How to Force Your Brain into a Flow State | Dr. Samuel Bartholomew's Pathway to Peak Performance

It's about weight loss, but overall it's about being healthier. It's going to have a huge impact inside your practice. Usually, you want to wait for patients to have been at their stable weight for at least 6 months. The last thing you want to do is do surgery. Then you either lose more weight or gain weight.

You've been voted by your colleagues 12 years in a row as the top guy.

There's a craft to it. I'm using my hands. I mean, as surgeons, we do that. I have to be adaptable. So, maybe we don't have something or the equipment breaks. I was in Ethiopia and there was an issue with the skin graft harvester. You know, when the lights were going out, the power was going off. Part of it is just having this mindset of, you know, if things come up, I need to be able to respond to the adversity.

I keep all my thank yous. It's hard to quantify, but it's it's a satisfaction of having helped someone and I was able to do my best and used my talents to do it. I mean, it's just uh it's the fulfillment of everything I wanted to do when I was a student.

Hey, we want to thank our sponsor, Ketone Aid. And if you're interested in ketones and how you can fuel your brain with them, go ahead and go to ketoneade.com/jock and receive free shipping. Now back to the show. Sammy Bartholomew, welcome back to the Pathway to Peak Performance, my man.

Thank you. It's great to be back with you.

Holy smokes. Yeah. All the way down from Portland.

Yeah, I had a great flight. It's fantastic to be here. I love coming back to the Bay Area and, you know, went to medical school here and absolutely just a a pleasure to be back.

Yeah. So, always always fun. Dude, you had a a wild trip recently, Ethiopia.

I did. I did.

Bring us up to speed on that.

Yeah, I had a fantastic trip. I was in uh outside of Addis Ababa. So, I have a colleague I work with who's an orthopedic surgeon, Dr. Gavin Button, and he has been going to this hospital in Negele Arsi. So, it's about 4 hours south of the capital in Ethiopia, and he's been doing orthopedic surgery there for about nine years. He helped set up the program there. So he uh we we've been talking about this like opportunities to do some you know charity surgery and uh work at the hospital there and it's something I'd wanted to do again for years now.

Now as we talked before I was uh last time I did any international surgery was in Nepal in 2008 and that's when I had that helicopter crash next to uh the base camp at Mount Everest and understandably my wife put the moratorium on doing any international surgery at that time and so kids are older and I've just been really wanting you know to do some more work internationally.

So we talked about getting this opportunity set up and it's a little different in that rather than go with a big group, it was just me. So individual surgeons or anesthesiologists go they travel to the hospital work with the surgeons the doctors there and uh they help get patients uh that had mostly burns um hand injuries um for reconstructive you know that needed reconstructive surgery and they actually were able to communicate with me a lot of these uh patients and send photos and we kind of set this up.

So yeah, I went late last fall and uh it was just tremendous. Uh long flight to get there. You know, that was probably just the hardest part of it. Uh you know, we drove about four hours on the roads to get to the the town. Uh got checked in at the hotel. They took me to the hospital and then I had a chance to meet, you know, prospective patients and their families and uh spent several hours just doing that. And that was uh yeah, it was tremendous.

Um, we kind of came up with the the surgeries that I felt that were feasible that I could do there. Uh, there were some that we just didn't have the resources for. There just weren't frankly things that I do typically and uh set up a surgery schedule. So, I was able to operate uh there for about 4 days solid and the team was incredible. Um, I really loved it because I was collaborating with the surgeons there and so I worked literally side by side with a number of the surgeons. Uh, Dr. G—I mean it just it was just tremendous. I really enjoyed that part of it. There's a lot of camaraderie when you work with other surgeons. It's really enjoyable. But it was uh tremendously challenging.

I got a chance to do you know a lot of hand surgery there. Uh mostly hand burns and uh children and some adults and then some facial burns. Um one of the most challenging cases was a large hemangioma. It was this very disfiguring facial hemangioma in a young woman that she had her whole life and uh we were able to remove that. That was the last surgery we were there and uh I think probably the most challenging I think did a lot of good work and tremendously gratifying.

But yeah that's I mean that's huge. I mean that those particular surgeries is absolutely life-changing. I mean not to say that any of the other ones that you—they're all life-changing right because those people come in to see you and they really are hopeless right?

One of the things with Ethiopia is that with the culture, they eat with their hands. They don't really use utensils. So, interestingly, when people have hand deformities or burns, it's a big stigma. And you know, whether it's kids or adults, they won't be accepted into the society or their family groups as much.

And so, a lot of what I did were treatment of some of these contractures and did a lot of skin grafts on hands and were able to, you know, change things where it really made a big impact. So it was uh very gratifying in that regard and it's they just don't have a lot of acute care for burns too. So I would see a lot of children that had just horrific burn scars. So I did a lot of releases and it wasn't just how it looked. I mean it's extremely functional, you know, um you know a hand at a wrist at 90 degrees, you know, unable to be functional at all. So able to correct these things and in a lot of cases restore some pretty meaningful function to these kids.

Yeah. As a guy who has, you know, a pretty serious had pretty serious wrist injury, I have to say that's also one of the more painful things that people can experience. Um I had no idea until um you know, I was just doubled over in pain all the time uh postoperatively uh where the first surgery didn't take. Uh luckily I was able to see James Chang at Stanford.

Yeah. He's a great guy.

Um yeah, that's you know that's huge. I mean, there's so much in that, so much baked into that. Also, this notion of the diplomacy around that um of an American going uh abroad, you know, people could easily say, well, well, there's plenty of people here in the United States that need that care, but at the same time, there's also a bigger mission to what you're doing.

That's a good point. And and I I had that same thought when I was younger, and I thought, you know, I can do things. So I take great pride in taking care of their community uh locally in Portland and taking care of people that are that don't have insurance that are underinsured. So that that has been something very meaningful to me um you know and part of my practice but going to a place where they don't have some of the specialty care that we can provide here or that uh they don't have the specialists in the right places in the right cities.

