The Post-Discharge Gap: Why the First Ten Days After Surgery Still Break Down

Episode Contents

• 0:00 Introduction to NovaNav
• 0:55 Guest Introduction: Dr. Robert Cunningham
• 1:00 Dr. Cunningham's background: Ireland, MGH, and UNMC
• 3:40 Fellowship training at Geisinger and entering practice during COVID
• 4:15 Launching the bariatric program at Methodist Jennie Edmundson
• 5:52 Technology's impact on surgical safety: AI image overlays and intraoperative guidance
• 7:21 Bile duct injury and the holy grail of cholecystectomy safety
• 9:07 Molecules and nerve identification for inguinal hernia repair
• 10:25 Patient-facing technology: what patients actually experience
• 12:13 Immediate result release in patient portals and the cancer diagnosis problem
• 15:48 The host's personal experience: discharge instructions and post-op confusion
• 17:55 Where perioperative navigation platforms fit into the care continuum
• 20:46 Building the bariatric program: institutional support and proforma negotiation
• 23:55 Program components: dietitians, physical therapy, psychiatric evaluation
• 26:07 First surgical outcomes and the role of the program coordinator
• 27:32 Post-discharge follow-up, phone calls, and the literature on outcomes
• 29:13 GLP-1 medications and their effect on bariatric volume
• 35:20 Cost analysis: surgery versus lifelong GLP-1 therapy
• 36:41 Rural healthcare, critical access hospitals, and workforce challenges
• 39:06 The limits of AI and the risks of removing human interaction from care
• 43:00 Loneliness, social isolation, and surgical logistics for older patients
• 44:17 Advice for surgical residents: communication as the defining non-technical skill
• 48:40 The full spectrum of communication: bad news, colleagues, and conflict
• 50:30 Malpractice data and surgeons who communicate well
• 51:44 Closing remarks

Key Takeaways

The conversation goes beyond program building. Dr. Cunningham breaks down how GLP-1 medications are reshaping—and in some cases complicating—the surgical pipeline, and why the biggest gaps in care still happen after discharge. Despite advances in technology, the first week at home remains one of the most vulnerable periods for patients.

Transcript

Welcome to The Surgical Journey, a podcast about putting patients at the center of surgical care. From preoperative readiness to recovery at home, we talk about the real processes and data that shape outcomes. Each episode features conversations with health system leaders, surgical teams, and technology experts who are changing how patients move through surgery and recovery. At NovaNav, we focus on making surgery easier for patients and their care teams.

That means clearer communication, reducing administrative burden, and smarter use of data. In this series, you'll hear how that work plays out in real clinical environments. Let's get into the conversation with our host, Lisa Miller. Welcome to The Surgical Journey.

Today, I have an exciting guest with me, Dr. Robert Cunningham. Dr. Cunningham is a surgeon who's building a future of bariatric care from the ground up.

He's a board-certified general surgeon, fellowship-trained metabolic and bariatric surgeon, who recently launched a brand new bariatric surgery program at Nebraska Methodist Health System in Omaha. So I'm going to hand this over to you, Dr. Cunningham. Would you share with our audience a bit about you, because you're actually an international physician as well.

And, you know, we'd love to hear more about who you are. Of course. Thank you. And it's great to be here chatting with you this morning.

I appreciate the opportunity to come on and speak on the podcast. So thank you. You gave a little bit of a brief background there, but so as I'm sure many people have picked up on already in the few seconds I've been speaking, I'm not from the U.S. originally.

I'm Irish. I was born and raised in Ireland, and I attended medical school there. So I went to the University College of Dublin School of Medicine in Belfast in Dublin, and I had a wonderful experience there and a great grounding in the medical sciences. And I actually started the first part of my training on my surgical training pathway in Ireland.

So I did my internship and actually what would be the equivalent of like a PGY2 year here. I was a senior house officer at St. Vincent's University Hospital in Dublin. And I actually completed the first stage of my examinations to, on my board certification, the equivalent of in Ireland, which is the membership of the Royal College of Surgeons.

And then I kind of decided for one reason or another that the grass is greener on the other side of the Atlantic. And I had been to the States and had done several sub-internships and rotations in both medicine and surgery at various relatively high-profile institutions. I had a pretty good idea of what the pathway looked like in the U.S. And so I actually started out as a prelim general surgery resident at a little-known institution in Boston known as Massachusetts General Hospital, which was really quite an eye-opening and wonderful experience.

I'm very grateful for the opportunity to be there for a few years and commence my surgical training in the U.S. there. I got to work with some world-renowned surgeons and see some really wonderful surgeries, technologies, and really some really bright minds in the field doing some really exciting stuff. I then was able to transition into a categorical general surgery position at the University of Nebraska Medical Center here in Omaha, which is now where I'm based.

And I completed my general surgery residency, so five years, including a chief here. And then I kind of had developed an interest later in residency in advanced laparoscopy, minimally invasive surgery, some robotics, and also kind of dovetailed with my interest in metabolic disease, bariatric, sporadic surgery, weight loss, et cetera. And I think really what attracted me to that was the ability to impact a patient so profoundly that it could really change the trajectory of their life. And in many ways, it is preventative for an extraordinary number of diseases that we see that is so prevalent in Western society, particularly in the U.S., unfortunately.

