Dr. Michael Snyder: Where Did We Come From, Where Do We Go From Here

– This whole thing was motivated, I haven’t really given a quote unquote inspirational talk for a few years, and the reason was I was always making, it always made me a little sad because I felt like it seemed like I was telling you what to do And so, we had a couple things happened in our clinical meeting Every Thursday, we have a clinical meeting, which I’m always 11.7 minutes late for And everyone else is waiting for me and I’m drinking my coffee and running around, just being a little late, and Hilary said, I said, what are some issues we should be talking about? Hilary said to me, well, we can tell you won’t know because no one tells you anything And I said, it’s true (audience laughing) Well, people get really embarrassed about you getting involved in their stuff if they’re slipping or having problems or having issues Unless it’s a real mental problem, they’d prefer not to talk to you I’m like, oh, that’s the saddest thing I ever heard And so, that’s my whole job Believe it or not, the surgery is easy for me, but finding the right surgery for the right patient, the right time and having it work for their life, oh my God, that is so hard So I thought, maybe if I show you that I’m not such a jerk and I won’t judge you and I’m– (audience laughing) Maybe people will talk to me about real life problems sometimes So that was the segue into this talk Then I was talking to some other of our clinical staff about what to do When we’re training a new nurse practitioner, we’re going through clinical scenarios, and it’s funny because almost every clinical scenario, I can tell you probably in 90 seconds (phone music ringing) what you should do, right? I need think about your lives, anything that’s problematic in your world, you could probably figure out in about 90 seconds what should be done If your kid comes to you and they’re terrible at calculus, you could say, you should probably pay attention in class, you should do your homework, you should go to your teacher’s office hours, and you’ll do better It’s not then, it’s not that simple It’s never about telling someone what to do It’s sort of engaging them on their level, where they are So hopefully this talk will be somewhat of a reminder of where you’re coming from, how you got here, what the issues are, and a little perspective I don’t have the right answer for you, but I hope at least something reverberates If this is useful, let me know, we’ll do more of it, and I can target more of what you need That’s where you do those questionnaires If it’s not helpful, well, at least you got out of the house for like an hour Okay? (audience laughing) All right so, next slide You’ve seen this I stole this from Facebook, who stole this from Facebook, who stole it from Instagram, who stole it from Pinterest who stole it from Twitter, I’m sure I put this over the scale and it went viral We have hundreds of thousands of people sharing this on the internet and I loved it I put it over the scale The scale can only give you a numerical reflection of your relationship with gravity, that’s it It cannot measure character, beauty, talent, purpose, possibility, strength, or love None of you believe that, right? (audience laughing) Because you judge yourself and you think about things in terms of it You came to me for surgery, it was to lower the number, which is, if we were on Jupiter, it would’ve been a different number, but it meant more to you than this But this is something you should think about every day, okay? Next, please So, a patient came to me two weeks ago and she said, I’m interested in a sleeve gastrectomy And I said, that’s cool We talk about the sleeve and where she’s coming from She had diabetes, hypertension, BMI 47, joint pain, a little urinary stress incontinence For guys, that’s when you cough and sneeze and pee a little bit, okay? (audience laughing) And so, and she said, well, how do these sleeves do long term? I said, what car do you drive? She said, I have a Hyundai Sonata I said, how old is it? She goes, it’s almost two years old I said, what’s it gonna be like in 10 years? She said, depends on how I take care of it So I just said, all right, we’re done I walked out of the room (audience laughing) I came back She said, what was that? I said, what do you mean? I said, I think you gave every answer I’ve ever wanted to give in my career, in one sentence, without even knowing anything on medicine She said, well, I mean, if I changed the oil and get it changed and keep the tire pressure up and drive with a little bit of integrity, maybe, these cars supposedly, their engine is good for hundreds of thousands of miles But if I don’t do that, I’ll ruin it I said, that’s all I gotta say I really, I have nothing more to say to you It was really a great moment for me because she taught herself everything she needed to know in seconds But that’s a lot of responsibility, doing it the right way Who are you? Okay, you’re here for a number of reasons You’re doing well and recognize the need for some acknowledgement and sort of like a champion of your path down here Kinda like a Broncos Super Bowl parade You deserve it Or you’re not doing great You may have fallen off the wagon and you really want me to harass you and beat you up Right? (audience laughing) You liked it People have that whole masochistic thing, it blows my mind You’re doing kinda eh, and you want some support, as you now return, or you want some healthy perspective

Or, you were dragged here by a spouse Okay, those are all the people in the room, and I can tell by how people encounter me coming in, where they are in this process The people that are kicking butt, came in and they’re like, hey, how you doing? I look great, I feel great People who are doing okay kind of said hi and nodded The other people kinda didn’t want to look me in the eye And we know who you are, it’s okay But that’s part, and the spouses don’t care at all They just turn off the sound on their phone so they can play Pokemon Go or something So that’s where we are Now this is what brought you here Next one, please The first thing I’m gonna talk about is a little bit how to be grateful This is kind of where Mary I’m sorry, any of you with a real spiritual and perspective path through life kinda get this better But the idea is, someone told me a joke the other day, which really reverberated for me And it’s kind of dumb, but I’m gonna go for it This is not a religious talk I don’t do religion talks Guy goes into a supermarket He has to go home within about 15 minutes and he is desperately late He has a list of things he must buy to get home So he’s driving around a very crowded parking lot While he’s driving around, he cannot find a parking space, and he is sweating His wife’s harassing him on the phone and he’s getting tense He’s gotta be home and he’s got tons to do and the kids are hungry And he’s thinking, God, or deity of your choice I really need a parking space You’ve gotta help me out here I’m in a really bad situation I’m late, everyone’s depending on me I need a parking space, can you give me a parking space? I promise I’ll give money to my favorite charity, I’ll be nicer to my wife and my kids, I’ll go to every soccer game, and miraculously, a space opens up right in front of him He says, oh God, don’t worry about it, I got it (laughing) That’s kind of what we all are doing here So I’m not talking about religion But on some level, you guys had a space open up for you for whatever the reason is, and we’ll get into the reason The idea, at some point, did you forget how it got there? At some point, did you forget what you, your family, your loved ones, society, our medical system did for you to get you there? That’s what we’re gonna talk about today Now, the idea is if I told