they refuse to listen and it is typically price that formed their decision or they really "like" a poster and that poster went to Dr. "X". Some people are simply sick of researching so even when they realize they did not choose the best physician for them, they go anyway. Others are desperate for a band and they no longer care about skill level. Be very careful and do the research.

I know of one person that had two friends that went to a specific doctor and that was her research. That's it, that is all she did. She went to the same doctor and ended up with an infection so severe she will lose her band. Actually, she probably already has lost it at this point. She also went to one of the two worst surgeons in Mexico. It happens all the time and it is not just Mexican doctors that cause infections, it happens in the US. You are not going to all the expense and trouble to be banded just to lose your band (and potentially your life) to a crappy surgeon. Do your research.

People make huge claims here about their doctors and they simply are not true. "My surgeon is a LEADING" surgeon in banding." Well, what does that mean exactly? What is a leading surgeon? "My surgeon is a TOP banding surgeon." Says who? Who makes these claims? I'll tell you who makes them; the doctors make the claims about themselves. I can say I am a "LEADING" nurse, does that mean anything? Does it make it true?

Pre-Op Testing

This is critical to have a safe surgery. You should get AT LEAST a complete blood count, chemistry panel, urine test, EKG, and chest x-ray. Do not settle for anything less. If the doctor does less testing than this he is pinching pennies in all the wrong places. This is your health, you are paying for these tests, make sure you get them. I know of one doctor that claims he does an EKG during surgery. That is NOT an EKG! That is a heart monitor and it does not have the same information as a full EKG. Besides, one of the issues they are looking for during surgery on the heart monitor is if there are any heart changes due to the anesthesia. If you didn't have an EKG before surgery how will they know if there are changes due to anesthesia? If you don not get these tests that you are paying for, the money is just going in your doctor's pocket instead of your health care. You are the consumer here, insist on the appropriate testing. Do you want your money for banding going towards your health care or your doctor’s new swimming pool? Bariatric surgeons are not typically hurting for money. They are being paid to do ALL the tests, get them done.

Post-Op Testing

This should be a barium swallow that is done after surgery. One doctor's office claims they cannot do a barium swallow after surgery because the barium is too thick. This is simply untrue. Barium comes in a powder form and it can be made as thin or as thick as needed. It can be watery or it can be very thick. The only reason for not doing a post op barium swallow is to save the doctor money. Again, this is a procedure you pay for, make sure you get it.

You want a barium swallow after surgery for various reasons. Example: What if you get home and have some sort of complication? You are going to have to have it done anyway and at home you'll be paying full price and your insurance is not likely to cover it. Considering you already paid for it in your surgery package you should have had it. You should be given the films to take home with you after this test when done in Mexico along with all your labs, EKG, etc.

You also want this test to make sure you are safe to travel back to the US. A barium swallow makes sure that band placement is correct, Fluid is traveling through your stoma, and there are no unexpected medical problems. It also does a great deal for you as a patient. When you can actually see the band and see the band working with your own two eyes, this makes a world of difference. It puts things in perspective for you as a patient.

What if you go for your first fill and your fill doc does not use fluoro? It is nice for him to see the films so that he can see where your port is and believe me, that makes it easier for you while he is looking for your port.

So there are many reasons to get the barium swallow after surgery. If your potential doc does not offer this important test, find a new doctor. You are paying for it, so get it.

Nude/Semi Nude Photos

Some doctors in the US and Mexico require pre op photos, some do not. Some require photos of you nude, some give paper undergarments to wear, some take pictures of you in your bra/underwear, some take photos fully clothed. They don’t typically tell you this until you arrive for surgery. You should probably ask if this is a requirement. If you choose to decline ask if they will decline to do your surgery. Quite frankly, that would have been a deal-breaker for me. I declined to keep any photos of myself at my highest weight and those were photos of me fully clothed that I owned, I would have never agreed to nude/semi nude photos for a doctor and his research. But not everyone has a problem with this.

The reasons for photos vary. Some are using them for research. Some want to be able to prove the surgery was necessary if it ever becomes an issue. But you have the right to not have nude/semi nude photos of yourself or photos of you at your largest floating around this world where they are out of your personal control. It is your body, do what you believe is right. I have yet to hear of any such photos being compromised so that isn’t the issue as much as the issue of your right to privacy. Do what is right for you, not your doctor when it comes to these kinds of photos.

Supervision

Regardless if you have surgery in a hospital or clinic you should have a certain amount of medical supervision. If you are in a hospital you will have that. If you are in a clinic you will have it. What about after you are discharged? It is quite common for patients to be sent to a hotel for an extra day of recovery while in Mexico. Some physicians do this, others keep you in the hospital the entire time you are in Mexico after surgery. What kind of supervision is there for you in a hotel? Is someone coming to visit you and check on you? Are they at least calling you? All doctors will tell you they are available but this is where you need to talk to other patients that went to that doctor. Ask them specifically, how much interaction did they have with the doctor or his staff while in the hotel.