I mean, the national obesity rate here is between 30 and 40%, depending on which study you read. It's still clearly a public health issue. It hasn't gone away, even in the era of modern GLP-1s. We're really only starting to make a dent in that.

So that was kind of what sparked my interest in that. So I did a fellowship year of bariatrics and advanced laparoscopic surgery at Geisinger Medical Center. And then I've been in practice since about 2019, 2020, essentially kind of got started really into the teeth of COVID, which was an interesting time to start practice. And I've actually worked in several different roles.

So I've been in private practice doing pure bariatrics for about two and a half years and in Kansas City. And I've worn many hats in practice, including general surgery, acute care. And so my current practice, I was recruited to start a bariatric program from scratch at my current institution. So I work for one of the affiliated hospitals to the Nebraska Methodist system, which is a Methodist Jenny Edmondson in Council Blossom, Iowa.

I've been there about eight or nine months now. And I'm really pleased with the progress we've made. We've gotten up and running with a program. We've done our first three cases.

We've got about well over a dozen, close to 20 patients going through the program, all new patients to the hospital to that program. And it's really been a wonderful journey, a remarkable learning experience. It's been a lot of hard work, but I'm really pleased with how things are going. And I'm really looking forward to the future there with that program.

I have some questions that I originally had sent to you. And now I have like about 10 more other questions since you gave your intro, but welcome. And I'm really looking forward to our conversation. So I'll start with one of the questions I had initially, but I wanna talk a little bit about what you talked about, which is the obesity being a public health issue.

I wanna kind of also get there, because I think it is, and I'd like some of your perspective on that. But first we'll start with, as you know, surgery is evolving faster at any point in the century, whether it's robotics to AI, diagnostics, where do you see the biggest opportunity for technology to improve surgical care? I mean, you've now built a program, so I'm sure this advanced technology, as well as your own procedures, you're really probably embracing more technology, obviously, than ever. So there's, I think there's a lot of different paths we could go down with that question just in terms of the impact of technology.

So, but maybe let's touch on a few of the more topical things that are really kind of the cutting edge, I guess. So I guess let's kind of address the elephant in the room, which is AI impact on technology, and I'll try and keep it more focused in sort of my area of expertise in surgery. So I think there are lots of really, really cutting edge, really cool projects that are ongoing in the background and research labs. I have a friend from residency who is a fairly big wig in the East Coast now, and he's the director of an artificial intelligence surgical AI lab, and doing some really cutting edge stuff on image overlays.

So looking at putting imaging studies real time onto 2D fields or 3D fields, depending on if you're doing robotics or not, but looking at taking a patient's own scans and overlaying them real time onto an operative field and identifying structures, really with a view to doing kind of fly, no fly. I'm not sure if you're familiar with that concept, but the idea of danger zones for surgery. So certain structures wish to be avoided, but often that structure can be right beside the intended target for a surgery. So for example, a very common surgery that lots of patients or lots of people who've listened to this podcast might be aware of, so gallbladder removal or cholecystectomy, probably one of the most common surgeries that's performed in worldwide, and particularly North America, and there are hundreds of thousands of these done every year.

And one of the more devastating potential complications of that is an injury to what's called a bile duct, which connects the liver to the small intestine, duodenum specifically. And that it's really been the holy grail of gallbladder surgery to drive that rate to zero, because we know it's been well studied, well established. There are dozens and dozens of papers written about this topic of how devastating that can be to a patient. And the long-term impact, et cetera.

So how do we utilize technology, including cutting edge, splicing of a patient's existing imaging, particularly a 3D axial scan onto a real-time operative field. And this really applies to when things are not quite as easy and straightforward as a nice, sterile laboratory experiment, or a nice, healthy, relatively skinny patient, where the anatomy is all very clear. It's the tough cases. It's the hot gallbladders.

It's the older male diabetics, who you almost universally know are gonna be really difficult cases, patients who struggle with severe obesity. So how do... I think there's a lot of really interesting things coming down the pike, just in terms of that one space alone, making surgery safer. So identification of critical structures.

Another, actually, I was just having this conversation yesterday with some reps from Intuitive about some things that are coming down the road in the very near future about particular molecules that can be administered to patients, either intravenously, most intravenously, or endoluminally, to identify other critical structures. So, for example, nerves, which are really important to say, for example, another very common surgery is inguinal hernia repair. There are hundreds of thousands of those performed across the U.S. And probably a lot of those are now moving towards minimally invasive, so keyhole approaches.

And a lot of those, which were previously straight-stick laparoscopy, are now going to some sort of a robotic platform. And there actually are studies out there now where patients will administer molecules that will identify the anatomy and prevent injury, devastating injuries, that can be very costly to fix or can really cause patients a lot of chronic pain and a lot of additional surgeries and things like that. So I think in terms of safety, surgical safety for patients, specifically in cavities in the body, so most commonly would be the abdomen, also the thoracic cavity. So I think there's a lot of really interesting advances that's been made from a patient safety perspective.

And I think, so I was thinking about this question that when you sent it to me earlier, that it's all one good me to say this, someone is really at the coalface doing these procedures, I'm going to meetings, I'm talking to colleagues, and we're all really excited about this technology and stuff. But I think one of the things that sometimes we sort of forget about is where's the patient and all that? How does that actually impact the patient experience? And the answer to that, I think, is not necessarily quite as straightforward as you and I might think about this, because the patient may not necessarily actually see any difference, all things going well.

