OAC Blogger - Proud Member

Obesity kills more Americans than previously thought: One in five Americans, Black and White, die from obesity

Obesity kills more Americans than previously thought: One in five Americans, Black and White, die from obesity

If you had any doubt whether or not to take action, this is your wakeup.

Got to meet Governor Steve Bullock two weeks ago, and ask him to help Montana cover obesity care with its Medicaid plans.  We used to cover, then stopped.  Now only 2 other states are in the same boat - Mississippi and New Mexico.  Will Montana be the LAST state in the nation to have discrimination in its laws for the health of its poorest citizens?

Also got to meet Senators Baucus and Tester - very much hoping they and their staff will persuade HHS Secretary Kathleen Sebelius to make sure all state baseline "EHB" plans require coverage of this disease.  Seriously - one in five deaths?  How can this be ignored, other than through discrimination?  I am not calling these fine public servants discriminatory, but when they allow a vocal ignorant few to keep them from SAVING LIVES, the effect is the same.  Citizens are begging for effective care, and we can provide it - but policies make a real difference.

Thanks so much to all our public servants, and especially to Commissioner Monica Lindeen and her staff for a receptive ear.

Bonuslife !

This is from the Summer 2013 edition of the OAC magazine.

Answer provided by Walter Medlin, MD, FACS

Dear Doctor, I am affected by

obesity and not interested in

intimacy. Why is this?

Dr. Walter Medlin

Putting the Frisky back in Our Business!

The dilemma for most of us: Wanting intimacy but

fearing vulnerability.

Sexuality is still probably the toughest issue to

discuss, or even to think clearly about in our

society. It’s very ironic that we are deluged with

sexual images and humor to sell stuff and to get

our attention, but Americans are fairly repressed

and conservative in terms of actual intimacy and

intercourse.

Media and society will show explicit violence over

sexuality for some reason, to the point of laughable

avoidance of male nudity. You can watch TV and see

murder, mayhem and meanness on network shows

even in the “family hour,” but there will be no actual

depiction of sexual pleasure on TV (unless it is

betrayal). We are far more comfortable as a country

with sexual tension than sexual activity.

Please let me remind you that you’re talking with

a surgeon about something that is usually more

in the realm of a counselor. As a member of your

healthcare team, I am very happy, though, to get

you started on this process and help if I am the

provider you’re most comfortable sharing these

issues with.

Getting Started

Let’s clarify some specifics. In what way (or ways) does

this loss of interest in intimacy bother you? Is it more of

an issue for you or your partner? Or maybe something

you have mutually decided is an area of desired change?

Misconception of Female Sexual Response

I highly recommend a book that I read for this article,

titled The Sex Starved Marriage, by Michele Weiner-

Davis, PhD. The book is very clearly written and reflects

an extensive clinical experience. One key concept is that

women often expect to be interested in sexual intimacy

prior to actually engaging in contact. This is often the

reverse of what actually occurs! Many women just don’t

get desire until actually involved in arousing activity. Dr.

Weiner-Davis also highlights many important areas in

her book that are listed on the following page.

One key concept is that women often expect

to be interested in sexual intimacy prior to

actually engaging in contact. This is often

the reverse of what actually occurs!

“ “

Medical

There are several factors that can lead

to loss of sexual desire or enjoyment.

Antidepressant medications in the

SSRI class can alter libido. These

include Celexa, Lexapro, Paxil,

Prozac, Zoloft and others.

Hormonal

Menopausal or premenopausal

changes can alter feelings of desire

and are often unrecognized in early

stages. The body can also have

adjustments after childbirth or

chemotherapy.

The term “chronic disease” covers a

lot of ground, but many conditions,

including diabetes, can contribute to

change in desire. Vascular disease is

more highlighted in males because of

the role in maintaining erection, but

likely has some role in female sexual

response as well. Smoking cessation

is always a good idea!

Polycystic ovary syndrome can give

women higher testosterone values,

which can lead to acne and hair

issues, as well as irregular periods.

Physical

Fatigue is probably most important,

medically, for desire. Low Vitamin D

is almost the rule in our patients, and

it takes weeks to months to correct.

