Ep#8 - Interview with Dr. Michael Devadas

Episode Summary

On this episode of The Australian Business Show, Dr Michael Devadas joins Nick Stehr to talk about what it takes to be in medicine, the importance of discipline and time management, critical medical advancements, measuring real success, the obesity epidemic, how the Covid pandemic affected health outcomes, the new weight-loss drugs, and the business side of surgery.

A specialist Upper Gastrointestinal Surgeon, Dr Michael Devadas performs bariatric (weight loss), oncology (cancer), and general surgery operations.

He is passionate about providing the highest level of care for his patients. His patient-centred, tailored approach to each case, round-the-clock accessibility, and long-term commitment to his patients' well-being sets him apart in his field.

Dr Devadas obtained his Fellowship in General Surgery with the Royal Australasian College of Surgeons in 2012. He then completed advanced training in the field of Gastro-Oesophageal Surgery through the highly competitive Australia and New Zealand Gastro-Oesophageal Association. He also holds a Bachelor of Surgery with Honours and a Bachelor of Applied Science in Medical Radiation Technology, Nuclear Medicine from Sydney University.

Timestamp Segments

·       [02:15] Behind the surgical scene.

·       [04:25] Michael’s mentors.

·       [08:30] Getting into Upper GI surgery.

·       [11:03] The parallels between medicine and business.

·       [13:29] Time management.

·       [16:54] Growth through humility.

·       [19:16] Medical advancements.

·       [22:20] What is success?

·       [24:01] The obesity epidemic.

·       [26:08] The state of health in Sydney.

·       [28:34] Mental health since Covid.

·       [30:08] Effective weight loss habits.

·       [33:54] The business of surgery.

Notable Quotes

·       “If you’re doing it for other reasons, you just wont last very long.”

·       “What you don’t see is the sacrifice.”

·       “It’s easy to be human, but it’s hard to be humane.”

·       “Success always looks overnight from the outside.”

·       “All solid cancers are related to obesity and being overweight.”

Relevant Links

www.drmichaeldevadas.com.

Dr Michael Devadas.

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Transcript

[00:01] Nick Stehr: I am super excited about today's episode, because our next guest is not only a highly esteemed Upper Gastrointestinal surgeon, specializes in bariatric, metabolic, and general surgery, leading the way in minimally invasive procedures, leading to better clinical outcomes. He also happens to be, probably, my oldest friend in the world, who I went to high school with, Dr Michael Devadas.

[00:31] Welcome to the Australian Business Show. In today's swiftly evolving commercial landscape, opportunity and challenge abound. It's imperative to stay on the cutting edge, emulating the strategies of the most influential business leaders and entrepreneurs. Join our exclusive network as we unite with the world's elite. Together, we'll uncover their success stories, gain fresh perspectives on market trends, and learn the innovative tactics they employ to propel their companies to the forefront of success. Now, here's your host, Nick Stehr.

[01:04] Nick Stehr: Mate, you're a pretty impressive individual. You gained your Fellowship in General Surgery from the Royal Australasian College of Surgeons in 2012, if I'm not mistaken, undergone advanced training in Gastro-Oesophageal surgery through the competitive Australia and New Zealand Gastro-Oesophageal Association. Jeepers. Say that 10 times real quick. Lots of published articles, as well. Peer-reviewed.

[01:25] Michael Devadas: Yeah, that's right. Multiple international and national journals, constantly presenting at meetings, as well.

[01:32] Nick: How are you finding the presenting? Do you enjoy that?

[01:34] Michael: Yeah. I mean, it's always a little bit anxiety-provoking when you're talking to a group of individuals that specialize in your same area, and for example, doing a masterclass session with surgeons from all over the country, telling them how I perform an operation, or the things I think about when I'm preparing for the operation. Often, the people in the crowd are people that mentored me and have worked with me, or share the same responsibilities, and so it's quite daunting sometimes, but at the end of the day, we all have something to contribute, and that's the thing about surgery. You get a good cross-pollination of ideas with different areas, which help manage patients better.

[02:16] Nick: You said something there that I want to come back to - what you think about before you go into surgery. Talk us through that, because it's something that not many people, I'm sure we've all thought about it, […] to cut people open, and something I want you to talk about, too, is you specialize, very much so, in the minimally invasive side of things, and I guess that's designed for better clinical outcomes, but talk us through that mental preparation before you're walking in to perform major surgery.

[02:43] Michael: The thing about surgery is, you can break it down into stages. The preoperative stage, the operative stage, and the post operative stage, and we often say that you can train a monkey to do the operative stage.