So if their surgery goes very smoothly, they have a good outcome, they're like, well, that went great, but I didn't see that there was any major difference, like I didn't have this surgery 20 years ago versus having it now, and I can actually tell that there's a difference. So I think one of the things that we also need to think about is what are the patient-facing aspects of technology that's coming out that's actually going to improve the patient experience? And I think that's where all the ancillary things around particularly surgery or anything to do with hospitals, doctors, procedures. I mean, just look, we all carry smartphones around, the impact of apps on our lives.

And one of the things I think that perhaps we don't really give credit enough for is the development of patient-facing apps that allow patients to directly interact with their own electronic medical record. And I think that's something that's kind of infiltrated into our ecosystem and no one's kind of given it all that much thought. And I think there's a few things to say about that. By and large, I do think that's been really good for patients.

It's great for them to be able to get results, to be able to access records. What do the doctors say about this? What do they write in the notes? And I would say in the vast majority of cases, that is beneficial for patients, beneficial for you and I.

We can look up our results. Like, what was my cholesterol two years ago? What is it now? And it's all there in a matter of seconds.

You don't have to be calling the doctor's office, wait for a call back, waiting on records to be sent out, all that. That's sort of now archaic. The one caveat I'll put in that is, information is just information. It's how you interpret and what you do with it.

So one of the slight downsides of that is the immediate release, for example, of results to patients when they come into the chart. And this is something that directly, I've experienced this directly numerous times, actually in the last couple of months, particularly with diagnoses that may not be favorable for a patient, particularly cancer diagnosis is the most common one you will see. So pathology results being immediately released to a patient's chart electronically. And they get a notification immediately that there's something.

I just had some lab work done a few weeks ago. I got a notification immediately when it was ready, but it was just that the results had hit the chart, but no, the person who had ordered it, the ADP had not a chance to even look at it, interpret it. If there was something untoward in there, they didn't get a chance to kind of screen that or give a chance to present to me. So I think with this advent of technology, it's bounding so far ahead of where society, ethics, all those things are at, that we may need to take a little bit of a pause and just say like how much information should be released?

Like, is there a balance there is what I'm getting on. I think where we're at in the field is a couple of steps behind how far ahead technology has gotten. I had never thought about the cancer diagnosis that the patient might be alerted of before the physician has had a chance to have a conversation, which is always the, you know, coming to my office, I'd like to have a conversation with you, which is the best way to have that because the patient has so many questions. I never even thought of that as an issue.

And it's a real thing of timing as well. So, you know, pathologists are working hard and they want to get things signed up before the weekend. So it gets released at 4.59 PM on a Friday. And this happened to me actually about three or four months ago.

I happened to be on call on a weekend. I came in, first thing I did was look at my inbox on Saturday morning and a cancer diagnosis had been released to a patient at five o'clock. So at eight o'clock on Saturday morning, I called and the patient was very grateful that I called because they spent the whole night worried about an unexpected cancer diagnosis. So those are the sort of things where I think there's occasionally once in a while while we're making so much progress forward in releasing information, transparency, which I think really is the way forward.

Patients need to be involved in their care to the level that they're able to be involved with. So I work in a part of the country where health literacy is not great. And in fact, it goes so far as to say that it's really quite poor and people's education level for some patients is not great at their ability to grasp sort of complicated surgical concepts, anatomy, what's the impact of this diagnosis? What are my treatment options?

What's immunotherapy? What's chemotherapy? What's a sentinel nose? You know, all of these things, all of these big terms that we throw around on a day-to-day basis without any, you know, any second thought about it can be very complicated for some patients.

So in this rush to release information, perhaps sometimes we're kind of forgetting that the patient is at the center of it. This is what we're here to do. We're here to look after people. But are we sometimes maybe creating an unnecessary anxiety for starters amongst other issues?

Yeah, I never thought that you're gonna, now I'm gonna go down a few rabbit holes about that. That's a really good point about really understanding your community and their characteristics or where they're at and how you're releasing technology. That's a really great point. You also made an interesting point about patient experiences, right?

And patient-facing technology and what they see. And my daughter last week had eye surgery, she actually had double eye surgery, and she did great, and she had a phenomenal surgeon. Everything was, the experience was great and the results were amazing. So I'm very happy.

But when, and I'm in healthcare, you know, not from the clinical perspective, but around the clinical perspective for over 30 years. So I'm very easy, fluent. I can maneuver around it. But of course my emotions are there, right?

And I'm not always thinking, because it's my daughter, but when she came out and then all of a sudden I'm like, okay, well, here's the antibiotic, I gotta give her the antibiotic. And all this information's coming at me. And I, you know, my daughter in post, you know, she's just come out of the OR and I basically went blank. And so later on, I'm like, okay, well, how many drops?

What are the discharge instructions? She's in a lot of pain. What do you mean? Is it Tylenol, is Tylenol Advil?

I think she needs pain meds. I actually called the doctor who I love, who's amazing. He came out of retirement three times. He's amazing, amazing surgeon he did.