any of you, if there was something you really wanted and there was a one in 1,000 chance of you getting it, would you be thrilled with it? Let’s say it was a job that doubled your income, it’s closer to your house, had better hours, was kid friendly, let you bring your dog to work, and you could wear band shirts and your jeans and flip-flops You’d be like, heck yeah, I want that job One in 1,000 chance of getting it and you got it You would think it was miraculous I’m taking care, and the bariatric surgical community is taking care of .1% of people that could be helped by bariatric surgery So you are one in 1,000 That’s pretty amazing Did you realize that? Even people are coming to my office, and we see anywhere from 70 to 100 new patients a month Sometimes, there’s some months, up to half the people who can’t get the surgery They can’t afford it, or they don’t have the benefit, or they don’t qualify, or something’s wrong with them medically or socially, or financially So the idea is that, that’s another part of the blessing you have to understand You are the one in 1,000 winner for something that you are desperately desiring and stuff That’s pretty amazing I don’t know in my life if I’ve ever gotten the one in 1,000 thing This is what all of you look like inside (laughing) This is a stomach I’m look out your bellybutton now I didn’t show you a web slide before surgery because you would’ve freaked out So, looking up, that under there is your diaphragm This is your liver Here’s your stomach and here’s your omentum And it looks like a sea of fat And it’s a sea of fat Every surgery I start out with is a sea of fat The art of what I do is not doing surgery It’s really, really easy I could teach you if we still have time It’s not really that hard I’m not just saying it to be helpful I’ve done a lot of it Everything that you do a lot of, you get good at But it’s trying to make up what’s valuable and real in a sea of fat And in reality, this is what was killing you The omentum, the central fat, the central opacities that leads to diabetes, hypertension, sleep apnea, PCOS, menstrual irregularity, joint pain Everything that ill heart cardiovascular disease So my goal of surgery was not to drop your scale It was to make you better physiologically And this is where it all starts And this is a huge liver This is a liver with severe fatty liver disease, which is pretty much everyone Now, we all, before surgery, you were hit by what I call weight loss porn The ideas that every single one of you did no fewer than 10 to 50 things that were expensive before you got in to see me The average person trying to casually lose weight, seriously, spends over $7,500 a year doing it,

and that doesn’t include changes of your food But you saw the Biggest Loser and you thought, that could be me The Biggest Loser is amazing If I just had my act together, I could lose the weight like these hundreds of pounds This is one of the Biggest Loser contestants that actually works for HealthONE She’s done a real good job at maintaining her weight I haven’t seen her recently, but she has really had a miraculous change Next But then this study came out last year in the Obesity Journal in May 2016 I’m sorry, this year And they studied season six of the Biggest Loser So what they did is they studied them The average weight, 140 kilograms before the show You can do the math if you have your phone out, times 2.2 pounds After 30 weeks, they weighed about 90 kilograms They lost about 130 pounds in the show Six years later, the average weight was 130 kilograms They had lost 10 kilograms, 22 pounds Hmm The resting metabolic rate, the rate at which they burned calories based on someone of the same size, decreased by 610 kilocalories on average per person So they were kind of ruined It’s like if the performance of your car went from getting 32 miles a gallon down to 18 It’s still a good car, it still runs, but it’s not working Erin Egbert was the best result She lost 263 pounds down to 160 pounds She now weighs 152, 157 She burns 552 calories less than is normal for someone her size So the idea is that you knew this, but on some level, you embraced this as the reality, and coming to surgery, before we can have the rest of this talk, you have to understand that what you have done to date, and what you could do without us, that doesn’t mean me, that means a good bariatric surgeon, and a good bariatric team, really would be fraught with horrible changes, real metabolic ruin How many of you in that process did ruin your metabolisms? I don’t know the answer, but things that worked before stopped working Next I’ve done a lot of surgery I’ve done 6,003 surgeries as of Tuesday, 6,003 bariatric surgeries I’ve done 21 open bypasses, 2,505 laparoscopic bypasses, 992 sleeves, 1,853 bands, 232 removals, 11 revisions, and 409 bariatric surgical revisions Average BMI of the patients starting out as 43 So I’ve done a lot of surgery So there’s really nothing that you can show me or tell me that would surprise me about this process, or about your physiology This is not a talk about surgery Next Why do I do this? I have to dispense with this, because this is important to me You can’t pay me enough to do what I do Any surgeon, how much do I have to pay each of you to put on some rubber gloves, and mess around with strangers blood and pass sharp instruments back ane forth A million a year, two million, three million? Would you even do it? It’s kind of weird So the reality is, you can’t pay someone for that The reality is I realize the extreme honor and privilege to do what I do I do what I do because you want me to do it, and you allow me to do it You allow me into your life You trust me It’s a relationship I love these relationships When I was a general surgeon, I almost went into banking Why? Because I didn’t get to talk to people, or help people, or deal with what was really ailing them It was all about, how can I get that breast biopsy done Are you good, if you’re good bye, I’d file it I don’t like that, I hate that I get to share in the miracle I use the word miracle luxuriously For me, I do believe that daily we see and experience things, and if we pay attention to, our huge blueprint changes on how you can view the world of your life, but I get to do that every day More important, I get to help with the transformation I love the fact that you guys are walking in and saying, oh you did this, you did this, you’re amazing I’m not that amazing We had one good day, right? But the reality is you get up, you did an amazing job, or you did an average job with it, or you took it, and you did kinda good, and you slipped back, but maybe we can transform you back That’s why you’re here, correct? If you have questions about me and why I do this, we can talk about it Next please What was your goal with bariatric surgery? Now we’re done with me Every single one of you has to think about this You all had a specific goal that you told me Now a lot of you lied to me, and you said, I want my diabetes better, but what you really want is to look good for your high school reunion Okay I get it (audience laughing) The reality is you wanted to be active What did active mean? Was it to be healthy? Was it to be hot? Was it to be able to shop at the GAP? Was it to be a good or better parent, grandparent, child, spouse, friend, coworker? Was it to be seen for who you are and not your size? Was it most important to you not to be the biggest person in the room? Do you guys remember that? Do you still that when you walk in? Yeah Was it to buy clothes in a normal shop? Was it to go to Elitch Gardens, and click into the roller coaster, and not get stuck or get the weight through? Was it to be able to sit on a chair and not think it was borrowed and it wobbles, or this is gonna break and it’s gonna be horrible?

