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Pre-surgery in the era of telemedicine



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So my insurance apparently is run by people who've had bariatric surgery, because the only prerequisites are a surgeon consult, a nutrition class, a psych eval, one support group session, a letter of recommendation from my PCP, and about thirty pages of forms to fill out between all of them. There's no medically supervised diet, no long run-up, no "prove you can do this by losing N pounds in M weeks". Super easy, and I'm done with my prereqs in two weeks flat, so now the insurance coordinator will go approach the insurance for authorization and after they get that, surgery is 3-4 weeks away.

But here's my dilemma: I haven't had much "individual" time. The nutrition class was 10 people, the support group like 50 people, and the psych eval was literally 22 minutes long. The surgeon consult was 15 minutes long. Everything was via Zoom.

At some point, they're going to have to bring me in and weigh and measure me, right? Theoretically there's going to have to be a bunch of medical clearances? A nutritionist with whom I'll work? Someone to talk to me about my prescription medications? Someone to go specifically over my dietary requirements post- (and pre-!)surgery?

I feel like there's about ten people I deal with, each of whom has some portion of responsibility for me, but nobody can answer the questions I have, and I feel like I need to go out and find my own nutritionist, my own psychiatrist, because it looks like it's just the surgeon.

Am I overthinking this?

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So I initially went in to start my bariatrics process at the hospital in February of 2020. They estimated the time was 6-8 months start to finish (surgery). This was right before the pandemic hit. Now being in Canada by March everything was starting to shut down. Panic was in motion and my initial consultation in Februarg followed by a group orientation in late February was all I had got to do in person. The next appointment I had wasn't until July! Like you it was on zoom. That I believe was a consult with the social worker. Basically someone who talked to me and asked me a bunch of mental health questions. Mostly to see if I was of sound mind, not super depressed or suicidal and if I was mentally prepared to go forward with surgery. She had one follow up over the phone a month later then signed off on her end.

Next was the dietician who did what dieticians do, ran me through a PowerPoint presentation about the 3 food groups. I was given a little homework to do over the next 6 weeks. I had to fill dietary sheets saying how much I drank that day, what I had for Breakfast, lunch and dinner plus Snacks. Times and a note about what type of food that was (ie Protein, carb, vegetable). Just basically making sure I understood food groups. Once submitted she reviewed them and another couple weeks later we went over it on the phone. She made some corrections, went over food groups AGAIN.. and gave some suggestions on what I could have to balance a meal. She discussed briefly the phase 1 pre-op diet, phase 2 liquid diet and phase 3 pureed diet. Gave suggestions and ideas about what to eat, to avoid etc. Nothing you can't find online with a little research. Finally she signed off. Then the 2nd wave hit in November and everything shut down again.

Fast forward I finally did my second doctor consult in January of 2021 and he reviewed the dieticians notes and social workers and then signed off. Throughout this entire now year that had gone by I was only ever initially weighed in and measured the first month. Blood work done that first month. A year had past and no updates to either were requested. More time goes by and I did a surgeon zoom meeting and he just asked me basic questions. I think the most in depth thing he asked for was to visibly see my stomach and move my head around so he could see my neck function. Then I had a brief phone call with pre-op questions. Finally a surgery date in May was issued. Again a third wave hit and that was cancelled. Finally I had my surgery July 23rd 2021.. nearly a year and a half after starting the process. That's socialist free health care for you though.. so I guess I can't complain.

Anyways that's the process I went through and I too was concerned at no point they asked for updated blood work or weigh ins. There was no real monitoring of diet aside from just telling the dietician I understood and showing her a brief demonstration. Throughout that year and a half I fell off the advised diet a bunch of times. I was very dedicated at first, then the delays discouraged me. The additional delays and run around and feeling like this is simply never going to happen really made me fall off. By the time my May surgery date came around I was eating like I ate before, I kind of just didn't care any more. I was also drinking a lot of calories. At some point I fell off the diet drinks and went back to regular and with no bloodwork monitoring or being held accountable, I drank myself into diabetes type 2. Which was found a 3 weeks before surgery when I was checked for the first time ever at a clinic for my blood sugar, which was a 26.8 on the meter. My own fault entirely, but had they done more in person check ups and diagnostics they might've noticed I wasn't losing weight, my sugar levels were getting high.

