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Coffee Time interview.

Coffee Time interview....with IFSO President, Dr Kelvin Higa

We talk to Dr Kelvin Higa (Director of Minimally Invasive and Bariatric Surgery, Fresno Heart & Surgical Hospital, Fresno, CA), past-president of the ASMBS, and current president of IFSO, about his career in medicine, the influence of his father and his views on the future of bariatric and metabolic surgery.

Did you always want a career in medicine?

Not really. I didn’t know any physicians personally; I had no idea of the lifestyle or the dedication involved with this profession. I knew the path was long and difficult, but the rewards would be great. Of course, I was only thinking of social status and income at the time, but now, looking forward, I can only think of the individuals we help and the lives we help transform. The old cliché of wanting to help people and make a difference became a reality.

IFSO President, Dr Kelvin Higa

I suppose the primary reason I chose this profession was that it was the most difficult, unobtainable goal I could imagine. Few members of my family had the opportunity to go to college and I remember thinking to myself that I do not want to look back on my life with the regret of never having tried. The tragedies we remember most are not our failures, but the opportunities we missed because of the fear of failure.

Medicine was not my passion at first; but has become one and for this I am forever grateful.

Why did you decide to specialise in bariatric surgery, what attracted you to the specialty?

My father was a motorcycle mechanic, but to this day, I think he would have been a great surgeon. He had this knack for being able to diagnose and fix things no one else could. His mind was all about problem solving and efficiency and I know my approach to medicine is primarily because of his influence. Naturally, surgery is mechanical thinking, so this was the only specialty I was interested in. Ironically, I remember him telling me that one day I would be a world-famous surgeon – and this was when I was 12 years old! Of course, he would follow that up with: “No matter how good you think you are, there is always someone better.” That’s my dad for you!

"The other individual that has influenced me has to be my wife, Gloria. For 34 years of marriage, she has supported me and taught me the true meaning of dedication, integrity, love and family. Truthfully, without her, I would not exist."

Bariatric/metabolic surgery was a fortunate accident. I was already living my dream: a busy general surgeon in a small California city. What could be better! Then one day, an insurance company asked my opinion regarding the difference between a BPD (biliopancreatic diversion) and a gastric bypass. I told them that I did not know, nor did I care. Besides, there is no reason to do surgery for weight loss – all patients need to do is exercise and diet.

They persisted and I reluctantly agreed. I told them to give me six months and I would have some recommendations. This was the early 1990’s, before the internet, so I accessed the hospital librarian and asked for every article and every reference regarding bariatric surgery. In two weeks, I had a stack of papers about 3 feet high. The first question I needed to answer was how effective diet and exercise was. To my surprise, the literature, even at that time could not demonstrate any demonstrable benefit for sustained weight loss. How could this be? This continues to be the primary recommendation we give our patients and the evidence clearly is in opposition! OK, then what about surgery? Surely, surgery must be ineffective and much too dangerous, eh? Surgery is not only effective, but also safe! What? My entire foundation regarding obesity concepts was now demolished! I think back about my epiphany almost 30 years ago based on the literature at the time and the continued prejudice and misconceptions still prevalent today. In this era of evidence-based medicine, we still hold on to old dogmas!

So, my interest in this field grew as my curiosity to this rising epidemic of metabolic syndrome developed despite the push toward low-fat diets and exercise. I discovered an aspect to surgery, I did not know existed: I could not only be a technician, but also a physician. Holistic and preventative care based out of a surgical practice – what a concept! During the 1990’s laparoscopic surgery came of age and with it a renewed prejudice against the obese patient. Obesity made laparoscopy more difficult and was even considered a contra-indication for MIS surgery. The bigotry openly displayed by my colleagues against individuals of size was so distasteful, I couldn’t help but be a proponent for ethical treatment of their disease.

Many of my colleagues questioned my decision and thought I was crazy as an up and coming surgeon to spend my time on a little known or cared about surgical procedures. But I knew that there was an entire segment of the population that nobody cared about and nobody wanted to treat. As a doctor, this did not feel right to me, I wanted to be their advocate, and that’s how I decided to start my surgical career in bariatric surgery.

Can you tell us how bariatric surgery has evolved during your career?