Pre-Op Diets

It is common for doctors to put patients on a pre-op diet before surgery. Many still say it is to shrink the liver, but that isn't quite true. The reality is that if someone is on a low-carb, low-fat, adequate-Protein diet of some sort they will lose weight and their liver will have less of a "slimy" feeling to it. It won't slip around as much during surgery. Every 10lbs you lose before surgery it makes it easier for your surgeon to do the procedure. The easier the procedure is for your surgeon, the safer it will be for you.

During surgery there are several incisions made and one of them is basically to hold the liver out of the way so the doctor can get to your stomach and secure the band around it. If it is slippery and difficult to manage, it makes it more dangerous for you, so the pre op diet is indeed quite important. Studies show that the liver does not actually start to shrink in size until you have been on such a diet for about six weeks or longer. Again, it is still quite important to follow the diet for your safety. Some doctors do not require the diet because it does not actually "shrink" the liver. Others do. It comes down to surgeon preference. Some doctors only require it for a specific BMI or higher. You need to ask about the pre-op diet and you need to know specifics.

Post-Op Diets

Most people believe the post-op diet means that when the stomach swelling is gone they are good to go and they can eat anything they wish. That is NOT the purpose for the post-op diet! Just because you CAN eat solid foods does not mean you SHOULD eat them. The diet has little to do with swelling and a great deal to do with other issues. But that is a post for another day. Find out what your doctor's post-op diet is, make sure you understand it well, and if you do not then ask questions.

Surgeon’s Staff

How easy is it for you to reach your potential doctor's staff? Keep in mind, when you are a potential newbie they will be on their best behavior. They will return phone calls and emails much faster than they will after you are scheduled and have surgery. So if you have a difficult time reaching the staff before surgery, what will happen if you have a problem after surgery and need to reach them? What about the middle of the night? Who answers their phones then? Remember that if you have problems in the middle of the night after surgery you will need to have someone you can contact in a pinch.

Statistics

You should ask your potential doctor's office about his stats for infection, slips, and erosion. Infection stats should be less than 1%. Keep in mind, not all infection is the fault of the doctor. There was a person I recently read that posted she went swimming in a public pool 4 days after surgery. Her post op instructions specifically said not to do that. Children PEE in public swimming pools; do you want your newly healing incisions soaking in pool Water with urine? If you do that and you get an infection is that the fault of your doctor? Even though it isn't his fault it will still go against his infection stats, so keep that in mind. Even so, infection should be less than 1%. MUCH less.

I am of the opinion that most slips (not all) but most are the fault of the patient. Not eating the right foods, not chewing well enough and PBing, etc. Global slip stats according to Inamed are around 3% so your doc's slip stats should be less than 3%.

The latest thinking is that erosion is from a band that is too tight. That can be a band that was too small for the patient at the time of surgery or the patient got a fill that was too tight and they did nothing about it. Global erosion stats according to Inamed are 1.3%, so your doc should be well under 1.3% for erosion stats.

There is one doctor who has a 4% erosion stat. When it came out on the boards that this is a concerning number they changed the way they word things. Instead of saying >1% infection, >2% slips, and >4% erosion he now combines ALL stats and says that his stats are less than 3%. He's just averaging them out to avoid the truth of the 4% erosion figure. An overall complication of about 3% doesn't sound NEARLY as bad as 4% erosion. But do people pay attention to these things? NO! They don't. So be very careful to ask for each individual statistic.

There is another trick to watch for. Ask your potential surgeon how many bands he has placed. Then ask if his stats for infection, erosion, and slips are the figures for 100% of his bands placed or if they are for a smaller number. If a doctor has a given statistic of 4% for slips, erosion, or infection but he will only provide you with the statistics from a given group or given study, those are not true figures.

For example, if a doctor claims to have done 1000 bands but claims an erosion statistic of >1% for the last 300 of those bands, why isn’t he telling you his true erosion statistics for all 1000 bands? They get tricky and you have to see what they are doing. They are being honest in the sense that they are telling you their statistics but only the good statistics. They are hiding the bad (and more accurate) numbers from you. This is another reason you need to research and this applies to US doctors as well as Mexican or any other country.

If they are a good doctor with a proven track record there is little reason to be deceptive, play games, and hide facts as their reputation and background should speak for itself. But do stop and think about it, if they are attempting to hide figures from you - they are doing this knowing full well their deception. Is this the surgeon you want to trust your health care and your life?

If you contact them again and the give you three pages of nonsense that still does not answer your specific questions, they are attempting to talk around your questions. No good physician will attempt this. They will just bloody well give you the numbers you have requested. If it is like pulling teeth to get the actual numbers, walk away. Find someone a little more honest.