Maybe steps could have been made to help me be accountable and stay on track. After all I'm an addict to food and flavor, leaving me for a year and a half with no support to do it all on my own just didn't work out for me. So I do hope your process goes faster and smoother than mine. But you are not wrong in being concerned by the lack of in-person check ups. Do yourself a favor and speak up and don't just stay silent like I did.

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I had my first contact with the surgeon's office on July 2. Today's July 29 and I'm done with the insurance requirements. I fired off an e-mail to my insurance coordinator, who is super awesome, and she gave me the direct e-mail of the person at the surgeon's office most likely to answer my questions.

But it all feels very assembly-line. This is a major, life-changing thing and I don't want to [bleep] it up, but I'm afraid I don't know what I don't know.

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3 minutes ago, vikingbeast said:

I had my first contact with the surgeon's office on July 2. Today's July 29 and I'm done with the insurance requirements. I fired off an e-mail to my insurance coordinator, who is super awesome, and she gave me the direct e-mail of the person at the surgeon's office most likely to answer my questions.

But it all feels very assembly-line. This is a major, life-changing thing and I don't want to [bleep] it up, but I'm afraid I don't know what I don't know.

Definitely ask questions. Do research on your own too. You're right this is a life altering major surgery. You're early on in your process so maybe they just haven't got to it yet. I'm not sure how it works with an insurance company but I would have to imagine you're going to go through some kind of program. It's not going to be your insurance approved you, now you meet with a surgeon and then the surgery is next month. Mostly all programs make you go on a pre-op diet and provide multiple consultations to tell you what you need to know. It likely will feel very automated, especially if everything is over the phone or zoom. But again don't be afraid to ask those questions or raise those concerns.

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But that’s exactly what it is. There’s no “program”. The doctor refers me for surgery, there’s this flurry of insurance checks, and as soon as the insurance says yes, they schedule me for surgery. The surgeons office said to expect around Labor Day or a bit after (early September).

It does feel completely automated.

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@John M...felt like deja vu reading your experience of the process leading up to surgery. I am of the Canadian persuasion as well (Ont.) but I went through it pre-covid.

Other than the advised diet they asked you to adhere to before the 2-week liquid one (I wasn't given a diet other than the 2-wk one). and the fact that my appts were done in person, sounds like we pretty much got the same info/services (or lack thereof) pre-op.

The only bloodwork/labs I had done were the first set in the beginning (which included an EKG...did you get one of those?) Nothing after that until AFTER surgery. Pre-surgery, I had one appt with social worker, 1 with dietitian and 2 with nurse (oh and 2 with the surgeon)...all of which lasted well under 15 mins each.

Now AFTER surgery I had tonnes of bloodwork/labs done, but thats another story.

So I'm not sure, at least in our respective cases, it was any better in terms of quality of care to go through this pre-covid (well, except for the delays, of course!). But you def won out at least on not having to drive 1.5 hours round trip for every appt, nor pay $23 in parking fees each time. Sigh.

I got the majority (if not all) of my information though my own research. Even post-op, I did not really follow my dietitians advice, as I chose to do an alternate "program"...she knew this (as I told her), and would often lightly chastise me during our many appts together. Personally, I felt like the advise dispensed was a one-size-fits all type of thing that wasn't adjusted at all to the individual. But that's just me. I mean, the guy beside me in the waiting room is like over 1 foot taller than me, and probably almost 3 times my weight...and you are going to tell us both to consume 1500 calories??

***NOTE*** To be clear, I'm NOT advocating not listening to your team! Ask questions as you said, and if you are not satisfied for with the answer, look elsewhere.

In the end, this same dietitian who would shake her head sadly at my food log was the first one to high five me when I got to goal. My nurse and surgeon were both pleased with me the entire time because I healed uneventfully with no issues, I was able to get off all my meds by end of month 1, I was losing weight steadily, and my labs always came back satisfactorily. I never saw the social worker again.

In my opinion, the support services provided to barbaric patients by our health care program (i'm just talking dietitians/nutritionists and social workers/psychologists...as the nurses and docs seem to be doing exactly what they should be doing) are severely lacking. You are better off shopping around and getting a private nutritionist and/or therapist on your own if you feel you need them.

Good Luck! ❤️

P.S. Not counting the months that I changed my mind TWICE about having the surgery, the entire process from referral to surgery was about 8 months.

