Table 3:

Factors influencing bariatric surgery referral and representative quotes

Factors influencing whether PCPs provide bariatric surgery referrals
1. Wanting to “do no harm”	- “There are some times when I think, ‘Boy, I’d really like to have this patient have [bariatric surgery],’ but I am a little afraid that with all these other comorbidities, their risk of complications [is] very high.” - “You read these articles right out of the New England Journal of Medicine: incredibly well-tolerated, and then you see patients who are disasters, and you’re trying to put it altogether. Are we missing something here? Are they selecting their patients so carefully that when you’re played over broader population like we see you can get disasters that you didn’t see in the study?”
2. Questioning long-term effectiveness of bariatric surgery	- “I’ve had another patient…she lost a lot of weight with surgery about twenty years ago. Gained it all back.” - “I’d say about fifty percent of the patients I know who had [bariatric surgery] have either out-eaten it or gained back most of the weight, and they are well on their way to the same complications they had prior to surgery - “So, I actually have a patient, where she is so skinny [after bariatric surgery], at this point and can’t absorb any nutrients, that we admit her to our inpatient service every month. So I think it goes both ways.”
3. Having limited knowledge about bariatric surgery	- Regarding whether bariatric surgery is typically performed laparoscopically or open: “I think most of the [bariatric operations] I’ve seen have been open, but, to be honest, I don’t truly know that because I think people had to have revisions and multiple abdominal surgeries afterwards. So, I don’t truly know what the initial one would be.”
4. Not wanting to recommend bariatric surgery too early	- “Often I feel I want to get their medical problems like diabetes and blood pressure well-controlled before I make a referral because, certainly if they have an A1c of 10 or blood pressures of 160’s over 80’s, they’re not in the best control possible. They’re not going to be a good surgical candidate anyway. So again, if the patient would have asked [for a bariatric surgery referral] at his first visit, I’d say ‘No. [let’s] fix these things well before we consider that. You need to try and fail multiple options that could be effective for you. And remembering again, bariatric surgery may help you lose weight but you still have medical problems we need to address. Those still remain lifestyle changes, and medications need to be a part of that.’”
5. Not knowing if insurance will cover bariatric surgery	- “I can’t keep [the insurance] straight, so, therefore, I don’t know even if it’s covered. Under what circumstances is it covered? At what BMI threshold is it covered, even if it is covered? Therefore, I’m naive to, can I even offer this to him or should I not set him up for anticipation and excitement about possible treatment, that he then crashes and burns and loses all faith in me because I said something was going to be available, an opportunity for him that truly didn’t exist?” - “I never bring [bariatric surgery] up because, usually, I assume it’s not covered, and for a lot of my patients, it’s not financially an option for that out-of-pocket at all.”
Challenges to pursuing bariatric surgery
1A. Meeting pre-operative requirements (patient)	- “He sees [the bariatric surgery team] every two weeks or at least every four weeks. He’s been doing this for a year. He’s getting very disappointed because they are telling him, “You have to make big lifestyle changes, dietary changes," and, of course, if he was successful, he wouldn’t need the bariatric surgery. But even with a year of intensive therapy, more than I can give my usual patient, his BMI remains 77. This is one year of a major bariatric center, throwing the kitchen sink at him, to try to prepare him for upcoming bariatric surgery, which they’re promising him. He’s getting very frustrated, because they have not cleared him for surgery yet, and he’s been in this process for a year, and he’s also not lost weight.”
1B. Living far from a bariatric surgery program (patient)	- “I’m in XXX County, and, as far as I know, there’s not a bariatric program there. We generally refer to XXX County, to their bariatric program. So, that is a barrier of location. Many of my patients in XXX think Milwaukee is like Chicago. It’s twenty minutes away, but, to them, that’s very far out to go to have to go to Milwaukee and see physicians.”
2. Primary care practitioner involvement in post-operative care (practitioner)	- “And again, ignorance here, I don’t quite know exactly what the frequency of what should be tested and what exactly should be tested and if it’s my responsibility as the primary doctor to manage those potentially malabsorption issues. Or should it be, in my opinion, maybe the surgical team and the nutritionist associated with that team during the follow-up and verifying that all the T’s and I’s are dotted and crossed.”