from the world's big
What the Public Needs to Know About Weight Management Surgery
Dr. Marc Bessler is assistant professor of surgery at Columbia University College of Physicians and Surgeons, and director of the Columbia University Center for Metabolic and Weight Loss Surgery. He is also the director of the Minimal Access Surgery Center at New York-Presbyterian Hospital/Columbia University Medical Center. A fellow of the American College of Surgeons, Dr. Bessler's clinical specialties include surgical management of morbid obesity, gastroesophageal reflux disease, laparoscopic surgery of the stomach, esophagus and hernia surgery, and natural orifice surgery. His research interests focus on hormonal, oncologic, and immune responses in laparoscopy.
He earned his medical degree from New York University School of Medicine, and completed his residency in general surgery and his fellowship in surgical endoscopy at the Columbia University College of Physicians and Surgeons and the Presbyterian Hospital in New York City.
Question: What are the biggest misperceptions about weight management surgery?
Marc Bessler: First of all I think the biggest misconception about overweight and obesity is that it’s the patient’s fault. This is truly a disease, now you’re right like we said before, you could eat less but that’s like telling somebody who has diabetes to control their sugar by just not taking in sugar and of course we tell 'em to do it but it’s very hard to do. Your body is mismanaging these things and so obesity is a disease, it is not the individual’s fault, it takes super human will power to keep obesity under control for the long term and that’s why these surgeries make sense. That these are very dangerous operations, I think 20 years ago the mortality rate of these operations were in excess of two percent. So of every hundred people that came in the operating room, two didn’t leave the hospital anyway, that’s not the case anymore. In a center of excellence, in a place that does this really well and a lot of it, the mortality rate for gastric bypass is about three in a thousan and the mortality rate for a lap band is less than one in a thousand. So these operations are much safer than they used to be. So much so that the risk associated with having the operation is way less than the risk of death from that operation over the ensuing years. Sorry, so much so that risk of having the operation is way less than the risk of having obesity for the ensuing years and you gain back not only the dollars put into it but the risk put into it over five years or so. Yet the other common misconception is that they always fail and people regain their weight back, some of the older operations didn’t work that well and some percentage of patients do gain weight back still but most don’t. With gastric bypass, I’d say 85 percent of patients maintain long term significant weight loss and with the lap band it’s probably close to the same just not as dramatic a weight loss.
Topic: Top experts working weight management surgery
Marc Bessler: Well that’s tough, I think that I hate to be specific about any institution, I think there’s centers of excellence, there’s two organizations that are documenting centers of excellence in weight loss surgery, that’s the American College of Surgeons and something called the surgical review corporation. A center that is documented as a center of excellence by those at least has more than the basics that they need to do this. A center that has one of these designations probably has long term follow up, so that’s really important and the surgeon’s probably have at least a minimum amount of experience doing this so that’s important. But truly you want somebody who’s done 500 or a thousand of these operations, the learning curve goes on probably to about 250 operations and then some. You want somebody who’s offering you all types of operations, not somebody who’s selling just one type or somebody who does 99 precent one type of operation because they’re probably trying to fit you into their operation, not find the best operation for you and you want some place that has a program for long term care and management and if you have all those three components you’re probably in a place that’s safe.
Question: What should the public know about weight management surgery?
