Latest / Becker’s Healthcare Podcast / The Future of Bariatric Surgery in the GLP-1 Era with Dr. C. Joe Northup

Transcript

The Future of Bariatric Surgery in the GLP-1 Era with Dr. C. Joe Northup · Becker’s Healthcare Podcast

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  - This is Scott Becker with the Beckers HealthCare
• 1:01
  - podcast.
• 1:02
  - Thrilled today to be joined by a brilliant
• 1:04
  - bariatric
• 1:05
  - surgeon and so many things going on in
• 1:07
  - bariatric surgery and weight loss and GLP ones
• 1:09
  - and a lot more. So so excited today
• 1:11
  - to talk to doctor Joe Northup.
• 1:14
  - And Joe is the president of the American
• 1:16
  - Society for Metabolic and Bariatric Surgery. We talked
• 1:19
  - about trends that he's watching,
• 1:21
  - his focus, his career, and a lot more.
• 1:24
  - Doctor Northup, we are so thrilled to have
• 1:26
  - you with us. Take a moment to introduce
• 1:28
  - yourself and tell us something about your career
• 1:30
  - and about the American Society of Metabolic and
• 1:33
  - Bariatric Surgery.
• 1:34
  - Sure. Thank you, Scott, for having me here.
• 1:36
  - It's great honor to be on your cast.
• 1:38
  - So, I am the president, as you mentioned,
• 1:40
  - of the, American Society of Metabolic and Bariatric
• 1:42
  - Surgery. It's a group of physicians and,
• 1:44
  - other, types of providers that focus on taking
• 1:47
  - care of patients suffering from the disease of
• 1:49
  - obesity
• 1:51
  - from, all aspects of management. I,
• 1:53
  - I am,
• 1:54
  - the director of metabolic and bariatric surgery at
• 1:56
  - Vanderbilt University. It's right. It's my real job.
• 1:59
  - And, you know, my career has mostly been
• 2:02
  - in bariatric
• 2:03
  - surgery. I started out, my training at the
• 2:05
  - University of Virginia and stayed on the factory
• 2:06
  - there. Did all types of surgery, but, you
• 2:08
  - know, I had such a passion and,
• 2:10
  - for helping these patients. And, honestly, it's the
• 2:12
  - it was the biggest impact I've ever had
• 2:14
  - on somebody to be able to perform bariatric
• 2:16
  - surgery on them and change their life and
• 2:18
  - their quality of life and impact their health.
• 2:19
  - And I just focused my career on that
• 2:21
  - to the last, you know, been doing this
• 2:23
  - for twenty years.
• 2:25
  - So amazing. And and talk a little bit
• 2:27
  - about I mean, you're at these magnificent institutions,
• 2:30
  - Vanderbilt Health, also University of Virginia,
• 2:34
  - remarkable career.
• 2:36
  - Talk a little bit about
• 2:38
  - what are you seeing in sort of bariatric
• 2:40
  - surgery today?
• 2:42
  - What kind of impact are GLPs one having?
• 2:45
  - Can it be complementary
• 2:47
  - versus negative?
• 2:48
  - What what are you seeing out there in
• 2:50
  - terms of the world of bariatric surgery?
• 2:53
  - Well well, certainly, you know, our volume has
• 2:54
  - been impacted by the implementation of the GLP
• 2:58
  - one medications, and it certainly has, you know,
• 3:01
  - decreased our surgical volume over the last several
• 3:03
  - years. However, you know, it's not it's not
• 3:05
  - against medications. The medications are you know, we're
• 3:07
  - gonna be grateful for them because they have
• 3:09
  - created a conversation
• 3:10
  - around the disease of obesity that just didn't
• 3:13
  - exist before.
