Latest / The Staple Line / Dr. Adrian Dan on the future of metabolic and bariatric surgery

Transcript

Dr. Adrian Dan on the future of metabolic and bariatric surgery · The Staple Line

• 0:00
  [gentle music] Hello, and welcome to The Staple Line. I'm John Scott, your host.
• 0:16
  Before we start, a few words about how to hear this conversation. The opinions you'll hear are our own.
• 0:23
  They're not the views of any organization, employer, or society we are associated with, and nobody here is speaking on anyone's behalf. This is education and discussion, not medical advice.
• 0:35
  Our disclosures and the disclosures of the MBS Digest team are on the web at mbs-digest.com/disclosures, and they're linked in the show notes. My guest today is Dr. Adrian Dan.
• 0:50
  He is Professor of Surgery at Northeast Ohio Medical University, and the Medical Director of the Weight Management Institute at Summa Health, the Program Director of the Advanced GI Minimally Invasive Foregut and Bariatric Surgery Fellowship, and a member of the ASMBS Board of Directors.
• 1:07
  Dr. Dan has asked me to share his disclosures. He is a proctor and instructor for Intuitive Surgical.
• 1:14
  He is a shareholder and key opinion leader for Fractal Health, and he's a founder and director of the National Surgery Review.
• 1:21
  He is here in his own capacity and not on behalf of Summa Health or any other institution, entity, or society. Dr. Dan, welcome to The Staple Line. John, thank you so much.
• 1:32
  Sincerely, this is an honor to be a part of your podcast. Uh, I don't do a lot of podcasts, so I'll admit I'm a little nervous, but more importantly, I'm very grateful to be here. This means a lot to me.
• 1:43
  Well, you're our first guest on The Staple Line, so this is gonna be a learning experience for both of us. [chuckles] What an honor. Well, there you go.
• 1:51
  So one of the reasons why I wanted to bring you on as our first guest on The Staple Line is because you have a great story, and I think that, that your story about how you got here to America and the road that you have been on to where you are now translates very well as far as the challenges that we're gonna face as a subspecialty, and I think that it's a very unique perspective.
• 2:17
  And so for our audience that, that don't know you very well, I, I, I just wanna just share a little bit of your story.
• 2:26
  If you just wanna describe for yourself, where did you grow up in Romania, and what was daily life like when you were a kid?
• 2:32
  Yeah, John, so I'll tell you, you don't have to twist my arm to talk about my, uh, my, my past and it's, um, it's something I try to relate to what we're facing today in bariatric surgery.
• 2:42
  I was born in Romania, and, uh, I traveled quite a bit. Um, I moved to Algeria at age seven, back to Romania at age 10, uh, to Germany, uh, till age 12, and then we moved to the United States. We were quite,
• 2:57
  um, lucky to be able to come to this country, and for those who don't know, this is the greatest country on the face of the earth. Take it from a guy who has seen, uh, numerous other options also.
• 3:08
  But along the way, I've, uh, done my education in several languages, four to be exact, Romanian, French, German, English.
• 3:15
  Many times doing my homework with a dictionary in front of me trying to figure out what words meant.
• 3:20
  And long before I knew anything about surgery, I, uh, learned a very important lesson, and that's that, uh, change and adaptability were, um, [lips smack] not an option, they were survival.
• 3:32
  And, um, to put that into context, um, I had to learn new languages along the way, and maybe it's time that our specialty learns a new language because we are an adaptable specialty. We've been here before.
• 3:44
  We've been through changes, and we've always, uh, responded. Well, I'm very lucky to have a wonderful family, wonderful parents who have been extremely supportive.
• 3:55
  Uh, but I did know that, uh, a lot of sacrifice came with, with moving across the world for more opportunity, and that's something I did not wanna squander.
• 4:05
  I was, uh, very lucky to be able to get into a, uh, six-year BS/MD program through Northeast Ohio Medical University.