Marc Bessler: Well I think that the most important thing to know is that right now less than two percent of people who qualify for surgery are having it. In most places that’s because patients really aren’t choosing it, I think there’s misconceptions about the risk and the benefits of this operation. These operations save lives, they make people have better quality of life, they make people healthier, they make people live longer. But there is some up front risk and you need to be at a center of excellence as we talked about, a place that does these really well to minimize that risk and overall the benefit is definitely there for almost everyone who qualifies for this operation and is appropriately evaluated. So I think that’s really, really important. The other important thing to know is that a lot of states, not New York fortunately but a lot of states the insurance companies don’t really allow patients to have these operations. The patients either have to fight, they get denied, they’re excluded from this and I think that’s really important. I think public health policy needs to be such that when things are medically necessary, when things are medically valuable, they aren’t denied patients and this is one area I think obesity in general is one area of sort of allowable discrimination because the public perception is still that obesity is the patient’s fault and if it’s the patient’s fault, we don’t have to pay money to give them an operation that isn’t gonna work anyway in their minds and that’s sort of the concept here. You wouldn’t hold back open heart surgery from somebody who has heart disease because they don’t eat a low fat diet and smoke. You have the operation and you educate them about proper diet and smoking, same thing here. You wouldn’t hold back a lung cancer operation from someone who has a history of smoking and we don’t hold back liver transplants from someone with a history of drinking, why, we recognize these as diseases with mortality associated with them and obesity is the same. Even more so, you don’t need to smoke to live, you don’t need to drink to live, but you need to eat to live. So you can go cold turkey off those other things, you can’t go cold turkey off food and really then it becomes a problem of regulation of amount, which is much harder than just stopping, you can’t stop eating therefore the disease is about regulation of the amount that you eat and that’s much, much harder to do.
Question: Insurance companies often do not cover weight management surgery: how can people afford it?
Marc Bessler: Well so how can people finance surgery, it’s two things, number one you can find an insurance company that does cover it, sometimes that’s a possibility, certain states almost everybody covers it. In New York it’s almost mandated, you’re right that obesity does disproportionately a bit effect the lower socioeconomic status, it’s unclear exactly why, perhaps fast food, things like that is more prevalent. There’s financing available through some institutions for this, so you can, you know, put it on a payment plan if you will. But again lower socioeconomic status folks, people who, you know, are relatively poor might not be able to afford a 20,000 or a $15,000 operation even paid off over time. I tell people who can somehow squeeze it together, you’ll put a car on financing even though you otherwise might be able to take mass transit because you want a car, 15 to $20,000 operation is affordable on financing if you recognize this is for your quality and length of life. Maybe more important than having a car in some ways. So I’m not telling people they should run out and pay for these operations if there’s other alternatives, certainly getting insurance to cover it, Medicare covers this at centers of excellence, Medicaid in New York covers it but not in all states and I think working to get legislation in those areas, working to make sure in the states that this isn’t routinely covered, to make sure that it is routinely covered is an important effort.
Recorded on: 6/16/08
Dr. Marc Bessler describes obesity as a disease, lists the best hospitals for surgery, and gives advice on how to afford the procedure.
What conditions of the new normal were already appreciated widely?<p>First, we understand that higher education is unique among industries. Some industries are governed by markets. Others are run by governments. Most operate under the influence of both markets and governments. And then there's higher education. Higher education as an "industry" involves public, private, and for-profit universities operating at small, medium, large, and now massive scales. Some higher education industry actors are intense specialists; others are adept generalists. Some are fantastically wealthy; others are tragically poor. Some are embedded in large cities; others are carefully situated near farms and frontiers.</p> <p>These differences demonstrate just some of the complexities that shape higher education. Still, we understand that change in the industry is underway, and we must be active in directing it. Yet because of higher education's unique (and sometimes vexing) operational and structural conditions, many of the lessons from change management and the science of industrial transformation are only applicable in limited or highly modified ways. For evidence of this, one can look at various perspectives, including those that we have offered, on such topics as <a href="https://www.insidehighered.com/digital-learning/blogs/rethinking-higher-education/lessons-disruption" target="_blank">disruption</a>, <a href="https://www.nytimes.com/2020/02/20/education/learning/education-technology.html" target="_blank">technology management</a>, and so-called "<a href="https://www.insidehighered.com/sites/default/server_files/media/Excerpt_IHESpecialReport_Growing-Role-of-Mergers-in-Higher-Ed.pdf" target="_blank">mergers and acquisitions</a>" in higher education. In each of these spaces, the "market forces" and "market rules" for higher education are different than they are in business, or even in government. This has always been the case and it is made more obvious by COVID-19.</p> <p>Second, with so much excitement about innovation in higher education, we sometimes lose sight of the fact that students are—and should remain—the core cause for innovation. Higher education's capacity to absorb new ideas is strong. But the ideas that endure are those designed to benefit students, and therefore society. This is important to remember because not all innovations are designed with students in mind. The recent history of innovation in higher education includes several cautionary tales of what can happen when institutional interests—or worse, <a href="https://www.insidehighered.com/news/2016/02/09/apollos-new-owners-seek-fresh-start-beleaguered-company" target="_blank">shareholder</a> interests—are placed above student well-being.</p>