Was it to be able to hang out with your family, and quote unquote be a good example? Was it to change how your life, how you live your life? When I see everyone as a new patient, I have the four same things I say to everyone You may remember I said when I consider someone’s surgery, I look at four things Number one, what’s your BMI? Number two, what are your medical problems? Number three, what are your risk factors? And number four, how’s it messing with your life? That’s when everybody cries Just be happy you’re not married to me because I make everybody cry (audience laughing) The idea is that, that’s the thing that’s important How is it messing with your life? You all had a goal Do you remember what your goal was? I’m gonna ask you some of these questions later Next Now, when you had surgery, there was a thing you said What would you have given to be a normal situation? Anything we do, and I’ve had major, major life tragedies that would just blow you away I remember the bargaining I did with whomever or whatever In every life and death situation, we all bargain our lives away We say, I swear, if I survive this and the surgery works, I promise to What was yours? Anyone? All right, well I’ll tell you some that I’ve heard I’ve heard people say, if I survive this, I promise to throw away all my big clothes That’s an easy one, some of you say it to each other in case he has something really good If I happen to survive this, I promise to work out regularly If I survive this, I promise that my go to is not going to be the fridge If I survive this, I promise that I’m no longer gonna be embarrassed about what I eat late at night I promise if I survive this, I’m gonna be nicer to people, I’m gonna be better, I’m gonna be more active You all had something, and I need you to think about this What did you promise yourself? What did you promise to your life? What did you promise your world before this happened, because you did promise a lot of people stuff Next Now is the time to revisit those thoughts What would it cost you to go back? What if you in the chair there with me? You’re like, who is this bald dude that talks too fast, and he wasn’t a jacket, sorry You were sitting across from me one day, because I see every new patient That’s a rule of mine I need to make sure it’s a good attitude, that we work well together What would it cost you to go back to that moment? What would you give to go back to that moment? When people are a year out, even if they’ve had a difficult time, and we’ll go through complications and stuff, everyone says to me, you know I would do this every year if I had to, right? And why? It’s not because you like surgery It’s not because you love the Oxycodone we gave you, although some people like a little too much It’s not because you got a few days off of work It’s because there was was something that really hurt you in your soul The question is, could you go back? It’s a very difficult concept going back to where you were What would that mean to you Next We knew that the number that didn’t work by experience We understood the numbers, and I remember when I talked to each of you about this, and some of you on the internet, doing the internet talk I give Some people in the one-on-one lectures, we talked about the fact that the results of 10% of excess weight loss in one to two years with non-operative means, and statistically at five years, 95% to 98% of the people gain back all their weight Some of you are thinking, oh my god that’s still me I’m still gaining back all my weight again The reality is, this is someone that hasn’t changed their metabolism, their life, their behaviors, like we do Remember the biggest loser discussion we just had You knew this, and when I told you this, a lot of you it made really sad, because you spent a lot of time and energy not knowing this Your doctor had recommended, Atkins, Shrakins, Sugar Busters, Synergetic, Weight Watchers, whatever, a million times and never told you that we don’t really ever expect it to work I give talks all over the world on this, and there is a talk I gave in France, before the shooting, like a few weeks before the shooting, which was terrible I had about 150 primary care doctors from around the world there, and I was getting pilloried why I’m full of it Okay, this was video, I did not see the whole thing I remember distinctly I said, everybody that’s had a patient that’s lost 100 pounds, stand up Everyone stood up, just showing me how stupid I am I said every one of you that has a patient that had 100 pounds to lose, that lost it and kept it off for five years, stay standing Half the room sat Everyone of you that has two people that have done it stand Six people were standing How many of you have had five One guy was standing All right, it turns out he was part of the bariatric program, which is cheating But the idea is that we all knew it wasn’t going to work

You just didn’t know Next Who did we anger with our decisions? Do you remember the moment when you said you were gonna do a bariatric surgery, and the people that tried to talk you out of it? Do you remember? You probably have a very distinct memory of calling your mom in Iowa, and she’s like, honey I love the way you are You don’t need to do it I think you’re fine I think you should try and do ketogenic, or gluten free again, gee-anno, gee-amoca, that is Maybe there’s something you could try one more time, and the people that spoke out against you, and how it affected them when you decided to do it, and how much you angered them in that process Are you still friends with them? What friends did we lose? What happened to your fat friends? I mean a lot of people, I always ask people, in one, two years, who are you not friends with anymore? Everyone’s like, I’m gonna be the same I’m not gonna change I’m not gonna change This is who I am, it’s just weight, and you change You do change You did change, and people changed the way they treated you Some people, they don’t even like you anymore Now a number of those people don’t like you because you’ve got your weight below theirs, and that really peed M O That’s good, you like that? (audience laughing) But the idea is that it did impact a lot of people around you, and it did change the way you dealt with the world, and the world dealt with you Do you remember the first time you walked in and someone looked you in the eye You know I had a lady who almost maced someone in the Costco parking lot, ’cause a guy followed her to her car He was hitting on her and she thought he was gonna try to attack her (audience laughing) She whipped around with her mace He said whoa, whoa, whoa, I just thought you needed help with your stuff (audience laughing) She said, that never happened No one was ever that nice to me before, which is really interesting Was there a certain anonymity to being really overweight, that went away Then when people started saying, you look really good, what are you doing? You look great What did that do to you? How did that feel? Did it make other people around you annoyed that you were getting that attention I always call that the heroin effect Everyone gets a buzz from that, and when did that fade? What happened? What can comfort us if we lose our dear, dependable friend, food? For me, I’m asked to talk a lot about weight loss issues, and why they got bigger in America? If you think about it, we didn’t change a lot Nobody evolves in the last 30 years, right? In one generation But in one generation the amount of obesity has increased five times Why is that? I think it all comes down to this Your brain is craving This is scientific aside Please feel free to play with yourself, when a lot information, if you don’t wanna listen to this Is that in your brain, what we crave is serotonin, and brain chemicals The things that give us a buzz and a high, and adapt us are what? We got the drugs that make our brain feel better, like the SSRI, Prozac, Wellbutrin, Celexa, which are great We got the bad drugs that some people take if they abuse narcotics or other types of medication that you don’t get legally We have sleep is really good for helping your brain chemistry, we have