Hypothyroidism is less common, but

treatable. Lack of regular exercise

directly affects sexual desire and

arousal and ability to orgasm. It also

indirectly affects fatigue, which is

part of the body’s counter-regulatory

efforts to dieting.

By the time many women reach our

clinic, they have been through dozens

of diet attempts throughout the years.

Their bodies have become welladapted

to this self-imposed “famine”

by going into a near hibernation

state, which is best characterized by

overwhelming chronic fatigue.

Medical, Hormonal and Physical issues

When you feel burnout in life, it is understandable to be

sexually disempowered. Clinical depression, medications

and body image problems can certainly have a role.

Understanding all of this is the first step to adjusting to it

all. Please note that I did not use the word “fixing” here!

An attitude of “fix” can block our ability to “treat.”

Behavioral and Relationship Issues

Another of Dr. Weiner-Davis’ ideas that I really appreciate

is that of “emotional nutrition,” which is an inborn need

to bond. How can we have a true sexual bond with our

partner if there is no friendship? Anger, cynicism and

even selfishness may all be reasonable responses to the

harsh reality of the world for many of us, but they also

isolate us. Balancing the need for self-care with the need

to be cared for requires a leap of faith!

Here are some questions for you and your partner that

may help you both identify intimacy issues:

• Are you in a relationship now? If so, how has

intimacy worked in this relationship in the past?

What previous relationships do you bring into the

current one?

• Are you a post-op metabolic/bariatric surgery

patient? Has your partner responded positively to

changes? Is your partner “oversexed” (exhibiting

an excessive sexual drive or interest)?

• Does your body image or previous sexual trauma

create fear or reluctance toward intimacy?

• Are you sexually active but feeling a lack of

desire/pleasure or not having intercourse? Do

you have a sexual relationship with yourself?

(Yes, we are now talking about masturbating, an

even more taboo subject than sex!) Do you have

thoughts but not act on them?

• How is your underlying friendship with your

partner? What other conflicts may be unresolved?

Some relationships undergo radical “power”

changes after bariatric surgery, and the partner

who has been taking the other for granted often

reacts defensively.

• How do you handle stress now? Food can be a

crutch even for normal weight people – they don’t

call it comfort food for nothing! You may need to

replace old coping behaviors with new ones.

• Do you have “safe” space in your relationship to

talk about issues without causing hurt feelings?

Are you waiting for your partner to agree with

you before taking action? When we offload the

obligation for our happiness onto our partner, it

can lead to a compounding of problems.

• Remember, change can be stressful, even if it is

winning the lottery. A new life can be disruptive,

and adjustment disorder is common.

Recognizing Other Important Issues

Most relationships hit roadblocks at some point, and

counseling can give tremendous benefit even if it is

only for a few sessions or a few months. Even when

the underlying sexual problem is completely related

to medication or physical problems, our feelings and

communications are easily disrupted. As the saying goes,

“Sex is only 10 percent of the relationship – unless you’re

not having sex, then it’s 90 percent!”

Here is a list of other concepts to explore:

• Distracted society (Internet, TV, busy lives)

• Anxious society (continual messages of crisis

and tragedy)

• Neurotic society (continual messages of

inadequacy)

• Pornified society (inability to live up to fictional

standards)

• Hyper-society (inability to just chill out for a

day on the couch with partner or self)

• Habit of avoiding, delayed gratification

• Does only intercourse “count” anymore? Are we

keeping score too closely?

• Romantic fiction (Is it okay just to “hook up”

with your partner occasionally? Does all sex

need to have deep personal connection, or can

it just be fun?)

• Spontaneous ideal (Sometimes planning, even

scheduling, can be helpful.)

• Sensitive feelings (Innocent comments can

cause real harm. Your body language may

be misunderstood as rejecting, even if it has

nothing to do with your partner.)

• Discounting positive attention (Negative selftalk

blocks romance!)

• Honest and CLEAR communication of needs

and turnoffs

• Do you talk with friends, but your partner is in

the dark?

• Be VERY careful of the word “should.” It is the

root of a lot of toxic behavior and unrealistic

expectations.