• 3:14
  - You know, having patients come in and talk
• 3:15
  - to their primary care doctor, GYN, or any
• 3:18
  - type of physician to start this conversation about
• 3:20
  - weight is a very important thing. You know,
• 3:22
  - out of all the patients that qualify for
• 3:24
  - bariatric surgery,
• 3:26
  - less than one percent
• 3:28
  - utilize that resource. So there's a lot of
• 3:30
  - patients that aren't being taken care of from
• 3:31
  - a lot of ways, and our indications are,
• 3:34
  - you know, based on your body mass index.
• 3:35
  - And then the higher body mass index is
• 3:37
  - where, you know, the procedures work, where the
• 3:39
  - medicines start to, you know, become less effective.
• 3:42
  - And I think that's been the impact of
• 3:43
  - this of the medications that everybody wants it
• 3:46
  - to be a a simple and easy problem,
• 3:48
  - and these medications work great for the right
• 3:51
  - patient. When you look at that, you know,
• 3:53
  - that twenty eight to thirty to thirty five
• 3:54
  - BMI, these medic and there's, you know, millions
• 3:56
  - and millions of people in The United States
• 3:58
  - that qualify for these. This has been such
• 4:00
  - a powerful thing.
• 4:02
  - But the problem has been and we've seen
• 4:03
  - this in our program as a frustration
• 4:06
  - where, you know, people coming back trying these
• 4:08
  - medicines and just not getting the the results
• 4:10
  - that they wanna see, but it's just basically
• 4:12
  - their body mass index is is higher and
• 4:14
  - they're not getting the health impact they they
• 4:16
  - want. So the medications are great. They're certainly
• 4:18
  - impacting our volume right now, but we're seeing
• 4:20
  - that trickle back up as people, you know,
• 4:22
  - try these medicines for six months for a
• 4:23
  - year, maybe have side effects.
• 4:26
  - Maybe they don't work for pace a lot
• 4:27
  - of patients, and then, they're looking for a,
• 4:30
  - you know, durable alternative.
• 4:32
  - Thank you. In terms of the American Society
• 4:36
  - of Metabolic
• 4:37
  - and Bariatric Surgery,
• 4:39
  - talk about sort of the core goals of
• 4:41
  - the society, the core focuses.
• 4:43
  - Where do you spend your time as leader
• 4:45
  - of the society? What are the big focus
• 4:47
  - It it's, it's it's a lot of
• 4:50
  - of of different levels of involvement. Our primary
• 4:52
  - focus, you know, is about taking care of
• 4:54
  - the patient. I mean, that's all we wanna
• 4:56
  - do is make sure patients are well taken
• 4:58
  - care of,
• 4:59
  - managed safely.
• 5:00
  - You know, we we focus a lot on,
• 5:01
  - you know, everything from data collection to, you
• 5:04
  - know, program development to education.
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  - The other, goal is to educate our physicians
• 5:08
  - and surgeons. You know, have we have courses
• 5:11
  - training every year, education every year, or twice
• 5:13
  - a year, and we have a weekend meeting
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  - and an annual meeting and really focus on
• 5:17
  - making sure that we're up to date. We'd
• 5:19
  - study new techniques, outcomes, research.
• 5:22
  - So that's our primary focus. We have a
• 5:24
  - large, allied health section of, you know, psychologists
• 5:27
  - and dietitians and
• 5:29
  - nurses and nurse practitioners, all those, you know,
• 5:32
  - other,
• 5:33
  - providers that, you know, help manage our patients.
• 5:36
  - So our primary focus is how we can
• 5:38
  - best serve our patients.
• 5:41
  - Thank you. And talk about you're in Nashville,
• 5:43
  - I take it. Are you in Nashville now?
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  - Yes, sir. You're located there,
• 5:48
  - one of the great food and music cities
• 5:50
  - in the country.
• 5:52
  - Are you allowed to have an absolute favorite
• 5:54
  - restaurant and bar
• 5:55
  - as a bariatric surgeon?