exercise, we have sex Some people think prayer gives you that same thing, and we have food No one gets any of that good stuff, but food is always there, always for us So the idea is when you start losing food, you gotta start using the other stuff, hopefully not bad drugs That’s what happened is on some level, you lost food Now I wouldn’t do the surgery if it means you couldn’t eat food, but on some level you have to own up to the fact, especially if you’re slipping backwards at all, that food is doing something for you that’s bigger than just liking the taste of a cupcake Does that make sense? It’s in your brain chemistry So you and I have to really work on the idea is how am I gonna get you that serotonin effect, the brain effect, without it having to be food ‘Cause you miss it and it scared you People say to me every day, just before they get on the table people say two things Number one is I wanna survive I’m like, you’re gonna be fine The next is, can I never have a blank again? I’ve heard pizza, I’ve hear beer, I’ve heard Twizzlers No good, Twizzlers you’re not gonna give up The idea is that you all thought that What did you give up? How did it change? Next We all knew our place in the BMI chart Remember that, you knew exactly Remember what the next time Do you remember the first time you looked at this and you were like I’m not that bad It’s the one time people give themselves taller heights, just so you don’t feel like, I’m 5’8″, you’re 5’4″ I don’t think so Could you measure me again? I have that discussion at least twice a month, where people are way off because they don’t like where they are on the BMI chart People are kind of glow when it goes down, and you get to a different color I’m color blind so I don’t know the colors, but I see that they’re really interesting So everybody knew their place on the BMI chart, and a number of you already knew it People come in and say, I’ve lost 140 pounds, and I’m still overweight Like, according to who? Your chart, right? Next please Where did we come from? There’s a friend of mine said I need surgery, and he said he has three sets of clothes He had big clothes, really big clothes,

and oh my goodness clothes That’s not the words he used No I mean that people super obese If your BMI is 50 to 59, you’re super obese I used to tell people where they were on the BMI chart, and they would freak out when I said super obese, ’cause it sounded like such a nasty thing to call someone The idea is, all of you knew where you were Next please Why? We knew what didn’t work Once again, 95% of people fail This is the real deal This is surgery This is an elective major operation, and each of you survived it, and some of you had complications Next please Some of you had an inadequate weight loss Some of you haven’t hit where you’re supposed to, or where you dreamed of, or where you had your numbers you wanted Some of you every medical problem isn’t gone or totally better Some of you it is, some it’s not Some of you had depression Some of you developed marital relationship difficulties Some of you had hair loss, some of you had anemia, some of you had nutritional issues We’ve never had a catastrophic one, on our program, but we watch you really closely, loose skin, a percentage of you If you sit anywhere in the statistics of bariatric surgery At 30, you don’t give a boot about your skin and it’s fine At 30 you care a little bit, not that much At 30 you really care and are saving up your pennies for plastic surgery You need a lot of them for plastic surgeries by the way Some of you had gallbladder disease develop with a massive weight loss, and there’s a million other things that could have happened Some of you had dilation, where your pouch got too tight Some of you couldn’t get through the nausea Some of you to this day can’t eat certain things I can’t eat chicken, I can’t eat steak, it’s too fast Next Nausea, vomiting Band procedures are common potential problems Next We lost weight You lost a lot of weight Do you realize how much you lost? Do you have a number, but do you realize what it did? There’s someone here today There’s a guy that sent me a text yesterday, and he went from a 6X to a 3X shirt in four months He’s thrilled with that You would think 3X he still has a lot of weight loss to go, and he’s rocketing, and he loves that The idea in his mind that 89 pounds, which is a great start, an amazing start by the way, changed his life Now he’s gonna forget that in a year but I have the text Gastric bypass and sleeve is an average of 80% to 87% excess weight loss at one year, and 65% or more maintained for 10 years With a band, the people that maintain their band is about a 58% excess weight loss off and maintained Where do you fall in terms of that? We became healthier If you look at it, there’s no medical problem that befalls most people in America that have weight issues that isn’t addressed on some level with this I don’t know who you are Were you the person with depression, pseudotumor cerebri? Do you have asthma, reflux, PCOS, your periods, are they wacko, gout? You know degenerative joint disease, urinary stress incontinence, type II diabetes That’s my favorite thing is I hate diabetes I love diabetics, I hate diabetes Mortality risk reduction, 89% in the five year period, and your quality of life improvement, 95% better That’s amazing If you take an adolescent with morbid obesity, their quality of life is a little bit worse than an adolescent with cancer That’s a good study So the idea is that if you think of your life, this little parenthesis at the bottom here, that’s where the money is Are you aware, are you thinking about your quality of life and how it changed? I’m just trying to get your gears moving, and all of us plateau at some point, and that sucks The idea is that some people, their weight got to a point where it wasn’t exactly where they want it to be, and I’ll show you band versus bypass data Many of us regain weight A lot of people after their one year period gain about 10% of their excess body weight loss, and that’s scary My whole life has been trying to flatten that curve When you gain that 10%, what happened? Were you embarrassed? Did you not want to come in? Well it happens classically, and we just had a clinical meeting about it today How do you deal with the regaining patient? We talk about it all the time, and it’s classically someone who at 5’4″ wants to weigh 145, which is a BMI of 25 They go to 165, and then they’re happy Then they gain to 175, 10 pounds, and they think oh I’m gonna lose it, and then we’ll see them, and they’re at 185, meaning now they’re embarrassed, and 195, they start don’t look at me in the hallway That’s the time that you come in, okay But the idea is that, that’s how your brain works, ’cause you’re proud of what you’ve done, but it’s not perfect, and you experience that it’s not perfect This is the weight loss Okay, look at it The weight loss with band versus bypass, no one gets to their excess body weight loss unless they’re really in a very rarefied group, the idea is that, and I showed you this data ahead of time, and this little whip up at the end, is where my career is spent trying to flatten that out