• Is impatience for a complete solution keeping

you from making small steps?

• Would regular exercise help?

• Do we feel overly responsible for our partner’s

happiness?

As you can see, there are a wide variety of concepts that

may impact sexual behavior and desire. It is important to

discuss these issues with your partner to encourage clear

and honest communication.

The Takeaway

Communicate with your partner, take that leap of faith!

If you have major anger, or major vulnerability, it is a

good idea to have a counselor. Just get started! Don’t let

intercourse or orgasm problems block the enjoyment

you can have with other components of an intimate

relationship (even if it starts alone). Most important –

don’t ever count yourself out! This important part of life

has not passed you by, even if you are far out of practice.

Expect to have some dead ends in your search for

solutions. No single source or practitioner has every

answer, and many of us practitioners have only limited

experience with certain components of sexuality. Be

wary of the easy answers, this is complicated stuff!

As you progress through examining and making changes

in your sexual life, expect that the questions may change.

I am a strong advocate of Mindfulness-based Stress

Reduction techniques for keeping our problems in

perspective. Remember, your most important sex organ

is your brain! Self-care is fundamental to happiness.

Most of us have ongoing negative internal dialogue

about weight and self-worth. Don’t beat yourself up just

for having a challenge in desire. It is not a “fault,” but

another opportunity for learning about this amazing

journey of life.

Here’s hoping you all have the frisky, romantic summer

that you surely deserve!

Be positive, but be persistent!

Answer provided by:

Walter Medlin, MD, FACS, is director of the Metabolic

Surgery program at Billings Clinic in Montana and an

OAC Advisory Board Member. He struggled with his

weight since first grade. After performing hundreds of

bariatric surgeries, he underwent sleeve gastrectomy

in 2008, with outstanding results. Dr. Medlin is also a

participating practice in the OAC Sponsored Membership

Program where he gives each of his patients a one-year

membership in the OAC and he is honored to be a

longtime member of OAC. Dr. Medlin is also an avid user

of Twitter; his handle is “@bonuslife.”

Exercise reorganizes the brain to be more resilient to stress

Exercise reorganizes the brain to be more resilient to stress

This is worth restarting the blog effort - I want this article to be "sticky" on the web!!!

Also, I added new links in on the column to the right - Downey Obesity Report is a great blog about all sorts of issues.

WLS Appeals is the leading attorney I know of in OAC and a great guy.  He can be super helpful - just read some of his posts for a flavor of his approach.

New video link

Diabetes Video postop Billings Clinic

Physician empathy and engagement - new study Yale

Well I am doing a lot more Twitter and Facebook lately, but would like to share more here.

There is so much that is of temporary interest, and I want to be more durable on the blog.

This NYT blog about physician empathy and engagement is a keeper!


http://well.blogs.nytimes.com/2013/04/29/overweight-patients-face-bias/?smid=pl-share

Many thanks to Dr Bobby Bhasker-Rao and his team in Palm Springs for excellent case observation on the da Vinci surgical robot today.  The gastric bypass procedure is excellent with current techniques.

Thanks also to my local Billings and onsite Palm Springs Intuitive reps for so much work to make the trip happen!

Sounds like my surgeon and friend in Grand Rapids, Michigan did his first robotic Sleeve Gastrectomy today, too.  Congrats Dr Jamie Foote!!!

First Sleeve Gastrectomy Operations at Billings Clinic!

Thanks so much to the dedicated OR and surgical floor teams that made yesterday's cases go so nicely! People are really pitching in to make things go smoothly - from the RN team lead who came in on her day off, to our Physician Assistant who stayed to back up Dr Murray, and did such a great job driving the laparoscope, to our great questions from nursing staff, and the equipment vendors who are making real cutting edge tools available to us here!

Thanks also to our patients for being extra patient with new processes and materials, and for giving us great feedback!

We have an information session tonight - always a treat!

Why not put in a picture just for fun - this will remind me to do more in the future.
Say Hi to my pill organizers!  One is for AM, the other for afternoon/evening.
I have been reading "The Power of Habit" and realize that a lot of our suggestions are to make easy to follow new habits...  This is the only way I can be even 80% compliant with meds/vitamins (and Devrom!)

