Michael Smith, MD (Host): Meaningful Medicine is a Novant Health Podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future.

Today I'm sitting down with Dr. Neil McDevitt and we're going to be discussing weight loss surgery. Before we begin, I always like to know

how my guests got into the field they're in? What was it that made you go down weight loss surgery? Because I know you went through a lot of general surgery and all that kind of stuff. What made you go down weight loss surgery?

Dr. Neil McDevitt: Well, thanks again for letting me be here. I tell you the amazing thing is as a surgeon, we spend so much time treating disease and we deal with really crises. This was the one thing I could do in my life where I felt like I was really helping people regain their life and helping them transition into somebody that they didn't even know they could be.

So it was a matter of just becoming part of people's lives and not just seeing a problem and having them go on, but being able to see them for decades afterwards. And there has been nothing more fulfilling than watching somebody become the person that they've wanted to be.

Host: Now I'm intrigued. I want to learn more about you and what you're doing. Great, great start. So walk us through the process a little bit of how patients ultimately get to you. Because I know there's some steps beforehand, right, that they have to go through? So tell us a little bit about how they make their way to you.

Dr. Neil McDevitt: Sure. And that's a little bit of a complex answer that needs to be said. How do people get to me? Well most of the time they get to me over decades of attempting to diet and lose weight and be on medications and different programs and they reach levels of frustration where finally they realize they need medical help.

And obesity is a life-threatening chronic disease. So at some point, they either decide to get in with their primary care provider or seek help on their own. And what happens is they eventually come to me. I like to say, I'm one of the worst kept secrets because patients will see somebody else who's gone through this process and say, all right, how did you get there?

And they eventually come to my door. And what I do is first of all, welcome everyone. I think the biggest struggle is patients don't quite appreciate that obesity is a life-threatening chronic disease, not a personal affront. So when folks come to us, the first thing we have to do is reassure them that they're never going to be judged, berated or belittled. That they are there to treat a medical condition and we're going to partner with them.

Host: Sounds fantastic. Now, you had mentioned, you know, by the time somebody does come and see you, they've already, as you said, a lifetime of dieting and who knows what else they're trying, but do you like, how do you handle that? Do you first, before surgery, go through some of that with them? Do you try some diet and exercise, maybe even the new GLP 1s that are out there, those weight loss drugs or is it just when they see you it's right to surgery?

Dr. Neil McDevitt: Oh, God, no. Really, surgery should be the last thing that we entertain. And ironically that's coming from a surgeon but it's a tool I can't take back. So we've gotta make sure that we have one shot at taking advantage of this tool. We need to do it right. So most, now, not most, all of my patients are professional dieters.

They are all extremely good at losing weight. The problem is finding a lifestyle that is sustainable. So what we do is individualize our program. We start to understand all of the different factors that contributed to their weight gain because it's not a function of eating too much and not exercising enough.

There is emotional, there are brain chemistry, as well as biologic reasons for obesity, and we've gotta vet those out so we can really individualize why is it, what things contributed to your obesity. And then it's a matter of designing a program that really takes those strengths and takes advantage of them while minimizing those things that are struggles or prohibiting you from losing your weight.

Michael Smith, MD (Host): Sustainability and that's so key, right? There's all kinds of diets out there that you could lose a lot of weight quick, but can you stick with that the rest of your life? That's a lot of stuff that comes up. I think that's fantastic. So you'll walk through all this, you'll figure out what's best for that patient.

And it sounds like, you tailor a personalized program for them, but at what point though, I mean this is about bariatric surgery, so at what point is surgery the best option?

Dr. Neil McDevitt: Sure. The first thing is obviously we don't want to change tires. We wanna fix alignments. And the majority of the weight gain is because we haven't fundamentally fixed the things that have caused the weight gain to begin with. So if after kind of correcting that alignment, really helping people change their relationship with food and they do all these things and we don't see any meaningful weight loss, then I think when we talk about GLPs and other medications, that's the next step. If we find that even utilizing those tools, we're not able to achieve adequate weight loss to decrease the risk of death, we're talking about death, and if we can't reduce that risk through all those other means, then surgery really becomes a viable alternative. The patients really, I find that need surgery are the ones that are so physically disabled because of their obesity.