Which band will you receive?

There are currently two brands of bands FDA approved in the US. Inamed and J&J. J&J was only recently approved for use in the United States, and many US doctors may not have experience with them. Remember this when you are arranging aftercare. It will be hard to obtain a fill for bands other than these two brands, as a US doctor can have problems with the licensing board if he works with a non-FDA approved device. Take this into consideration. If you get an Inamed brand band you should be given the empty box, an instruction book, and an ID card showing the size and type of band you have. If you get a J&J band you should receive the empty box, two booklets, and an ID card. You may need these items to prove to a US doctor that you have an FDA approved device so they can do your fills. Not all doctors require you to show them the box and information but some do.

Transportation

How will you get from the airport to the hospital or clinic? What about the hotel? Does the doctor provide this? Most do. You should have no additional transportation expenses and this should be taken care of for you by the MD office. You should be able to take $50 with you for incidentals, tips (airport, etc.) and dinner before surgery. Everything else should be included in your surgery package.

Finding a Fill Doctor

Make sure you an find a doctor within driving distance of you before heading to Mexico for surgery. Some live close enough to the border to drive there, for others it is an inexpensive flight for fills. Regardless, you need to work out a fill person BEFORE having surgery in Mexico.

Me either! I'd love to see the research this presentation was based on. It boggles my mind.

I wonder if part of it isn't that soooo many cheat on the post op diet and when they cheat, they really go for it. Fried chicken, etc. I wonder if this isn't just to get people to be a little more compliant.

Edit to add: This would also explain the drastic increase in future slips as well. People believe they are safe if they don't slip while eating the wrong foods. Not true, the post op diet sets the tone for the life of the band.

Yup, it will be very interesting to see what the slip rate is in say three years.

This is a great thread you two.

And just an FYI for you, Lauren: At the ASBS convention this past June (when they released the AP band) there was a presentation about the post-op diet and guidelines for revision to allow softs to solids much earlier than before. I notice that Allergan hasn't changed their reccs on their website yet, but I found it interesting that someone would present to a group of bariatric surgeons that it is okay to eat earlier. Perhaps your doc had read the latest from the convention and that is what made her put less emphasis on the post-op diet.

I have to wonder though if part of the reason for the change in diet comes from patients complaining and griping about being hungry so much. And/or if the change was intended for AP band patients only.

But thinking logically about the stomach and it's action to digest, I can't imagine that speeding up the post-op diet would be fine and dandy. But I'm not a surgeon and I'm not a bariatric researcher. Of course, one can always go slower on their post-op stages themselves.

That's interesting. I have to say that I am VERY careful now, just because I am terrified of PBing or vomiting, in case it would cause my band to slip. I take anti-nausea pills at the first sign of nausea (thankfully, only had to a couple of times), and I am completely neurotic about chewing.

I've even told people in PMs lately that while it isn't a good idea to go faster than your post-op diet allows, it won't hurt anything to go slower than it requires, just to be on the safe side. I kick myself every day that I did what I did after surgery. Unfortunately, there's nothing I can do at this point to fix it, all I can do is be careful.

I posted this last July. It is a copy of an article I found while doing research before my surgery. I hope it's helpful. Good Luck!.....Banded by Doctor Francisco Gonzalez, Tijuana Mexico.

How to pick a WLS surgeon by Ken Miller

Surgeons, surgeons, surgeons! They’re everywhere! You can’t turn on your TV or read a magazine these days without seeing an article or an advertisement about one of the hundreds of surgeons who are now performing some type of weight-loss surgery. News of the rising tide of obesity in America is being matched article by article and celebrity by celebrity by a rising tide of weight-loss surgeons and hospitals who recognize a gold rush when they see it. All that advertising and noise about different procedures and different surgeons can make for a lot of confusion.

It’s a mistake for you to simply go see the surgeon that cousin Jane went to, and undergo the same WLS procedure she did, just because Jane looks like she’s really doing well right now.

What are the important factors that you should consider BEFORE you put your life in the hands of a particular surgeon? I’ve been studying this question for about two years now and I’ve interviewed many WLS patients, both in person and through the forums at Bariatric Support Centers International (Bariatric Support Centers International :: Success Habits Of WLS Support) and I believe I’m ready to suggest a process that a WLS investigator, like you, can use to find the right match between your needs and the experience and surgical skills, and pre and post-op education and support programs, that a particular surgeon can offer you.

The FIRST, and perhaps the most important step, is for you to: Decide which of the various procedures being performed today is right for you. It’s a mistake for you to simply go see the surgeon that cousin Jane went to, and undergo the same WLS procedure she did, just because Jane looks like she’s really doing well right now. Each type of WLS procedure carries with it a unique set of advantages and disadvantages over the others. Even if Jane really studied and thoroughly understood what all of the advantages and disadvantages of each procedure are, her choice of the best one for her may not necessarily be the right choice for you. You are the one who will live the rest of your life with the benefits or consequences of your choice, not Jane, and not your surgeon.