So your experience is not singular You’re not here ’cause it’s singular, but there is a little whip at the end All right, now we understand that you know where you are So the big question, and this is a big one, is what did you promise to do if you lost the weight? If you survived it, and it worked? Every single one of you made a promise to yourself, to your friends, to your family Maybe you are still paying a debt on this, and you made a promise that if survived this ordeal, you would do something to be successful You would have a buy-in, you would have a contribution The question is what have you done with that? That’s really the question we’re dealing with Now this is my hard part, and this really what comes to me as hard This is my parental thing I’m trying to be parental This is my parental This is my frustration If any of you, I asked you what’s the hardest thing you’ve ever done in your life, not one of you would say, have bariatric surgery Not one of you I’ve had people with the leaks, and I operate on ’em four times I put stents in, and IR drains, and antibiotics and PICC lines It’s not common It’s very, very rare, and I’ve had ’em say to me a year later, I’d do it again Are you freaking kidding? (audience laughing) You know what, I wouldn’t do it again to you I feel so bad The idea is that if you have lived a full life, or at least part of a full life, every single one of you has dealt with diabetes and major medical problems, which were terrifying and really disrupted your life, your family’s life Most of you have experienced first hand or familially real illnesses I’ve experienced catastrophic illnesses in my family, catastrophic freaking illnesses, that have really destroyed a lot of stuff, but also made us better in the process Freaking divorce, do you know how hard that is? Death, I have people that I would give anything to talk to one more time We’ve experienced debility Well a lot of you really have lost debilities, and you’ve done all that, and none of that is even close to how easy bariatric surgery was I hear every day this is really hard What does that mean? Is this the hardest you could imagine doing? Is it even close to the hardest thing? Is it on your tongue freaking torn? Next The thing that really frustrates me is I see how you change People come in and like, ah, I have 60 more pounds to lose Then I see that your clothes are totally different You’ve got a cool haircut, you even got money You got that dying thing going again, you got a haircut, and you’re waxing all that stuff (audience laughing) I see how you walk in, you look people in the eye, and you stand straight up I see people’s shoulders again Look how tall I got? You’re not tall, you’re just not doing this any more I see that, and I hug them and people are really physical afterwards, and maybe beforehand you weren’t You did the side hug thing But whatever it is, because you don’t want to squish up against people, whatever your deal is but I see that I see how the clarity in people’s eyes, and even people that have lost a lot and gained a lot, and I say, how you doing? Oh I lost 160, I gained back 40, I’m down 120 They’re still kinda happy It didn’t ruin everything Promotions, there are people I work with every day, and their jobs have changed and promotions have changed Is it that people don’t judge you by weight I don’t know, probably to some degree Is it how you come across? Probably Confidence, relationship changes I had a patient come the other day and said, my husband, I’m kinda PO’d at him because he’s so horny for me now, (audience laughing) and he’s so interesting, and he wasn’t very interested before I’m like, I remember him He really loved the heck out of you I don’t think you were so nice to him He’s like yeah, she used to give me the, turn off the light, make it pitch black Don’t look at me, I look horrible He’s like, that wasn’t very enticing to me But the idea is that she’s doing him with all these things, but it was her behavior that did it When I pointed out, and I don’t wanna talk about that because it gets a little weird My hint is that I have to deal with this all the time, and people don’t understand the power that it has in their confidence, and they’re proud of themselves Everyone that has this surgery on some level has become more able That doesn’t mean your were disabled before, it means you’ve become more able Every single one of you walked down here easier Even if you have debilities, it became a little easier Everything got a little easier Not necessarily after parking at the closest distance space, driving around in circles, driving 25 things Or, do you ever walk inside and not be this slutty mess, or have to do the jacket around the waist so that they don’t look at your butt thing Whatever you got going on I mean, but everyone’s shank is up how they do that I see it, I know that, but I see people coming in and that’s the thing that really gets me the most

The question is from me, why would you ever squander this opportunity? You’re one in 1,000 You’ve done all the hard scary stuff You promised a million things to a lot of people, including probably your spouse, and your god, and your country, that you were gonna change, and what’s going on? Is there a key element? Are you one of those people who wants to fail? You’re good at failing, right? Up ’til now, although it was fraught with failure, we knew the diet and wouldn’t work, because we’ve proven that a million times over, and statistically it’s been proven by the National Institute of Health, but you were good at it You were really good at losing 30 and gaining 30 back, and you’re like, here we go again There I am pizza The idea is that you were good at that Maybe it’s easier Maybe it’s too much responsibility to succeed Are you that person? Is there comfort in failure? That there is a comfort in doing what you do well A kid who’s a bad student, he’s really good at being a bad student They’ve defined themself like that They bought the clothes at Hot Topic, they wore the skinny jeans, and they get the stupid haircut and the nose ring, and then they’re good at it Why would you take that away from them? It’s really hard to change the way someone views themself Maybe that’s what you’re doing Now, the one thing that happened to me this morning I was walking through Rose Hospital, and there’s someone here that I had operated on, and they said to me I went, ah, you look amazing They said to me, I just have 10 more pounds to lose I said, what? They said, if I could just lose 10 more pounds, and they did that face and the grab I said, what if you didn’t? What do you mean? I said, what if we just said no? BMI’s 26, you wanted 27, you want it to be 25 Why don’t we just say we’re good at 27? They said, I don’t know how to do that, because their whole life and efforts have been spent on messing with their brain according to how they’re gonna lose weight Now if they don’t think about that, what are they gonna talk about and think about? The corollary is, I had a patient come in, and she was at her target weight She wanted to weigh about 180, and she was 178 I said 186 is your number That’s your red letter number 186 you come into emergency, you get three weeks to get it in, if you’re above 186, I’m gonna get a tattoo done at the office I’m gonna put on everyone’s wrist what their number is that they have to come in I’m gonna get a tattoo done, okay We’ll have it look totally appropriate, it won’t be a problem (audience laughing) She started to cry, and she said, if I don’t think about my weight, what am I gonna think about? Is that you? What if every single one of you took a breath and said, I’m pretty good here pretty amazing here I’m doing a good job, I’m better, I’m happier, I’m healthier Yeah, I got some things I gotta work on in my life but weight’s not one of ’em I’m good How boring would that be? What would you do with your time? Can you do that? Are you even capable of doing that? That’s very difficult Next please There’s a guy Simon Sinek I’m not going to promote him, But this one, this morning is closed, and I can talk to you about some other stuff, if you wanna talk personally about it But he said, working hard for something we don’t care about called stress Working hard for something we love is called passion Why can’t you be passionate about just being happy? Why can’t you be passionate about finding some satisfaction and we classically call your non-weight loss goals I’m not gonna tell any of you to just be happy with who you are weight wise, because I don’t know the number, and I have a medical agenda, and do have a personal agenda of making sure you get to an area where you’re comfortable, but it’s probably not where you think you should be I’m pretty fricking happy with what you guys are doing, and how you’ve done You’ve made miraculous changes, you’ve changed your life fundamentally I hope I’ve woken you up to the reality that you went through a lot to get here, and you’ve done a really good job with the hard part Now it’s just a question of not making it the stress and the pain of not succeeding, but embrace what you’ve done to succeed and move forward I want you to count up in your brain on some level what your non-weight loss goals are I’ll give you an example My sister had bariatric surgery She’s very public about it I didn’t do it, that would be weird Her goal, her top two goal was to have boots

