Episode 23: Revisional Bariatric Surgery with Dr. Francesca Dimou

Unlock the secrets to successfully navigating revisional bariatric surgery as we invite Dr. Francesca Dimou, a pioneering Bariatric and General Surgeon with a talent for robotic procedures, to illuminate the complexities of this life-altering medical journey. Transitioning into a new chapter at USF and Tampa General Hospital, Dr. Francesca Dimou outlines the essential steps she takes in the intricate dance of preoperative evaluations. As she shares her algorithm and stresses the importance of diagnostic tests, you'll discover the empathy and expertise needed to set patients up for triumph in the face of obesity's challenges.

As we wade through the murky waters of insurance coverage for bariatric surgery, Dr. Francesca Dimou and her team of patient navigators emerge as beacons of hope, guiding patients through the labyrinth of policies and procedures. It's not just about the physical transformation; the conversation turns to the emotional odyssey patients embark upon, confronting societal misunderstandings and internal battles. With Dr. Francesca Dimou's insight, we're reminded that obesity is a chronic disease demanding a cocktail of surgical intervention, medication, and lifestyle changes, all delivered with a generous dose of compassion.

Finally, we converse on the synergistic power of a multi-generational surgical team, where experience meets innovation, and colleagues become confidants. Dr. Francesca Dimou reflects on her own professional voyage, which took an unexpected detour from anti-reflux to bariatric surgery, a field ripe with the potential for impactful change. She emphasizes the mentorship that sculpted her career and offers pearls of wisdom to young surgeons: Embrace the strength of a united team, and you'll not only excel in your field but also ensure the highest standard of care for those you serve.

Transcript

Speaker 1: 0:00

Welcome to Core Bariatrics podcast hosted by Bariatric Surgeon Dr Maria Iliakova and TMA LaCose, bariatric Coordinator and a patient herself. Our goal is building and elevating our community. Core Bariatric podcast does not offer medical advice, diagnosis or treatment. On this podcast, we aim to share stories, support and insight into the world beyond the clinic.

Speaker 2: 0:24

Let's get into it. Today we are so glad to have with us a Bariatric and General Surgeon that works with USF University of South Florida and Tampa General Hospital. She recently transferred from Wash U in St Louis. She's performed over 500 robotic surgeries and I was lucky enough to meet her in one of our committees, in our professional organizations. She did fellowship at Cornell Residency at the University of South Florida in Tampa and she's back home now. Please welcome Dr Francesca. Thank you for having me. Thanks for being here, look forward to it.

Speaker 3: 0:56

Yes, of course, I'm glad you're here.

Speaker 2: 0:58

I'm excited to talk about everything. Oh yeah, so you just moved back to Tampa. How's it going?

Speaker 3: 1:03

Yes, so I just moved back and started here at the University of South Florida and Tampa General in October so only a few months and I was at Wash U for four years. 2019 is when I started my practice there and I started in September and then March of 2020, covid happened, so navigating that as a brand new Bariatric surgeon. So it's a little bit different here, because now I have a lot of experience under my belt. So, fresh out the gate, when building a practice and coming out of training, you don't take risky procedures, you kind of go with simple things and you are really risk averse which you should be because you're building your reputation and those sorts of things.

Speaker 3: 1:50

And then I think it was probably after a year, year and a half I started doing more revisional cases and so patients came specifically to see me and so here at Tampa General, it's unique because I started doing more revisions first than primary Bariatric cases, because that was what was put in my clinic and I'm not opposed to it. It's just different and it's unique. But now I have a different. It's a different health care system that you have to navigate, different specialists you have to develop relationships with, especially for patients who do require revisional surgery. I do have a specific algorithm in how I work patients up because I need to set them up for success. It's not the primary bypass or sleeve, it's they've had multiple surgeries or they've had multiple complications and I got to get them set up to have the best outcome possible. So it's navigating that as well.