[02:55] Nick: That monkey's not operating on me, incidentally.

[03:00] Michael: Pretty smart monkeys. At the end of the day, preoperatively, a lot of thought goes into it, even behind the scenes. Patients don't actually realize, sometimes, how much depth we go into a particular problem before we decide on doing anything at all, particularly with the oesophagus and the stomach cancers. I work with a whole team of very dedicated individuals that, we discuss the smallest things to the largest things, from pathology, imaging, patient characteristics, comorbidities, medications, treatment algorithms. So, on what you would call Game Day, the operation day, everyone in the room is prepared for what's going to happen, and the reason we do that is, by systematically thinking about a problem and coming up with a strategy, you can define your goals accurately and get the best outcome that you want, and at the end of the day, that's what we're there for. We're there for one reason. Help people, but also do it safely, effectively, with the minimal amount of damage to normal structures or the patient's quality of life, as possible.

[04:10] Nick: Yeah. Look, I take my hat off to you and all of your colleagues in the fraternity, because it's certainly not something I could do, and what I like about what you said there is the value you place on the outcomes you're delivering and the improvement in life. Obviously, I've known you for a really long time, but I know you were always going to be a doctor, but who were the key mentors that really inspired you to want to go down the path that you've on now?

[04:35] Michael: I guess, before I get to my mentors there, one thing you should know is, I think the qualities that I possess is sometimes an inability to believe that I could do something until I've done it, and I question myself. I questioned my judgment. I think that, sometimes, I think I'm not good enough to do this, and I think that makes me a better doctor and a better surgeon, because I'm always striving to do things better and to think about things differently, and to learn about what I'm doing, and that's how I've found I'm able to have longevity in this job. We do anywhere from 50 to 80 hours a week, not uncommonly. If you don't have that, then you burn out very quickly. So, you’ve got to really think about what your objectives are and why you're doing it, because sometimes, if you're doing it for other reasons, you just won't last very long, and I guess my mentors, the people that I looked up to, were the people that actually had a complete and utter disregard for any other value, other than being the best they could, and helping people.

There are some people driven by prestige and the monetary, and they were forced into it by their parents, whatnot, and you could tell what people's motivations are, sometimes, and I think, at the end of the day, my mentors were the ones that I trusted. I knew, deep down, they were doing it for the right reasons, and they were selfless, and one of the things I wanted to talk about was, people think it's great. You're a doctor. You're a surgeon. You go to parties and people are like, “oh, wow. That's really good.” At medical school, we call it the M-Bomb. “I'm in medicine.” What you don't see is the sacrifice, and I can tell you, for years and years, I've missed out on things, and my family will tell you, I missed funerals, weddings, birthday parties. Luckily, I was there for my kids’ births, but that was touch and go for one of them, but that sacrifice means that what you've done is worthwhile, and I don't think that anything worthwhile comes without sacrifice, even in business. Puts your time on the line. You put your heart on the line. You put your body on the line, and you sacrifice certain things, and when it succeeds, that makes it all the better.

[07:01] Nick: Yeah, and I love that you talk about business, because, as you know, business is my thing. That's what I love. I love to do business, in all manner of the sense, and that's what inspires me. I don't have the drive and the inspiration to do those things, but I agree with you. I think anything great and worthwhile takes sacrifice. So, if it was easy to do, then everybody would do it.

[07:23] Michael: My mentors are the ones that I thought sacrificed a lot more than anyone else that I knew. They were always so generous with their time and their advice, and I guess, you talk about being in business and all the rest of it, but I know what your company does. I know that the core objective of your company is to help people.

[07:44] Nick: Yeah, correct.

[07:45] Michael: And that's something that you've never deviated from, even though you've got these business obligations and things. The core of your company is an altruistic good. See, in my mind, what's our life worth unless we're there to help people? You can have all the money in the world. People will hate you. Your children will hate you. You won't enjoy life. You don't know how to relax because you're always driving to do something that is external to what is good. I guess, that's what makes it worthwhile for all of us. We've got to find value in something and think about how we can achieve being better humans. It's easy to be human, but it's hard to be humane, as I say.

[08:27] Nick: Yeah. Correct. That's good. Easy to be human, but hard to be humane, but now you specialize in Upper GI surgery, with a particular focus on stomach and oesophageal cancers. Was that by design, or what happened to push you down that road?