So I was able to go and you know the great thing about working with these uh surgeons was trying to give them you know some insights on what I do give them some training and not teaching them to be plastic surgeons but teaching them some of my thought processes and some of the techniques and that was just tremendous rather than just coming in and doing surgery and just going out trying to leave some you know impact behind and establish a relationship and I'm looking forward to going back. I mean, it was uh you know, there's more surgery I think I can do there and some more teaching and just really really great relationships.

And I think as a as a as a surgeon in particular, you're an ambassador, you know, for the specialty, but also for your country and trying to be a a good guest and just be a good traveler and um be gracious and um you know, realize that uh there's just different levels of resources what we have and and doing the best I could to improvise and adapt and do the best we had with the resources available and that was just part of it.

Amazing to to hear that. Um because from you know my understanding I've never done that obviously uh but my understanding is that for many of those people that simply just would never happen. It would never have an opportunity to like here in the United States you have at least you could figure something out some way one way or the other but there just uh never going to happen.

It it was really eye opening. I mean that Sunday when I arrived and I went to see patients at the hospital, it was a little overwhelming because of just the amount of trauma and disability and just the pathology I saw. You'd never see that. I mean to see it all in one afternoon in several rooms was just kind of shocking that people don't have access to care and then they just heal with these injuries that are just you know very debilitating and you know deforming and uh you know really uh gave me a chance to really trying to help people with these skills that I had and it was just uh was a tremendous experience. I mean, I'm just so incredibly glad I went and uh boy, it was just uh you know, it's great. I mean, it's just I I've been looking forward to doing something like this again for years and it just really supercharged me. When I had the experience and I got back, it was just tremendous.

Yeah, you were fired up. Um, you know, it's interesting. Here we are in the United States where it's like, um, you know, everybody's talking about GLP-1s in a country like Ethiopia where you're—but I don't know is it 30 years, 40 years, 30 years out of a famine that that's got to still have an echo effect throughout. I mean, generationally that that's got to uh have a real toll.

I really don't see that same degree of metabolic disease or patients are overweight there just because of the I think because of the culture lifestyle availability of food. I mean it's just very different. So you know we were dealing more with untreated injuries or burns. I mean we had patients travel from hundreds of miles away from the border of Sudan because there's just no one around or or they'd been to other hospitals and frankly wouldn't uh they couldn't get the care they needed there. So yeah, it was uh I I I was humbled to be able to do that for a few of the patients particular that had gone to the capital and couldn't get care and then we were able to do the you know some surgery for them you know at the the hospital there.

Yeah. Some of the Sudanese patients uh it's dangerous uh actually try and make it there.

Yeah. I mean there's a lot of unrest in the north in the Tigray region of course Somalia to the east. So you know on the border of Sudan I mean there's just a lot going on. I mean, where I was in the central part, very safe. There were no security issues at the time, but you know, there's a lot going on in the borders around Ethiopia. So, that that's definitely an issue and getting patients for follow-up.

So, but technology, you know, they could send photos. They said they were sending photos and followup to the medical team there and then they'd send me things on Telegram, you know, on the app to, you know, update me, send me pictures because, uh, I want to see how they're doing and, um, you know, make sure everybody's healing up. Okay.

Well, congratulations. Uh, thanks for doing what you do. Um, bringing it back, you know, it's interesting. Yeah, last time, you know, we had so much to cover. We didn't get to spend as much time as I would have liked to talking about really the pathway to peak performance around perfecting like the surgical side of things. And you know, as time has gone on, one of the things I love about you is that I feel like you kind of take this approach of, you know, hey, I'm only as good as my last surgery. I'm kind of looking for that next, you know, that next peak opportunity to really take it to the next level. And you know some of the cases um whether that's a reconstructive uh you know breast cancer situation or an aesthetic situation, one of the—I think I like the fact that you don't you don't ever kind of rest on your laurels, you're always looking for okay how can I make this better, how can I achieve the best outcome. I really admire that, so I'd love you to talk more about what's going on for you in terms of your your pursuit of that.

Well I I think it's I I learned it from, you know, my professors, my mentors nearly never to settle and you never really um you know, there's always a better way to do something. So, I think I've had that mindset and I think it is a mindset, you know. I think—I mean I've been in practice now 18 years and I I think I always have the mindset that I can do this better, faster, I can make it look better if it's something aesthetic or maybe there is a better technique, make it more efficient in a way. Maybe we can save some uh cost savings, you know, for how we set up things for the procedure. I mean, there's just a lot of different ways to look at it.

But I think it's a constant process of analyzing your results, looking at what things, you know, your outcomes, and then looking at how you can improve them. And so it's, you know, you're—I'm constantly looking at, you know, how am I doing something? Whether it's a type of surgery and then going back and analyzing the last 10 results or 20 results and, you know, is this working out well? Is it not? You know, I'm trying new little things. Um, you know, in terms of the surgical technique, um, I'm trying to constantly learn. You know, I'm reading a lot. You know, I go, uh, to meetings or I see what other surgeons do. I mean, I think to think that I've got it all figured out, you know, that's—I can always do something better. Can always see what somebody else is doing somewhere else, whether it's here, Europe, South America. You know, there's a lot of surgeons that share information. I mean, it's an incredible technological marvel.

You can see, you know, we we we just have so much more access to what other doctors are doing now as opposed to the card catalog days, before you had videos you could watch, before you could see meetings broadcast across the country or internationally. So, I think that I'm able to get access to more new thoughts than I would have 50 years ago, 100 years ago. You know, you get a lot of that information going to meetings, you know, surgical meetings back in the day, and you still do, but I think that, you know, I can learn a lot now. Um, whether it's from PubMed, it's reading journals. I mean, always looking for something different.

And I think it's just a mindset of I want to do this better. I mean, I want to do it better. I want a better outcome and, you know, sometimes try things, little tweak, and maybe it works great, maybe it doesn't. And trying to look, but you know, it's interesting. You know, I remember people telling me, "Yeah, you're probably going to do things a lot differently when you go into practice than you do in your training." And it's so true. You know, I do things very differently. See what's worked for me, made adjustments. You know, you do things that are practical.