P.P.S. Sorry this was so long.

Edited by ms.sss

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I am in the US and I have done all of my visits for the whole process (six months so far) over Zoom. I finally got a surgery date for Sep 13 and the only thing I will need to do in person is have labs drawn. Then I will just go in the day of my surgery. I have had several meeting with the surgeon, nutritionist, and psychologist alone plus some group classes. I found them very helpful and they all allowed time for me to ask many questions. I'm concerned that you weren't given a time to ask questions about the pre-op and post op diet. I had a lot of questions, but maybe your diet is just liquid so very simple. My diet is going to be low carb, low fat, high Protein, so I had to ask a lot of questions about what I can and cannot eat before surgery.

But, don't you have a number you can call, or a patient gateway system you can message your providers with questions?

Good luck!

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I have (now) the surgeon's assistant's e-mail and cell number... it feels very weird. Obviously I can put my foot down at any point. We did have a long talk about the post-op diet. It's hard to trust the process when the process is opaque.

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I would just keep asking questions, and keep doing your own research on here and by watching YouTube (I recommend Dr. Matthew Weiner). That's what I've done to keep myself sane during this 6 months I've been waiting. I have found the wait to be incredibly frustrating because my surgery center is understaffed, so I have to wait a long time for the scheduler to call me back for the next appointments - like weeks! So I've just read everything I could. I think I would feel a lot more scared if I hadn't read so much. The mayo clinic (Mayo.org) is also a good resource. They have good health information on everything, including weight loss surgery. Also ASMBS.org (the bariatric surgery professional group).

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On 7/29/2021 at 11:43 PM, vikingbeast said:

I had my first contact with the surgeon's office on July 2. Today's July 29 and I'm done with the insurance requirements. I fired off an e-mail to my insurance coordinator, who is super awesome, and she gave me the direct e-mail of the person at the surgeon's office most likely to answer my questions.

But it all feels very assembly-line. This is a major, life-changing thing and I don't want to [bleep] it up, but I'm afraid I don't know what I don't know.

If you think that is assembly line, from what I hear in some of these hospitals it is one Sleeve after the next like well....an assembly line. I guess that is ok since repetition is good. I just hope I am in the morning when they have energy and stamina instead of late afternoon when they are fatigued and ready to go the heck home.

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My experience has been completely different from the ones I read above.
I’m in Wake County NC, and if coming here for surgery is an option, I would suggest exploring that option.
I began the process in January with research and my surgery was June 8, 2022.
My initial ZOOM consult with the Patient Administrator and the surgeon lasted 2 hours: 30 minutes with PA and 90 minutes with the surgeon.
I went through EXTENSIVE pre-procedure testing: physically and psychologically.
A massive hiatal hernia was diagnosed, and I was screened by a cardiologist (also extensive) before everything was sent to my insurance company. I also had a sleep study and a CPAP machine was prescribed.
I went to a nutrition introduction and the nutritionist has been there since February to answer every question. I had a nutrition meeting 1 week prior to surgery, and the nutritionist conducted another class while I was in the hospital and came to see me 2 mornings in the hospital and I have another class in a week.
The hospital and practice I used are CIGNA Bariatric Centers For Excellence. They practice ERAS- Enhanced Recovery After Surgery. I was never given narcotics…only a nerve block and two mild pain meds prior to surgery. I did not need any pain medication either post op or when I came home.
The care I received was absolutely top notch from beginning to end. The hospital staff was superb.
If this is an option for anyone, I recommend it without hesitation. I am 67 years old and I intend to lose 100 lbs. i underwent a hernia repair for a massive hiatal hernia, my gallbladder was removed and I had gastric bypass.
Hope this helps someone.

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My initial consult with the surgeon was in person. I've only talked to him one time since, and that was to do an EGD.

My initial consult with the nutritionist was in person. We've been meeting on Zoom every month. My final visit with her will be in August, and it will be in person.

I meet - in person - with the medical weight loss gal, about every 6 weeks. She's prescribing me some medications to help me lose weight before the surgery. They have one of those scales that scans your body mass and gives you a cool little printout with your fat percentage and stuff. I like it. :)

My psych eval was on Zoom and it was 2 visits and a phone call for feedback.

My surgeon's office has monthly support group that meets on Zoom, as well.

These are interesting times that we're living in!

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