[08:42] Michael: I had a couple of professors at work who were obviously a lot more senior than me, and they knew me since I was starting my training, since very early in my training. Some of them knew me as an intern and a resident, and a medical student, and they saw that I had potential, that I was trainable, teachable, affable, and available, and I think that's what we look for, in everyone, including people with company structures, businesses. You want someone who's affable, available, and teachable, because not everyone can get it. Not everyone has the skillset, the dexterity, the knowledge.

[09:24] Nick: Humility, too. To have the humility to know what you know, and know what you don't know, and be humble enough to ask for help or advice.

[09:31] Michael: Exactly, and that's what these mentors of mine, they sat me down when I was coming towards the end of my general surgical training, and they said, “We think you've got a talent for this particular area. These are the reasons why we think so, and we would really be keen to develop you and support you to do this training.” So, it was by selection, rather than my own want, but I guess, the thing that attracted me was that we work on the surgical soul, which is around the big structures. We work in the mediastinum, next to the heart. We work in the abdomen, and sometimes we also open the mesh, and there's not many surgeons that go into those three domains.

[10:16] Nick: I know, you've said to me a couple of times, in other conversations, where when you're in the scrubs and you're gowned up, you're in the surgical area, that's where you feel like you are whole. I mean, I'm not taking away from your family. I know you're an incredible family man, but that's your Zen space, almost.

[10:36] Michael: That's definitely my zone. Sometimes, when I’m doing things outside of work. I think, “where's my scrub nurse? Where's my glove?” You get used to that environment, and you're very comfortable in that cold room with the cold steel knife in your hand. It sounds a bit weird, but you do it for so long, you, by default, become very comfortable, and you're in control of that situation, whereas outside that environment, sometimes you do have a bit of a lack of control.

[11:03] Nick: It's interesting, the parallels that you talk about, that I'm drawing here with business, and I think therefore in life, is being coachable, the humility we spoke about, the value set. Again, business without the right values and knowing what their values are, and almost measuring every decision they make against that value set, like you would in doing, not doing, or taking a certain course within a procedure, would be the same, but I hadn't thought about it, until we had this conversation, about a lot of the parallels between business and what you do as a surgeon.

[11:36] Michael: I totally agree. There are so many parallels in business and in medicine. Team structures, communication, goal objectives, and outcomes, and KPIs. You're measuring your standards against other people.

[11:51] Nick: Yeah. I guess the thing about constant education and improvement, always looking to re-educate, relearn, look for better ways of doing things, again, it's got to apply for you, too. In business, if you're not moving forward, you're dying, you're going backwards. So, it's got to be the same in your field.

[12:10] Michael: Exactly, and if we don't recognize what we're doing, what we're doing well, what we're not doing well, you can't evolve. As you said before, we've progressed into minimally invasive surgery and robotic surgery, now, and the thing about that type of surgery is we're minimizing harm to the patient. We're going away from the big, old-style incisions with the prolonged recovery, and now we're trying to fast-track people to recover quicker, with less impact on their quality of life and health, in general. So, imagine you open an abdomen, and you open a chest with big incisions, and the patient's in hospital for four to six weeks. Whereas now, we do an ORP hole with maybe three incisions in the chest and four or five incisions in the abdomen, which the biggest incision is usually to take out the specimen, which is probably a few centimetres, but imagine the recovery from that, compared to the olden-day cuts. We're literally making the length of stay a quarter of what it used to be, and we can push it even further, and one of the things I really like about surgery is that we do push that envelope. So, we're constantly evolving, and that's where the research and looking at your data and extrapolating where the elements are that we can improve, are so important.

[13:28] Nick: How do you manage your time around that? I mean, you spoke before, about 50 to 80 hours a week is not uncommon, and all of the preparation you've got to do, the research, the consultation, not just with the patient, but with colleagues, and then you've got to still self-educate and stay across latest research, latest best practice, because we're talking about parallels of business and what you do. So, time management is a critical skill that you've got to learn in life, let alone in business, and then with what you do, how do you structure your day? How do you manage your day and your weeks?

[13:58] Michael: Basically, my day and week is set around a four-week rotating schedule, and the fundamentals of it are operating days, consulting days, and acute surgery, or emergency days, where I'm on-call, and generally, you can be on-call for usually about a week, plus 4 24-hour shifts during a month, and in between cases, what people may not understand is that there is some downtime. So, you may have, for example, the other day, I had seven operations when I was on-call. I was on-call for 24 hours. I wanted to do an emergency case, and I got bumped by a caesarean section. So, the Ong team brought their case in, and it took them about an hour and a half. So, for that hour and a half, I'm either seeing a patient in emergency who's come in, who needs something done, or I've got downtime, where I can sit on the computer, review an article, do a literature review. You’re constantly using that time in a productive manner, because in the hospital, there's really not much else to do. We don't have a games room. We don't have a social club, because everyone's usually doing something. So, you use your time that way.