Make sure you have the right procedure for you, even if you have to travel a significant distance to get it. There are hundreds of internet websites where you can study the various procedures and WLS patient forums where you can obtain advice from many different people who have had one of those procedures. Make sure you do your homework first. THEN go looking for the best surgeon to perform the particular type of surgery you believe is right for you. If you go looking for a surgeon first, you could easily end up with the wrong procedure and the wrong surgeon for your needs. Narrowing down the list of procedures to the one you really want will automatically narrow down the list of surgeons you’ll need to examine. If they don’t do the procedure you want, don’t waste your time investigating how good their skills or their program are because those things are secondary to getting the right procedure for you.

Second: Make a list of all the factors that are important to you as you consider surgeons.

Your list might look something like this:

• Price (and cost
  
• Insurance Coverage
  
• Close to home
  
• Hospital reputation and the qualifications and experience of its staff and facilities
  
• Bedside manner of the surgeon and nursing staff
  
• Years of experience in the WLS field
  
• Experience performing your chosen procedure
  
• Understands newest techniques and equipment
  
• Mortality and Complication statistics
  
• Who trained the surgeon in WLS procedures
  
• Nurses’ opinions
  
• Thoroughness of pre-op testing and education
  
• Scheduled post-op follow-up visits with the surgeon – is the price of these visits extra, or included in the surgeon’s initial fee?
  
• Scope and reputation of post-op education and support programs – are they available where you live?
  
• etc

As you write down your list, it will become apparent that you’re going to have to make some tradeoffs as you put your list in priority order. For instance, which is more important to you; insurance coverage (price?) or the surgeon’s years of experience performing your procedure? Before you automatically answer, “Insurance coverage,” perhaps you should look a little deeper at this issue. Don’t assume that the “list of providers in your area” that your insurance company gave you is a complete list of all your choices. Sometimes insurance will cover the same procedure by many surgeons who are outside of your local area, and sometimes it can be less expensive to travel to another area of the country where you could receive the same procedure from a very qualified surgeon for significantly less money than it would cost to have surgery in your home town. Yes, insurance coverage may be near the top of your list, but it doesn’t necessarily have to be at the top of your list where it over-rules every other decision you will make.

If you’ve been paying attention, you have realized by now that no one can give you a pre-prioritized checklist so you can mark off the items as you move down the list and then the best answer for you will simply fall out at the bottom of the list. But, we can help you understand some things that might belong on your list that you may not have considered before. With that in mind, let’s briefly discuss each of the items on the above list and point out some details you should consider as you evaluate your options for a qualified surgeon. Obviously, these are not in any particular order, because the final order that’s right for you will be different than the list for many others

Experience performing the procedure I want.

Mark Twain said it best: “There are three kinds of lies: lies; damned lies; and statistics!” As you interview your prospective surgeon (or his office staff) about their experience performing weight-loss surgery, make sure you listen very closely to how they express their statistics. Don’t accept statistics that are jumbled together with a lot of other numbers that don’t really apply to your question. For instance, if you ask for the number of surgeries performed by the surgeons at a particular practice, don’t simply accept a total number for ALL of the surgeons who have ever worked there. A particular practice may have performed 10,000 gastric bypass operations, but none of the individual surgeons have performed that many. You aren’t going to be operated on by all of the surgeons. There is going to be one surgeon in charge in the operating room with a scalpel in his/her hand and they are going to be totally in-charge of what happens to you while you’re there. You need to know how many times each surgeon in the practice has performed your chosen procedure – not how many surgeries all of the surgeons have performed; and not how many total weight-loss procedures each surgeon has performed either. A surgeon may have been performing a particular procedure “open” for 15 years and has performed thousands of that particular operation during those years, but he may also have next to zero experience performing that same surgery laparoscopically. Valid, well researched, statistics show that it takes a lot of practice for a surgeon to become an expert at performing some of the more complicated WLS procedures laparoscopically.

You probably don’t want to be the first patient in line for a surgeon to practice on. Granted, somebody has to be first, but are you sure you want it to be you? Maybe you do, but at least you should know you’re one of the first; and if you ask the right questions you will know how much experience the surgeon actually has performing the exact procedure you want to have.

Surgeon’s Age and General Surgery Experience vs Recent Training and Ability to Manipulate Laparoscopic Instruments.