Telemedicine - the future is here, Rules need to catch up!

Wow- I am at a great Eastern Montana Telemedicine Network annual Facilitator retreat.

Great talks so far from Jonathan Linkous, the CEO of American Telemedicine Association and Paula Guy RN CEO of Georgia Partnership for Telehealth - THANKS SO MUCH!


Brace yourself for a 4G revolution!

First Billings Clinic Gastric Bypass - thanks to TEAM!

I want to send a major note of gratitude to the many people who made today's case a success.

There have been so many dedicated workers giving their best to Metabolic Care - inpatient, outpatient, support services.  Many run-throughs, pathways, new materials, etc.

This is how great care is delivered - thank you all!  We are just getting started...

Thanks to Billings-Montana Dietetic Association, and Montana Osteopathic Medical Association!

We had the opportunity to present to both groups in the past week.   What a great time to meet providers in multiple areas of practice!

Metabolic Disease and Obesity touch so many - and it's just a pleasure to share care as a team.  Medicine is going through difficult but necessary changes as we meet the challenge of incredibly complex care, and learn to do it more efficiently and effectively.

My hope is that we will build tools that keep the patient in the Driver's Seat...  Expect a lot of bumps in the road as that happens, but stay engaged - it really makes a difference.

Duodenal Switch, Surgical Robotics

My day yesterday was "activating" for two important areas that I have been circling for several years.

I first sat at the console of a daVinci robot in Spring 2003 while doing "Top Gun" advance laparoscopy training with Dr Butch Rosser in NYC. It was very promising, but surgeons weren't ready yet with fully evolved techniques to use the tool.

As of 2012, that is no longer the case.

I got a chance to hear several great lectures and see operative video of Robotic surgery - the tool is useful in ways that have evolved. Got a chance to test drive the SI model that Billings Clinic owns, and plan to move forward with Advanced training.


Our new focus on metabolism has brought the Duodenal Switch operation back toward the mainstream of thought in our society. Many leaders are proceeding into this procedure with care - but more will be offering this. Also, as we see limitations with Sleeve Gastrectomy, and even with Gastric Bypass, alternatives are necessary, and backup options require that we be masters of all approaches.

Much more to come on these subjects - ask if you want more on a particular topic!


INTUITIVE SURGICAL ROBOTIC SURGERY

Duodenal Switch Interest Group Homepage

Progress is not always exciting... But still takes effort

Here at the big meeting - we seem to cover a lot of the same subjects, but every year things move forward.

The sharing and mutual education from around the world, the involvement of more specialties and Allied Health professionals will make best patient care and outcomes.

I am learning so much about successes and challenges of colleagues. Very excited about more minimally invasive approaches, new tools, new thinking.

It's how we improve exponentially faster than by experience alone - instead, it's "experience together"!!

At the Annual ASMBS meeting - San Diego

It is always a treat to run into friends from training, and to see those people who we follow virtually on emails, phone calls, etc.  The first part of the week is dedicated to Allied Health Professionals - and the work they do to keep programs on track is impressive.  Change happens with deliberate effort.  This is a group with passion, focused on delivering high value, high quality care.

The new quality initiative with American College of Surgeons (MBSAQIP) is the next step in making progress for the care we all aspire to.

I wish patients and administrators could see this stuff happen, but the results will speak for themselves!  Data is not easy to obtain for long term care, or for complex disease and treatment.  This new project makes it more affordable, less cumbersome, more useful.

Making progress with Regional Chapter ASMBS ND, SD, WY, MT

Last week (the Saturday of Memorial Day weekend)  Dr Lloyd Stegemann of ASMBS and Joe Nadglowski, President of Obesity Action Coalition gave up time with their families to help Surgeons and Allied Health Practitioners from Colorado, South Dakota, North Dakota, Wyoming, and Montana start Chapters of ASMBS.

Colorado is populous enough to do its own Chapter, but the rest of us are coordinating to form a Dakota/Yellowstone Region chapter.  One surgeon drove through the early morning hours after being on call the night before - from South Dakota!  That is commitment, and I am very proud to be associated with such devoted caregivers.  More to come on this after our national meeting in a couple of weeks!