Speaker 2: 2:44

So you talk about an algorithm for revisional surgery. Just to sort of break that down Sounds like one. You're offering a new service or sort of an updated service to what was available before, which congratulations, because that's a really, really big deal in patient access. Two, for folks who have had surgery before and may need surgery down the road if they don't have someone like you in the area, they're kind of host and have to travel far to get that kind of service. So first of all, congratulations on developing something like that. That takes a lot of guts and skill. But can you tell us a little bit more about what it takes to actually get revisional surgery? What's that algorithm you mentioned?

Speaker 3: 3:19

So typically what'll happen is patients will come to me. Either they'll have, let's say, a hiatal hernia and they had a prior sleeve. I've had also several patients currently in my clinic that are undergoing workup. They've had a history of a VBG, which is a you know, or they'll say stomach stapling, and that was done a long time ago. That was done in the 80s kind of thing. So typically for those patients it depends on what the problem is.

Speaker 3: 3:48

So if they're having any sort of acid reflux or any sort of forego problem, I do a full forego workup. So that includes pH menometry, a swallow study and an EGD, and the reason for that is that gives me all the information. As far as any issues with you know, motility, if there is a pH issue because sometimes if they're having reflux after a bypass, why is that non-acid or acid reflux it does help. Also, the reality is is insurance approval, because sometimes insurance sees it as, oh, I'm doing this other weight loss operation, but that's not what I'm doing it for. I'm doing it because they can't eat or they have an ulcer or someone and so forth.

Speaker 3: 4:27

And the other thing I do, especially in the older cases, like a VBG, I will get a CT scan Because sometimes they don't know and I'm kind of guessing, and that's fine. You know, it just wasn't a popular operation and there aren't very many around even now, and so I'll get a CT scan also to have a better idea and kind of get a lay of the land, because the majority of these operations that I do are robotic. So then I can kind of tell exactly what's going on, and that helps me as well and I tell patients ahead of time. You know there's going to be a lot of steps along the way, but I need all of that information to put all the pieces together again to make sure that I do a safe operation for them and I give them the right operation.

Speaker 2: 5:06

So that's pretty interesting. Your workup involves a lot of imaging and kind of procedures, like you mentioned, and sometimes that can be really scary to people coming into the process. And I'm telling you I'm actually going to call you out a little bit you had not had surgery before, but part of the typical protocol was actually a scope, an EGD, and you had said that you've mentioned since that time that if you actually knew why you had to do the scope, that you would have gone through that process. So this is kind of a combo question to both of you what do you think makes it possible for patients to go through a lot of procedures or a lot of workup when they don't necessarily know why that's happening or what? That can be intimidating.

Speaker 3: 5:46

Tammy, you can go first, because my hands will probably be long. No problem.

Speaker 1: 5:50

So really, the reason, the two main reasons that well, three I should say that I didn't undergo the scope was well, for one, the provider that I originally seen didn't really did give me the choice, because I didn't have acid reflux, I didn't have any issues, I was like a picture perfect patient, I guess. Quote unquote. So I also PTO was limited, and then also my resources to having some a driver take me there and bring me back, because if it was my husband then he had to take a whole day off. So, but now, so I really was just looking at the work aspect because I knew I was going to have to take a bunch of time off of work after surgery. But now, looking at it and knowing why we do it, you want to look and see the lay of the land and make sure there aren't other issues going on and if there is, you can prepare for that for surgery. So there's a lot of things, education wise, that I learned that I would have done it if I knew all these things.

Speaker 3: 6:52

Yeah, and I think the thing is is that education is empowering to patients. You have to explain things to them, and so I always tell them. I explain what if we do a, whether we do a bravo or pH, with impedance? I explain, you know we're looking for a numeric value. You tell me you have symptoms, but I need a numeric value because what if you have these symptoms after surgery? I can kind of compare, you know same with the manometry that tells me how things are moving down. And I'm also very, very honest with patients about manometry. I tell them they're going to hate it and it's miserable, because I did it in training, so we learned how to not only do the manometry but read it.

Speaker 3: 7:30

Inserting that probe is awful. Patients don't like it, and I remember my attending at the time we told the patients not that bad, and I was like, no, but it is. And I was like, but it is. And so I tell patients, so at least they have that in their mind. And then sometimes they're like actually it wasn't as bad. And so I think you have to.