There is a very interesting tradeoff that you may encounter as you choose a surgeon. Older surgeons who may have been performing a wide variety of “open” surgical procedures for many years may have more experience than a young surgeon who is relatively new. The older surgeon may have much more experience dealing with the diagnosis and treatment of complications following the actual surgery than a new surgeon may have. But . . . a newly trained, young surgeon may be much more skilled in the use of laparoscopic instruments (that are used for the majority of WLS procedures these days) than an older surgeon might be. Newer, younger, surgeons might have much more experience mastering the type of eye-hand coordination that is required of a laparoscopic surgeon than the older surgeon has developed.

The rise of video games in the last 20+ years has produced a generation of people, including new surgeons, who have thousands of hours of practice watching a video monitor and matching the movements that occur on the screen with the movements of their hands that are not directly connected to the objects on the screen and are not directly viewable with their direct line of sight. Some older surgeons who are accustomed to looking directly at a patient’s internal organs through an open hole in their abdomen are not able to make the transition to performing laparoscopic surgery with a level of skill that can match many of the younger surgeons.

Only you can decide which is more important to you in choosing a surgeon; years of experience in general surgery or specific training and experience in the use of remote instruments and monitoring devices. Of course, there are younger surgeons who are very capable of handling post surgery complications and there are older surgeons who have skillfully made the transition from open surgery to laparoscopic surgery. But, how do you know who is skilled and who is not? That brings us to our next subject . . .

Mortality and Complication Statistics.

Let’s talk about what I personally believe to be the most important information you can use to evaluate a particular surgeon – their own personal mortality and complication rates. Some surgeons who have been performing WLS procedures for more than about ten years may not have kept statistics prior to that time, but every reputable surgeon keeps statistics these days. Not keeping statistics on the outcome of his patients’ complications, or not being willing to share those statistics with a prospective patient is a big warning sign that should set off alarm bells in your head.

The fact that a surgeon may not have kept statistics, or may choose not to publish them, does not automatically mean that he or she is a poor surgeon. But, it does mean that you have no way of accurately comparing how well their patients do compared to other surgeon's patients.

Modern medical facilities, like every other serious business in today's world, know that the only way to really tell if you are making progress in refining your techniques and practices is to keep statistical track of what happens when you make changes to the way you do things. If a surgeon is simply processing bodies and is not seriously keeping track of what happens to those bodies after he operates on them, he is not responsibly keeping track of the results of his “practice”. In today’s scientific world, its not enough to just THINK your results are OK; the means is available to every surgeon and hospital to track and evaluate their outcomes against national norms. If the surgeon you are investigating does not keep personal statistics and willingly share those numbers with investigators like you, I believe you should seriously consider finding another surgeon.

What kinds of things should you look for in a surgeon’s statistics?

• How many WLS patients has that surgeon operated on and what time period have those patients been spread out over?
  
• How many of his patients have been “open” and how many have been laparoscopic?
  
• What percentage of the surgeon’s practice is devoted exclusively to WLS?
  
• How many of his patients have died?
  
• What percentage of his patients are released from the hospital during the time period that he describes as a “normal hospital stay,” and how many of them have to stay longer? It doesn’t take very many days in the hospital to add up to a very big bill if you are one of those who have to stay longer than normal because you had complications and neither the hospital nor the surgeon are going to discount their fees for services if you have to stay longer than you originally planned.

Check to make sure that all of the statistics you get are telling the whole story, not just the parts that an ad man decided to tell you about in an advertisement or brochure. For instance, do the mortality and complication rate statistics cover ALL of the patients the surgeon has operated on, or did someone reset the statistical clock at some point in time so the numbers only include the last year of the surgeon's practice? Are you getting mixed numbers that indicate that the surgeon has performed 2,000 surgeries in the last five years, but the mortality statistics only cover the last year, because the surgeon had a string of deaths that occurred a little over a year ago and his numbers look better if he quotes the total number of surgeries that he's performed, but only quotes the percentage of patients who have died in the last year. I know, this sounds very skeptical and implies that there are surgeon's out there who would intentionally mislead you. We'd all like to believe that every surgeon is honest and reputable, but the fact is that surgeons are like every other group of human beings. Some are truthful and some are not. I believe that the vast majority of surgeons are reputable and would never consider doing anything that even remotely resembles the situation I've just described, but I believe I have an obligation to describe some worst case scenarios so you'll know what to watch for. Remember, the purpose of this article is to suggest ways that you can sort out which surgeon is right for you and which one(s) are not right for you.

What kinds of factors might influence you to choose a particular surgeon even though his statistics might not be as good as another surgeon’s numbers? Alice Vodicka, a former patient and bariatric support coordinator for a very well known bariatric surgeon, expressed it this way: “Pick a surgeon based on his/her ability to take care of you if problems arise . . . choosing the right surgeon means finding the one that can handle the complications. Make sure your surgeon has been performing bariatric surgery for quite some time and that he has been able to competently handle the problems that arise, as opposed to sending you to a more experienced surgeon to resolve problems.”