But I actually didn't get anyone in the office and I could have pushed more, but I didn't have any way of following up. Now, I figured it out eventually once I got my head back, but it's a lot. Yeah, you made the point that it can be kind of overwhelming. Like it's all well and good for us to kind of sit here at the 10,000 foot view and discuss these broad concepts, but it's when you're in that situation, either you are the patient or you're looking after the patient at home.

It's like, well, what was the dose? How often do I take this? Is this supposed to look like this? What am I supposed to do with this dressing?

Is it supposed to be draining? Is it not supposed to be draining? What do I do with this surgical drain? Do I charge it?

Do I not charge it? Is there blood in it? Is there not? And it can be very overwhelming for patients, I think.

So we're, and I think one of the things that I would see or feel really moving towards is things like Novav and other platforms that will be a bit more focused on the patient experience, both before, particularly procedures, both before and after. I think any sort of invasive procedure, there can be so much detail, so much, how do you prepare for this? How do you prepare for your colonoscopy? What should your stools look like beforehand?

What means you're not prepped? What can you eat? What can't you eat? And there's so many, there's a lot of phone calls, a lot of office time taken up with just that nitty gritty of the minor details that I think that is low hanging fruit for the software application industry, startups like Novav, et cetera, to tackle that and make that experience a lot smoother, make, and then also I think on the backend, now obviously you mentioned that your daughter did really well, didn't have any problems, but we know that not all patients don't have that experience.

Some patients do experience complications. I had a favorite mentor in residency who said big operations equals big potential complications. So patients going home after major surgeries, I think the biggest surgeries you can, like liver transplant, organ transplants, we call it transplant, used to have the nickname of maximally invasive surgery as opposed to minimally invasive surgery, like they use the biggest incisions by and large these days still. So how do they, how do, like what to, what should your wound look like?

What should your drain be putting out? Are there platforms or apps that can guide you through that to reduce the number of phone calls, reduce the middle of the night phone calls? Hey, my drain has stopped draining. Like, what should I do?

Is this an emergency? And being able to triage things a little bit more on a device or a phone that's right beside you as opposed to having to make a phone call, getting an on-call service, speaking to someone who's not your surgeon or isn't even in the office. I think that's where, going back to what we said a few minutes ago, the patient experience of, while we live in this wonderful technological age, yet I'm still dealing with paper and things like that. How do we move that end of it forward, I think?

Yeah, thank you. I think there's a lot more conversation around that. And it just, it was interesting just for me to be able to be in that situation, but you make some really great points about literacy and access. And just, I never even heard the terminology, those maxill, those larger surgeries, right?

That we should be paying attention to and those outcomes. But I really want to move to you as it relates to bariatric surgery, because you said some things on the intro that were really interesting to me. But you've built the program. I guess I'd like to understand, that's a big endeavor to build a program.

And so, you talk a little bit about, I think already about technology, but maybe talk about maybe the patient and what happens after surgery and what you do. I heard you also say on a Saturday, you were looking through your charts, which is pretty amazing. So that was a manual review versus an alert. But can you talk to me about how you think about, just your, maybe take us through building the program and I'd also like to know how your patients are feeling that have gone through the program.

Like you, I mean, there's probably a lot of reward, a lot of successes. I'd like to hear a little bit about that too, if you don't mind. Of course. So I'll be taking it back a couple of months.

So I started my current role in July of 25. And obviously I'd been in contact with initially the, my now partners who had kind of recruited me and then hospital administration. And they, it was a service line, so bariatric surgery wasn't a service line that the hospital offered. The system did, but a different, bigger hospital across the river.

So I hope those are familiar with the anatomy of the Midwest. We understand that Western Iowa, obviously the river and borders directly onto Eastern Nebraska. So the Omaha Cancer Blossom Metro is essentially all one big Metro, but they're completely different. Obviously states, et cetera, all the different things that go with that.

So they, the hospital system had a bariatric surgery service line, but not this hospital. So I was bringing something new and I'd made it pretty clear they were looking for a general surgeon, but also looking to add new service lines, new patient volumes, et cetera. And this is a service that actually isn't offered on our side of the river in the Cancer Blossom Metro. There's really no programs at all until you get about an hour and a half west of us.

And there's only one program between us and Des Moines. And then it's quite a long ways north and south. So we draw on quite a large catchment area in Western Iowa. And obesity is a huge issue, even more so in the Midwest, even more so in Western Iowa.

And there really hasn't been great options up until kind of we had started this program. So the first thing that was really important was institutional support. So I sat down across the table from the CEO and said, not to put too fine a point on it, here are my skills, here's what I'm bringing. And I had a proforma, I had numbers and dollar figures, all that kind of stuff.

And I said that I'm not signing paperwork until I get it in writing that you want to do this and you're gonna support this all the way to what's called a center of excellence standard so that we will get accredited as a bariatric surgery center, et cetera. So got all that squared away. And really the key thing underpin this has been institutional support. And what that really looks like, that's kind of a very sort of abstract concept.

But what it looks like is hiring people and allowing me to put all the pieces in place that construct our program or how it runs. So while I'm here talking about it as if it's my baby, it's not. I kind of spearheaded it a little bit, but there are so many aspects to it. So what the program involves is meeting me first off and you have multiple months of dietitian delivered nutritional education.