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  - And if you do have a favorite restaurant
• 5:59
  - and bar,
• 6:00
  - can you tell us your favorite couple that
• 6:02
  - you spend time at for when when we
• 6:04
  - visit Nashville? Like like, are you allowed to
• 6:07
  - as a bariatric surgeon? And if so, what
• 6:09
  - are the favorites?
• 6:10
  - Yeah. You know, I'll I'll I'll pause it
• 6:11
  - and say even patients don't you don't have
• 6:13
  - to be perfect with your diet for the
• 6:15
  - rest of your life. It is okay to,
• 6:17
  - you know,
• 6:18
  - in enjoy some maybe some unhealthy foods or
• 6:21
  - have a dessert. It can't be every day,
• 6:22
  - but, you know, it's fine. So I would
• 6:24
  - say my you know, I've I've been here
• 6:25
  - about three years. My favorite restaurant so far
• 6:27
  - is probably
• 6:29
  - Etch, that I've been to. Just a fantastic
• 6:31
  - local place. And as far as,
• 6:33
  - bars, you know, the the local Nashville folks
• 6:36
  - try to avoid Broadway as much as we
• 6:37
  - can. So, there's a couple places on Printers
• 6:40
  - Alley that have been great, especially the the
• 6:42
  - Bourbon Street Blues bars. Yeah. My personal favorite.
• 6:45
  - This is some good
• 6:47
  - Fantastic. And and did you if if I
• 6:49
  - have this right, you're a West Virginia
• 6:53
  - guy to begin with. Mhmm. And do you
• 6:55
  - ever look at West Virginia and think, it
• 6:57
  - is amazing what is going on with that
• 7:00
  - state, the growth and the sophistication of health
• 7:02
  - care in that state,
• 7:03
  - and how much it has grown over the
• 7:05
  - last decade or two, and and how many
• 7:06
  - positives have happened in that state?
• 7:09
  - Yeah. You know, I'm I'm, West Virginian to
• 7:11
  - the course. My my home state, my my
• 7:13
  - parents, my sister, my all my family still
• 7:15
  - live there. So it's it's it's near and
• 7:17
  - dear to me. And, you know, West Virginia
• 7:19
  - has struggled a lot with health issues in
• 7:21
  - the past. I think,
• 7:22
  - a few years back, last time I looked
• 7:23
  - at the ratings, you know, Huntington, West Virginia,
• 7:26
  - one of our largest cities, was the unhealthiest
• 7:27
  - city in The United States.
• 7:29
  - So I think they've taken that to heart
• 7:31
  - and really tried to focus on nutritional education
• 7:34
  - and, you know, encouraging activities and and and
• 7:36
  - bringing a lot of positive things to the
• 7:37
  - state. I mean, it's a beautiful place. If
• 7:39
  - anybody if you've never been, I I encourage
• 7:41
  - you to go there. It's great skiing and,
• 7:44
  - white water rafting is is fantastic and a
• 7:46
  - lot of outdoor activities and, great things to
• 7:49
  - do there. It's a it's a beautiful place
• 7:50
  - with with fantastic people.
• 7:52
  - It it is. And the West Virginia University
• 7:54
  - School of Medicine
• 7:56
  - is unbelievable. It's gonna be a crown jewel
• 7:58
  - in academic health centers as well as,
• 8:00
  - it's, wonderful. The Vandalia system is fantastic, and
• 8:04
  - they've done a tremendous job there in the
• 8:06
  - health care side.
• 8:07
  - And and and tell us a little bit
• 8:09
  - about so so
• 8:11
  - what happens to bariatric surgery in the long
• 8:14
  - run-in
• 8:15
  - the world of the GLP
• 8:17
  - medicines? What does that what does that look
• 8:19
  - like? What what percentage of patients still end
• 8:22
  - up getting bariatric surgery
• 8:24
  - versus therapeutic outcomes?
• 8:26
  - And in the ideal world, bariatric surgeons work
• 8:29
  - closely with the medicines as well. What what
• 8:31
  - what do you sort of see in the
• 8:33
  - long run,
• 8:34
  - the the future of bariatrics?