[15:16] Nick: That's a discipline, as well, isn't it? It's got to be a discipline, and clearly, you've got that discipline. You talk about the sacrifices you’ve made, and I saw a lot of it, too, through those early years of you going to university and the studies that you did over those many years, but there's also a discipline that comes with that. It would be easy to, I don't know, jump on so much of this Facebook, social media rubbish, looking at fast cars, whatever the case may be, but there's a discipline associated with your time management, to go, “No, I need to get into some of this stuff here.”

[15:44] Michael: Absolutely, and you know, yourself, when you're growing up, you say to yourself as a little kid, “I'm going to get up at this time. I'm going to do my sit-ups, my push-ups. I'm going to get ready for school. I'm going to go to school. I'm going to play this sport.” You picture yourself, what you're going to do when you're playing the sport, and then you go out and do it. You think about how you're going to do it before you’ve actually done it. That sets you up for life, that discipline.

[16:09] Nick: I think a lot of people have it, but I think a lot of people don't have that, naturally. I think you can learn it, but that's something that you've had, naturally. Other people have had to develop it, and other people still have never even considered it. They just exist. I've had people talk to me about living a life of design, not by default. It's like they just roll through life, because either they didn't know better, or their examples were poor. You did have that from an early age, and it always intrigues me, the difference between somebody who's at that stage going, “well, I didn't know.” By comparison, I didn't know what I was going to do. I had no idea. I fell into sales and then fell in love with business, and enjoyed that, but I guess the message there is that we spoke about discipline, we spoke about humility, but that foresight, that planning, I mean, what you're talking about there is almost vision. It's goal setting. It's saying, “Well, where do I want to be and what's the path to get there?”

[17:06] Michael: That humility has a lot of aspects to it, and thinking that you're not good enough, and you need to work harder to achieve something. Thinking I could go two ways. I can work harder, or I could just go with the status quo.

[17:20] Nick: So, the next time I ever have to have a procedure done, if it's not you, the question I'm going to ask that doctor is, “do you think you can do this?” And if he says no, then I'm going to let him do it. If he says yes, I think I'll find somebody else. He's too confident.

[17:35] Michael: That's a very extreme way of looking at it. I think that humility is something that drives you, and that fear that you're not good enough drives you, and when you start seeing runs on the board, that's something that keeps you going. If I had thought about it at the beginning, would I end up like this? I never would have dreamed of it, and it's just step by step. It's one thing after the other. You just do one part, see how you go, and then you reassess, and then start the next step, and that's what my life's been about. At any stage, I could have gone backwards, and some parts of my life, I probably did go backwards. That sacrifice comes with not looking after yourself, not sleeping properly, feeling that you'll let others down around you. All of those feelings drive you, to some extent.

[18:29] Nick: I know exactly what you mean. Every successful person that I speak to has a similar story. Success always looks overnight from the outside, but they don't see the blood, sweat, and tears that go into it, and the sacrifice, but success is overnight, only from the outside, looking in. Everybody I know, that's successful, I mean, there's always unicorns, but that's not normal in life, and that's what we see on social media and everything else, but the people that make it, they make mistakes. They go backwards three steps, to go forwards five. They make mistakes. It’s ready, fire, aim. As long as you're moving forward, you can adjust your trajectory. If you're not moving anywhere, then you're in a hell of a lot of trouble.

[19:14] Michael: You've got to have that plan.

[19:17] Nick: What have you seen, in terms of advancements? So, 2012 and then to now, we spoke about minimally invasive stuff. There's been a lot of advancement in that. Robotic surgery, you spoke a little bit about that, but what else, and then, what's next?

[19:31] Michael: So, I guess with the advancements in medications, pharmaceuticals, immunotherapy, advances in chemotherapy, treatment algorithms, surgical procedures, as I mentioned before, fast-track surgery, where we have algorithms in place to get patients across the line and home faster, but safely. Antibiotics. There's been so many things over my time. When I first started, I remember seeing gastrectomy patients in a hospital for four to six weeks, and we would do one case a day, one gastrectomy for cancer. Now, we can do six to eight cases in a day, and patients are home by day two, and the technology advances are phenomenal. We used to have to literally hand-tie every vessel. Very time consuming, very methodical, and now we've got energy devices, which is like a Lightsaber. You can burn through things, and they seal the vessels off at the same time. So, those advances have meant that our efficiency and effectiveness has improved. Our identification and dissection of tissue planes has improved. Our vision, our optics.