that zip over her calf That didn’t happen when she got to her goal weight, but she was electric in that After a while it was just boots that she put on I mean, the thing that you were most looking forward to, how could that become something so unnecessary and cavalier? I mean for me that’s an allegory to how we view everything I mean we pee in water better than most people drink, but not one of you appreciates that I’m praying about it every day, because I’ve lived in those places where you can’t drink the water The idea is that you can’t take things for granted that really are fundamental changes of your life that have made you happier, healthier, more satisfied, and productive Why don’t you just win with that? Why don’t you assume that it’s part of who you are It’s what you love It shouldn’t be a stress I’d should be part of your passion Next So what’s within you? This is that quote I always do, and I love Emerson I rely on him so I can be smarter He said, “What lies behind us and what lies before us “are small matters compared to what lies within us.” There is not one of you that I wouldn’t trust with my life If I had a heart attack right here and flopped on the ground and started spewing blood out of my mouth, every single one of you would come over and try and help me It’s not because you know me or ’cause you like me It’s ’cause how you’re wired? You’re good people Most people are really good people The idea is that within you is this perfect, wondrous, able person that has a true, good heart, who wants to move forward with what’s really within you, and it’s more than you body It’s more than your shape It’s more than your weight, and it’s more than your size You don’t even understand how impressive that is, and it’s gotten better with the weight loss, because you’ve gotten more able, and more accomplished, and that needs to be part of you It’s what’s within you that’s the difference So what do you need to do? You need to relearn the tools It’s very simple You need to relearn the rules of what we do, and it’s not hard You can go to Hilary’s classes, or go to our startup class, or you can come see me You can go on the internet You can do our shopping class, and we’re gonna teach you this Five or six meals a day, 78% protein, four to six ounces size, don’t eat jerky meat Do you want me to do it again? I just saved you a lot of red tape (audience laughing) Five or six meals a day, 78% protein, four to six ounces in size, don’t eat the jerky Okay, anything else? We’re done That’s what you need to know Are you doing that? That’s four fricking things Are you doing that? That’s what you need to do You need to practice them You are not gonna be perfect There’s nothing worth doing that you’re perfect for the first time You need to practice them You need to set very realistic goals of how you’re gonna practice these simple things, and be accountable You’re gonna have to hold yourself responsible, and it doesn’t mean if you don’t do it, you’re a bad person None of you is a bad person We’ve all done bad things, but none of you is a bad person You’re going to have to ask for grace and forgiveness for who you are, and come to this realistically Relearn the tools, practice them, hold yourself responsible, and at the end of the day, it is a matter of your life, your death, and your integrity You promised a lot of people you would do this If you don’t do it, that’s not nice That’s called integrity Your health is better, and life and death is important, and this is a matter of life and death You’ve done the most important difficult part to get where you are Realize, it’s about your life, your death, and your integrity You can do this, and it’s not hard as long as you keep working with us to do this Next please I texted it to myself I think my son told me this He found it somewhere, and I texted it to myself, so how pathetic is that? I don’t even have the time to get on Vimeo or Facebook, but this is what I texted myself A goal without a plan is a wish What’s your plan? Every single one of you is gonna wanna come in, hopefully, and talk to us about this, and I only have one question What’s your plan? Let’s create one If you’re just hoping that you weight continues to go down, and you’re hoping that you exercise, and you’re hoping that you feel better, and you’re hoping now that you’re awfully slim, you can maybe some day be off Metformin, that’s called a wish What’s the plan? Next “You gain strength, and courage, and confidence “by every experience in which you really stop “to look fear in the fac, and do the thing you cannot do.” It’s pretty important, isn’t it? It’s the cabin You already did it, you already did You already looked death in the face You let me rearrange your guts That’s weird All in the name of getting happier, and healthier, and able What’s gonna be harder than that? I punched holes in each of your belly,

like four or five times I mean that’s assault Would you let me do that to you, under the guise of helping you That’s scary, that’s dangerous, and that’s impressive has heck, that you let me do that You did the hard part You should gain strength, and courage, and confidence by the moments at which you stare death in the face Boom, you did it What are you gonna do now? What would you do not to go back? What are your non-weight loss goals? Have you achieved them? What are you gonna do to achieve ’em? What’s your plan? Imagine yourself six months from now Just imagine six months from now If you picture yourself the exact same, and you’re not happy, you’re gonna be the exact same Everyone close your eyes and picture yourself six months from now What does your life look like? What does your family look like? What does your love look like? What does your day-to-day activities look like? What do your meals look like? What does your grocery cart look like? What does it look like to be able to play with the people you love? What does your medication look like? You gotta picture it Open your eyes If you don’t picture it, it’s not gonna happen, so start picturing it, and let’s start working on it That’s it Questions (audience clapping) – [Narrator] Thank you for coming We’re gonna go through some of these questions, but I wanna tell you one thing that I wanna cry right now, because 100% of all your questionnaires, we must have 60 of them here 100% of you said, my quality of life is great 100% of you said, my medical conditions are much better Everything that’s on here is related to three, and maybe a little behavior stuff All stuff Dr. Snyder can help you with, so I’m like, congrats to you guys – Good job (audience clapping) What time is the documentary? – [Narrator] Noon 7:20, people have good timing We should have slowed down or had more slides (speaking too far from microphone to be heard) I can’t read it (audience laughing) I need glasses so I’m funny when (speaking too far from microphone to be heard) The ones you think I could answer – [Narrator] So plateaus are always a big one – Plateaus, so everyone has a plateau A plateau is a part of the process Plateauing is healthy Early on when you plateau, you’ll lose sizes while you’re plateauing, it’s probably a little bit of your body redistributing what you’ve got Okay, protein, fat ratios change The first thing to do when you plateau is give yourself six weeks and don’t change anything The next thing you do is don’t ask anyone about what to do Because all the things that you’ve done in the past that worked, thin thighs in 30 days, cayenne pepper with vinegar and lemon juice, you know the hot ass model workout or something like that Whatever, don’t do any of that The next thing to do is dispense from everything you think you should do So number one, give it time; number two, dispense with everything usually do; number three is then keep a food log, and an activity log for one week Now I’m not a calorie guy, so I don’t what you writing down calories