But I think getting back to your point, it's a mindset, and it's constantly looking at results, re-evaluating, and deciding what am I going to do next? But it's never being satisfied with the status quo. Because honestly, you can always do it better. And there's always somebody else trying to do it better, too. And there's that sense of a little competition which kind of keeps me hungry. I guess it's a good thing.

It is a good thing. It's good for patients. It's good for me. It's, you know, and it's whatever, I suppose, whatever industry you're in, but I think having that mindset uh helps.

Yeah, the field, I mean, plastic surgery's certainly advanced quite a bit. Um, and it seems like it's really accelerating now. There's some really interesting new developments. Um, not only do we have, you know, the GLP-1s and other peptides that, you know, will obviously be integrated into a practice like yours, um, to address all sorts of things. I mean, I think the plastic surgery practice is one of the next places where we'll see just a massive growth in sort sort of uh, peptide therapy uh, pre-operatively, post-operatively. So, huge opportunities there. Also, there's some uh stuff that when you told me about it, I was kind of like, whoa, dude, that's interesting. Um, so AlloClay, well, AlloClay is is a great—so, it's it's basically a product, but it's human-derived fat cells. Now, historically, fat grafting is kind of come into vogue.

It's been developed over the last several decades, but it's this idea of taking someone's fat, doing liposuction, and then you transfer that fat to another part of the body. And whether it's for reconstruction—I do it for breast reconstruction—or to the face for adding fat back where maybe it's lost to aging or you know different problems, trauma, what have you. But it's—no, it's taking spare parts, so to speak, and using those to remodel or contour. Now a lot of the patients that benefit from this don't have a lot of fat. Maybe they're very thin. And what AlloClay basically is, it's an off-the-shelf product. So, it's human-derived fatty tissue that you can take in a syringe.

You know, it's an injectable if you will. The problem until now has been most of these injectables, the fat ones in particular, they're really small volumes. And if you want to make a difference, say in the body, breast, you need more volume. You know, you can't inject a cc and expect to get a big result, right? You're not going to inject 100 cc's of this. It's kind of cost-prohibitive. So, it's a new product.

So, I think it's exciting because it does give patients an opportunity that don't have fat or they don't want a donor site. You know, maybe someone doesn't want liposuction. They want a little more—or less, I should say—downtime. So, it it's it's a great product. It's just getting out there. There's one for the body, and I know that that same company is developing one for the face, too. It's a little bit smaller pieces of fat, basically, little smaller parcels of fat. But, um, you know, it's just all these things will get refined to some degree.

And I think uh you know eventually we'll try to get this to the point where all that fat will survive. I mean this is the weak point of fat grafting. Even if it's your own fat, you're transferring the fat, all of it's not going to survive. Some of it undergoes apoptosis and gets absorbed by the body. And it's, you know, there's a lot of research going into, you know, how to make that fat survive and how the body can nurture it, and and it works. I mean, I've used it with breast reconstruction patients especially who have had radiation, and you can see the results. It changes the tissue, there's some rejuvenation there, and it's really a way of quantifying that and trying to get the ret—we call it retention, you know, how the fat survives and how much of it stays.

So, I think if we can improve that with different growth factors or things and get that to the point where it's, you know, this is—it's kind of the wild west. There's a lot of different ways people are looking at this right now. We're trying to improve retention, but I don't think we have it quite figured out yet, but makes it—it's exciting for the future when we do.

Yeah, I mean that's—it is super cool. It's one of those things that you know when you told me about that it reminded me of the movie Fight Club, you know, where they're going over the fence to get the big—it is, right, and the fat is leaking everywhere as—yeah, the liposuction clinic, yep.

So, it's not quite that much. It comes in these little syringes. But, yeah, it I I think it's exciting. It's just, you know, there's always new stuff and, you know, I I you know, we'll we'll see how it plays out and but it's got some potential. Yeah.

Well, that's cool. Um, and also I mean I think for the hybridized, or is that what you say is a hybrid sort of like you know—yeah, I mean that's kind of one of the hot things I think uh for aug—you know, hybrid augmentation it's called. So for patients who want a little bit more kind of cleavage or filling in the upper chest, um you can do a breast implant which has you know very distinct volume. You know what you're going to get that's off the shelf if it's a silicone implant. And you can add whether it's fat or AlloClay to you know kind of the décolletage area here uh to add some fat in the kind of the cleavage. And that's kind of like in some ways it's kind of like smoothing the edges, right?

It's sort of the notion of like people that are so thin that it can help. Yeah. Because the patients who really benefit the most from it are often the thinnest patients who don't have a lot of donor fat. I see this with women that have breast reconstruction where I wish we had a little more donor fat we could get for the uh the fat grafting. But yeah, so it's it's just I I think all these technologies will—we'll find out a way to kind of make them, you know, uh work together, you know, and kind of blend them and use them, you know, synergistically.

Yeah. I have this crazy hypothesis um and that is that, you know, fat and—it it has its own like system and its own hormones and signals. Yeah, it does. Yeah. Yeah. And so, you know, as we start to think about the notion of trying to remove visceral body fat, um, and you know, which ultimately when people are really, you know, on a peak performance, kind of like, hey, I'm really trying to live my highest performance I possibly can, uh, you're trying to get subq fat down and really, you know, be as fit as you possibly can. Um, I had this thought and it is kind of—it's kind of out there, but the notion of liposuction to remove fat from the body could have a health benefit.

Uh, you know, I think that it's—well, I wouldn't recommend it as a weight loss tool, you know, and part of it has to do with the amount that, you know, the volumes you can remove. And I think there's probably some evidence to suggest it's the visceral fat, you know, which uh may be contributing to more of the problems. But it's—so it's it's a great idea, but I wouldn't necessarily recommend that as a weight loss solution or good news. I'm not sure metabolically how much it changes.

I mean, that's that's a good point if you—but you know, I think for the most part though, you know, maybe 10 pounds of liposuction. I mean, there's kind of what we consider a safe limit to one setting, one one surgery for how much you'd take off. It has to do with fluid shifting and it has to do with with local anesthetic and what you can do to really minimize the physiologic impact of taking that much fat out and exchanging that much fluid.