Speaker 3: 7:48

You have to give that information and give them a reason for things, especially if it is a long list of things or a workup that they're going to have to undergo, because in their mind, like you said, it's work, it's money, it's cost, they're deductible, and so you have to provide them with them understanding. It's to help tell a story, in a way. I tell patients it's kind of like we're in a movie and they're the main star, right, they've been in the movie the whole time, they know everything, and I'm coming in like three quarters of the way in and I have to like catch up and put all the pieces together of that movie in order for us to get to the end. And so that kind of helps too, because I wasn't there for the last 20 years or whenever they had their original surgery. So I have to kind of piece things together and do it safely for them.

Speaker 1: 8:38

So quickly, because I don't know what is that procedure that you were just talking about, Just in case patients, sorry, just in case patients are listening to this and don't know, what it is and have to do it.

Speaker 3: 8:51

Yeah. So a menometry basically is kind of I call it like a noodle. It's a little noodle that goes into your nose. You are awake for the procedure. You do have to be awake for it, and so when the tube goes down into your nose it goes all the way into your esophagus but kind of goes, you know, between the esophagus and the stomach. That's kind of ideally where you want it. And while you're awake with this tube in your nose you have to drink water and the probe senses the water based on temperature of the water, and so then that helps us see the actual function of your esophagus, the actual muscle movement. So sometimes we see abnormal menometry, let's say, for patients who've had a sleeve, for whatever reason, they may have abnormal movement of their esophagus, and so that kind of gives us again more numeric values into what's actually going on in the physiological component of that.

Speaker 1: 9:44

That makes sense. Thank you for explaining that Absolutely.

Speaker 2: 9:48

Yeah, I think that's a big. That's really key, tammy, I'm glad you brought that up, because a lot of people, even with a scope, they've never had a procedure before. A lot of folks that we operate on or are considering for operations are well below 45 or 50 when they're getting colonoscopies and so they maybe never had a procedure really in their life and all of a sudden you're coming with a menu of items that people have to do and maybe seeing some other physicians or some other folks that they really need to get evaluated by it can be very daunting, yeah it can, it can be.

Speaker 3: 10:17

And I think that's the hard part too. So you are mentioning, as far as you know, you know, being a bariatric coordinator and things like that. And now we have the role of patient navigators, because every patient's insurance is different and every policy or whatnot is going to have different requirements. And then if you're like giving them this laundry list, it's either like, oh my God, like I have to do all this stuff yes, you know. And so sometimes it's like wait, what do I have to do again, you know. And so that can be overwhelming.

Speaker 3: 10:45

And what I also tell patients is you know, especially when you do like an info session and you're talking to patients, patients will say, well, I have Blue Cross, blue Shield. Does that cover bariatric surgery? And I said I don't know, it depends on your policy. And the thing is is people will call insurance. You'll call your insurance and you'll just talk to a generic person and say, do you guys cover bariatric surgery? And that generic person is going to give you the generic yeah, we do, but your policy may not cover that. And so that's what we have to be very explicit with patients because, yeah, blue Cross, blue Shield offers bariatric surgery, but your policy or your employer may not provide that benefit to you.

Speaker 1: 11:26

And then, especially in your case of doing revisions, you have to check to make sure they do the second surgery because some insurances will not even do any second bariatric surgery.

Speaker 1: 11:39

Yeah, at the end of I could have put myself in an office somewhere and not seen patients. Honestly, just talk to them before they come in, whatnot. But I wanted myself at the checkout so that after their appointment I can say I know, you just got thrown a lot of information. Here's how to contact me. Do you have any questions? Because you know the second that they walk out that door. That's where all the questions come.

Speaker 3: 12:03

Oh yeah, oh yeah. It's a lot. And I think, for patients as it is, when they come into clinic to see me, they are already so nervous, they're nervous, they're emotional, they in reality don't want to be there. Right, like no, and that's the thing is yeah.