You talk about robotics, freedom of movement of the wrists of the robot, which is far better than our own physical hands. No tremor, the stability, the lack of fatigue, the dexterity, these things are what we're talking about for the future, and to be honest with you, my son, who’s 12, was saying, “I'd like to be a surgeon one day. What do you think? I'd like to see what you do,” and I said to him, “when you come time to do this, it's going to be very different. The game's going to change a lot. You're going to be taking in AI to help you make decisions. You're going to be using mechanics to help you achieve your objectives, which I could only dream about now.”

[21:33] Nick: Yeah. Who's coming up with the new innovations? Is it doctors and surgeons? Is it companies? Is it both? Collaborations? Who's bringing that to market?

[21:43] Michael: The massive collaboration between industry and clinicians, and it's overseen by the administration, and as you know, we have our limitations to the administration. There are bureaucracies, political agendas. There are funding issues, as we know, and a lot of the time, that weighs in the heaviest, in terms of what we can actually achieve, and when you talk about these technologies, they're not cheap. So, can everyone afford it? No. Can we distribute it to the whole population? Probably not. So, we've got to think about how to do things effectively, but also cheaply, sometimes.

[22:20] Nick: Efficiency means we can do more with less, and better. One of my mentors, he told me, in a business sense, but again, here's another parallel. He talks about, how do I do things better, faster, and more efficient?

[22:33] Michael: Because, as you know, time is the biggest value. Time is money. Time is what you need to spend with your family. Time is everything, and the funny thing is, we measured success, and I know, 20/30 years ago, we measured success on what car we were driving, how much money we were pulling in.

[22:51] Nick: Wasn't much.

[22:55] Michael: Now, I look at success as a different thing. Monetary is one part of it. Success, to me, is giving my children the experiences that I didn't have, spending quality time with them, and also enjoying my life and feeling that I've done something worthwhile, and that when I die, people will remember me for the right reasons, because when that time comes, and it comes for all of us, you've got to look back on your life and think, “what did I achieve? How was this a productive life?” And too many times, I've seen colleagues who just put their head into work. They tail-up, head-down. They don't look left or right. They come to the time of retirement, or when they're just about to slow down, and then something happens.

[23:43] Nick: They probably burnt through a marriage or two.

[23:46] Michael: With covid, that's really taught us to take a step back, and sometimes you could die without any warning. So, you really start thinking, “what's important to me?” 

[24:00] Nick: So, a lot of what you do obviously heavily revolves around obesity. Would you call it an epidemic? Is that in your mind?

[24:09] Michael: Yeah. So, I described Western Sydney as the epicentre of the obesity problem in New South Wales. The Murrumbidgee area, the Western Sydney area, more than 60% of the population is obese, and I'm not talking overweight. I'm talking obese.

[24:29] Nick: Define obese.

[24:31] Michael: So, body mass index over 35. So, you're overweight if your body mass index is over 30, but that's your height in meters, divided by your weight. So, your weight divided by height in meters, squared, and that's the number they come up to. That tries to account for anyone's height, ethnicity, circumference. It's just a generalized descriptor.

[24:55] Nick: The other word that we use a lot, obviously, in the industry, is bariatrics. Is there an industry-accepted definition of bariatric?

[25:03] Michael: Bariatrics. Well, the BMI is a main criterion for bariatrics, but we’ve shifted away from that now. We're talking about metabolic surgery. We've found out, over the years, that the weight is related to more than 100 disease processes. The classic ones are things like obstructive sleep apnoea, osteoarthritis, diabetes, sleep apnoea, hypertension, but imagine, all solid cancers are related to obesity and being overweight.

[25:34] Nick: All are related, so not necessarily exclusively caused by.

[25:38] Michael: A risk factor is obesity. Ovarian cancer, gastric cancer, colon cancer. Being overweight is a risk factor for those cancers.

[25:49] Nick: So, you hear different media things all the time, and I don't tend to watch a lot of it because it all tends to be a lot of rubbish and negativity, but you hear about Australia being the fattest country in the world now. Is that true?

[25:59] Michael: Last time I looked, it was the fourth fattest, but a very pessimistic way of looking at things.