And I think they found out probably the hard way because of some of the complications people had by doing massive volume liposuction. And you can still find clinics or go to places that will do it. But generally you're going to limit that, you know, to a safe amount. So, it's not going to be as physiologically significant as say, you know, weight loss with the GLP-1 with surgery. So, it's uh I think it's always there to help target and remove stubborn areas is probably the best way to look at it. It helps with contouring. It's a great tool to use for, you know, uh additionally with like an abdominoplasty, but um as a primary weight loss tool, um I wouldn't recommend it personally. I mean, I I think you can find clinics that may tout that potentially, but I wouldn't recommend it as such.

Yeah, that's why I said it was a crazy idea. I wanted to get your take on it.

But, you know, first to think of that, I mean, that's a, you know, it sounds like a great idea. We'll just suck all this fat off, but again, it has to do just with the fluid shifting and um just basically how much the body can tolerate.

Yep. So, I'm curious what your thoughts are, how much GLP-1s are going to change the face of plastic surgery.

Huge. So, I think this is one of the hot topics of 2026 and GLP-1s are I think most people are aware of them. If they haven't heard of them, they've probably been not paying attention, but I think everyone has at least heard of things like Ozempic, Mounjaro, Wegovy. I mean, because I I think they've made a huge impact on our society, frankly. I mean it's a huge um change and I think it's helped a lot of people lose weight and it's affecting things like other health issues, obstructive sleep apnea, diabetes.

I mean and I think because I think up till now I think the evidence has suggested that weight loss surgery has really got the most long-term stable weight loss for for patients, and it'll be curious to see kind of how GLP-1s on a maintenance program will will kind of impact that. So I mean but it's another tool, you know. It's not without its own risks and complications of being on the medication. People have side effects, but I am seeing a tremendous amount of patients—and it used to just be the weight loss surgery patients, but now I'm seeing a lot of patients on weight loss medication, the GLP-1s, that have extra skin and they want the skin removed. So I mean that's a really common side effect, or after this kind of dramatic weight loss you got loose skin, doesn't retract, and people look for a little nip and tuck to improve their contour, you know, in a in a stretched position.

You know you know those closures, you know you fiberglass um that kind of create scarring, how do you minimize—what were the techniques that you use to minimize like you know there's the Embrace product that you can use, is this great—

I yeah, I think there's some thoughts around this and what I do, I mean, tummy tuck closure is a great example. Um, deeper level sutures to kind of offload some of the direct tension on the epidermal layer, try to offload some of that direct tension so the scar is less likely to spread. I mean, I mean, at the base of all plastic surgery is really good surgical technique. I mean, I think that's what we're all as plastic surgeons really trained to do and really good at. And then there's some nuances to that, but also, you know, where we put the sutures, the kind of sutures we place, that type of thing. But it's just I think taking the tension off the scar helps.

And then there's the aftercare. So aftercare with silicone taping, scar gel, all these things I think can be very helpful. Embrace is a great product because it does do a—you know, that where it's taking some of the tension off, you know, offset some of the natural forces on these scars.

Yeah, the Embrace product is interesting because they're going through a clinical trial right now on uh diabetes and this is a human trial where they're looking at um you know scarring from repeated injections, whether that's just type 2 injecting insulin or pump um where you're type 1 pump pump placement and cycling the location of that which causes you know uh scarring and uh skin deformity, which is pretty interesting when you think about that, that you could get to a place where um you could start to use that to slow that um degenerative effect of—

Yeah, I mean things like—I mean there's some you know help by just direct pressure on an incision with either tape or especially silicone impregnated tape is really helpful, you know, I've seen this directly um but it's all, you know, and something we can do after the the insult or the trauma or the surgery to help modulate the scar. So I think all these things are helpful. Genetics definitely plays a role in scarring, as does I think nutrition, and then again how we're careful for the scars after.

So, but let's get into this because we talked about a couple of things that are kind of important for people to understand. Number one, you could have multiple layers of of of stitches. So, you could be stitching something—we were talking about a particular case where you had to go in and kind of move some tissue around. You have to secure that tissue in order to get it to close up and then you're closing and closing again. Uh, so I I'd love to talk more about that. And then I also want—I do want to get to nutrition because I think that's something that people probably uh it's it's kind of—it's out—it's been out there but it's not something that people really talk about a lot and I think that could be really helpful to people.

Well, I think in terms of you know closing wounds, I mean I think of oncoplastic breast reconstruction. So this is something in terms of breast reconstruction that's really been, you know, I think developed and honed more in the last couple decades. But it's this idea of taking a lumpectomy defect. So if you look at the two different ways you can treat a breast cancer, yeah, the two options are a lumpectomy where a part of the the tumor and some adjacent normal tissue is removed and that's followed by radiation therapy of the breast, versus a mastectomy. So in terms of outcomes similar, it's just there's, you know, pros and cons to each approach.

For the majority of patients that have a lumpectomy though, most patients don't need reconstruction. But when you have patients that have a lot of breast asymmetry or there's a really large tumor relative to the size of their breast and they're going to be removing quite a large amount, I will do rearrangement of the tissue. So it's this concept of rather than just putting stitches in to close the skin and then you get radiation—it causes this kind of contracture in this big divot and it can be quite deforming—the idea is to rearrange the breast parenchyma, the breast tissue in a way to kind of close off that cavity, and then that can be combined with a lift or some balancing where you're trimming a little bit of tissue off to help offset some of that asymmetry. So, I think it's a brilliant idea and it's something that uh for the right patients really helps and it can offset some of that asymmetry. But it's this idea of closing things in layers and just um you know it's a it's a creative solution to a difficult problem that's really hard to fix on the back end. So it's a nice way to approach lumpectomy defects in a lot of patients.

But in terms of nutrition, I think nutrition is key. You know, we know that when patients are undernourished or they have diabetes where there's some metabolic—there there's things are just out of sync, people don't heal as well. So I think protein is is very important for healing. So, I'm always on my patients about that. Um, I have a little informational sheet about, you know, nutrition and and healing afterwards. But most people don't eat enough protein, I think, at baseline, but it's important to get that protein after. I always have patients recommend a multivitamin. Ideally, you're getting all your nutrients in your diet, but I think um after, you know, surgery, a multivitamin can be helpful.