Speaker 3: 12:25

And the thing is is that they have been. Our patient population has been stigmatized and ostracized and judged all of their lives and they're just told you need to eat less and exercise more and that's going to solve all the problems. And I tell patients I said, would you be nervous if you were coming here for your blood pressure? And they're like no, and I'm like and that's the thing is is that we have to change the mindset of obesity and that obesity is a disease, it's a chronic disease and it's not a choice. There are all these components and, yeah, and we are. We have no idea, because everyone thought surgery was this cure. And then if patients gained weight after surgery, they were like, well, you're a failure. And now we're like, well, that's maybe not necessarily true.

Speaker 3: 13:10

And then it's like and then everyone thinks we'll go via nozepik is going to be the answer to everything, and I don't think it's an either, or I think it's a complex disease that we have to understand and we have to stop blaming people for it, because that's not fair, absolutely.

Speaker 2: 13:25

Amen. You're very much preaching, and I appreciate that, because there's this sentiment sometimes that people don't even come back to get seen if they regain weight or if they happen to have reflux or some other issue after surgery, because they're so afraid of the judgment or afraid that they'll be told this is all your fault and we can't do anything for you, when actually it's usually not anything to do with what you did as a person. And then, too, there's actually a lot of options on the table to be able to help people at this point.

Speaker 3: 13:56

Yeah, and I think, again, it's all about expectations, it's all about knowledge, because I tell patients one thing so I say, if I give you a gastric bypass and you see me a year later and you're like, hey, doc, I've been doing all these things, I still can't get those extra 10 pounds off, and so on and so forth, that's one discussion. And then we're like, ok, well, we can maybe add a medication, or we can look at other things, or so on and so forth, and it's not that you're a failure, it's not that your surgery failed, it's just your metabolic set point is different. Now I tell patients that same patient. I say, well, if you come to me a year later and say, well, you know, I'm eating Taco Bell, and I kind of let things go, that's a different discussion Because, again, treatment of obesity is multifactorial. If surgery, it's potentially medications, it's diet, it's all of those things, and so it's all about perspective. In that sense, yeah, absolutely.

Speaker 2: 14:53

So I'm curious. Actually, we've talked a lot about what you do now and some of the cool and complex things that you break down. How did you get into this field? What brought you to it?

Speaker 3: 15:01

Bariatrics in general. It was funny Because when I went to fellowship I thought I was predominantly going to do anti-reflex surgery Because that was a lot of my training. But then when I went into fellowship and I purposely chose a fellowship that gave me a variety, Because I didn't want to kind of pinch it home myself, so I did something where I did complex abdominal wall, I did foregut and then I did bariatrics, and then I thought I would never do robotics, I thought I would just do leprosy.

Speaker 2: 15:28

You ended up in Florida. How could you avoid it? I know.

Speaker 3: 15:31

And then I did it and I loved it and I loved the operations but also I loved the patient population. I loved taking care of those people. I loved seeing how much they changed afterwards. And it wasn't about a number on a scale, it was about life goals. And I really realized that in my first job, where it was like a patient would say something like I was able to take my son and I could go on the roller coaster Because it wasn't a weight restriction or one woman was like I've never been on a plane and I finally got to go on a plane and I wasn't embarrassed Because we always drove everywhere.

Speaker 1: 16:11

You just did two things. Yeah, I used to go on roller coasters Wins, we go every year to Adventureland here in Iowa and a year before my surgery I got onto a roller coaster and it couldn't shut. So that was heartbreaking, Because my oldest son was like mom, why did you get off? And I haven't been on a plane since middle school and here I am going on planes now.

Speaker 2: 16:36

So it was just a few things that you never seen, and it was very either.

Speaker 1: 16:42

My anxiety was a little through the roof just because it's a new thing, but weight had nothing to do with it. Me not fitting in an airplane seat had nothing to do with it. So, yeah, yeah.

Speaker 3: 16:55

It was more of like getting through. It was more like TSA security.

Speaker 2: 17:00

Literally Not using a shoe or that power Exactly.

Speaker 3: 17:05

It's like getting all your stuff out on time. That's a whole separate stress. But yeah, I mean that's kind of how it should be for what we do. And then the revisional work was something that it was, I would say I fell into it. But also there is so little on on against I don't want to say I didn't have a choice.

