Setting Up an Obesity Centre: Scope of Practice

Now that we have considered issues related to personnel and consultants, we need to define exactly what the scope of practice is going to be. 

Obviously, this will depend on the setting, the personnel, the infrastructure, the funding model (public or private) and a host of other considerations. 

For example at a surgical centre, one will not only have to decide what procedures are to be performed but also just how much pre-surgical workup and management and what post-surgical follow-up will be provided. At our centre, which is a publicly funded joint medical and surgical centre staffed by family doctors, internists, dietitians, psychologists, nurses, and surgeons, we can offer extensive pre-surgical work up as well as extended post-surgical follow-up (generally up to two years). In addition, we have a robust roster of consultants, who provide a wide range of support. 

It is however, also increasingly common to find surgical centres that work closely with referring physicians, who perform much of the patient selection and pre-surgical workup as well as post-surgical follow-up. In this scenario, the surgeon only sees the patient a few times prior to surgery and rarely post-surgery, unless there are specific surgical issues that may arise. 

Irrespective of which model you chose, it is essential that much attention is paid to patient selection, education, work-up and preparation for surgery. The notion that patients may be chosen based on a single visit or even just a phone call is laughable, if this was indeed a laughing matter.

Similarly, I strongly feel that the surgeon is obliged to ensure that competent post-surgical management is in place and I would consider it ethically challenging to perform bariatric surgery, where there are significant doubts regarding the post-surgical long-term follow-up. Indeed, ensuring that patients fully understand and appreciate the need for long-term (lifelong) follow up is only part of the obligation. Patients may be so eager to get surgery that they do not give much consideration to the need for post-surgical care. Futhermore, in many places, there simply is no post-surgical care outside of surgical centres, so that patients who run into problems will likely find themselves left to fend for themselves. 

But also the medical programs need to define their scope of practice and think about what services will be offered. Given the complexity and heterogeneity of obesity, centres that offer a limited number of treatment options (e.g. one dietary approach, such as a ketogenic or formula diet), will necessarily not be able to help all-comers. In fact, it may well be that this very treatment option is contraindicated in some patients, something the centre needs to be very clear about. Furthermore, in my opinion, any obesity centre that does not also address the common psychological or psychiatric issues present in this patient population, cannot claim to provide a holistic approach to this complex chronic disease. 

Another issue related to scope, is deciding how much effort is to be put into managing comorbidities or other health issues present in the patient that may be the direct consequence of excess weight or otherwise complicate obesity treatment. A broad definition of obesity or bariatric medicine would in fact cover all areas of medicine relevant to the care of the patient with obesity (in the same way that geriatric medicine would seek to address the spectrum of care for the elderly patient). However, given the wide range of problems, it is highly unlikely that any obesity centre can provide all of these services to its patients. Rather, it is likely that the patient needs to be in the care of other physicians, especially their family doctors. In such cases, being clear about what will be managed at the obesity centre and what will need to be managed elsewhere, is of considerable importance. 

Obviously, no centre can be everything to everybody – but being very clear about exactly what services will be provided and which services may need to be sought elsewhere is not only honest but in the interest of patients trying their best to live with this chronic disease.

@DrSharma
Berlin, D