Like a lot of people are, they don't even know it, but they're amino acid deficient. I think the majority of people are. Um and that notion of using essential amino acids, you know, for the longest time the in the training community or performance community and that you're talking—people are talking about BCAAs. Um and the reality is you come to really you come full circle back to, you know, um there are a couple of different things now that are—you know, there's uh there's one that's nine which are the nine essentials. Uh there's one that's 21 which is all 21. Uh then you know there's the BCAAs. I think if you can figure out how to get those amino acids in, you're going to have a much better um response.

The other night, you know, it's funny. I had um I woke up with some acid reflux and um I was like, "Huh?" And I took some—I have some essential aminos that are just right by my bed as I take them. And I took 10 um so I guess that would have been the protein equivalent of about 50 grams of protein. Um and you know, N of 1, right, so not going to say this is going to work—sometimes the best kind—yeah, not going to say that it's, you know, going to work for everybody, but for me, acid reflux gone and able to go back to sleep, and uh or just you know it was like a—I don't know, it was reflux, it was more a burning kind of uh feeling so um—

Yeah, the nutrition piece is so key, I think so many people are clueing into this now.

I think you're right. I mean, I've had this talk with, you know, um definitely interested in like, you know, just this whole concept of wellness and I think it's becoming more accepted, you know, this—that the idea of nutrition and what we put in our bodies has an effect on our brain health, our gut health, our performance overall is—I think it was, you know, it's not just a lifestyle, but it's it's, you know, food is is medicine, this idea. And it's not kind of this hokey sort of thing, it's it's it's real. And I think that, you know, taking ownership of what we eat and our nutrition is incredibly key, and I think if we don't, we're we're not going to perform at our best.

Great place to start is always with some labs uh to kind of understand. I mean, this sort of one-size-fits-all where we come—we've come from take L-carnitine. Well, what if you—like you know I have a neighbor who has a condition where if he takes L-carnitine he's going to have a problem. I think it really comes down to—there's a company that's offering a really comprehensive lab panel. Um some providers, some docs that I talk to are like, "Hey, that's way beyond what we really actually need." And you know, but the notion is it's good to have it and it's good to have it over time in case, um you know, somebody was saying that they—that the cancer is detectable at a certain point in time. There's a doctor out there who's like, "You can see the markers and it's like here's where it starts to present. This is where things start to go south." Um and if somebody sits on the receiving end of, you know, oncology, so cancer reconstruction, um that's being on the receiving side of that. It's it's kind of interesting to think that we may be heading off uh a lot of these problems by the changes that people are making in their diet and lifestyle.

Yeah. I mean, I I think it's just a matter of time till we have a greater understanding of those things. I mean, there's an awareness of it. We're we're analyzing this. Everyone's coming at it from kind of a different angle, but I think we're going to see more understanding of how these things work and how to synthesize a lot of these, you know, different tests. I mean I I I just think as this matures and becomes more sophisticated in how we get the data and analyze it, and then how to how to apply it to people individuals—you know, this idea of precision medicine, which is a broad topic, but I think you can apply it to the idea of performance and, you know, what's the best you know approach for the individual because it's definitely not a one-size-fits-all.

Well, peak—I think peak performance, you know, is is personal. You know, it's just this notion of an N of 1. You know, you're you're N of 1 as a surgeon. You have your own—you may be listening to all sorts of different inputs and uh have all sorts of experience, but you have your own unique take on it. I love like sort of your approach of like having talk, you know, talk to you as you're leaving the OR, right? And you're kind of like hotwashing the case, you know? I can I can tell you're doing it. You're hotwashing the case. You're sort of thinking, "Okay, what what was going on in that?" And then, you know, you got your after-action report, you know what I mean? Right, that's that's kind of what it is.

Yeah. And I still keep notes. I had some some professors in surgery that uh would, you know, kind of gave me that idea, you know, "Keep note cards or take notes." And this is before, you know, we had uh smartphones, on each case, you know, whether it was the technique or just kind of, "Hey, did this work, did this not work?" And I still do that. I keep notes on every procedure. I decide—I may have thousands of these notes, and then update them if something worked well.

So I mean, you know, it's it's really getting into the details of things. I mean, we're talking about a lot of things for peak performance in general. But you know that in terms of the surgery, I mean, surgery is about details. So it's a lot of little things that I think work well and don't, but I think it's analyzing things.

But yeah, I'm always looking at that and I and I think that's a mindset we learn as surgeons. So I think my my training was really good at that in general surgery and plastic surgery because, you know, the morbidity and mortality conference is a is a is a way that there's the sort of examination of things that don't go right, things that go wrong in surgery. And it's a way to look at, "Gosh, what happened? What can we do better?" Even when things go well, like, "Hey, that went really well, you know, what part about it was something maybe I did a little different and how can I refine that, or I'm going to do that again next time," sort of thing.

But it it's very detailed. I mean, there's a craft to it, you know? I mean, it's I'm using my hands. I mean, as surgeons, we do that. I mean, it's—we have a lot of technology now, but it's still pretty, you know, human in that regard. You know, it's it has to do with our human performance and coordination and dexterity. So, yeah.

I mean, that's the thing though that I was so excited about having you come back to talk about this piece because it's just this area that we just didn't get enough time in, and that is the pathway to peak performance and being like—you've been voted by your colleagues 12 years in a row as, you know, the top guy. That's a huge accomplishment. And I just want to congratulate you, number one. Number two, the other thing I want to say about that is that doesn't happen by accident. That happens by like rigorous preparation and having a routine and really doing the things that you do in order to get there. And that is—that's transferable. So what we can all take away from that regardless of the profession, whatever we're doing. So for for peak performance, it is about a relentless pursuit of incremental improvement. But having that routine, right? I think you're a routine-driven guy. You like to do things where you set yourself up to win. Um, you're certainly not winging it, you know? I mean, it's a it's a pretty pretty well-defined process for you.