[26:06] Nick: We're only number four, but when you first started calling Sydney, sorry, I shouldn't say Sydney, but Western Sydney, the epicentre of obesity, that was in 2018. So, what's happened since then? Here we are, six years later. Is it the same? Is it worse? Are we improving or what's happening?

[26:28] Michael: Good question, Nick. We're definitely going backwards. What we've found, they call it the Red Rooster Life. Eastern suburbs have a very limited amount of takeaways, like McDonald's and Red Rooster, whereas you look at Western Sydney and Southwestern Sydney, there's massive amounts of fast-food chains. It's a sugar problem. It's a fast-food problem. It's a lack of exercise, and basically, you could go to Woolworths, spend $250 on your groceries, or you could get a Maccas every day of the week, and probably spend $150, and we talk about health literacy. People don't actually understand what they're putting in their body to cause this. It's not taught properly. My kids now have fruit break at the school. We never had fruit break. So, imagine now, we're actually teaching in the schools, the harms of sugar and how to eat properly, and that only does so much. I think we need to really look at policies, and we have public bariatric programs, but they're so inefficient and ineffective. Similar to anything that is government-run, there are so many competing interests and politics, and we have to go through red tape. It's a bit disheartening, at times, but that's the future. We have to work with it. We have to overcome those hurdles.

[27:45] Nick: It's disappointing to hear. I mean, at HLS, we deal a lot with falls detection with one of our technology products, and I don't know if it's gone backwards, in terms of falls, but I know that through the literature we've done, we haven't made any impact on the rates of falls, and falls is one of the leading, probably […], but falls being one of the leading cause of premature death in aged care, but how do you solve that problem? To me, this sounds really frustrating, because this is something we're well-educated about, as an industry, not just as a population, and yet you're in the epicentre there of it all, and yet you're saying we're going backwards.

[28:25] Michael: Yeah, as you know, it's so multifactorial. You address one element and there's 100 other competing elements that you have to think about, as well.

[28:34] Nick: What about mental health? Is mental health a major factor?

[28:37] Michael: Oh, massive. Look at patients that are presented for surgery. 20 to 30. Many of them have some history of abuse, whether it's physical or emotional, or financial abuse. There is abuse there, and sometimes, the weight is a barrier for people to get close to them. We've worked closely with psychologists, and psychiatrists to try and address those issues.

[28:58] Nick: Have you seen a decline since covid? I mean, there seemed to be, again, it's anecdotal, as far as my knowledge of the data goes, but the decline in the rates of mental health, or the increase in the rates of mental health problems, I should say, since covid, have spiked. Have you seen that, and how does it relate to obesity and health-related complications?

[29:22] Michael: As you know, with lockdown and restrictions on where you could go, people were very sedentary. They were sitting at home. They weren't working. They were probably drinking too much, eating too much, and passing their time that way, and since covid, what we've found is, people have probably become less worried about their health and more worried about enjoying life. I think that, more recently, these interest rate rises and financial pressures we’re experiencing, the first thing people cut out is elective surgery, and you think about big drugs that we're talking about these days, like Ozempic, Mounjaro, injectable drugs, which are causing weight loss. It's going gangbusters. It's the fastest growing industry in the world right now. Billions.

[30:09] Nick: Ozempic. So, is it the silver bullet, or do people just see it as an easy option? I don't have to exercise. I don't have to change what I'm eating.

[30:18] Michael: I guess, a lot of people would look at it as a cheater’s a way out, but at the end of the day, we're trying to change the brain and the body into gaining healthy weight loss and improving insulin sensitivity and decreasing fat absorption. Basically, these drugs, they do have some effect, but the problem is, if you don't marry that with the lifestyle changes, then you'll get side effects, like diarrhea, nausea, vomiting. Of course, side effects can happen for any reason, but they will compensate people that don't change their soft drink consumption, the calorie or fat food ingestion. They're the ones that tend to get the side effects more. We thought this could be a game changer, but it's not. What it's doing, it's opening the gates for people that have contemplated surgery to actually come to surgery, because they often try the drugs. It's either not available, it's too expensive, they've tried it for 6 to 12 months, they don’t want the increased expense going forward. When you look at the cost effectiveness, surgery is by far the most effective and efficient procedure. It outweighs pharmaceuticals at the moment, and the way they designed the pharmaceuticals was to mimic the changes that happened after metabolic surgery. So, that's how they’ve been developed.

[31:39] Nick: How many people can afford that or are private funds funding that?