• 8:37
  - Yeah. It's it's a great question. I wish
• 8:38
  - I knew the exact future of what we're
• 8:40
  - hold. What we hope to see is that,
• 8:42
  - you know, we continue to present,
• 8:44
  - our our treatment
• 8:46
  - as what it is, extremely safe, extremely effective,
• 8:49
  - extremely durable. And I think that's the biggest
• 8:51
  - change that we need to look at is
• 8:52
  - the durability of treatment. But we see with
• 8:54
  - the medications, while the medications are great, when
• 8:56
  - you stop the medicine, the vast majority of
• 8:58
  - people within thirty days are putting significant weight
• 9:00
  - having significant weight recurrence.
• 9:02
  - And with bariatric surgery, you have a procedure.
• 9:04
  - Again, these are done as outpatient. Next day
• 9:06
  - surgeries,
• 9:07
  - go home in the morning after this procedure,
• 9:09
  - and it's a, you know, a very durable
• 9:11
  - it lasts. It lasts for years and years.
• 9:14
  - So I I think that we will see
• 9:16
  - as people come off the medicine, a lot
• 9:18
  - of times we we tell people that, you
• 9:19
  - know, I have a good friend that just
• 9:21
  - described this to me. Taking a GLP one
• 9:23
  - is like trying on surgery.
• 9:25
  - It's the same physiologic effect. It's just more
• 9:27
  - powerful. The internal GLP one and the other
• 9:30
  - hormones that are activated
• 9:31
  - give a much more significant impact
• 9:34
  - to,
• 9:35
  - your your overall health and weight loss. That's
• 9:37
  - why the weight loss is better. So I
• 9:39
  - I think what the future will be, I
• 9:40
  - think,
• 9:41
  - the
• 9:42
  - conversation will continue. I think weight will become
• 9:45
  - more focused on, you know, in in family
• 9:48
  - medicine and, patients' lives, and they won't be
• 9:52
  - intimidated
• 9:53
  - to ask about it. I think, you know,
• 9:54
  - we need to educate that this is a
• 9:56
  - disease. Obesity is a disease,
• 9:58
  - not a character flaw. And there's still a
• 10:00
  - lot of stigma and bias that puts this
• 10:02
  - on the patient's behavior,
• 10:03
  - not on the disease process, which is really
• 10:05
  - is a disease process. So I I think
• 10:07
  - the future we're gonna is still very bright
• 10:09
  - for bariatric surgery. I think the medicines are
• 10:10
  - gonna become more common. I think, you know,
• 10:13
  - bariatric surgery is gonna become a more prominent
• 10:16
  - option for patients once they realize how safe
• 10:19
  - and effective it is. And, you know, I
• 10:21
  - I I think there's gonna be a lot
• 10:22
  - of primary treatment and, either with surgery or
• 10:26
  - maybe the primary GLP ones. And then I
• 10:28
  - think there's gonna be patients that transition to
• 10:30
  - the, you know, the newer oral, GLP ones
• 10:32
  - in both groups, for for long term success.
• 10:36
  - Now I'm I'm gonna make a confession,
• 10:39
  - doctor Northrop.
• 10:41
  - Sunday,
• 10:42
  - I had a horrible day of eating. I
• 10:44
  - I I went overboard.
• 10:46
  - We had pizza.
• 10:48
  - The kids ordered some other stuff that went
• 10:51
  - with the pizza. I ate a lot of
• 10:52
  - that too.
• 10:53
  - Had a very bad day of eating.
• 10:56
  - How guilty should I feel, or do I
• 10:57
  - just move forward to the next day? And
• 10:59
  - is it okay? But the pizza was fantastic.