Speaker 3: 17:28

I would say that those patients started coming into my clinic because my other two partners also did very similar operations and, being at WashU, we were the only huge medical center that would even take care of these patients, and so we were at Catchman's area, not only for Missouri, but for Illinois, sometimes Kentucky, tennessee, arkansas, so we saw people from everywhere that had complications, and so I had to take on these patients. But also, at the same time, being a young surgeon, I was fortunate enough where I had two colleagues that were awesome. They're my good friends, they're my mentors and they helped me through that too, because I could do it. But it's always nice when you're a young surgeon to have that backup. And so they helped me and taught me so much, because I saw things that I had never seen before and patients with complications from surgery that I had never managed before, but with my colleagues I was able to take care of those people and really have that kind of aspect of changing their life as well.

Speaker 2: 18:36

So that's a really interesting thing that you mentioned. You basically not only were able to use the skills that you had, but because you had good mentors where you worked, you were actually able to do even more complex things and grow into a role where you could take care of whoever came in the door. You actually were able to figure out a way, even if it was complex. It sounds like.

Speaker 3: 18:57

Oh yeah, my one senior partner, Chris Egan, has been doing bariatric surgery for 30 years, has done over 4,000 bypasses and I'd call him Sometimes. I'd call him because I'd be on call. I'd be on Christmas. I'd be like, hey, Fritrisco, what's up?

Speaker 2: 19:12

And he was just like and I'd talk to him.

Speaker 3: 19:15

And I'd say, hey, like what do you think? Or I've never seen this. And he's like, oh yeah.

Speaker 2: 19:19

I've seen that I'm like, of course he's so experienced yeah, he's so experienced.

Speaker 3: 19:24

And Shayna Eckhaus was my other partner. She's, I think, three years older than me. She came from Duke and is now back at Duke, but she taught me so much too. But then it was awesome because it was nice to have also two female surgeons that were so close and she didn't do a lot of robotics. So then she would call me in when she did robotic cases and I kind of helped her with robotics and then she would come in because I would be like hey, can you take a look at this? And she's like, yeah, sure, and so we were just very it was a very great collaborative team that we had. That I was very appreciative for, and I think that's probably the most important thing when I tell junior trainees, like, going into their first job, you got to have the right people, because that makes such a huge difference to who you will become as a surgeon a thousand percent. And they really, really helped me. I cannot thank them enough for my first job and I talked to Shayna still all the time.

Speaker 2: 20:19

Wonderful person.

Speaker 3: 20:20

Yes, that makes a lot of sense.

Speaker 2: 20:22

Yeah, can you talk a little bit more about? Yeah, so we definitely do have some listeners who are in the medical field, and I think that, for I really want to emphasize something that you said, which is when you're looking for a job, especially your first job, it does matter who's around you and the people there. Can you tell me a little bit more about how? Did you know you were coming into an environment where you would be supported, where there would be that kind of relationship, or was that one that you actually participated in making yourself?

Speaker 3: 20:49

I got the sense and I felt that at the time with WashU and the MIS section. It was a little bit unique at the time that I came in because a lot of people were young surgeons and I thought you know you have the senior surgeons as well that were more experienced. But the reality is is there is a different feel when you have colleagues sort of around your age range. You know, because I loved Egan, I could call him anytime but it was nicer because Shayna was closer to my age.

Speaker 2: 21:21

Right, you know what I mean.

Speaker 3: 21:23

It was just easier to call her and even if I had a hernia, that I was on call, I would call my other colleagues who were also younger, and so I felt more and I think that's the thing is that when you have that group and you get that sense too and even my group here, they are younger and I know them Like I knew them through the conference trail and those sorts of things, but they call me and they are like, hey, can you come take a look at this? I do the same thing. So you really want that team effort where you're not on an island and you can get that sense when you interview.

Speaker 2: 21:55

Yeah, that makes a lot of sense. And then from the patient standpoint, I think what's really interesting about that is it's safer for patients too, because there's more than one set of eyes and the combined experience in the room sometimes means more than the experience of just the person.