All weight-loss surgeons have patients with complications. All weight-loss surgeons, who have been performing WLS for very long, have had patients who died from complications that arose during or following surgery.

Many complications are not the fault of the surgeon; they are a normal part of the risk that goes along with the intensity of a particular type of surgery and with the general size and health of WLS patients. I know Alice’s surgeon takes on patients who are much larger than many other weight-loss surgeons will accept as candidates for surgery. Working with larger, more fragile patients will negatively affect his statistics. He knows these are higher risk patients when he accepts them, and they understand that his statistics are naturally affected by his willingness to operate on higher risk patients. Many of them also understand that by choosing to operate on more difficult patients (who many other surgeons have turned down) also means that he will naturally have more experience knowing what to do when his patients experience difficult complications during or after surgery. Alice, who was not one of the super-morbidly obese patients we’re talking about here, believed if there’s a good chance that she might have a serious complication, she wanted to be in the care of an experienced surgeon who had lots of experience saving the lives of patients who knew their personal health problems had already stacked the odds against them before they went into the operating room.

Complication and mortality rates can be difficult to compare because not all surgeons are required to keep the same statistics and they can choose how they present those statistics to the public. If you are not familiar with how to interpret statistical numbers, don’t just give up and decide you can’t use them to evaluate a prospective surgeon, find someone who is knowledgeable and who can interpret them for you – perhaps a relative or your family practice physician can help you with them.

One last thing about statistics; carefully consider the source of those numbers. The best place to get them is from the hospital(s) where your prospective surgeon operates. The second best place to get them is directly from the surgeon’s office. The worst place to get them is from someone in an internet chat room or from cousin Jane. If the hospital will give you complication statistics for individual surgeons, they will be presented in the same way for every surgeon operating at that hospital; they won’t be presented in a way that makes one surgeon look better than his numbers really are. If you get them from the surgeon’s office, they will likely be presented in a way that minimizes the problem areas of his statistics, but the numbers you get will probably be true because it would be a total disaster for a surgeon to present false numbers to patients and then have those numbers be revealed as false in a malpractice lawsuit. If the surgeon has performed both “open” and laparoscopic WLS procedures, get their statistics for each category of surgery listed separately so you can see what the surgeon’s patients’ outcomes are for the type of surgery that you are considering. An individual surgeon can hide poor laparoscopic stats in the midst of good “open” procedure stats, just as a group of surgeons can hide poor performance by one surgeon on their staff amidst the better statistics of his more qualified partners.

Do not trust or believe “statistics” that you hear in internet chat rooms; no matter who you hear them from, including the surgeon himself. We work with patients and surgeons from all across the United States so I've had the opportunity to see first-hand some situations that most prospective WLS patients never get to see. I’ve personally witnessed groups of patients gush many times about how great the statistics were for a particular surgeon’s practice, while the surgeon himself was there in the chat room, listening to the false numbers, and remained silent while inaccurate statistics were passed along to unsuspecting patients and investigators. Patients commonly pass along glowing statistics about mortality, complication and success rates to new investigators . . . who then pass them on to others. Be careful where you get your numbers, and if you can’t get any accurate statistical numbers from a responsible source, be even more careful about choosing that surgeon or practice.

Bedside Manner

Which is more important to you, a surgeon’s skills in the OR, or their personality skills in the examining and recovery rooms? You don’t always have to choose one or the other, but many times there is a tradeoff you must make. Some people are comfortable placing their life in the hands of a surgeon who has lots of experience and great statistics, but who is arrogant or standoffish in discussions with them prior to surgery; and others cannot seem to trust a surgeon’s technical skills unless they feel comfortable with him outside the OR. Of course it’s quite possible to find surgeons who possess both skills, but some surgical nurses tell me that surgeons seem to be particularly prone to developing one skill or the other. Many doctors become surgeons because they have great technical operating skills but they lack the personality to be good pediatricians or family practice docs. Others may not have the surgical skills, but they are able to make a living as a surgeon because their personality or bedside manner skills are highly developed and many patients naturally trust their surgical skills because the surgeon is such a nice guy.

Again, in my estimation, the best way to cut through the real questions that arise from this issue is to examine their statistics. The last thing you want to do is choose a surgeon who has thoroughly honed his people pleasing skills at the bedsides of patients who have spent months in the hospital recovering from complications that were the result of his inadequacies as an actual surgeon. I know of one particular surgeon who really excels in this area. His patients, many of whom have spent months in the hospital or have returned to the hospital for many additional surgeries to repair the complications that came as a result of their initial WL surgery, sing his praises far and wide. With the hint of a tear in their eye they tell their friends and WLS investigators that they would have died if it weren’t for their doctor who “saved” them. This is one of the major reasons NOT to simply accept cousin Jane’s opinion about who is the best surgeon. All surgeons have successful patients; even the least qualified surgeons have a certain percentage of patients who recover nicely. Because a particular patient came through surgery without complications is NOT a reason to believe that the next patient will do well with that same surgeon. Again, look at their statistics. Their proven statistics will give you the best understanding of what your odds are of being complication free when you leave the OR.