[31:44] Michael: They're not, and if you look at something like Mounjaro, which is touted as one of the more effective ones, you're looking at an outlay of $450 to $700 a month. How many people could afford that for 12 months?

[31:57] Nick: So, what about the surgical side of things?

[31:59] Michael: Surgery should cost you around about $4-6,000, and that should include everything. So, you weigh up that cost versus the injection. People try the injections, they either don’t like them, and they may come to surgery, and we initially thought that these medications would really reduce our workload, but it hasn't had that effect. I suggest to my patients, if you've been on these injections, and you’re losing maybe five to seven kilograms in six months, you should probably think about doing something else and not wasting your money on it.

[32:33] Nick: I went through a time where I decided I had to lose weight. Was I obese? I don't know. I didn't measure my BMI, but I can tell you, I had to go through fairly significant change on my diet because I started the exercise and I had zero effect, at my age. I either couldn't exercise enough or, I'm not sure, I don't understand the science behind it, but I can tell you the thing that worked for me was the diet side of things. I had to get serious about what I was and wasn't eating.

[32:56] Michael: I reckon, 80% of it is diet. Achieve 12-1500 calories a day, you will drop weight. I try to keep things simple because I'm a surgeon. I try not to overthink things. Four cans of Coke a day, or Coke Zero, there's a lot of chemicals that are potentiating your hunger. You’re going to eat more, you’re going to miss meals, you’re going to have more […], and snack after dinner. These are all the problems that most of us have. If you look at intermittent fasting, if you stop eating after 8pm, of course, you're going to stop your night-time snacks. Of course, you're going to lose weight. You've just got to have a bit of common sense about it.

[33:33] Nick: I'm terrible. I go searching for chocolate after dinner, all the time.

[33:37] Michael: If you’re tired, poor, and you're working all day, that's where you find comfort. We’re all human. That's the thing.

[33:44] Nick: Moderation. You've got to be able to find balance in things.

[33:47] Michael: At the same time, enjoy aspects of your life when you can, but also balancing that.

[33:53] Nick: Yeah. I would suggest that most people think that surgeons make a lot of money, they’re very wealthy. Talk to me about the business of being a surgeon. You and I, we did touch on this a little while ago, and it intrigued me because, if I remember correctly, you said they’re notoriously bad at managing their money and managing their business because they're so focused on maybe clinical outcomes.

[34:14] Michael: The worst financial decision is to get a divorce. That's what I've been talking about, but one thing that they do not teach you at medical school, or in your training is, either be a practitioner with a […] and a staff, and how to run your business. So, after you finish training, there are certain courses that the AMA or the College of Surgeons may run, but you really have little to no idea until you start doing it. The AMA comes out with guidelines on how much to charge people, what is deemed acceptable. The Medicare rebates are based on standards in the 1980s. If everyone went off the Medicare rebates, there's no way you could sustain your practice. It's absolutely impossible, and so that's where these out-of-pocket expenses contribute. If you break it down to an hourly rate, say, for a surgeon versus a tradesman, you wouldn’t pick surgery. Think about the hours you do, that you do not get paid for, even with the rebates from, say Medicare or the private health funds, they'll pay you for the operation, and maybe one follow-up visit, but if you have a cancer patient that you're following up for five years, there's no money in that, and how can you have a discussion with someone about their cancer and say, “this is how much I'm going to charge you for your operation”?

The way I look at it is, the bariatric surgery, or metabolic surgery, is like getting married. You have wedding expenses. It's very expensive. You say you need flowers for your wedding. They’re three times more expensive. That’s the same as metabolic surgery, and then with the cancer patients, they never chose to have cancer. So, how can you charge it? So, we have a policy of just low gapping all of our patients, because it's not something they've chosen, and at the end of the day, that's what we've been training for, is to help people. So, that's what I mean. We're not businesspeople.

[36:19] Nick: When you say we, your practice, specifically?

[36:23] Michael: Particularly, my mentors. I've seen these guys, my mentors and myself, operate for three days with maybe six hours sleep. Who would do that for their job?

[36:33] Nick: Mind you, I don't know if I want somebody operating on me with that little sleep.

[36:38] Michael: It's like when you're doing a complex resection, which takes 22 hours, and then someone comes in with a knife in their abdomen or chest. You don't have an option.

[36:49] Nick: I get it, but it's a scary reality, isn't it?

[36:53] Michael: It’s not a glamorous job. It's not as glamorous as people think it is, and I think if you put in the amount of hours that we do, for the time that we take off and actually enjoy ourselves, it's minimal.