Speaker 1: 22:10

That's the surgeon.

Speaker 2: 22:13

So you're speaking, I think, to something that's a huge quality and safety issue for the people we take care of too.

Speaker 3: 22:19

Exactly, and I think us as surgeons, as an individual person. We don't know everything, we haven't seen everything, but that's why it's all about that, what I don't know about that I wish I wish you know what I mean, right? No, I don't.

Speaker 1: 22:36

Say that You're willing to say I don't know it all and I'm not afraid to call someone and be like I've never seen. This. That says a lot about your character for sure, because there are some people that will be like, oh yeah, I've seen it all, I can do anything, and then have issues because they just yeah.

Speaker 3: 22:55

So good for you for not having yeah.

Speaker 3: 22:59

I love a good team approach and also not only that, I enjoy it. I enjoy going my partners, even if they don't call me, I go see and I'm like, oh yeah, Like I see what they're operating. They come see me Like hey, what's going on? And I think you should have that team approach, Because what we do is hard and we take care of complex patients and you want to do the right thing for the person, and so if there is someone else that knows about it, then you should be able to go to that person.

Speaker 2: 23:26

Yeah, that's a great approach and I do think that there is. Luckily we're trained that way. We don't always end up in situations where we work in the real world that has that kind of cross coverage, but definitely it is beneficial for everyone involved most times. Yeah, that's great, that's great. So are you enjoying Tampa overall, being back and kind of being back home, being back in your environment? I know the insurance is probably a little different, but overall it is.

Speaker 3: 23:55

It's crazy how Tampa has changed, and so I left in 2018.

Speaker 3: 24:03

So left pre-COVID, obviously, and the population here has exploded, so the number of people that have moved to Tampa has exponentially increased post-COVID.

Speaker 3: 24:19

And so what's interesting is you have a hospital system that was used to a certain number of people in the city, and that hospital hasn't grown to accommodate all the people, and so now Tampa general is working feverishly to build a new surgical pavilion to help expand those things, and so I'm learning how to.

Speaker 3: 24:43

That's a whole separate thing that I'm learning how to navigate, because I came from a system that was a huge system but didn't have anywhere near the population of people here, and it's interesting too, because you have so many other facilities in the area, you have so many other hospital systems in the area, and then you also have the component of patients don't always live here full time, so some come from the Northeast, there's snowbirds, and that always makes me nervous because I'm like I don't want to do this big surgery. And then you go back up to Jersey, and so I'm learning how to navigate those things too, because it's a different landscape here than I was used to, and I think that's also just because of how Tampa has changed. There are some places that I don't even recognize. Channelside used to be dirt and now it's like Michelin Star restaurants and all this other stuff and I'm like what happened? So it's just crazy how it's grown, which is good for the city.

Speaker 2: 25:50

That actually brings up a good point, though, because I think a lot of places don't necessarily get the get bariatric care or foregut care, good reflex care. There's never really enough to go around, and even in a place like Tampa, where I think people have the belief, probably, that it's like oh, there's so much of it, it's totally easy to get that no big deal. Even in a big population it's actually not that easy.

Speaker 3: 26:14

Yeah, just because there's so many people I think I read somewhere that 5,000 people are moving here every quarter or something. Crazy, just the number of people. And because also, what we see is people will live in Florida, because now again, how COVID has changed things is everyone works remotely, so people's jobs will be in New York, but they will reside in Tampa, and so it's just kind of crazy now that everyone works from home and everything's digital and technology and stuff.

Speaker 2: 26:46

In dealing with people who do travel, since that seems to be the specific kind of snow bird or digital nomad situation in Florida. Do you have patients that applies to, and how do you counsel them differently or work them up differently than you would anyone else?

Speaker 3: 27:01

I would still do the same work up.

Speaker 3: 27:03

I did actually have a patient recently and I did a big revision on her and I waited purposely because she was like I'm going to be up in the Northeast for the holidays and so on and so forth for like two or three months at a time and I was like I'm not doing your surgery until you're here for at least six months.