MOST IMPORTANTLY!!!  The influence we can all have together - our competition is not other towns, surgeons, or hospitals - it is limited access to care...

I am excited to help lots of people in our region join OAC, and to make a difference in the health of so many.  If we are able, we will partner with employers, insurers, hospitals, equipment makers, and legislators to eliminate the institutional bias that keeps people from evidence based care!

Please take some time to explore the links over on the right side of the Blog.  I am learning WordPress, and will be making this more dynamic, but the basics are not hard to find.

Thank you for caring, thank you MORE for signing up for OAC, and making your voice count!

Video Blog about Obesity Action Coalition (OAC) and advocacy!

Bullying - the role of weight bias

Joe Nadglowski commentary about weight bias and bullying

Thanks for another great piece of writing! The OAC continues to lead...

Sleeve coverage great link. And I am a man of mystery!

I am more active on my Twitter feed of late - will get more active here soon!

This link is the official ASMBS, SAGES, Obesity Society, and ASBP response to Centers for Medicare and Medicaid Services regarding Access to Care for Sleeve Gastrectomy.

asmbs.org/2012/04/asmbs-…

The link to comment has a button at the top of the page to select the comment period.  If you commented lately, you will need to "reset" to the more recent group to find yourself.  Apparently, I am not allowed to reference myself as a patient, so some of my comment was "redacted"!

Wow!  I feel like a spy!

Call to Action: irresponsible Medicare denial of Sleeve coverage

Ok - I have been neglectful of this blog!  Have been retweeting a lot of the interesting stuff I see online, instead of posting links here.  Some good stuff on @bonuslife

I will post again soon with report from trip to DC for advocacy, but want to call URGENT ATTENTION to all about Medicare's unbelievable rejection of coverage for Sleeve Gastrectomy just yesterday.

HERE IS THE LINK FOR YOU TO COMMENT (may have to copy and paste to browser)

Many thanks to the leadership of ASMBS for their call to action.

The entire text of the decisions can be found here:  http://go.cms.gov/Hel9dT

You can comment easily - just use the button on the top right of the page.


Here is my public comment - but please post your own - every person counts (and it can be short!)

Subject: Public Comment for Bariatric Surgery for the Treatment of Morbid Obesity

This is a notification that CMS has received your comment, as stated below, for the subject topic.
First Name: Walter
Last Name: Medlin MD
Email: --------

Comment: As a metabolic surgeon, and sleeve gastrectomy patient myself, I am distressed at the number of avoidable deaths this policy will cause. I have many Medicare patients who are waiting for this coverage for various reasons. 


Many are poor candidates for the adjustable gastric band due to large hiatal hernias or fear of the variable outcomes with bands. Some of these also have had celiac or inflammatory bowel disease, or nephrolithiasis, or extensive small bowel adhesions that greatly increase the risk of gastric bypass. 


This policy forces our seniors into a bad choice, and I speak from personal experience. This rightfully will be construed as an economic and discriminatory decision, setting the bar unnecessarily higher than for other disease treatments. 


While I agree that study of all our treatments should continue, it is frankly outrageous that this well studied, widely adopted intervention is rationed from our most worthy citizens. 


Unfortunately, I will have to bring obituaries to my Senators and Representative. This is a dangerous, harmful decision. I respectfully request that you immediately provide full coverage in line with STAMPEDE trial criteria.

Address #1: 2800 10th Avenue North
Address #2: 
City: Billings
State: Montana
Zip: 59107
Phone: 4062382500
Fax: 
Organization: Billings Clinic












Here is my letter to our Montana Senators.  Many thanks to their team for wonderful visit last week!  I didn't think it would be this soon that we had a crisis to discuss!








Dear Senators Tester and Baucus,

It was very nice to meet with you and your staff last week.  

I hope you will ask Medicare officials to listen carefully and respond to comments on their decision to deny coverage to millions of Americans for Sleeve Gastrectomy.

As a surgeon with the means to pay, I went into my own pocket to receive this care, but most of my patients do not have that option.  It really is terrible to see them suffer needlessly when we have effective, durable, evidence proven treatments that are life saving and life altering.