No, I was very fortunate to be—I mean, just recognized, you know, and I've really—I I think part of it is, you know, I've just got my head down. I'm working hard. And I think, you know, if you if you're working hard and taking good care of patients, people notice that. And I and I think that's what that is. And I think that's, you know, it's it's—I'm honored to be recognized for that. And uh, you know, as a as a surgeon, and, uh, I take great pride in that. I mean, it's, uh, I I love what I do and I love taking care of patients. And, uh, it's nice when that's recognized, and, you know, both patients and other doctors recognize that, too.

All right. So, let's talk about— people don't uh, often understand the rigors of an OR, the prep prior to. It's kind of like flying a plane, right? You—I mean, you got to have your flight.

Yeah, there's definitely some uh similarities in terms of the operating room being compared to aviation in terms of safety and things, but it's uh yeah, we have checklists and different things.

But how do you like—so, what I'm getting at is, all right, so night before you're you're getting ready, you're going to get a—get your dinner in. You're going to do the things that you need to do. Maybe you're doing some reading, you're doing whatever it is that you're doing. How do you prepare yourself mentally? What are the things you're doing? Uh, I know that you pray for your patients.

I do. I do. I pray every morning to be a good surgeon and do a great job in general. And then I I definitely—I have some patients that have more issues and pray a little bit more for them if they're having trouble healing or something. So, I mean, that that's a personal part of it. Um, but part of it is preparation.

I mean, I think as a surgeon, especially for plastic surgery, it's, you know, uh, reviewing cases, what I'm going to be doing, and then kind of, you know, we talked about this last time, you know, ski racing the course in my head, you know, sort of doing the surgery in my head in a way, or what do I need or what extra equipment do I need? So just kind of, you know, and it gets automatic after a while, but and actually thinking about doing the surgery so that if I see something that maybe I wasn't anticipating, I'm I'm thinking about it before I'm in the operating room, and then I'm talking to the, you know, my folks I work with, the personnel, to get the right equipment I need.

So a lot of it's just, you know, trying to be as mentally prepared as I possibly can, but it's getting—it's getting sleep, making sure I had a little something to eat in the morning. I mean, just kind of knowing how I work, you know, and honestly, as I've gotten older, making sure I've got enough recovery and exercise. You know, I I I gained a lot of weight in residency, you know, I did residency for eight years, which is a—which is a long time. You had two residencies and a year of research, and really have worked on losing that weight over the last, you know, 18 years, but got more into—back, I should say, into exercise.

Cycling is my thing. You know, I love cycling and you know, it's good for my mind, my body, but it's it's helped me in terms of endurance like in the OR. You know, I can do a 10- 12-hour day in the operating room on my feet and I can do it and then get up and do it the next day. You know, if I have days where, you know, in December is a busy time, some days I'll have four days in the OR, you know, it's usually about three a week. But, uh, being able to do that and that's important, too, you know, being physically able to, um, you know, have those long days on my feet.

So, well, you know, you just tapped into something which kind of brings us back to this flow state, notion of flow state, getting into—lots of people described it lots of different ways here. Ultimately, it's that you preparing yourself to enter a flow state. Um, it—there are some things that you can do and you're doing them. So you're—you know, when you say, "Well, I can just do that again," you know, it's that—it's that notion of, "I've lined myself up to make this thing happen in a way where I can get into a 10- and 12-hour operating day." And there's also another piece that you just said that is transferable to everybody. You have this technology that you use, scans, you have all this stuff, but you can get into a case and you can find something that you weren't anticipating. And it's how do you stay calm under pressure in those moments? Cuz that can be probably, I would imagine, uh, a little taxing. As you get older, it's probably like, "Hey, I've been here before." But, uh, you know, getting into that flow state where you're able to actually, you know, figure it out. Tell us more.

Well, I yeah, having to be adaptable and, uh, you know, because I I definitely like things a certain way. I mean, I think if you talk to anybody I've worked with in the operating room, the scrubbers or the circulator will tell you, "Yeah, it's very particular." But I think, you know, I I have to be adaptable. So, maybe we don't have something or the equipment breaks, things happen. You know, I've certainly had that happen. I was—was in Ethiopia and there was an issue with the—the uh the skin graft harvester and, you know, took a little longer. We had to troubleshoot some things and get it fixed and, you know, when the lights were going out, the power was going off.

So, I mean, it's part of it is just being like having this mindset of, you know, if things come up, I need to be able to respond to the adversity and keep my eyes on, you know, focused on what we're trying to do here because sometimes, you know, I'm human. You you get you get upset about something or somebody's, you know, it's—it's, you know, I want this to be a certain way. And if it doesn't, I have to be able to just regroup and say, "Well, let's let's do what we can and uh, you know, get this taken care of."

But in terms of things that are unexpected, I mean I I think I use less technology in labs than I did when I was first in practice. I mean, there are certain situations where we have to get things, but um I really order things now if it's really going to make a difference clinically. Is it going to change what I'm going to do? Are we looking for a certain outcome in the lab test or something? Um, but I think you have to be adaptable and able to deal with adversity or unexpected circumstances.

And I think it's true with anything, and you have to do it with poise. I mean, there's a great term that—it it was an address by Sir William Osler. He's kind of a famous, you know, medical doctor, and it was—it's called aequanimitas. So it's this idea of, you know, grace under fire, poise, and uh I I think as—is especially as doctors when things are, you know, especially when somebody's life on the line. I remember this from my training, you know, when people were, you know, say there's a a code blue or somebody's having a cardiac arrest, you know, and just and and just seeing the focus on, you know, the residents or the, you know, the doctors who had come in, you know, the the senior staff, and seeing that—such a great model for me as a student to see like, you know, this is how people deal with stuff that just is, you know, can be frightening and somebody's sick, but they're focused or using their training and they're, you know, directing the team and doing what they need to do under very difficult, stressful circumstances.