That’s obnoxious, it doesn’t work Write down frequency, volume, how you feel, what you eat, when you eat, and then bring it to us, or email it to us That’s the first step The first step is you have to realize that you’re not an objective participant You have an agenda Keep a food log, and then come in and see us or email us, because it’s always something It’s always something, and we can help you figure out what that is Now one thing is the number of people that derail themself by saying, I can’t blank, so I won’t be successful I don’t have time to exercise, so I’m not gonna be successful I can’t ever not eat rice, because it’s part of my culture I can’t be successful I actually have no time, and I can’t sleep more than four hours at night, and I won’t be successful We can work with all that You can lose weight without exercising You can lose weight while having some indiscretions in your diet We just have to teach you how to do it That’s another excuse That’s another way of embracing failure I don’t embrace failure Yes – [Narrator] So this one says eating is not fulfilling any more Why do I eat if I don’t enjoy it? – Ooh, good question So eating is not fulfilling Fulfilling has a lot of different meanings, but people in our practice means is, I can’t eat whatever I want, and it’s not so fun Why does it gotta be fun all the time? What have you done in your life that you were productive? If you’re married, and you’ve been married 10, 20, 50 years, you’re doing something you don’t necessarily wanna be doing every day (audience laughing)

If you have a job, any job in America, a percentage of it is the hemorrhoids of that job Oh Thursday is accounting day Whatever Why does food have to be the source of entertainment? My first question is what do you miss? How can we bring it into your life within reason without you feeling denied of it, and also, where also can I get you some satisfaction? Classically I do this all the time I have people come in and say I gained 15 pounds ’cause my secretary has M&M’s on her desk, and I cannot walk by them without eating some M&M’s In fact, I pee just to get them, ’cause I have to walk by the desk I’m like, whoa, whoa, whoa I think that you really love M&M’s I really love M&M’s I can’t live without M&M’s You can’t live without M&M’s Can you eat peanut M&M’s? What do you mean? Peanut M&M’s Three times a week you can have one shot glass full Yeah maybe shot glass That means you gotta pick three One day Monday, one Wednesday, one Friday Well pizza? No, no, no, no, no (audience laughing) M&M’s was the problem So people wanna have a problem, and they don’t want permission to have a problem I wouldn’t ever live my life without eating a creme brulee ‘Cause I just love that I like the whole crunchy caramel top I like the whole squishy bottom Maybe it’s just what they serve it on I like it when it’s kinda warm I hate it when it’s still cold in the middle, but the idea is that But I don’t eat it every day, and I know when to eat it and how to bring it into my life So we should help you with the same thing You should still do that, but if you’re getting all of your entertainment from food, you have a big problem It’s not a food addiction It’s because you’re trying very hard to fail You’re trying very hard Before you come in and talk to us about it, because you will and you should, you have to figure what are you getting out of it? What are you getting out of it? Don’t hold up I’m addicted to carbs Okay, there was period of time you didn’t do them, you could have a food issue, and I’m not declining that Food issues are catastrophic, can be even lethal, but the idea is that I don’t think that’s we’re talking about – [Narrator] So this one says, it’s difficult to get in the five meals a day – All right, it’s difficult to get in the five meals a day So you have read your survey, you should eat five to six meals a day, 78% protein, four to six ounces in size Oh my fricking god You cannot eat this much food How long does that take? Eight minutes That’s not difficult but that’s just stupid Honestly, it’s not difficult I’m the busiest human that I know on this planet, okay, and I eat five or six times a day I have food with me all the time I have food hidden all around the places I go, and I do it It’s not stupid that you’re stupid, it’s stupid that you think that’s a valid excuse What it really means is it’s not that important to you If it’s not that important to eat five or six meals a day, don’t eat five or six meals a day You’ve chosen that If that’s your limiting factor, then you’re not planning, your not aware, but I certainly promise you, the person that asked that question, and I’m asked it every day so all of you are not stupid I’m asked it every day You still pick up your kid on time from school, and that’s a lot of work, and you still get up and shower, and get to work on time You still put on your deodorant, and you still have many habits of your life that you use success and happiness in a fulfilling and functional life, that you worked into your life Why did you choose this one not to do? What’s so hard on this one? I don’t understand that If you have a problem with it, bring it to me, and we will talk about it, and I will write you a doctor’s note that you can keep food at your desk, and I will say you’re life’s at risk If it really comes down to that I have done that for people who work for DOT and all that I’ll write you a doctor’s note that you can have a protein bar at your desk and a meal shake if you want Good, I’ll let you have the whole fridge next to it, and I’ll write a whole new note Whatever it takes, and I’ve done this many, many, many I’m always like, what’s your limiting factor? Can’t have food at my desk Now you can (audience laughing) I need a fridge Must be provided a fridge Oh my god, I will get you whatever you want What’s the reason why that’s so important? Is it hard? Yes Is it the hardest thing you’ve ever done? Oh come on, it’s harder to get up to the speaker All right, next – [Narrator] Body image and excess skin – Okay, so body image is a different one This is something I’m very passionate about My family have a huge history of body perceptions I can’t remember them I’ve never heard a woman in my gene pool say something nice about themselves First of all, you have to remember what your self talk is What are you saying to yourself, and I had a talk with a patient last month, and I remember distinctly ’cause it actually made me cry I won’t cry, but it’s funny that story made me cry She said about herself things that if I were at a party and someone said about her, I would have punched him, and I don’t really even know how to punch (audience laughing) She was so horrifically demoralizingly, horrible to herself

The things she said were horrific I said, that’s the meanest thing I ever heard First of all, we have to figure out are you like that? Are you that mean to yourself? Do you really hate your butt that much that you would say that? Do you really think you’re that horrible, and look that horrible, and and that your clothes squish you in a way? Is it that bad? First of all we have to put it in context Can you be that mean to yourself? I don’t think that’s okay I don’t think that’s okay So first of all, I have to slap you around, a few (mumbles) Body image is a deal It’s America There’s no image we have that isn’t of perfection The first thing thing I tell when this comes to me is you have to delete all your social media Because you’ll never be happy, because you’ll never look like her She isn’t even pretty She’s just got that one side of her with the wrinkles The idea is that personally what is your perspective and how you treat yourself The skin issue is real, and the value you have to understand No one’s ever asked me to gain all their weight back ’cause they don’t like the way their skin looks, but there are people that don’t like the way their skin looks I think it’s real I wish I’d have invented Spanx I think it’s brilliant, brilliant, but the idea is that there are ways to hide it There are ways to package it It’s certainly easier to get into an airplane seat than 400 pounds to have a little