• 11:02
  - So I felt like it was an intentional
• 11:04
  - bad eating day. Do I get to forgive
• 11:06
  - myself for that and move forward, or how
• 11:08
  - does that look? How do you deal with
• 11:10
  - that mentally? Never feel guilty. I I tell
• 11:12
  - patients all the time, you can't worry about
• 11:14
  - yesterday. You can only worry about tomorrow.
• 11:16
  - And, you know, yesterday is yesterday.
• 11:18
  - And, you know, to be very honest, I
• 11:20
  - I tell patients all the time that long
• 11:22
  - term when you're eating, you know, people are
• 11:23
  - eating normal food and having I was like,
• 11:25
  - look. If you're following the diet,
• 11:27
  - and exercising and taking your multivitamins, doing things
• 11:29
  - you you're supposed to on Friday,
• 11:31
  - You know? Maybe it's a slice of pizza,
• 11:33
  - maybe it's a chicken wing, maybe it's, you
• 11:35
  - know, Nashville hot chicken or, dessert. Whatever your
• 11:38
  - thing is, it's okay. And, never feel guilty
• 11:41
  - about having a bad day of eating. And,
• 11:43
  - you know, I've had a lot of successful
• 11:44
  - patients. They call them cheat days, which is
• 11:45
  - a really, you know, the perfect term, but
• 11:47
  - they'll still have a bad day of eating
• 11:49
  - and and just the rest of the days
• 11:50
  - are good, and that's okay. It's okay. I
• 11:53
  - shouldn't take myself too bad on that. It's
• 11:54
  - like that. Guilty. So is it is it
• 11:57
  - you've had this great career as a leader
• 11:59
  - in bariatric surgery.
• 12:01
  - What advice do you give emerging leaders about
• 12:04
  - having impactful careers, careers they thrive in and
• 12:07
  - enjoy?
• 12:08
  - You seem to love what you do.
• 12:10
  - Talk about that. How does somebody get to
• 12:12
  - that spot where they can combine making a
• 12:14
  - great living with loving what they do and
• 12:17
  - having an impact as a leader.
• 12:19
  - Give us some thoughts or advice that you
• 12:20
  - give to emerging leaders. Yeah. I I think,
• 12:23
  - you know, I think the,
• 12:25
  - you know, I see this a lot. A
• 12:26
  - lot of people ask me this question, and
• 12:27
  - I say, never strive for leadership. Strive strive
• 12:30
  - for goals. Strive for accomplishments. You know, my
• 12:33
  - passion in ASMBS other than, you know, taking
• 12:35
  - care of patients was access to care. That's
• 12:36
  - how I got involved in in our society
• 12:39
  - was helping pea patients get access to having
• 12:42
  - you know, we we struggled a lot in
• 12:43
  - the past of getting coverage. You You know,
• 12:45
  - the medicines are kinda seeing it now where
• 12:46
  - they're very expensive and they were dropping coverage
• 12:48
  - on medications.
• 12:49
  - Bariatric surgery used to be that way when
• 12:51
  - it was kinda thought of as a,
• 12:53
  - you know, a character flaw or something behavior
• 12:56
  - problem and really had stringent criteria. So getting
• 12:59
  - that passion about that one topic,
• 13:02
  - of of getting patients access to care, that's
• 13:04
  - what kinda launched me into the ASMVS. I
• 13:07
  - I I worked hard on this committee, and
• 13:08
  - then I was chair of this committee and
• 13:10
  - got recognition that way and got involved in
• 13:13
  - other aspects of our society.
• 13:15
  - And I I think that's the biggest thing
• 13:16
  - is don't strive for, you know, hey. I
• 13:18
  - wanna be president of the society. Strive for
• 13:20
  - what can I do to help patients or
• 13:21
  - help our help the members of that society?
• 13:24
  - So that was always my my passion toward
• 13:26
  - that.
