The death of a specialty
Years ago, Tuberculous was a terrible killer before antibiotics. During this dark time a treatment called Plombage (collapse therapy) emerged. I vividly recall seeing a patient’s Chest Xray almost 40 years ago and being completely baffled. The guy’s chest appeared to be full of ping-pong balls. It was a common thoracic surgery in the 1930s to the 1950s. When antibiotics came along to treat TB, such surgical procedures for TB vanished and many feared thoracic surgery would vanish as a specialty.
Fortunately, as more people smoked, lung cancer surgery became more necessary and, a bit later, Cardiac Bypass came along to save the day!
Well, we’re now witnessing another potential death of a specialty: Bariatric Surgery
Bariatric Surgery has had rough ups and downs over the years. When I was in Medical School, weight loss surgery was felt to cause only problems and was frowned upon. A few years later, gastric bypass surgery appeared and patients tended to do well. As obesity reached epidemic levels, bariatric surgery became a profit center for hospitals.
Bariatric Surgery poses a lot of dilemmas. For the first two years, it seems to work. Then… it doesn’t work. 70 to 100 pounds of weight loss makes everyone happy. Then, the weight, or at least some of it, returns. There are complications and they can be rather nasty. Nevertheless, as of a few years ago, choosing bariatric surgery as your specialty seemed to be a solid decision.
Then… something happened..
Enter the GIP and GLP-1 drugs. I’m talking about Mounjaro, Wegovy and Trulicity. There is a lot of promise in these drugs. Time will tell if the downsides exceed the possible benefits (I’m skeptical).
Bottom line: Bariatric Surgery may have met its match.
It’s awful to contemplate. Bariatric Surgery appears to be a very difficult field to master. Suddenly, we just callously look at them and say, “We don’t need you anymore.”
Seriously, have you referred anyone for weight loss surgery in the past six months?
I applied to medical schools that still had departments of “Dermatology and Syphilology”. Already a term most schools had dropped at the time, but a few where the sign was still on the walls.
Well if the pills work to keep the weight off, I’m all for it. I did have some young patients back in the day that had gastric bypass (some J-I people too so I’m showing my age) miserable the year after the procedure. After they lost the weight, they were very careful at what they ate and kept themselves in a normal body weight range. Yes, I had some failures too but the center I referred patients to would try to psychometrically sort out most patients they thought would fail after gastric bypass. I had a couple of morbidly obese patients that didn’t fit the psychometric profile and were (rightly in my opinion) refused a procedure. Man, I got tired of listening to their “witching” in the office. The whiney asses probably would have failed anyways and became obese again. Thankfully those were rare. The ones that got through the assessment did fine but I understand some can “stretch the pouch” and get fat again.
I just saw a patient of mine in Walmart who was young when I practiced and went through the gastric bypass procedure. We’re both older now and she’s very happy and kept the weight off. She was immense I have to say but after partitioning controlled her appetite, she lost the weight and still looks in great shape in “our” older ages.
I’ve been retired for 2 years and likely haven’t seen her for four years. I had many patients who had the gastric bypass procedure and they feel like “chit” for a year. After they get through that, they become fastidious about what they eat and keep the weight off. I have to admit that some patients don’t adopt that attitude unfortunately and are at risk of gaining the weight back. I had a few that went back into the obese ranges but didn’t progress to morbidly obese on the weight regain.
Weight loss is a tough nut to crack. If the new drugs help, great! Unless it causes your nose hairs to fall out! (Bland attempt at humor!)
I still recall the words of the bariatric surgeon that taught about the specialty when I was in medical school over 30 years ago. He claimed that he had a 100% dissatisfaction rate. He said he could make people not eat, but he could never kill the demon that made them eat. If these medications can get people to eat only when they’re hungry then good riddance to the surgery. Someone I knew and considered a peripheral friend was a bariatric surgeon and he was extremely full of himself and extremely prideful that his time was worth 20 to 40 times what mine was as he made millions of dollars a year. (It turns out it was not all honesty made, and he is in prison today.) There are some medical skills that are just no longer needed and I hope to have that yet to be an ever longer line of procedures. I hope that the bypass surgeons become obsolete someday, more immediately I hope that the valve surgeons become obsolete. We have good transcutaneous options, so there is a future in which long scars on an abdomen will never exist and long scars along the back will certainly never exist. I hope it’s soon.
Knowledge, skills and technology changes,so does our medical world.Some is good,some bad.
The only sin is not learning,growing an being a better Surgeon /Physician. Better NP, PA-C,RN, LAB TECH Xray Tech.. Amazing times after centuries of not much changing.Thank God..
Personally, as a non-surgeon, I have a great deal of Schadenfreude at seeing these millionaire hotshot bariatric surgeons being put out of business! I can’t recall ever having referred anyone for the surgery. It never made sense to put oneself through that post-operative misery and $40,000+ when all you have to do is use a little self-control and eat less. But of course that’s not the American way, is it?
In order to get a job, residents are advised to find a unique niche within a specialty. Which works great if they are hiring what you have in the area you want to live. But you can just as easily train yourself out of a job. It is impossible or close to impossible, to pick a niche that will be in demand for 40 years