Speaker 3: 27:21

She was like, okay, you know so and so forth, and I think when patients realize and especially for a revisional patient when I tell them the magnitude of the operation that we're doing and those sorts of things, I think they really get a better idea. You know it's not. I tell them I'm like this isn't? You know, we're not removing a mole or something like this is a big operation, although I'm doing it robotically, and there's four small incisions. It's a lot of work on the inside and so I want to make sure that you are okay, because I also I know this is going to be shocking as a surgeon, I'm a control freak and so if it's my patient, I want to be able to take care of them and I want to be able to be there for them if something happens.

Speaker 1: 28:02

Yeah.

Speaker 2: 28:04

That makes a lot of sense, yeah, and I think that sentiment is really important for everyone to hear too, that these, even though they are safe surgeries, they're people, are really worked up really from head to toe and they're done in minimally invasive ways, with cuts that look really small on the outside. These are big changes that people are going through, so I'm really glad that you mentioned that as a specific consideration for your practice.

Speaker 3: 28:29

Yeah, and I think for those undergoing bariatric surgery, because they'll say things like well, is it like my getting my gallbladder out? And I said same incisions. I said, but when you have a gallbladder, you kind of go back to your normal life, right, you just kind of hear feel a little sore, or whatever I said the biggest thing is is like what I tell you is I'm going to do this surgery on you in a couple of hours and then you're going to wake up and now I'm going to tell you to change everything that you've ever done for however many years you've been on this earth, and I expect you to do it today.

Speaker 3: 28:59

You know, and that's hard you know, like take small sips and make sure you do this and make sure you do that, and so I think, and when I tell patients, it's more of the mental aspect of things, it's interesting. Yeah, and sometimes patients are like what you know, they get offended. I'm like, no, I'm like it's the psychological change, it is your relationship with food that changes. It is how you, you know, are with family and friends. It's everything.

Speaker 1: 29:27

And so we can give us all situations and if you even want to indulge in something, you can't, and that is mentally.

Speaker 3: 29:34

Yeah, the mental part is definitely huge and yeah it's hard, it is hard and so and I think that's the thing that unfortunately some people don't understand outside of patients, like even other physicians, you know they'll be like, oh yeah, just give it. You know, just do a bypass, and I'm like that's not how that goes, and so it takes a lot of time and I think, if anything, sometimes the psychological evaluation before surgery is probably the most important part.

Speaker 1: 30:06

Yeah, yeah.

Speaker 2: 30:08

Very much so. Yeah, that's key, and I think a lot of people are afraid of that because they think they'll stop them from having surgery or stop them from having a revision, but oftentimes it's the opposite it actually is. It's a way to enable someone to do well and to identify things. So I'm really glad that you're bringing that up, because that is a source of concern for a lot of people considering this.

Speaker 3: 30:30

And I think it's just you know, and again, patients are fearful, they're going to be judged, they're going to be like analyzed or whatever, and it's more about understanding and having insight. Like Tammy mentioned, your relationship with food, how you use coping when food and just those sorts of things, because that will be different post-surgery and what that looks for what that looks like is going to be individual, you know, or different for every individual.

Speaker 2: 31:00

Yeah, definitely. Well, this has been a very wide ranging conversation.

Speaker 1: 31:05

Yeah, yeah, I know right.

Speaker 2: 31:08

So from St Louis to Tampa. I'm sure Tampa is thrilled to have you back, because it sounds like you're making waves. No pun intended, but you're really offering a service that's not only extremely high quality, especially with the revisional work that you're doing, but really compassionate, and just everything that you do shines through as focused on taking care of people.

Speaker 2: 31:29

And I'm very proud to know you. You served as a mentor to me also in the brief time that we've known each other. I really appreciate it. So thank you for being such a guiding light in this space. Really appreciate it, thank you guys.

Speaker 1: 31:42

Thank you guys for having me. Yeah, absolutely Thanks for being here. So, for those that are listening, don't forget to like us on Instagram. Send us a message if you want us to discuss anything, but otherwise we will see you all next time. Thank you for being here. Bye.

Speaker 3: 31:57

Bye. Guys, Bye.