• 13:27
  - You know, as far as the the patient
• 13:29
  - care, it it really was a you know,
• 13:31
  - I tell I've, you know, medical students and
• 13:33
  - residents now, and I I always say, look,
• 13:35
  - you know, the the the thing that follow
• 13:37
  - your passion, I I don't really strive to
• 13:39
  - that, but, you know, you find something that
• 13:40
  - you have do have a passion for, something
• 13:42
  - that you like. So I always say, you
• 13:43
  - know, find the thing that you really like
• 13:46
  - and the and the bad part of it,
• 13:47
  - everything has bad parts. It's like find the
• 13:49
  - thing you you love to do and the
• 13:50
  - bad you can tolerate.
• 13:52
  - And,
• 13:53
  - that's kind of when I tell people to
• 13:54
  - do that. There's you know, being a surgeon
• 13:56
  - is busy and it's stressful. But, you know,
• 13:59
  - when you get to see that patient hit
• 14:00
  - that 100 pound mark or, you know, tell
• 14:02
  - you this you know, I have so many
• 14:04
  - stories about the, you know, getting to go
• 14:05
  - to amusement park that could never fit on
• 14:07
  - a ride before and riding all the rides.
• 14:08
  - And it's the stories like that are just
• 14:11
  - makes you keep getting up and going to
• 14:12
  - work every day.
• 14:13
  - Thank you. And when you it's bariatric surgery,
• 14:16
  - do you start off with a residency in
• 14:18
  - general surgery and then go into bariatrics? Or
• 14:20
  - what does that look like? Is bariatrics end
• 14:22
  - up being a fellowship? How how does that
• 14:24
  - work? Yeah. In this day and age, I
• 14:25
  - mean, historically, it may have not have been,
• 14:27
  - but but the modern path is the, you
• 14:29
  - know, the path that I took was you
• 14:31
  - did your general surgery residency, and then you
• 14:33
  - went into a, bariatric surgery fellowship, which is
• 14:36
  - one to two years. And then, your,
• 14:38
  - certificate. And we actually have a certification now.
• 14:40
  - We've always had a general surgery certification for,
• 14:43
  - you know, being board certified. And now we
• 14:45
  - have a, subspecialty
• 14:47
  - certification for bariatric surgery now.
• 14:50
  - That's
• 14:51
  - fantastic. And
• 14:53
  - and any other thoughts you have that you'd
• 14:55
  - like to share with the audience today? I
• 14:56
  - mean, certainly a changing time in bariatric surgery.
• 15:00
  - Are are guys excited? Are they nervous? Are
• 15:02
  - they trying to do more therapeutic stuff too?
• 15:04
  - How how does that look for a bariatric
• 15:06
  - surgeon today?
• 15:07
  - There there's a lot of anxiety. I mean,
• 15:09
  - we're we're down over thirty percent in the
• 15:11
  - last,
• 15:12
  - three years volume wise. So there's a lot
• 15:14
  - of people that, you know, you know, there's
• 15:15
  - a lot of you know, some of the
• 15:16
  - medicine that if you're in private practice, it's
• 15:18
  - your business as well, and your people are
• 15:20
  - struggling maintaining their business.
• 15:22
  - So there's a lot of stress, you know,
• 15:24
  - with the with our surgeons and staff. So
• 15:26
  - I I think the future is hopeful. I
• 15:28
  - think, you know, our data is
• 15:30
  - strong when you look at the outcomes of
• 15:32
  - bariatric surgery.
• 15:34
  - But I think the biggest thing we need
• 15:35
  - to focus on is is educating patients more.
• 15:38
  - You know, bariatric surgery shouldn't be looked at
• 15:40
  - as a last resort
• 15:41
  - or, hey. Let me try everything first. And
• 15:43
  - if that doesn't work, then I'll have a
• 15:45
  - surgery. Bariatric surgery is first line treatment, Especially
• 15:47
  - for resolving type two diabetes and blood pressure,
• 15:50
  - the medicines can't touch that, and we can
• 15:52
  - actually accomplish those goals plus much more significant
• 15:56
  - weight loss. But I think the biggest thing
• 15:58
  - that the patients need to know, one, as
• 16:00
  - I've mentioned before, this is a disease, not,
• 16:02
  - you know, something, oh, let me just diet
• 16:04
  - and exercise it away. That's not really how
• 16:06
  - it works. We have to treat this disease
• 16:07
  - with our best tools.