At first, we only had one or two procedures, then came laparoscopic surgery that led to a whole host of innovations, but I think one of the most important factors is that the specialty itself has evolved into its own branch of surgery with rigorous scientific research taking place. We have people looking into the pathophysiology of the disease, the influence of hormones, gut bacteria, biochemical interactions – we are not just performing weight loss surgery – we are performing metabolic surgery. For me the more complex the surgery has become the more exciting it is and there are still so many questions that need to be answered.

"The next generation really needs to pick up the baton and say, ‘If we are going to be taken seriously we have to increase the scrutiny of new procedures and/ or technologies, and issue guideline statements and position papers to protect our patients. In addition, we need to make care and treatment affordable. We can’t just be promoting surgery; it must include preventative and non-surgical modalities as well."

Regarding innovation, I think as a specialty we must be careful about how eager we are to adopt the latest technology or procedure without thoroughly examining its safety and efficacy. Currently, the bariatric and metabolic societies do a poor job in directing what the standard of care should be. The next generation really needs to pick up the baton and say, ‘If we are going to be taken seriously we have to increase the scrutiny of new procedures and/ or technologies, and issue guideline statements and position papers to protect our patients. In addition, we need to make care and treatment affordable. We can’t just be promoting surgery; it must include preventative and non-surgical modalities as well.

Who have been your greatest influences and why?

My father was without doubt the greatest single influence on my surgical career. He approached every problem in a very disciplined and systematic way, and that included business and life. For him, it was all about integrity and ethics.

I remember once a college professor coming to my father’s business wanting to buy a motorcycle – maybe he was having a midlife crisis. My father persuaded him not to buy a motorcycle. Now my father could have sold him a very expensive, high-end motorcycle and he would have made good money. But he knew that the professor was too late in life to learn how to ride a motorcycle, he knew it was the wrong thing to do. Integrity is important in life. Today, I see surgeons performing procedures because that is what the individual is demanding, but without asking the question, is it the right treatment for this patient?

The other individual that has influenced me has to be my wife, Gloria. For 34 years of marriage, she has supported me and taught me the true meaning of dedication, integrity, love and family. Truthfully, without her, I would not exist.

What experience in your training/career has taught you the most valuable lesson?

When I was a third-year medical student on rotation at the VA medical centre in Los Angeles, our team was making rounds on a comatose patient and acting rather unprofessional with our conversation. The chief resident, Chris Gibson, softly asked all of us to follow him out to his office. After he shut the door, he made it clear that he never wanted to see us act disrespectful in front of a patient, even a comatose one, and reminded us of our oath as physicians. At the time, I had convinced myself not to go into surgery (I didn’t like any of the surgery residents), but after that undressing, I thought: “well, if Chris Gibson can maintain his humanity, perhaps I could as well…”

What are the biggest challenges facing bariatric and metabolic surgeons over the next ten years?

The biggest challenge is that there are not enough of us. The epidemic is not slowing down and we are treating less than 1% of individuals who really need our services. Training takes time; the field is evolving so rapidly, that now, even most fellowship-trained surgeons do not have the experience to qualify them as masters.

Despite the current literature and overwhelming evidence to the contrary, there is still reluctance on the part of medical providers to treat obesity, let alone refer for surgery. Some of this is our fault. We tend to sell what we do; not advocate for patients. We often abandon our patients after an operation and are unwilling to care for another surgeon’s patient. This sends the wrong message and contributes to the negative impression many primary care physicians have for our specialty.

Surgical treatment is too costly to apply to the millions of patients who need our help. We must develop less expensive, but equally effective therapies if we are to make an impact on this epidemic.

What are your current areas of research?

We are currently developing ERAS protocols and methods of pain management without the need for narcotic supplementation after surgery. We continue to investigate methods of augmenting performance after procedures and ways in which to improve quality as well as reduce costs.

Away from surgery, how do you relax?

My life and career have turned out to be nothing like I imagined. It is so much more. The world of bariatric/ metabolic surgery is one in which surgeons like Chris Gibson is the norm, not the exception.  My time is spent trying to bring these individuals together to collaborate and educate and develop the platform to train more physicians in this exciting field of surgery. Some might say that I have no life. If they only knew!

DO NOT MISS Dr Kelvin Higa's Presidential Address at this year's IFSO World Congress, on Friday 1st September, in The Great Hall at 11:20am