We have a full comprehensive program. So physical therapy is a really important part of it as well. So we have a wonderful physical therapy department at our hospital who will have multiple visits with a patient. They'll do a full cardiometabolic workup and they'll give them specific exercises targeted to, again, going back to what the patients are able to do, physically what they're capable of, allowing for limitations of orthopedic issues, et cetera, with a real focus on resistance exercise.

Because we know that about 20, 25% of the weight loss with any sort of significant weight loss is muscle mass, which is okay to a point, that's kind of what you expect, but you want to minimize the skeletal muscle loss and accentuate the adipose or fatty tissue loss. So, and then we have a comprehensive psychiatric and psychological evaluation, all of which happens during the brand. And it took quite a long time to get all those pieces in place. We did have quite a lot of the infrastructure in terms of the personnel, and we're blessed to have two full-time dietitians on site who are really engaged.

They're really interested in our patients. They're real champions for our patients. And our patients have had really good feedback from what the materials they've received, the one-on-one education. We do a lot of it in person.

So our psychiatric evals are done tele. So we are able to kind of do a hybrid of meeting patients, again, where they're at. A lot of patients, particularly in West Toronto, don't like traveling very far for appointments. They don't like going into the big city, as they call us.

They're not fond of crossing the river over into the Omaha Metro. So we've really worked hard to try and meet patients where they're at. So with our first few cases right at the end of last year, and I actually just saw both of those patients back for three-month follow-ups in the last two weeks, and they are doing fantastic. They are so happy.

They've had a stellar response. I think between them, the combined they lost over 120 pounds in three months. And are both just, they came into the room, and actually our coordinator, who was hired to the role after I came at my insistence, really, she was like, she got goosebumps. She was so excited for them because she had shepherded them essentially from the moment they had expressed interest in the program, all their preoperative workup, their appointments.

She's, I really, I can't liken her to a shepherd because she really shepherds these patients through the program and got them to the surgery. She was there the day of surgery. She was actually in their cases as well. She was able to come to the operating room, see what I did physically on the robot for these cases.

She called them like every day afterwards. And actually that's one really critical component that I think will be, has been very successful thus far and will lead to significant success down the road is that close follow-up. So that actually, there is good data that phone calls to patients, just even a phone call alone after discharge before that one week follow-up, generally most patients will be seen about a week to 10 days after surgery in the office. But close phone follow-up afterwards, there's actually a number of good papers and literature showing that that significantly improves outcomes from very measurable metrics.

So reducing patients attending the emergency department, reducing issues with dehydration, reducing complications, et cetera. I do think that's also one aspect of certainly perioperative patient care, the platforms like Novavax, et cetera, are looking to harness and to accentuate would be that close patient support, like the daily reminders, the prompts about, have you gotten your fluids in today? How many ounces of fluid have you gotten in? Have your bowels moved?

How do your wounds look? How many times have you walked today? And those quick prompts, like we're also used to prompts on our phone for a thousand different, sometimes pretty mundane or sometimes frankly useless things, but there's an opportunity there, I think, to impact patients in that critical first, you know, five to seven, 10 days after a procedure, either minor or major, perhaps even more so with a major procedure, like a gastric bypass or bariatric surgery, where those prompts, the, hey, like, you know, have you been up walking around today? You know, how everything's going?

Have you had any fevers? You know, how has any nausea? Have you gotten your fluids in? Those sort of prompts can really reduce the issues that can happen in that first week to 10 days afterwards.

So we're, we've had quite a few referrals for our program. We've, I think we have about close to 20 patients going through it now, and the feedback has been really great thus far. There's been a lot of interest from referring specialists, both within the hospital and then our primary care network in our hospital system, but also independents of Western Iowa. There's been a lot of, I've got a lot of very good positive verbal feedback that they're really happy the service is available.

A lot of patients are really happy that they don't have to travel. I've had quite a few patients actually, I've seen a few patients in the office, a few more reach out who had started programs elsewhere, but due to logistics and geography, they weren't able to complete them. I think it's, and it's one thing perhaps that maybe listeners to this podcast may not quite realize that there's a, there are very common misconceptions that surgery is cheating in the way out, and that couldn't be any further from the truth because it's actually really difficult to get through a well-designed preoperative program. Now, I've really made it a huge focus of our program to reduce the barriers, both to entry and actually getting through our program, but those barriers still do remain to a certain extent because for most insurance plans, it requires at least three months, if not four months of visits.

So it's not like, for example, your hernia or your gallbladder or your minor skin lesion, you go see a doctor, it gets taken off, sometimes same day, you make it a phone follow-up, you never see them again, or that issue's over and done with. For patients going down this pathway, it's a huge time commitment. I tell patients it's, you know, this will, this is a train you get on for four to six or maybe even seven months before you actually get through it and then it's lifelong follow-up after that. So to say that it's cheating or the easy way out or it's not doing it properly, it's just really not true, actually.

So I've been really pleased with how things are going. I've had a lot of interest. Patients are really happy with our first couple of successes and we're looking to build for the future as well. That's fantastic.

So I have a couple of things. You're a doctor with a proforma. I'm sure you're probably the first CEO that came across. So I'm sure he was probably a little surprised.