Nurses Opinions.

Perhaps the best group of people who can answer your questions about surgeons is the nurses who work in the O.R. and on the recovery floor in the hospital where your potential surgeon operates. These nurses are exposed daily to the immediate results of a surgeon’s skills. They know who the best technical surgeon is in their hospital and they also know who has the best bedside manner. In my estimation, the best way to choose a surgeon is to obtain the statistics of the surgeons you are investigating and then compare the results of those statistics with the opinions of the nurses who work with them on a daily basis. Nurses’ opinions can be hard to obtain however. A hospital is a very highly charged political environment and the last thing a nurse needs is a prospective patient running around telling everyone that “Nurse Smith told me that Dr. Suess has the best bedside manner, but Dr. Welby is the best surgeon.” Most nurses will refuse to answer your questions if they feel there is any possibility that you will pass on what you heard from them to others. Also, most nurses will avoid giving you a clear answer if you ask them directly, “Who is the best surgeon here?” Hospital rules may prevent them from answering that question, but they may be able to answer what amounts to the same question if its phrased a little bit differently. After explaining who you are and asking some preliminary questions, make the last question you ask them be this one: “If you were going to have weight-loss surgery at this hospital, and you were going to have (state your chosen type of surgery), who would you chose for a surgeon.” This question does not require the nurse to place them self in the position of being the ultimate judge of one surgeon vs another, but simply asks for a recommendation based on what the nurse feels would be best for them personally. I believe you can trust this recommendation above the recommendation of your primary care physician, or your cousin Jane, or any advertisement you might see.

Post-Op Education and Support Programs.

There are three major keys to long-term WLS success:

• Choose the right procedure for you.
  
• Choose the right surgeon to perform that procedure with the right hospital staff to assist them.
  
• Choose the right after care education and support program to assist you with all the hundreds of issues you will have to deal with long after the surgeon and hospital have moved on to their next surgery patient and you are out there in the world by yourself where the surgeon is assuming you are successful because he really doesn’t have any method of knowing otherwise unless you are sick or admitted to the ER.

Thoroughly examine the surgeon’s aftercare program to see if it provides real quality education, training, and support for you and that those three things will be available to you where you live, not just in the city where the surgeon performs surgery. Education; Training; and Support are three separate and distinct things.Many surgeons assume that they are all the same thing and they are all adequately covered by one or two patient led support groups that meet once each month in cities near their office. They are not.

“Education” means providing multiple methods of teaching you WHAT you need to do to make permanent changes to your lifestyle and habits. There are many facts you need to know so you'll understand what to do with your new body to keep it strong and healthy and so you can lose all the weight you should and then be able to maintain your ideal weight.

“Training” means providing you with instruction and opportunities to practice HOW you can make those changes you learned about through the education classes and written materials. True lifestyle changes require practice, not just knowledge. What methods does your surgeon have to teach you HOW to make those changes, not just what the changes should be?

“Support” means providing you with access to technical people, like nurses and dieticians who can respond to your medical issues. It also means providing you with opportunities to be helped and assisted by other WLS patients who have been through what you are going through and who can offer numerous solutions to your problem so that you can find a solution that is right for you. Once a month support groups are essential to the success of any quality WLS practice, but there are few patients who can schedule their needs for support so that it falls on a particular day of the month.

A high quality program will also provide you with an opportunity for daily interaction with other patients through online programs like chat rooms and forums for discussion of your problems. Chat rooms and forums can be found in hundreds of locations on the internet, and you can get lots of information from those sources, but the danger that exists is that many of the sites that provide these services do not have any standards for the support and advice that is offered there and they have no means of monitoring the information that is exchanged there. The best aftercare programs will not only have these resources available for you, but they will operate them as a specific function of the surgeon or hospital and they will constantly monitor the advice that is presented to you to make sure that no one is giving you bad advice that will harm your weight-loss progress or maintenance. Some surgeons and hospitals choose not to operate these services themselves, but choose to make sure their patients have access to them through third party providers who they know they can trust.

Making an informed choice when you choose a surgeon is not a simple task. It requires some work on your part. You need to study and ask lots of questions: some are factual questions that others can answer, and some are emotional questions that only you can answer. In the end, if you’ve done your homework, you’ll make a decision that’s right for you and you’ll know that you made the best decision you could make with the knowledge you had available at that time.

Does that mean that you won’t have any complications? Not necessarily, but it does mean you will have done everything you can do to eliminate them if possible.