Photo: Getty Images<p>Third, it is abundantly apparent that universities must leverage technology to increase educational quality and access. The rapid shift to delivering an education that complies with social distancing guidelines speaks volumes about the adaptability of higher education institutions, but this transition has also posed unique difficulties for colleges and universities that had been slow to adopt digital education. The last decade has shown that online education, implemented effectively, can meet or even surpass the quality of in-person <a href="https://link-springer-com.ezproxy1.lib.asu.edu/article/10.1007/s10639-019-10027-z" target="_blank">instruction</a>.</p><p>Digital instruction, broadly defined, leverages online capabilities and integrates adaptive learning methodologies, predictive analytics, and innovations in instructional design to enable increased student engagement, personalized learning experiences, and improved learning outcomes. The ability of these technologies to transcend geographic barriers and to shrink the marginal cost of educating additional students makes them essential for delivering education at scale.</p><p>As a bonus, and it is no small thing given that they are the core cause for innovation, students embrace and enjoy digital instruction. It is their preference to learn in a format that leverages technology. This should not be a surprise; it is now how we live in all facets of life.</p><p>Still, we have only barely begun to conceive of the impact digital education will have. For example, emerging virtual and augmented reality technologies that facilitate interactive, hands-on learning will transform the way that learners acquire and apply new knowledge. Technology-enabled learning cannot replace the traditional college experience or ensure the survival of any specific college, but it can enhance student learning outcomes at scale. This has always been the case, and it is made more obvious by COVID-19.</p>
What conditions of the new normal were emerging suspicions?<p>Our collective thinking about the role of institutional or university-to-university collaboration and networking has benefitted from a new clarity in light of COVID-19. We now recognize more than ever that colleges and universities must work together to ensure that the American higher education system is resilient and sufficiently robust to meet the needs of students and their families.</p> <p>In recent weeks, various commentators have suggested that higher education will face a wave of institutional <a href="https://www.businessinsider.com/scott-galloway-predicts-colleges-will-close-due-to-pandemic-2020-5" target="_blank">closures</a> and consolidations and that large institutions with significant online instruction capacity will become dominant.</p> <p>While ASU is the largest public university in the United States by enrollment and among the most well-equipped in online education, we strongly oppose "let them fail" mindsets. The strength of American higher education relies on its institutional diversity, and on the ability of colleges and universities to meet the needs of their local communities and educate local students. The needs of learners are highly individualized, demanding a wide range of options to accommodate the aspirations and learning styles of every kind of student. Education will become less relevant and meaningful to students, and less responsive to local needs, if institutions of higher learning are allowed to fail. </p> <p>Preventing this outcome demands that colleges and universities work together to establish greater capacity for remote, distributed education. This will help institutions with fewer resources adapt to our new normal and continue to fulfill their mission of serving students, their families, and their communities. Many had suspected that collaboration and networking were preferable over letting vulnerable colleges fail. COVID-19's new normal seems to be confirming this.</p>
Photo by Joshua Lott/Getty Images<p>A second condition of the new normal that many had suspected to be true in recent years is the limited role that any one university or type of university can play as an exemplar to universities more broadly. For decades, the evolution of higher education has been shaped by the widespread imitation of a small number of elite universities. Most public research universities could benefit from replicating Berkeley or Michigan. Most small private colleges did well by replicating Williams or Swarthmore. And all universities paid close attention to Harvard, Princeton, MIT, Stanford, and Yale. It is not an exaggeration to say that the logic of replication has guided the evolution of higher education for centuries, both in the US and abroad.</p><p>Only recently have we been able to move beyond replication to new strategies of change, and COVID-19 has confirmed the legitimacy of doing so. For example, cases such as <a href="https://www.washingtonpost.com/education/2020/03/10/harvard-moves-classes-online-advises-students-stay-home-after-spring-break-response-covid-19/" target="_blank">Harvard's</a> eviction of students over the course of less than one week or <a href="https://www.nhregister.com/news/coronavirus/article/Mayor-New-Haven-asks-for-coronavirus-help-Yale-15162606.php" target="_blank">Yale's apparent reluctance</a> to work with the city of New Haven, highlight that even higher education's legacy gold standards have limits and weaknesses. We are hopeful that the new normal will include a more active and earnest recognition that we need many types of universities. We think the new normal invites us to rethink the very nature of "gold standards" for higher education.</p>
A graduate student protests MIT's rejection of some evacuation exemption requests.