• 4:14
  It was called NEOUCOM at the time, and then I followed that up with a surgical residency at Michigan State University, and a, um, advanced laparoscopic and bariatric fellowship at the Cleveland Clinic, where I had the, the privilege to work with some of the, the greatest, uh, minds in minimally invasive surgery and bariatric.
• 4:35
  Um, I owe a lot to Dr. Phil Schauer and Dr. Bepan Chandhwi, who, who have been my mentors, along s- with so many others.
• 4:43
  And really, those are the things that motivate me, all the people that came before us and all the people that are leading the way currently. Too many to mention. They know who they are.
• 4:52
  Uh, those are probably the most important things to me, the, the personal relationships, the friendships that we make along the way as we try to check all the boxes and serve to the best of our ability.
• 5:02
  So going back, uh, when you first came over, what were those first years like when you, when you came to America? Do, do you have memories of those days? Oh, of course.
• 5:12
  So, um, a lot of change, a lot of adaptability, a lot of trying to figure out what American culture was like. It wasn't just about learning the language.
• 5:20
  I came here without, without a lick of English and, uh, learned English by watching
• 5:26
  sitcoms like Happy Days and Cheers and all those great sitcoms from the '70s and '80s, and, uh, that's where I learned a lot about America and American culture and pop culture, and, um, that served me well in order to be able to, uh, to be a part of society.
• 5:43
  So when did you start getting the idea that you might wanted to be involved with medicine? Yeah.
• 5:49
  So in high school, I, um, did a little volunteering at the, at the local hospital where, uh, back then they let the volunteers shave the patients if they needed a shave, and, um, I would do that.
• 6:02
  Uh, and that's, that's where I found out about Coumadin and what happens if you get a little nick Then I thought that this may be something that I, uh, would wanna pursue as a career.
• 6:12
  So I did apply for the BS/MD program, and from there, um, you know how that goes. It's one thing to the next, and eventually you don't pick your specialty, your specialty picks you by, uh, by, um,
• 6:26
  trying to get into something that fits your personality and, a- and your strengths. And along the way, I thought surgery was that for me.
• 6:33
  And while at the Cleveland Clinic, the passion and conviction with which my mentors did their job in metabolic and bariatric surgery rubbed off on me, and, and that's how I'm here.
• 6:44
  So what about your upbringing shows on how you treat your patients and how you run your program today?
• 6:51
  Is there anything that translates from your, your time in Romania and your transition here to America that, that kinda percolates in your daily practice today?
• 7:00
  Well, I think a lot of things do, and it's things I've picked up along the way, and things that my mentors have taught me.
• 7:06
  I think it's very important to approach what we do with a sense of humility, and remember every day, uh, maybe start with a prayer and start with a reset and, uh, a reminder of why we're here.
• 7:18
  It doesn't take much for one, one of our family members to be on the other side of the, uh, of the equation to realize just how much our patients count on us and how much they need us.
• 7:30
  And, um, every day you try to make a difference and to tr- try to make your, um, your efforts count to help a patient, to help someone, to alleviate suffering, to help a family get through a tough situation.
• 7:44
  And those are the things that have, um, that have led to, uh, the approach that I take with my patients. You've gotta put the patient first. It can't just be, uh, something we say. It can't just be a cliché.
• 7:56
  It has to be, uh, how you approach every single day where you show up to the operating room or to your office.
• 8:03
  Now, have you had trainees that have come from other backgrounds outside of America, and have you seen some of the, the, the challenges that, that you went through and that, that they went through, and how did you approach them?
• 8:16
  Absolutely. So my trainees along the way, as you know, I have quite a passion for surgical education. I've seen trainees from just about every walk of life, and, uh, it's important to remind them to make it count.
• 8:28
  Their efforts, uh, their impact on the patient, whatever you do that day, make it count. Don't just go through the motions. Don't just check the boxes.