Yeah, so I mean, I did put quite a bit of work into that. So I think one of the nice things about kind of my career as far as I've actually, I've spanned several working and employment scenarios. So being in private practice was a huge eye-opener just from the financials end of a practice, healthcare, medicine, surgery, like what are the numbers that people look at? So I probably have a bit more of an insight to that than certainly coming out of training, I had no idea about any of that stuff at all whatsoever.

It's definitely one thing that is, it's just not even on the radar. There never was one question on the ab side, which is the training exam you take during residency, a sort of a general search anyway. There was never one question about finances or like what's an RVU, like what's a billing, what's a collection, what are overheads, what are your practice, what should your practice overheads be? Payment models for CMS, if that impacts you.

I mean, there's so much that really a resident surgeon should know. Yeah, like what's a 90-day post-op, what's a zero-day, like you just mentioned CMS, how do hospitals get paid? Why does your CMS star rating matter? These things are just, they're not even on the radar in training.

So that's been a huge learning curve. And I do think, again, kind of going back to your original question of how is technology gonna impact our, I think that particular question, the dollars and technology, I think, is a huge unanswered question in medicine in general, but also particularly surgery. I think we're starting to get to the point where it is starting to come to a head, I think, because technology costs money, costs more and more money each year. So we have all these fancy toys and really cool equipment, but it all costs, you know, it's gonna cost at least like seven figures.

But if hospitals are getting less and less reimbursement from whatever their payer is, CMS, commercial insurers, there's a problem there. So you've got costs going up, you've got revenue going this way, and then it's like, well, what happens in the middle there? So I think that's a bit of an unanswered issue in our field. So Mortgum.

Yeah, so I actually wanna jump a little bit, but I wanna make a comment that I love that you said about cheating. It's actually the opposite. I feel like I agree with you because I've known someone who's gone through a program. I think it's the opposite of cheating.

I think it's a real commitment to their life and to their outcomes and, you know, versus like you mentioned, GLP ones. And I would have thought that the GLPs would have impacted, you know, bariatric more, but you're saying that it really hasn't. I mean, that's probably more than- So if you look at the numbers, it certainly has a base anecdotally around the country, talking to colleagues, and the data is lagging us a little bit behind in terms of the actual like finalized numbers, but certainly anecdotally 20 to 25% decrease in primary bariatric surgeons in the country, which, you know, is our field gonna go away? No, that's a hyperbolic response.

Has it taken a bit of a hit? Certainly. Are we going to need as many bariatric surgeons going forward as they did in the past? Perhaps not, but I do liken this to, you know, major well-known examples.

So Herceptin didn't make breast cancer or breast cancer surgery go away. It's not like the field, you know, just melted away. And that clearly wasn't the case. And even the newer monoclonal antibodies for all manner of colorectal cancers, et cetera, there's just as many colorectal surgeons as there was before.

So I see it as being, it's a wonderful tool. They're really powerful medications. They work very well. Are they as good as the rarefied error of randomized control trial is going to be translated to the real world?

Probably not. I think we've already seen that data. That's been pretty well established already that they're very good, but no medication is ever really quite as good as a randomized control trial. And I think that the two big unanswered things are number one, the pharmacy benefit manager studies that have come out in the last two years that's showing the fall off rate after 12 months is significant, like 30, 40, 50% of patients are no longer renewing their prescriptions.

And then two, what happens when you stop taking it? And the data's even kind of coming out now that chances are there's going to be significant weight regain. So these are lifelong medications. And then neatly circling back around to what we just talked about five seconds ago about costs, dollars, and there's already been some fairly astute bariatric surgeons have looked, done cost analysis.

Actually, the last major meeting I was at, someone presented a paper on us looking at the break-even and it's kind of like the 15 to 18 month mark where the dollar figures start to favor surgery as a one-time high upfront cost, whereas being on a lifelong medication. But that whole field is so completely in flux with pricing changes, et cetera. Yeah, that's a great point about that cost analysis. So to jump to something that I didn't think we would talk about, but now that you've mentioned it, is that ability for a hospital, particularly if you're in a rural area, I believe, or somewhat of a rural area, right?

Kind of, yeah. So we serve a rural area now. We're in kind of a suburban area, I would say, but we draw from a huge swath of Western Iowa. And most of those communities are pretty rural, yes.

So I don't know how familiar you are with the Rural Healthcare Transformation Fund or how that impacts your hospital at all, but that might address some of the, we need more technology or we need more, it may not be, it's really workforce. There's a lot of pillars. So it'd be interesting to see how that is going to help to address what you just spoke about, really. Yeah, it will be.

I will say, so part of our practice, my partners and I, we do outreach at much smaller, like critical access hospitals, three different ones. And it will be, I guess, the way I'll phrase this, I'll be interested to see what happens. Those hospitals are struggling. They have been for a long time.

And even with the changes in reimbursement several years ago, where critical access hospitals essentially get back what it costs them to do everything. One of the major issues is attracting doctors to come work and provide services there. The idea of the classic kind of rural general surgeon who was a jack of all trades, did everything from the scalp to the toes and could take on anything, deal with everything. That's, while those surgeons do exist, they're unfortunately becoming a much rarer breed.

And I think the other issue is people want access to healthcare 24 seven, and it's just not feasible for human beings by and large, with a few superhuman exceptions aside, to be on call 24 seven and to take on the stress and the burden of all that call. I think that's really one of the key issues that faces rural healthcare is being able to provide a basic level of services, but you have to pay people to do it. And it still is a human provided service. Now, there are lots of things that can be offloaded to technology, computers, AI models, et cetera.