Photo: Maddie Meyer/Getty Images<p>Finally, and perhaps most importantly, we had started to suspect and now understand that America's colleges and universities are among the many institutions of democracy and civil society that are, by their very design, incapable of being sufficiently responsive to the full spectrum of modern challenges and opportunities they face. Far too many higher education outcomes are determined by a student's family income, and in the context of COVID-19 this means that lower-income students, first-generation students and students of color will be disproportionately afflicted. And without new designs, we can expect postsecondary success for these same students to be as elusive in the new normal, as it was in the <a href="http://pellinstitute.org/indicators/reports_2019.shtml" target="_blank">old normal</a>. This is not just because some universities fail to sufficiently recognize and engage the promise of diversity, this is because few universities have been designed from the outset to effectively serve the unique needs of lower-income students, first-generation students and students of color.</p>
Where can the new normal take us?<p>As colleges and universities face the difficult realities of adapting to COVID-19, they also face an opportunity to rethink their operations and designs in order to respond to social needs with greater agility, adopt technology that enables education to be delivered at scale, and collaborate with each other in order to maintain the dynamism and resilience of the American higher education system.</p> <p>COVID-19 raises questions about the relevance, the quality, and the accessibility of higher education—and these are the same challenges higher education has been grappling with for years. </p> <p>ASU has been able to rapidly adapt to the present circumstances because we have spent nearly two decades not just anticipating but <em>driving</em> innovation in higher education. We have adopted a <a href="https://www.asu.edu/about/charter-mission-and-values" target="_blank">charter</a> that formalizes our definition of success in terms of "who we include and how they succeed" rather than "<a href="https://www.washingtonpost.com/opinions/2019/10/17/forget-varsity-blues-madness-lets-talk-about-students-who-cant-afford-college/" target="_blank">who we exclude</a>." We adopted an entrepreneurial <a href="https://president.asu.edu/read/higher-logic" target="_blank">operating model</a> that moves at the speed of technological and social change. We have launched initiatives such as <a href="https://www.instride.com/how-it-works/" target="_blank">InStride</a>, a platform for delivering continuing education to learners already in the workforce. We developed our own robust technological capabilities in ASU <a href="https://edplus.asu.edu/" target="_blank">EdPlus</a>, a hub for research and development in digital learning that, even before the current crisis, allowed us to serve more than 45,000 fully online students. We have also created partnerships with other forward-thinking institutions in order to mutually strengthen our capabilities for educational accessibility and quality; this includes our role in co-founding the <a href="https://theuia.org/" target="_blank">University Innovation Alliance</a>, a consortium of 11 public research universities that share data and resources to serve students at scale. </p> <p>For ASU, and universities like ASU, the "new normal" of a post-COVID world looks surprisingly like the world we already knew was necessary. Our record breaking summer 2020 <a href="https://asunow.asu.edu/20200519-sun-devil-life-summer-enrollment-sets-asu-record" target="_blank">enrollment</a> speaks to this. What COVID demonstrates is that we were already headed in the right direction and necessitates that we continue forward with new intensity and, we hope, with more partners. In fact, rather than "new normal" we might just say, it's "go time." </p>
Manly Bands wanted to improve on mens' wedding bands. Mission accomplished.
- Unique materials include antler, dinosaur bones, meteorite, tungsten, and whiskey barrels.
- The company donates a portion of profits to charity every month.
These new status behaviours are what one expert calls 'inconspicuous consumption'.