• 8:36
  And, uh, I try to pick up on people's strengths and see the best in my trainees and in every single person. They-- Every single person that I, um,
• 8:45
  collaborate with or interact with, uh, does at least one thing better than me, so I try to learn from them and I try to teach them also. And, um, and it's that conviction that, um, that helps us, um,
• 8:59
  be the best doctors that we can. It reminds me of a, um, saying that my mentor in residency, Dr. Saha, taught me.
• 9:08
  He didn't just say it, he actually lived it, that every single day when you think you've done everything you can for a patient, that's when you gotta figure out what you can do next.
• 9:18
  And again, that's, I think, something that, um, applies to our specialty today, and we can learn a lot from that saying. That's great. So tell me this.
• 9:28
  You know, we've spent a lot of time together in the, the ASMBS, and, and you wear a lot of hats in the organization.
• 9:34
  What is your, your favorite thing that you've done so far, uh, for the, for the organization in bariatric surgery? If I had to pick one thing, John, it has to be the educational stuff.
• 9:45
  I was, uh, honored to be able to be the, um, uh, chair of the Bariatric Surgical Training Committee.
• 9:52
  I followed in the footsteps of some giants before me, and I was able to, um, to found the fellows program and the surgical happy hour, uh, bariatric happy hour rather, and be the, the co-founder and, um,
• 10:08
  f- founding co-director of the START program. But those are things that I've, um, been able to do because of my interest in education and putting together courses.
• 10:18
  So I've had the opportunity also to put together our, uh, focused practice designation review course, and ultimately be able to be the program chair for
• 10:29
  our ASMBS weekend and national meetings in two thousand and twenty-five and two thousand and twenty-six. And those were just the greatest honors of my surgical career.
• 10:39
  So, uh, it's the educational stuff that I absolutely love to do, and, uh, I'm only here because people have taken the time to teach me things, and I think we all have to give back a little bit and make sure that we teach others and help them come along and bring the next generation along as best we can because they should be better than we are today.
• 10:58
  [outro music] Excellent.
• 11:06
  So you and I, we, we've been on the board for at least two years together, and I know we talk about some pretty heavy topics, and obviously, you know, the biggest topic that we've discussed is, you know, the challenges to our specialty.
• 11:17
  You know, we are-- we are kinda at an inflection point. So why do you think that, that things are changing, and why would you consider this an inflection point?
• 11:26
  So before I dive into that, I do have a couple more personal disclosure. You know, I, I love quotes and analogies, and you might hear a few of those as we get through this.
• 11:35
  Um, I also suffer from a severe, severe case of, uh, optimism. I do tend to try to see the best, um, uh, possible scenario and hope for that at least. And most importantly, John, I do not have all the answers.
• 11:48
  I actually think our answers lie with the, with the membership of the ASMBS and the membership of our, of our specialty. But yeah, um, we face a conundrum and a paradox, um, in metabolic and bariatric surgery.
• 12:01
  You see, we are living in the most successful moment in the history of metabolic surgery. But at the same time, uh, the most uncertain.
• 12:11
  And when you talk to our, um, to our members, you talk to bariatric surgeons, you can see that even though we've been
• 12:20
  more scientifically validated than ever, more technically sophisticated, more clinically effective than at any point in, in, in our history, um, by every metric, we should be thriving.
• 12:32
  In the recent past, we are not, and I believe there are reasons for that, and I think, uh, we're at a time and point where we have to determine who we want to be, and also a time that demands that we ask those questions.
• 12:46
  Now, our specialty has had obstacles in the past, and, uh, w-what do you think we can learn from some of the obstacles that we've had before? Yeah, that, um, history gives us quite a perspective.
• 12:59
  Our specialty has never been rooted in stability. It's always been rooted in change. As a matter of fact, change has been the constant. I know it's an oxymoron, but that's the truth.
• 13:09
  Change has always been the constant, and a lot of times when we challenged things and changed them, we came out better on the other side.
• 13:16
  Back in the '70s and the '80s, bariatric surgeons were not regarded as, as the cream of the crop. There are some of them were regarded as charlatans and, uh, doing something ba- that is, um, unsubstantiated.