So, I think that I I use that uh particularly in the reconstructive surgery. I mean, I I would say that the the cosmetic surgery generally things progress and it's very different, but when I have reconstructive patients, sometimes things are are more difficult or there's some difficult bleeding or there's something that's unexpected and I just have to be able to deal with that. And you and you can't always prepare mentally for everything that might happen, but I think just being uh, you know, flexible and willing to come up with creative solutions helps.

You hit on a couple of things. Um, so um, you know, my middle name is Fraser F R A S E R. So that's clan Fraser, clan of Lovat. The family crest name, you know, the—the motto is Je Suis Prest, which comes from France, but translated to to uh to Latin is um In utrumque paratus uh or semper paratus, which is, you know, always ready. Um and so that, you know, sort of notion comes from um the the things that they had to deal with. But that—that also that peak performance in the OR, that ability to stay calm under pressure in that moment when you really got that—I mean, that's kind of doctor a patient wants to see, is to know that in that moment, "Hey, I got you," know, because not everything goes to plan.

You know, my uncle just recently um had uh normal pressure hydrocephalus. You know, he had four cardiac arrests in the process of trying to get to the surgery. And I think that that's pretty scary for family members. So, you know, this notion of not only are you managing um the the case, the preparation of it, you're managing the OR and the staff that are associated with how you're going to—you're going to do things, you're managing equipment, you're managing the patient, and you're managing their loved ones who are concerned about what's going on. That's a lot. That is a lot.

Yeah. I mean, I think I think you become used to it, but but it is tremendous. You know, people really trust you with their lives, honestly. When you go to—when you go through surgery, I mean, there's an anesthesiologist, you're you're there, but it's a tremendous amount of trust that people put in me and and the, you know, the surgical profession in general.

And so, you know, I think that's why it's so important for me to be prepared, do my best for patients, because I got to show up every day for— I mean, it's so incredibly important. You know, these are patients with, in some cases, cancers, life-threatening conditions. Um, and just any surgery in particular though, just having that trust that people put in me to be able to take care of them, get them safely through it to the other end, and uh give them the best outcome I can.

Let's talk about the satisfaction associated with that. The amount of work that you put in to be where you are today, you know, that's that to be that peak performer. I remember you talking about walking down, you know, life not flashing before your eyes until you're walking down Qatar. Yeah. Yeah. Um, there's a lot—a lot of miles in between there and here. Um, and you know, 8 years residency, one year research, um you know, that's a lot of preparation, that's a lot of work to be ready in those moments. What is the sense of satisfaction that you have today in in your life?

Well, it's tremendous from from different aspects whether it's, you know, my marriage, my my sons, professionally. Um, but just going back to, you know, we talk about professionally with the as being a surgeon. Um, I keep all my thank yous. It's kind of sentimental. Some a patient sends me a thank you, I have this massive file of all the thank yous I've saved over the years. And maybe I'll read them again someday when I'm retired. But it just it it just makes me feel so good. And I I save it and I read these, but there's just something—I mean, it's hard to even put a—I mean, it's it's hard to quantify, but it's it's it's a satisfaction of having helped someone and I was able to do my best and used my talents to do it. I mean, it's just uh it's the fulfillment of everything I wanted to do when I was a student and it does feel good.

Now, there's a lot of problems with modern medicine, a lot of frustrations, but at the end of the day, that's what I still enjoy doing, taking care of people, being kind to my patients. I mean, I think it's more than just transactional. That's why being a physician is, you know, it's an ancient profession, you know, and I think that there's just that other aspect of being a doctor and being a surgeon where I'm able to make a difference in a way. And it's—it gives me that kind of satisfaction that I think if I—at least for me, if I was doing something else, I I I just don't think I'd get.

You know, it's really incredible. I mean, I've been thinking about that a lot more now as I've been in practice for longer and thinking about, you know, especially traveling to Ethiopia and being able to do some surgery there and just uh it it just feels good. Feels good. It's affirming and it's uh and it's it it it reaffirms that idea that I'm doing the right thing. As frustrating sometimes as the practice of modern medicine can be with insurance and all these things, it I I don't want it to be too much of a distraction because I think it can be. I mean, whether it's an electronic medical record or the, you know, insurance issues or all these pre-authorizations, it it at the bottom line is I'm taking care of someone. I'm trying to do a good job for them, help them, and uh it feels great. I mean, I love it.

Well, I went and did surgery in Ethiopia. I mean, it it feels good. And I thought, gosh, you know, here I am going across the world with just a suitcase and I'm able to go do surgery in this other hospital. I mean, like, I just was really uh I was grateful I was able to do that and that I had this this training experience to be able to do that. I mean, it was really uh made me—it made me feel good because I I had all this idea that I wanted to, you know, do all these great things and you don't have to travel around the world to do that, but I I really felt it was it was great to be able to share that and go somewhere and, you know, it was the—it it was really tremendous. So I I really uh I feel good looking back on my career that I've done that, you know, I've I've worked hard. I've done all the things I wanted to do and it's trying to, you know, continue to do that in a way that's meaningful.

Well, that's, you know, definitely tremendous. And I think, you know, I mean, a huge investment, a life well-lived, a commitment to excellence, uh, a pathway to peak performance, and think about all of those, you know, those thank you notes and how those—I don't know, but maybe, you know, stopping to smell the roses sometimes, but, you know, kind of be too much. Um, well, so—

I I just got a a a Christmas card from a patient's family. And so when I was first in practice, uh, this young man had a had a dog bite. Was very deforming injury to his mouth. I did a reconstructive flap on his mouth and his—and, uh, every year they send me a card and, uh, got to see him, you know, grow up in the pictures and, uh, it's just things like that. I mean, that's just a little icing on the cake.

I think one of the things that's really great about that is bringing it back to helping people understand just how important, you know, that is for a lot of people, this great unknown and you're dealing with stuff. I mean, one of the things I'm super excited about with stemodonics is the notion that, hey, we can time capsule somebody's stem cells at a young age and then when you need that tissue uh to uh address that lumpectomy or potentially um you know, you have a mastectomy, um and be able to use—potentially use that tissue or for a variety of other things that, you know, obviously we're a ways away from that, but the notion of being able to view that is pretty is pretty profound.