People who need to lose weight in order to have a knee replacement, right? They could do everything. They could diet, they could eat grass. They're still not going to lose adequate weight to get that knee replacement. Without that knee replacement, they're not going to get the movement they need to sustain that. So it's really about providing a catalyst for that lifestyle change.

Host: Just in general, I, I, know this is a kind of a broad question, but, in general, what are some of the body composition measurements, you know, we look at a whole bunch of stuff, right? BMI, waist to, to hip circum - or all that. What, are the key ones you look at that help you maybe to decide we really gotta, or even comorbidities that are happening with them. Tell us a little bit how you still make that decision that surgery is the best choice.

Dr. Neil McDevitt: Well, obviously I always have to work within the confines of insurance, so I have to speak the same language as the insurance company. So what they're looking at is BMI is the first thing. BMI of 40 is about a hundred pounds over ideal body weight. And if we're making all those measures to correct your alignment and help you with your health, and you still are a hundred pounds over ideal body weight, then that weight is a significant reduction in your life.

Not only is an impediment of your ability to, to function, but your survival. So those patients, by definition, are candidates for surgery. Big things we look at are as if your BMI is lower. But big contributors to mortality and, and risk for your survival are going to be sleep apnea, diabetes, high blood pressure, and cholesterol.

Those four big ones are really indicators that surgery is probably a good choice because what we'll see is up to 80% of patients, 80% of patients will see their diabetes go away, go away after bariatric surgery.

Host: That's pretty impressive. So surgery, is it for some, some patient, what do they have to do now to prepare for that?

Dr. Neil McDevitt: Well, the first thing is obviously they've gotta commit to a lifestyle change. We have to make sure that you're not smoking. We've gotta make sure that you are eating a sustainable plan, that you've got all the infrastructure in place, and then what you do is after seeing me, we get you in with a dietician.

We get you in with a psychiatrist, mainly because after bariatric surgery, so much changes and we want to make sure that we've got the support there to help you navigate those changes. We have a full battery of blood work. We make sure you're healthy from a cardiac standpoint, and we get specialists involved as needed.

That process usually takes a minimum of about three to four months, but it can take years if people are anxious about pursuing surgery. And once we have all that in place, then we go ahead and we move forward with doing the surgeries.

Host: Let's move now the conversation into kind of recovery. You know, it's a big surgery as you said, and all surgeries are big, right? It doesn't matter who you are. A surgery has certain risks. It's a big hit on the body. Tell us a little bit about how people are able to recover from this. Do patients see immediate results with this? What are some of the things they deal with in recovering from surgery? So paint that picture for us, what it's like.

Dr. Neil McDevitt: Sure I, you know, there've been so tremendous advancements in science and particularly with surgery, you know, we used to talk about 25 years ago doing these surgeries through big open operations. We now do them laparoscopically through typically five small incisions, and I use the aide of the Da Vinci robot system.

So I actually have a robot assist me in doing these to improve the precision. Because of this, most of these surgeries, people are up and walking within an hour of surgery. They're drinking immediately after surgery, and most of my patients are going home within less than 24 hours. And when they get home, they're up, they're walking, they're returning back to their activities of daily living, their function, you know and within a couple of weeks, I find that people are really returning back to most of their normal activities.

Host: That's amazing. Now I have to ask, so you're using a robotic system to help and assist. Again, we don't want to get into the weeds with that because I know it's probably very complex, but tell us a little bit, because I'm curious now, how has that affected your skills as a surgeon? Obviously it, it must improve surgery and outcomes, right?

Dr. Neil McDevitt: Well, it's epic just as far as our precision. You know, it used to be that I was doing these operations effectively with chopsticks, big, long instruments that can only do two little things. Now, the instruments I use, I sit at a console. It's got kind of a virtual, headset that I watch, and when I move my hands, what I do is paralleled inside the body.

So it's almost as if I have my hands inside your body when I'm tying a knot or cutting a blood vessel or securing something. So I have the ability to have literally the movement of my hands inside the body. When I do this, the instruments are doing the same thing as opposed to me just trying to do it with two degrees of motion.

It is just been an epic transformation of what I can do and the safety of what I can do.

Host: I would love to talk more about this so much, but we're going to move on with our focus here. That's fantastic, by the way. Let's talk about, how do you support, how's your program support patients even after surgery? We talked a little bit about recovery and what goes on there, but I'm talking now, months, years is, tell us a little bit about what goes on there.