• 13:30
  And that stigma and bias still exists today, but we have overcome a lot of that by, uh, responding and by, uh, improving our, um, our procedures.
• 13:41
  We have come from open surgery to laparoscopic and now robotic operations and endobariatrics, and, uh, that is something that will continue to improve.
• 13:52
  We have responded by putting together a tremendous amount of data and, uh, building evidence. Our leaders have never retreated. Our leaders have always responded, and I think it's time that we, um, that we do that again.
• 14:06
  So if you had to, to list some of the challenges that, that face us, there are some pretty obvious ones, but, uh, y- we always have to be thinking about other challenges down the road as well.
• 14:17
  So what do you see as the biggest obstacles for not only bariatric surgeons, but everybody that's in the obesity treatment space? So I think that's a great question, John.
• 14:28
  And there are forces, and these are powerful forces that are re-reshaping everything around us. And, and it's important to point out that these are not coming at us in isolation.
• 14:40
  They're coming together, and you see them, you feel them every single day, and so does everyone who's a bariatric surgeon or is in obesity care.
• 14:51
  And these are fundamental changes, and if I had to categorize them, I think, uh, the biggest ones are, of course, stigma and bias that continues to affect not only our patients, but continues to affect the people who care for those patients.
• 15:04
  Um, they're often told that, "Hey, why can't you, um, why can't you stick to, um, to real surgery?" Or patients say, "Why can't you, um, eat less and move more?" We hear that all the time.
• 15:15
  Um, there's also been a major change in the landscape with the, the new GLP-1s, the incretin-based medications, and, uh, I think it's important for us to remember that, uh, the success of, uh, any type of therapy should never be a threat to us who have dedicated our lives to improving the health of our patients and treating obesity.
• 15:36
  Um, these are not our competitors.
• 15:38
  A matter of fact, we often argue about which, um, therapies are better, which therapies have an edge, when in reality, there is a huge number of patients that's completely outside, um, any evidence-based treatment.
• 15:54
  So we're arguing about, uh, who should get the patient, when in reality, uh, nobody's getting the patient or the, the proportion of patients that should get obesity treatment. And there's a couple other things.
• 16:06
  There's value-based care and the, the realities of healthcare economics. You know, we're no longer being, uh, judged on volume as surgeons.
• 16:14
  We're being judged on outcomes, and our value-based care partners, third-party payers, government payers, they're paying attention, and they wanna know what kind of outcomes they're paying for, and that's okay.
• 16:25
  We just have to figure out how to engage that because bariatric surgery is not a liability. It's actually a huge opportunity there.
• 16:33
  These healthcare episodes, like a bariatric operation, when viewed across the entire lifespan of a patient, uh, could actually look quite inexpensive, uh, compared to looking at them as a single event.
• 16:45
  And then there's technological disruption, and that might sound like, uh, you know, innovation's a good thing, but when you have private practice docs that have to learn three different, um, EHRs and, um, they have to, uh, learn robotic surgery and every new laparoscopic gadget has some kind of, uh, new, um,
• 17:07
  button and, uh, you gotta take into account data analytics and, um, the digital surgery and, uh,
• 17:19
  the prediction of outcomes and all the things that can come with, with, um, with new technology, it's a lot to keep up with. So these are the main four categories, in my opinion, that right now are, um, are
• 17:34
  a difficult thing for bariatric surgeons to face and to take all of them on simultaneously. [gentle music] So you said at the beginning that you were an optimist.
• 17:50
  I share your optimism, but I would love to hear, you know, if you had a plan or if you, if you, if you had a crystal ball and said, "Okay, here are some things that we could do," or that c- you know, that people around the country could do or, or where the technology's heading or, you know, what would be the thing that, you know, helps kinda solve some of the biggest problems that we have for our patients, obviously?
• 18:15
  You know, you, you, you talked about the fact that The, the, the biggest issue that we have is, is, is not GLP versus surgery.