• 16:09
  - And the other thing is safety. I I
• 16:11
  - I to me, I the thing that I
• 16:12
  - gather is the biggest
• 16:14
  - roadblock to having a procedure is that it
• 16:17
  - seems high risk or extreme.
• 16:19
  - Even 40 ago, these weren't high risk or
• 16:22
  - extreme.
• 16:23
  - You know, they're they're so safe now. The
• 16:25
  - complications are safer than knee surgery or gallbladder
• 16:27
  - surgery. Some of those common operations you do
• 16:29
  - in The United States.
• 16:30
  - You know, the like I said, we're we're
• 16:32
  - doing our our length of stay is average
• 16:34
  - is one day. The patients are usually home
• 16:37
  - out the door by 09:00 in the morning
• 16:39
  - at the day after surgery, and we're even
• 16:40
  - doing these in a lot of locations as
• 16:42
  - as outpatient, same day surgery going the same
• 16:44
  - day. That's the reality, and that's the safety
• 16:46
  - profile of these. It's like I said, it's
• 16:48
  - it's the best thing I've ever done for
• 16:49
  - anybody. And,
• 16:51
  - my biggest complaint from patients is why didn't
• 16:53
  - I do this sooner?
• 16:55
  - And and doctor Northrup, one last question.
• 16:58
  - In the, in your office,
• 17:01
  - in the very back, one of the things
• 17:02
  - that's behind you is a guitar.
• 17:05
  - Is it is it is it sort of
• 17:06
  - like if you're in Chicago,
• 17:08
  - you almost have to have a Michael Jordan
• 17:10
  - jersey someplace that's almost sort of comes with
• 17:12
  - the territory in West Virginia.
• 17:14
  - Maybe it was major heroes back in the
• 17:16
  - day.
• 17:17
  - In in in in in Nashville,
• 17:20
  - is it mandatory to have a guitar on
• 17:22
  - the shelf, and do you play it at
• 17:24
  - all or are you learning to play?
• 17:26
  - Well, you know, I I have played guitars
• 17:28
  - for
• 17:29
  - quite a while. I I have more guitars
• 17:32
  - than I have talent. That's my biggest problem.
• 17:34
  - So I have a lot of guitars here
• 17:36
  - in my home office, and I keep one
• 17:37
  - in my,
• 17:39
  - academic office on campus. So,
• 17:41
  - I try to play, but I've kinda played
• 17:43
  - for myself. I wouldn't I don't like to
• 17:44
  - play in front of the people because I'm
• 17:45
  - pretty terrible at it, but, I enjoy it.
• 17:47
  - It's relaxing, and I sometimes I call it
• 17:49
  - my thinking stick. I'll I'll pick it up
• 17:50
  - and, you know, just fiddle with it while
• 17:52
  - I'm working on something to kind of keep
• 17:54
  - me focused. So, but I do I do
• 17:56
  - love to play guitar, but, I'm,
• 17:59
  - not a great talent at it. Much better.
• 18:01
  - We we we we respect it tremendously. I
• 18:04
  - am very similar with golf clubs. I have
• 18:06
  - no shortage of golf clubs, and they way
• 18:08
  - outnumber my golf talent. So I totally respect
• 18:10
  - it. Doctor. Unother, what a total pleasure to
• 18:12
  - visit with you today. Thank you so much
• 18:14
  - for joining us on the Veterans Health Care
• 18:16
  - podcast.
• 18:17
  - A a fascinating field and great to speak
• 18:19
  - to you. Thank you so much for joining
• 18:20
  - us. Thank you, Scott, for having me here.
• 18:22
  - It was an honor.