But I think it really, again, going back to, I do like to link parts of conversations together. Going back to what we talked about a few minutes ago about the patient experience and the patient is at the center of it. I don't want to be looked after by an AI chatbot. I don't want to be looked after by a robot.

I mean, if Push came to show up, there was a- A camera in the room. Yeah, it's a little Orwellian, I think, at times, a little Big Brother-ish. I do think that one of the kind of societal things that we've noticed, and I'm just getting enough gray hair now to say that I've seen this transition, is that the move towards less and less human interaction, less and less like someone being there physically in front of you to explain things to you, to help you with things, to help you with dressings, et cetera, is all that going to be replaced by robots? I think that will be a very dystopian world.

It'd be like something out of a Philip K. Dick novel that I'm not sure, but that may be where we're heading, but I'm concerned from a human perspective that we get there before we've even realized that that's what's coming. And I do think we need to certainly get bringing it back to medicine, human surgery. How do we figure out how to serve our patients who live in these areas where their local hospital may have shut down?

I was just reading something, I don't know if it was the New York Times, New York or something, but up in much more sparsely populated states like Idaho and places like this, where it's really a struggle to keep hospitals, their local hospital services open. How do you get ambulance coverage? Like how do you get EMS coverage in these rural counties if farmers have accidents, people are out hiking, all these sort of things, and middle of the winter, the weather's bad, a helicopter can't fly. Like, how do you get to a hospital before your accident or your heart attack?

You need a stent. You still need humans to figure out human problems. And I think the technology is wonderful, but it needs to service and improve our lives and make things better and easier for patients going through surgery or procedures who have emergencies. So that's the sort of, I do have a bit of a concern that we're moving so quickly forward with technology that we kind of forget that people live in rural Western Iowa and they want to be able to have a human interaction for, to someone to hold their hand like for a cancer diagnosis or say like, how can I help you?

Like, what's your experience? It was like, what are your feelings about this? Like, what questions can I answer? You know, that's still that human one-on-one interaction.

So I think that's kind of something that will be interesting to see how that develops in the years to come. Yeah, I mean, it's the experience and the heart. You know what I mean? Like you said, it's so beautiful.

How do they feel? They want someone next to them. And I do really, I hope that some of this, the funds addresses more the workforce to have the more people approach than it is more the technology. And I'm very, you know, tech, you know, I love technology, obviously being here in OpenAb, but even outside of that, but I don't think I'll ever replace a human being and being their experience and be able to see something because their experience over the years has shown them, wait a minute, there's something wrong.

And maybe the labs don't. So I don't think, and you're right. Yeah, and it may be that there's sort of a hybrid model where you do have say someone on call, but it's a video. Like I think at least a human, you know, while what we're doing right now doesn't quite replace a one-on-one sit down in a studio.

It's not bad, actually, all things. I mean, it's real time, it's live. You can see someone's facial expressions. You know that there's another human on the end of the line or on the end of whatever platform you're using.

I think it's when you get, you totally remove that human aspect to it that it becomes very cold, very impersonal. You sort of feel like who's looking after me? Is anyone looking after me? Like, I think one of the issues that we face in society these days in 2026 is a loneliness.

There's certainly a loneliness epidemic. And we do see that. Like I see that very viscerally in my practice. Not infrequently, I see older male patients coming in and that's even something as simple as that.

Like, what are your logistics for transport, for surgery? You can't drive yourself home afterwards. The hospital policy is you can't drive yourself home after any sort of procedural sedation or general anesthesia. So, but that really becomes a very visceral issue for quite a few of my patients, actually.

Like, oh, well, I got to organize a friend or a colleague. I don't have anyone at home. I have no family around. Older patients whose significant other may have passed away.

It's that sort of thing that I think we sort of forget about with technology. It's fine if you live in a major metro or whatever, but that's not everybody, you know? Yeah, it's great. Great points.

It'll be interesting to see how, I think, hopefully that's a lot of the issues that it's meant to solve for, right? Very, very practical. Maybe we'll go with taxis and fix it all. Yeah, that's right.

I went on one like last year, it was in California. I was like, it was pretty interesting, but they seem to work well though. So maybe that is a solution. It's a great idea.

So my last question, and you mentioned a little bit about, you know, maybe not, maybe, yeah, I mean, surgical residents or medical students, but it'd be interesting to see what you're saying in light of that. So if you could tell a surgical resident to one skill set outside of like a technical proficiency that would define whether they thrive or struggle, or just generally speaking, what's your advice to a surgical resident or someone coming out of school? So I actually, I printed out the questions you sent me, and that was one that kind of gave me some pause. I think like, what do I think is really important inside of your technical ability to perform a surgery and have low complications, et cetera?

And it is a little bit cheesy, a little bit cliched, but I think I try and focus it to be more useful advice and just say, you need to be really good with people. Some people are very good with people, okay? They have wonderful interpersonal skills. They're able to, you know, enthrall an audience.