There are a lot of bariatric surgeons out there and I’m sure there are several who would be just right for you. It’s my sincere hope that this article helps you find them and know them when you see them.

Ken Miller

Bariatric Support Centers International

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I really like this article, I think it's right on the money. Just make sure you read post #1 so you can see HOW do to these things and post #2 so you can be organized when you do so.

There were a couple of issues that hit home, one is:

All weight-loss surgeons have patients with complications. All weight-loss surgeons, who have been performing WLS for very long, have had patients who died from complications that arose during or following surgery.

Many complications are not the fault of the surgeon; they are a normal part of the risk that goes along with the intensity of a particular type of surgery and with the general size and health of WLS patients. I know Alice’s surgeon takes on patients who are much larger than many other weight-loss surgeons will accept as candidates for surgery. Working with larger, more fragile patients will negatively affect his statistics. He knows these are higher risk patients when he accepts them, and they understand that his statistics are naturally affected by his willingness to operate on higher risk patients. Many of them also understand that by choosing to operate on more difficult patients (who many other surgeons have turned down) also means that he will naturally have more experience knowing what to do when his patients experience difficult complications during or after surgery.

This concept holds very true in the US as well as Mexico. There are a handful of surgeons that others surgeons will refer the tough, tricky, or difficult cases to. It's because they CAN handle the problems and complications. They CAN do the tricky cases. In my original post I wrote that it is important to consider the skill level of the doctor. Does he just do the easy banding or is he capable AND does he actually DO the tough cases. Can he do a band after a botched gastric bypass? It's much more difficult than most might realize. Most docs will refer the patient to someone who can do the tricky stuff. Do you want to go directly to the guy that CAN do the tricky stuff or do you want to go to the guy that refers the complicated people to someone else? It's really an important issue to consider.

That does mean the ones who will do a tricky or complicated case might have a higher mortality rate. It does not mean they are not a fantastic surgeon with great skill.

I know of one US doc that totally botched a Gastric Bypass and the patient was not going to survive without a repair procedure yet no US doc would touch her and you know why? First of all most docs can't do the extra difficult procedures and of the US docs that can do them, they don't want to because it will mess with their stats. If the patients were to die then they have a death on their stats. So they keep referring the patient to someone else until someone else is willing to quite literally save the patient's life. That's how important stats are to docs. They will turn someone away vs. saving their life because they don't want to mess with stats.

That's how political and dirty medicine can potentially be and yes, I'm talking about within the United States. I totally understand why someone would refer a patient if they know darn well they don't have the skill level for a specific procedure. The doc should be hugged to pieces for being honest. He might excel in a different area but not that particular procedure. I have a problem with docs that CAN do the procedure but they don't want the risk of messing with stats.

The patient I was referring to above with a botched US gastric bypass went to Mexico because she couldn't find anyone in the US to help her. Without surgery, she would die. With surgery she "might" survive. Well, she didn't. She passed away from cardiac complications. Is it the docs fault? Nope, but it still goes against his stats. Since a doc has a mortality stat does that mean he's bad? In this case by the time the patient finally found someone willing to help her it was simply too late. No surgeon could have saved her at that point. But it goes against that doc's stats anyway. It sure does not mean he's bad, it means he cares more about the patients than his stats.

There is one doc being discussed right now regarding a death. He's in TJ. A family member is blasting him on every band board. Just remember, "stuff happens" and it isn't always the fault of the doc. Sometimes patients break the #1 rule in medicine and they die regardless of surgeon skill. In that case I honestly don't know if it was a freak thing or if the doc messed up but remember, due to confidentiality issues the doc cannot come and explain his side but the family can. So it makes the doc look bad. Maybe he did screw up, maybe he didn't. We'll never know on a chat board.

wasa,

GREAT post ... any plans on writing one for plastics?

wasa,

GREAT post ... any plans on writing one for plastics?

Oh sheesh... I hadn't even thought of that.

Perhaps after my TT in December. HA!

what is ap band. what can you tell me about the new Johnson and Johnson band, I hear it is designed for less slipage and smaller port. who is using it in mexico?

DJ,

there is a great search feature on this board. just type in AP Band (lots of topics here)

i havent read much about J&J band, maybe try google??

Just wanted to thank you for all of the information!

Thanks Again

dt

This is an excellent post. I wish that I had this information before being banded, even though my operation was done in the USA.

Wasa,

This research is absolutely amazing. Thanks so much - wish i had 1/2 the information of this post before i was banded.

Where is your doctor located? Do they have a site? Just wondering. Thanks again!!!

Where is your doctor located? Do they have a site? Just wondering. Thanks again!!!

I started to post it but I deleted it.

I'd rather not post MD info here so this thread can be as objective and neutral as possible and not to sway anyone one way or another. If you don't mind I'd prefer to PM or email you the name.