My blog and Twitter posts may be a bit too passionate, but I hope your team might review the links to the cooler heads at ASMBS, and stop this policy that hides bias between the lines of "we need more studies".  That sounded hollow coming from the tobacco industry, and from opponents of safety systems in cars.  It sounds no better coming from our Medicare administrators.

Thanks!

Walt Medlin MD

Billings, MT

blog - www.bonuslife.net

Twitter @Bonuslife 

Below is the email I am sending out to Bellingham PeaceHealth St Joseph Medical Center Physicians and Allied Health Practitioners today...

Dear Colleagues,

It has been an honor to work with you all these last 2 ½ years. Though I have consulted on over 200 patients for obesity and metabolic issues, we have only been able to take 12 to surgery here locally, because of a variety of factors beyond my control. My practice closes this Friday. Dr. Bachman has agreed to take over my charts for clerical continuity, with the understanding that specialty Bariatric care is appropriately referred to regional providers. I include a partial list below, and encourage you to use these providers for your own liability protection when patients are complex.

I have been asked to start a Bariatric Surgical program at Billings Clinic in Montana, to complement their World-Class Endocrinology service. I will still get to do Trauma and General surgery as well, so will be fully engaged and supported in a tertiary center.

My only regret is knowing that many will continue to suffer and die needlessly without treatment here in Bellingham. Many just do not have the resources to travel. Most patients now do have excellent coverage – it simply is a matter of finding the location that accepts it.

I hope to keep making my blog a valuable place to send patients to explore links and resources www.bonuslife.net
And my Twitter is @bonuslife

Again, many thanks for being so supportive. Please continue to speak up for this group that is so stigmatized and unfairly marginalized by society and industry. Your compassion alone makes a difference, your timely referral saves lives!

To quote Goethe – “Knowing is not enough, we must apply. Willing is not enough, we must do”
Or to paraphrase - Actions speak louder than words!!!
Sincerely, gratefully,
Walt Medlin


REFERENCE FOR REGIONAL RESOURCES------

University of Washington – has 4 world class surgeons who I know well. They are the best of the best.
800-326-5300 for Medicon, or 206-598-2274 for the clinic.
(http://uwmedicine.washington.edu/Patient-Care/Our-Services/Medical-Services/Bariatric-Surgery/Pages/default.aspx)

www.pugetsoundbariatrics.com based in Edmonds, with office also in Barkley area.
Drs Landerholm, Billing, and Crouthamel are excellent, though a bit controversial with same-day surgery for sleeve gastrectomy.
I do not believe they take Medicare, but do have preferred provider status with PeaceHealth. 800-558-6514

www.NorthStarMedicalSpecialists.com our local Medical program with Dr Tony Burden (at Lakeway entrance to I-5 N) 676-1696
Dr David Lauter comes up from Bellevue, and does take Medicare with his Center of Excellence at Overlake

www.nwwls.com in Everett has until recently been only Lap-Band (which is falling out of favor). Drs Michaelson, Chock, and Montgomery are now adding full spectrum care, including Sleeve Gastrectomy and Gastric Bypass. They are a great clinic, and nearest actual OR facility. 800-350-2263

www.ghc.org Group Health covers many of our Whatcom County neighbors, and does a great job, though the out-of-pocket expense is >$1,400

Swedish, Virginia Mason, Evergreen and Northwest Hospitals all have excellent programs as well, with Center of Excellence certification.

Madigan Army Medical Center is actually a national leader. I highly recommend them for your patients with Veteran’s benefits (and spouses)
http://www.mamc.amedd.army.mil/gensurg/referrals.htm



Dietitian Support - Rachel Akins RD at South Campus has extensive experience with the Group Health Program.

www.accomplishbariatric.com is a Seattle based telephone Dietitian counseling service that I have used with great results. They are very cost effective, though not usually covered by insurance (4 sessions are less than $300 though!)


Psychological Support – Marlene Sexton LMFT has been our local professional, and runs a highly regarded support group as well.

Free support group (which all post op patients should attend at least a few times each year) is 7PM the first Wednesday each month at the HEC.