• 18:24
  The biggest issue that we really have is that the vast majority of people that have this disease process aren't getting treated at all. I think that, that, that's number one.
• 18:32
  And so how do we, how do we as people that deal in this disease bay, we address those questions? I love it. Um, so I love how you phrased that. It's not GLP-1s versus surgery. It's actually
• 18:44
  obesity therapy versus therapeutic inertia and the lack of, uh, of applicability of the treatments that we do have. But I'm gonna go to my first quote that I'm gonna use.
• 18:56
  One thing I wanna set straight, bariatric surgeons are a part of the future. Mark Twain said, "The reports of my death are greatly exaggerated." I think that's exactly where we're at today.
• 19:05
  As I mentioned before, change has always been a part of our field, [lip smack] and, uh, we've had to, um, fight for our legitimacy, and we've had to improve and refine our surgical approaches before.
• 19:18
  We've had to collect data and set higher standards, and we've done all those things. Uh, we've had to reframe the scope of our practice. Just in my,
• 19:27
  in my personal career, we've gone from bariatric surgery to metabolic surgery. And we've had to produce high-quality evidence, and we need to continue those things.
• 19:38
  But in my own career, at-- if you look at my, my 20 years in, in surgery, I can tell you that bariatric surgery became metabolic surgery, and general surgery board certification became a focused practice designation in metabolic surgery and ABOM certification.
• 19:55
  I used to do adjustable gastric bands and gastric bypass, and now it's almost exclusively sleeve and SADI. Laparoscopic became robotic and, uh, sometimes endobariatric.
• 20:07
  And mostly surgical care has turned into multimodal therapy. That is a huge seismic change over 20 years, and I could tell you, John, I never felt like I changed specialties.
• 20:18
  As a matter of fact, I'm, um, uh, I was a bariatric surgeon then, and I'm a bariatric surgeon now. [lip smack] And in the moment that we're facing right now, some people call it a crisis. I'm gonna use another quote.
• 20:32
  In Chinese, the, the word crisis actually composed of two characters, and John Kennedy, uh, this is his quote even though it's, it's about a Chinese character.
• 20:41
  And the two characters represent danger, and the second one represents opportunity, and that's where we have to, to look here.
• 20:49
  Maybe instead of asking, "How do we bring bariatric surgery back to what it was 10 years ago?"
• 20:55
  Maybe we ask, "How do we, we reinvent the field in such a way that bariatric surgeons, um, are truly the only specialty that can take care of the patient across the entire spectrum for obvious reasons in a way that we are at the center of that rather than on the periphery?"
• 21:13
  So in a nutshell, if we take these forces and we stop looking at them as threats, but look at them as the, the, the puzzle pieces that when put together can actually, um, result in something far greater than what we had before, maybe that's the way that we look forward.
• 21:31
  And imagine if, if data was the way that everyone would, um, would be referred. Imagine if medications continue to increase awareness.
• 21:44
  Uh, imagine if, if the data continues to increase, uh, access to care where patients are no longer subject to a primary care doctor who may or may not understand obesity and its treatments but is being told by, uh, by
• 22:01
  analytics whether GLP-1s, an endobariatric procedure, or bariatric surgery is the right therapy for them.
• 22:10
  If longitudinal care was constant, if the patient navigation was supported by computer assistance, if all those things were put together so we can bring a lot more people to the ecosystem.
• 22:22
  You know, we always talk about the 1%. For 20 years that you and I have been in practice, we have never been able to budge past the 1%.
• 22:29
  That number may remain the same, but if we increase the denominator or the number of eligible patients, the number of operations that we will do will increase tremendously.
• 22:40
  And I think that's, that's where the opportunity lies to increase the, the front door, to build a bigger house, a bigger ecosystem, and put the patient at the center.
• 22:52
  And in that manner, um, bariatric surgeon and patients and everybody in the specialty will win.