Um, hey, one thing that going back to the GLP-1 side of things, I've heard a couple of different stats. One, somebody told me it was 60%, another person said it was 73% of all patients have a needle phobia. Uh, so they just literally see that. Yeah. So, it's like they they they have to go into the practice to get the injection. Yeah. Yeah. Sure. Um, but far more convenient uh for a patient to be able to self-administer those absolutely medications. Take a—take a pill. Yeah. So, so now yeah, you're on it, right? The the whole pill thing that's happening.

Well, we know they work and it's just a question of how effective they're going to be, and it's going to open up the door to—and hopefully it's going to help health, too. I mean, it's all—it's about weight loss, but overall it's about being healthier, feeling better, it's performing better. It's—I mean, there's just so much that goes with it because I think that uh it's just kind of part of our Western American diet and just, you know, you know, ideally we, you know, we'd all have good health habits going in, you know, but I think that sometimes we just need a little help. Yeah. And I think that that medication is a is a way to do that and help lose weight when other things just aren't working.

Well also addressing the insulin issue. I mean, we think about like neurocognitive decline, uh, people calling it that—yeah, that is interesting, that other effect of GLP-1s on brain health and yeah, there's—I mean, I think that they're discovering more benefits of those and so be curious to see what that is.

Well, I think it's going to have a huge impact inside your practice because you're going to have those people. And I think what's going to be really interesting—I don't know, you know, I'm not a doctor, but I I think you have to manage those cases pretty carefully because rapid weight loss can lead to these like—you've seen it, right? They have these—yeah, I—biggest loser piece like, you know, and part of it too is, you know, there's a lot of different things and and all this has been learned from experience with patients who have weight loss surgery.

So gastric sleeves really hot now. Roux-en-Y gastric bypass. But usually you want to wait for patients to have been at their stable weight for at least 6 months generally so that that skin has some degree of elasticity, it's going to contract, but also that their weight doesn't yo-yo up and down, you know, because the last thing you want to do is do surgery, then you either lose more weight or gain weight. So it's just trying to manage these patients in a safe way.

And so I mean and getting back to your point about, you know, it is, you know, unknowns and scary, part of what we do as surgeons, what I do, is is educate patients. And patients want to feel confident that they have someone that they know what they're doing, that they're going to take care of them, but it helps demystify a lot of these things. So, education's big. I love explaining things to my patients because I think that when I explain things about a procedure, about the recovery, takes some of the fear out, takes some of the stress out because they think, "Okay, I've got this. I can do this." Because I've seen thousands of people go through surgeries and I have the benefit of seeing that from my perspective as a surgeon. Whereas, you know, someone comes into the office and they haven't had surgery before, it's all unknown. So, I think that there's a lot to be said about experience and about how I use that experience to take care of my patients.

Yeah, it's reps, right? I mean, you're just putting in makes a difference. Yeah. I mean, yeah, there's something to that 10,000 hours. I mean, whether it's that or more. Um, but experience matters. Yeah, having, you know, been there, done that, and had great results.

So one thing I would say, Dr. Bartholomew, is um you are truly a peak performer. I remember we once took a walk. I think it was like a 6-hour walk in San Francisco. Yeah. Right. Yeah. And um right, stretching the legs, that's a long—it was a long walk. Yeah, it was a long walk. I don't—I don't remember the actual step count, but it was pretty serious. And you—you've just been a guy that is consistently pushing the upper ranges of sustainability, right? You know, like, what is—how do I—how do I make that happen? And yeah, uh I would love for people to understand that what you do is rigorous. It is like you've got a rigorous life in um in everything that you do.

So, it's, you know, clinically, uh, personal, um, you know, being a father, all of those things, being a member of, um, your church, um, and all—all of those things that you're involved with leads to a full life for kids. Oftentimes, you know, one of the big points of the show is to be able to show this next generation, younger folks that are coming up, like, hey, something that we didn't get. But maybe you got lucky and you had—you know, some people just don't. I talked to somebody who didn't really have a mentor, didn't have any mentors, had to kind of negotiate it on their own. This notion of some takeaways, yeah, you're going to give um you know, three takeaways to uh a kid today. Um, you know, let's virtually like uh mentor someone.

Yeah. I mean, find your passion, find out what's going to be most meaningful for you. You know, that was—that was part of a big thing for me. We talked about that last time, that I had to really figure out and do a lot of discerning, like, where my energy should be directed. And then once I figured that out, then basically being all-in, you know, really dedicating and—and dedicating to achieve what that would be. You know, for me it became medicine, being a surgeon, you know, and I think it's—there's—there's a lot of sacrifice that goes into that. Um, but it's just being—it's just dedication, dedication and sacrifice.

And then, um, you know, I was thinking about this, you know, coming down here. I I think there's definitely something to giving back or or the volunteer work or doing, you know, helping others, whether it's in your profession, in my profession, or outside. But those are some of the most meaningful things I do.

I mean, I get tremendous meaning, and, you know, being a husband, being a father, that is the best thing, you know, and I—that's the kind of stuff that just makes my life worth living, and being a surgeon is just icing on the cake, you know? There's just—I I can do what I love to do, but I also feel like I'm—I'm helping someone in a way that if I think of, at least for me, if I was doing something different, I wouldn't get to. But it's helping others in a way that, uh, with volunteer work or reaching out, that that's been important for me, too. It it really has.

And I think, you know, with some of the plastic surgery work I do in town in Portland or even, you know, in—internationally, like just I I think it's important to have some um some service as part of what, you know, I've done. I think that's really important because that helps me feel like I'm giving back in a way.

Yeah. Being a part of the community um giving back absolutely critical and um and being able to help those who can't help that are, you know, struggling to help themselves. That's a huge—that's a huge piece. Um, so, oh man, you know what? Any day hanging out with you is a good day.

Always great. I'm—I'm psyched I got to come down and hang out and uh look forward to chatting more and getting caught up. We're gonna have a dinner tonight and it's gonna be cool.

All right. Yeah, it's fun. Okay. All right, my man.

Okay. Thanks for coming.

Thanks for having me.