They have great one-on-one skills. They have great eye contact. If that is not you, and I've, this is definitely something that I struggled with, and I continue to work on on a day-to-day basis. It certainly was occasionally an issue at times in training, and I've definitely met innumerable residents in every field going through training that if interpersonal relations are not your forte, you would be very well served by working very closely and very diligently on that and working on a range of skills in that.

So being able to go all the way from presenting to an audience of hundreds, being able to communicate clearly difficult, esoteric, technically challenging concepts to an audience who doesn't understand, knows nothing about the field, to be able to take all the intelligence that you have and all the training and skills that you acquired and all the master's degrees and the PhDs and the papers and the bench research and make it accessible at a large scale to an audience who doesn't understand, but also you gotta be able to shift, and you have to have the range of skills to be able to sit down with a patient at the bedside in the midst of the worst day of their life and say, and it's not just, it's great to be able to offer hope and be able to say, oh, we're gonna fix this, and I'm the swashbuckling surgeon who's gonna ride in and save the day. It's harder to sit down and say, I don't think surgery is a good option here. I don't think, what do you want from this? Because I'm not sure that what I can do for you is going to align with what you want.

And then be able to be able to break really bad news to a patient, a cancer diagnosis. I'm sorry, there aren't any more. And that's, that I think is, that spectrum from being able to talk to hundreds of people to one person and say, I'm sorry, there aren't any more options here. You have end stage whatever disease or you have widely metastatic X cancer.

We need to focus on comfort at this point. So being at that, that I think is, and then within the middle of that spectrum there is also being able to communicate and your interpersonal relations with your colleagues, people in the hospital, everyone from the CEO and the C-suites to the nurses. And it's easy when things are going well, but it's, you gotta be able to focus on when things are not going well, when you're butting heads with someone, someone's got a very different plan, someone's angry at you, nurses are angry, you didn't get back to my call, family are angry, like being able to pivot and being able to kind of roll with the hits a little bit, not take everything very personally, be able to not let the red mist come down, to be able to think coolly under pressure. That I think are the skills that will really separate people coming out of residency, residents coming out from really succeeding.

And I've seen numerous examples over the years of people who didn't have great communication skills, never realized their communication skills were poor. It really held them back from what should have been a stellar career otherwise, you know, in any field. Or the other end of it is that they got really burnt out from the grind. Sometimes it can be quite a grind of dealing with, you know, tough topics, tough patients day in, day out, and not being able to step back, kind of compartmentalize it, that sort of stuff as well.

I am so glad you answered that that way. I agree with you a hundred percent. And I think that's everywhere, being able to communicate and have the skills, whether you're, you know, speaking about very advanced topics to the patient and having the, you know, the ability to talk about all kinds of things. I think communication is it, Warren Buffett said, what was it?

I think he said his number one skill that he learned early on, he went to, I think it might've been a Dale Carnegie or some program that was speaking and it was communicating. And I actually think that's great, great, great advice. I'm so glad you answered it that way. I didn't have any, you know, thinking about what that would be, but I happen to agree with you.

And I think also patients and people in general are far more forgiving for somebody who's just willing to work it out, you know, talk things out, you know, not get things so hot, like, you know, even in a bad situation, just being having that grace to be able to, you know, be a little more level-headed, right? And- And there's actually, there's actually some pretty good data that surgeons are better communicators are less likely to be involved in medical malpractice suits as well. Like that's pretty well-established, so. I, it doesn't, I think there's patients generally speaking, and I've had my own experiences with things that have gone wrong and I've actually had a paid physician walk in and actually nothing he needed to apologize.

It was tough to do it, but he did. And, and it was, you know, something had gone wrong and it was fine. Like, I was, I was so amazed that he had just the ability to come back in, you know, as a hospitalist and he wasn't really a caretaker for my family member, but I, to this day, I was so amazed and impressed and left it there. Like things happen, right?

Dr. Cronin, I mean, life happens. Somehow we think that medicine has to be perfect and it's not. And I think that I always say to my friends, I'm like, you can't expect perfect everywhere.

We don't have all the answers to everything. Not everything is known. And even if you do have all the answers, you know, statistically there's still going to be some things that don't work out perfectly. And it's being able to recognize, to admit like, look, I'm sorry you had a problem.

But, and I think what patients really, my understanding of that is that they really want to hear that, A, you care. B, you know, you know what's going on. And C, you're making some sort of an effort to remedy it if it can be remedied. People just want to be heard.

They want to be acknowledged. They want to say like, look, I have a wound infection or I've had this major problem or I've had a nerve injury or something like, yeah, look, I'm really sorry. And then that gets into a whole other, we could spend hours talking about, you know, good patient communication preoperatively, pre-procedure. Like, what are the potential issues here, you know?

What could happen and that sort of stuff. And patients just, they want to know that there's, again, getting back to, there's a human on the other side of that interaction that, yeah, look, I'm sorry things didn't work out as well as you had planned. I'm sorry that we fell short on these things. Or I'm sorry there was a scheduling issue and your something didn't get sent out or your case still got delayed or something, you know?

Yeah, absolutely. So Dr. Cunningham, thank you for spending time. I know we went a little bit over, but thank you for, you know, continuing the conversation.

It's been great to have you on that surgical journey. It was my pleasure. Thank you so much. Thanks for listening to The Surgical Journey.

Join us next time as we continue examining smarter, more connected approaches to perioperative care.