• 22:58
  You have to remember that if you look at comprehensive metabolic care all the way from prevention to nutrition and physical activity, behavioral therapy, pharmacotherapy, endobariatric, uh, bariatric surgery, and then the follow-up longitudinal care that's necessary, who better than bariatric surgeons to be able to orchestrate all that?
• 23:19
  So I'm kind of excited about the future and where it may go. [outro music] So here's a loaded question for you, Adrian. You're the champion of education, uh, in the ASMBS by far and away.
• 23:36
  Uh, y- you have certainly led the way with the START program and, and, uh, and a lot of the stuff that we've done for the fellows. What do you tell residents now who are express interest
• 23:50
  getting into bariatric surgery but are hesitant due to the falling volumes? Do you tell them that this is the right time? Do you tell them that maybe they should think of something else?
• 23:59
  What-- How do you have that honest discussion with them at this point in time? So the honest discussion h- comes, uh, it's a two-way street. The, the trainee also has to be honest.
• 24:10
  Why are they interested in bariatric surgery? Is it for a paycheck? There's many ways that you can get a paycheck. Or is it because their passion and interests are truly in metabolic and bariatric health?
• 24:22
  So If we determine that that is the case, I remind them that their generation has to understand that maybe, just maybe, the definition of what it means to be a bariatric surgeon has been too narrow, and we need to widen that.
• 24:36
  So I would encourage them to embrace it all. Embrace everything from obesity medicine and getting your ABOM certification to making sure you, um,
• 24:49
  you establish yourself as a metabolic and bariatric surgeon and get your focused practice designation, and also that you embrace the new technology such as robotics and endobariatrics, magnets, all of the things that are gonna be our response and our future in order to be able to provide therapies that not only, um, not only, uh, are effect- but also will be able to provide a need that will be created by the success of GLP-1 medications.
• 25:20
  You know, you and I, John, we've talked a lot about this, and, and I love your analogy of, uh, Flowers, uh, uh, for Algernon about a mouse who took a drug and tasted, uh, incredible intelligence, and then when that drug was taken away, um,
• 25:37
  they missed it. It's the same thing here.
• 25:39
  Uh, the success of GLP-1s is gonna create a lot of, a lot of patients who for one reason or another are going to want a more durable, uh, approach, whether it's because of cost or increased dosages that leads to more side effects, or even the fact that the anchor of being on a medication for the rest of your life is not something they want to, um, they want to accept.
• 26:03
  But we have to be ready with procedures that these patients are going to, to accept and be willing to, um, to consider. So that's what I would tell my trainees.
• 26:15
  It is a much more broad specialty than it has ever been, and it may actually take longer to train in metabolic and bariatric surgery because the metabolic and bariatric interventionalist of the future is gonna have to do it all: uh, obesity medicine, endobariatrics, metabolic and bariatric surgery, revisional surgery, and the long-term care of, of patients in the ecosystem.
• 26:43
  Excellent. [gentle music] Very good. Well, it's been a joy talking with you today, Dr. Dan. How can people get in touch with you? Uh, would you like to share your email, maybe some of your social media handles today?
• 27:01
  I will just share my email. Um, dana, D-A-N-A, @summahealth.org. Also adriandanamd, one big word, @gmail.com. I'm always happy to hear from, um, anyone who's-- shares the passion for, um, metabolic, um,
• 27:20
  bariatric surgery as well as obesity medicine and the comprehensive metabolic healthcare model. I love hearing from our membership.
• 27:28
  I take my, um, my role on the board of directors very seriously, and always happy to hear, uh, what people have to say and, uh, know how I can represent them in that capacity.
• 27:40
  So, uh, it's been an absolute pleasure, John, and I think this has went by way too fast because I really enjoyed chatting with you, and gosh, I could go on. Excellent. Very good. Once again, thank you very much.
• 27:51
  And, uh, for everybody else, don't forget the next episode of The Staple Line will be released next Wednesday. Catch it every week at mbs-digest.com. Once again, I'm John Scott. See you next week.
• 28:14
  [outro music]