[37:06] Nick: And as a business, thinking about the business side, I mean, I love the ethics and I resonate with those. Even in our own business, there's certain things that we'll do with people that either have an acquired disability or are born with a disability that we don't necessarily advertise, but we take a lot of pride in the value set of what we do and the people that we help, but there's a business about what you do, because how do you grow and scale? We talk, in business, about build, grow, scale your business. How do you grow and scale your business?

[37:38] Nick: Good question, Nick, because I was with another surgeon, and I was going to become the major shareholder in the company, and the two of us together would do all these cases, and projected how much money the company would make, and realistically, he was probably three to five years of retirement, and I said to him “look, once you retire, there's just me, and the workload by default will more than half the state of the work,” and it didn't make sense to me. So, I guess growing and scaling, you can't really charge patients more. There's a limit. There's a ceiling there. Either you operate more, or you have some structure where you bring on other surgeons, and then they pay a fee to use your business name, your facilities, because that's where my value is. My value is in my team. They're an experienced bunch of people that have been doing it for years now. If I go, where do they go? Think about succession planning. That's more about what I think about, instead of growth and business, making more money. I think more about succession planning, and if anything happens to me or I’m on holidays, who looks after my patients? Who would I trust to look after them? So, I guess it's a bit of a different mindset.

The concept of how to run a business is a little bit foreign to me. I have a practice manager who's extremely good at it. She invoices all the patients, she collects the payments, she rationalizes everything, and I don't even get involved with it. I don't even know if she's doing the right thing because I'm too busy to think about it.

[39:20] Nick: Jeez, it takes a lot of trust.

[39:21] Michael: It takes a lot of trust, and you can easily get taken advantage of, but I've resigned myself to the fact that if I’m concentrating on that part the business, that it will affect by operative decision-making. I may be taking about someone and doing the operation because I get paid for it, if I’m worried my income, and I don't want to think about that. I don't want to have that over my head, thinking I only made that decision because I wanted to get paid and that's what I mean. It's a completely different mindset.

[39:53] Nick: Almost thinking there's a business opportunity in this, to be able to build something, to look after your business, another surgeon’s business for them, to say, “hey, listen. This is what we do. You go and do what you need to do,” and there's something about that. When we run a business, we run a business by its numbers. We need to know, again, we get taught, by mentors and coaches, know your numbers. One of them, in particular, is like, “mate, it’s a decimal. Don't tell me it's about 2.5 this, or whatever. It's a decimal. Know your numbers,” and you wouldn't have a clue, would you, what your profit and loss is, what your cash flow statement looks like, what your balance sheet looks like?

[40:32] Michael: We discussed this the other week, when I find out what the company made, I just looking at it and think, “what the hell? […]” If you had to spend too much money, I wouldn’t even know. It's going somewhere, and a lot of it is going to the taxman, but if you think about it, some of the most successful medical companies are the ones that have scaled, like laser surgery. They get lots of clinicians to do it. They have a set aim and plan.

[41:07] Michael: This vertical integration of things.

[41:10] Nick: I would love it if someone like you came along and said, “I want to take over this, and sort out all of this.” That'd be the dream.

[41:20] Nick: Well, maybe we'll do some business, as well. I love talking to you. You’re my oldest and one of my best friends, but also one of the inspirations in my life. You really are. I think, your humility, the lives that you change, the lives that you impact, and what you do is an absolute inspiration, and you've got an incredible, beautiful family to boot. So, thank you so much for giving me some of your time. I know how busy you are, and how in-demand you are. So, it's been an absolute pleasure. So, thank you very much.

[41:51] Michael: You saying that means a lot to me. I can’t state how touched I am by those words. It goes both ways, and you and Mel were inspiration to me, and I've seen the struggles you had early-on. I didn't help you with those struggles, I'm not proud to say.

[42:10] Nick: Hey, this is what we spoke about. Am I successful? Absolutely, I am. Am I where I want to be? Yes, but there's no destination. I even talk to my kids about this. Don't focus on getting there. You never get there in life. There is nowhere to get to, because otherwise you're just constantly disappointed. Just keep going. Keep striving and know that there's going to be good times and bad times, and the bad times let you appreciate the good.

[42:33] Michael: You enjoy the journey.

[42:34] Nick: All right, mate. Thank you, very much.

[42:36] Michael: No worries. Thank you.

[42:38] Nick Cheers. Talk to you soon.

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