Dr. Neil McDevitt: So, I think one of the differences of how my practice has been run over the last 20 years compared to a lot of other practices is I expect them not to follow up medically. I expect them to follow up for not just support from medicines and vitamins, but social support as well. What we do is we allow the patients to really dictate how often they see me.

A lot of times when things are going difficult in their lives, they feel like they need that additional support, and they're seeing me as a surgeon in addition to my staff, not just seeing somebody that's working beneath me or with me. So I think that has provided some really personal investment on my side with them.

And then what we do is we do support groups that aren't designed around food addiction per se, but they're about reengaging the world. One of my favorite supports groups is I do an annual kayaking trip with my patients. And if you are dealing with obesity, the idea of being pinned in a little kayak is absolutely frightening.

And what I can do is take patients that have lost the weight, get them in a kayak and explore nature. We go out onto a creek called Shem Creek where we get to see wild birds and we get to actually be on water level. We've seen manatees and dolphins, and once again, it's about reengaging the world in a meaningful way with your families.

We do 5K Turkey trots, and one of the newest things I found out is here in Charleston, we have one really big bridge called the Cooper River Bridge, and a lot of people are scared to death of this bridge. So this month we are all going to meet under the bridge as our support group and as a group, we're going to walk to the top of this bridge and walk down, and we're going to help people overcome their fears and once again, expand their repertoire of how they can engage the world.

Host: That's fantastic. How does it make you feel to see your patients kind of make strides and, and reach their goals? It, it just must make you feel fantastic. 

Dr. Neil McDevitt: I have the best job in the world. Maybe short of you, I, I might be gunning for your job, but I have the ability to imagine people when I meet them. And they are dealing with the frustration and a lot of times the guilt of having this problem that is very visual, that is very obvious to everyone around them, and they feel like failures and I get to imagine who they become.

And then through the transformation of surgery, I get to catalyze this emergence of people becoming who they couldn't even imagine they could be. And when they are out there riding bikes with their grandkids, or I had one that ran the Disney half marathon, or they are watching the birth of their children, their grandchildren when they weren't expected to even be alive for it.

It is just the most fulfilling life that you could imagine. We talk about physician burnout and with the type of job I have and what I get to imagine; I feel at times sometimes the patient visits is more for me than it is for them.

Host: Great way to end. But, but I am going to ask one last thing. I always like my guest to kind of summarize, you know, you had mentioned maybe some people are scared of surgery, reluctant of all this, which is totally understandable. What do you want to say to that type of person, to help them, if surgery really is what you guys think is the best thing, what do you say to them to help change their mind?

Dr. Neil McDevitt: First thing is I don't want to push them into surgery. What I want people to realize when they come to see me is that what I want to do is help them understand the why between why they gained the weight and help them come up with a sustainable lifestyle change. That is my first job. Under that umbrella, if you don't need surgery, because you just need an alignment change. I don't fire you. I'm here to support you and you have achieved your goals and you validate our theology, if you will, on obesity. If surgery becomes the tool, then we will utilize it when you're ready. Not a minute before, not a minute after, because only when you're ready to fundamentally make a change will you be successful.

Host: I think we both would agree being in medicine, especially with surgery and outcomes and recovery, if somebody's ready, you're going to get the best results. I think that's fantastic. This was great. Thanks for coming on the show today.

Dr. Neil McDevitt: And if you have a second, Mike, if I could just make a quick little statement, our philosophy. I believe there's two different types of hunger. I think there is body hunger, which is driven by a multitude of hunger hormones, the most famous one right now being And 1. And I think that there is brain hunger. And I find that a lot of my patients are compelled to eat, not because of true body hunger, but because of the emotional connectivity that food gives us. It's comfort food. It's called that for a reason, and this is not something that is a conscious choice.

We're being compelled by our brain chemistry, and what I want to do is take away the guilt of that, to help people understand why we eat in a really judgment free zone so they can see why, instead of judging themselves for the fact they did. And I think that's crucial if we're going to be successful long term.

Host: I think that was fantastic. Thank you so much again. To find a physician, you can visit Novanthealth.org. And for more health and wellness information from our experts, you can visit healthy headlines.org. Thanks for listening.