extra skin, and if it’s really important to you, you’ll want to find a way to fix it We’ve got behavioral dietary ways to mitigate it a little bit, but the reality is, a lot of time, it’s what you got, and you have to figure out what the importance is to you – [Narrator] Scary, but foods are sneaking back in – Sneaking back in I think that’s very valid Everything’s gonna sneak back in The idea is that when you see someone When I see someone that needs a revision or considering a revision, or quote unquote has gained all their weight back I always know their story, and I’ll quiz you Every alcoholic that becomes an alcoholic again has the same thing in common They took that drink Every marriage fails for the same reason, they didn’t communicate Everybody who goes back to jail, goes back for the same reason, they started hanging out with those people again Everyone that has bariatric surgery that gains all their weight back has the same thing They just didn’t do the rules that they were supposed to follow It’s the same story Barring technical problems, very, very rare, it’s always the same story It always starts with the foods are coming back in Now once again, it’s non-catastrophic It’s not gonna ruin everything You’re not a horrible person You didn’t destroy yourself, you didn’t lose your integrity What it really means is that you’re not paying attention, you’re not being mindful in a way that’s important ‘Cause it’s some reason not as important to you What you need to do, is be honest with yourself about what’s going on, and come talk to us, and we’ll teach you how to manage it I’m never gonna tell you not to eat something Never, it’s just not my thing I wouldn’t do it If you told me, I’d go no But we will tell you how to manage it, and that’s important It all comes down to your habits – [Narrator] Eating out of boredom – Eating out of boredom The question is why are you bored? First of all, why are you bored? Your life is full now We just said, you did all this work, you’re now able, you’re now fit, you’re now ready, you’re kicking butt, and now you’re bored You’ve got a lot to do I’ve got a lot of things for you to do Come mow my lawn (audience laughing) I actually kinda like it That’s so much fun The idea is that you gotta just figure out what the boredom is before you address how you’re taking care of it What are you bored about What’s your life like? What behaviors are you doing in your life? Then what is the food doing for you? It comes down to the other question It’s not really about what you’re eating It’s why you’re eating, and what it’s doing to you I know what it’s doing for you I’m a scientist I know it’s making your brain feel amazing It’s giving you habits that are comfortable to you, and it’s making serotonin build in your brain, and it’s really give you and appetite satisfaction, and it’s really reflective of things that are going in your life that give you comfort I can even give you an example There’s not one of you when you think of going home for Thanksgiving, you don’t think of one indulgent thing to eat that really makes the holiday Mine is I go home, my mom makes this chocolate pie, that’s probably full of seven of them There’s nothing but cakes But the idea is that it’s so good I’m like, I think about that Now I don’t even know where this came here so I could have chocolate pie, but the reality is, it does something for me that I really can’t imagine not having I have to figure out how to fit it into my life Does that make sense? We’ll do two more, then we’ll go – [Narrator] Being patient with the weight loss and realistic expectations – Oh, that’s a really good one ‘Cause that’s what a lot of you were talking with us The question is, how do you be patient with the weight loss, and what are your realistic expectations? So let’s talk about expectations first The categories of success are non-weight loss goals, and weight loss goals, and health goals Those are three things we deal with Those are really all the things I care about,

and that really goes into quality of life The non-weight loss goals Hey Amanda’s an expert at this She says, what’s the best thing about this? Even people that kinda feel that they have 50 more pounds to go, it’s amazing, I shop at the GAP, or wherever you go They have something that’s going on there, non-weight loss goals and you really have to have a finger on ’em Even if you still wanna lose those extra 10 or 20 pounds and you think it’s going to do something to you, there’s something that’s good going on A lot of good things that have improved your quality of life as you all pointed out, you really have to embrace that Next is health goals Your health is getting better whether or not you’re trying to not make it better Your health is getting better It’s probably one of the best things you can do for your health, and the the idea is you have to embrace that There we can talk about the weight loss goal, which is really what you’re talking about What I expect in the American Society for Metabolic and Bariatric Surgery, I’m a fellow of ASMBS, it’s a new designation, I got it, thank you I really want 19 letters after my name So the idea is that they say an excess weight loss of 50% of more of the excess weight loss is considered a successful bariatric surgery So I think that’s setting the bar kinda low, but there’s really not one of you that hasn’t achieved that, so you can say high five as a Center of Excellence member, congratulations, you’ve achieved successful bariatric surgery Well that’s not enough Well that’s the arm, okay So that’s what we talk about when you wanna lose 80% of your excess weight loss, 90%, etc What I care about is that the number’s moving People are devastated when they come to me after one year, and they have 50 pounds to lose I tell them I want you to lose two pounds a month this year, 24 pounds They’re like, well I wanna lose 50 Like, where you going? Let’s do 24 this year, and 24 next year That’s doable That’s not fast enough Fast didn’t work before, why is it gonna work now? Why you gotta be so fast There’s nothing worth doing that you have to do right away, unless it’s CPR (audience laughing) Let’s just slow down What I wanna see is progress, and we’ll help you with that progress If I say to you I want you to lose 36 pounds, you’re like, oh crap, that’s a lot of weight Let’s do it in three years That’s a pound a month, and they’re like, well that’s not enough Three years is pretty fast You gained back that weight a lot faster than that many, many, many times, so let’s just take our time It’s okay, it’s okay – [Narrator] They’re all pretty similar I think carbs are the big one – Carbs, we love our carbs I don’t hate carbs I think carbs are wonderful They’re for flavor and fun Go two meals without protein, throw on some carbs for flavor and fun One question Does anyone have any questions I didn’t answer? All right so what I’m gonna do, is I’m gonna stay here We’re gonna be up here and talk for a little bit There are a couple things I have to say First of all, if you thought I was hard on you, I’m sorry, not that sorry, but I have to say that Next is I wasn’t joking when I said I love this, and I love you for letting me do this This is really important to me, and I really would do anything to help you with this, so you need to communicate with me You gotta let me know what I can do to help you, what we can provide for you to make it better, and what you need If you need more attention, we’ll give you more attention If you need more accountability, we’ll give you more accountability If you want us to hold your hand and write out what to eat every day for the next two weeks, we’ll hold your and write out for you what you need to eat every two weeks It’s okay, it’s what we do for a living, and that’s to be paid to do that too So I’ve expanded my staff notably to accommodate you, and I’ll expand it more The hospital’s happy to do whatever it is to have you, so you have success If every Monday night you want a back on track meeting, well every Monday night we’ll have a back on track meeting You gotta tell me what you need Don’t be embarrassed You’re fine Thank you (audience clapping)