Navigating Difficult Conversations in Clinical Practice

Xiao Jing Wang, MD, of the Mayo Clinic Minnesota, briefly introduced the importance of provider explanations for improving patient treatment outcomes. The literature is full of examples of how patient education through careful communication increases treatment adherence and improves health literacy, self-efficacy, and patient satisfaction, in addition to improving symptoms and markers of disease progression. Effective physician-patient communication is now included in the AGA guidelines as a marker of quality care. The goal is to build an empathetic collaborative patient-provider relationship that can reduce anxiety and improve outcomes. Even the perception of provider empathy has been shown to improve symptoms and markers of inflammation. Provider communication is an important tool required for patient care.

Eamonn M. Quigley, MD, from Houston Methodist Hospital, and Andrea S. Shin, MD, MSc, from the University of California Los Angeles, posed a few patient questions about the microbiome that they regularly hear, and how they explain what is known and what is not. 

A patient says, “I got this report back on my gut microbiome and I don’t know what it means, should I be worried? The report says I should change my diet and take a prebiotic?” It is important to be as transparent with patients as possible, without making them feel as if they have wasted their money. You might approach the conversation this way: “Not only is there not enough information about the testing methods, but also we don’t yet know what a healthy or normal microbiome looks like. Many things effect the microbiome—genes, diet, environment, medication use, and disease—what the differences in the microbiome between people means for health has not yet been determined. A snapshot from a single stool sample is not going to tell us much about a disease. Because of the lack of evidence, we are discouraged to order tests or change care based on microbiome test results.”

Another patient tells you, “I had a breath test, and it shows I produce too much methane. I looked it up on internet and it says I should be on two antibiotics. That sounds dangerous. What could they do to my system? Should I take them?” There is some evidence that supports a combined antibiotic regimen for a methane-positive breath test, with rifaximin and neomycin more effective than neomycin alone. However, the study design was not clinically relevant and there was no rifaximin alone arm. Additional retrospective studies show mixed results. Neomycin also has some black box warnings that patients should be made aware of. A patient might be told that, “While the combination looks like it might work and is sometimes used in practice, it is not included in any evidence-based guidelines.” Another unknown is whether methane producing microbes alter GI physiology. Methane status has been linked to constipation and low gastric mobility, as well as shifts in the stool microbiome profile. Dyssynergic defecation may be associated with a methane-enriched microbiome, but the link is not completely clear. The key messages for patients would be that (1) the cause and effect of methane on IBS is not established, (2) the accuracy of methane breath testing is affected by a lot of factors, and (3) current evidence is limited for combination antibiotic treatment. Again, it is important to be as transparent with patients as possible, without disregarding their concerns.

Lin Chang, MD, from University of California Los Angeles, reviewed neuromodulator use in IBS and other DGBIs. While the distinctions between different types of medications might be too complicated, it is important to gauge each patient’s interest and ability to understand and be a part of the decision-making process. 

Patient message 1: “Use of neuromodulators does not mean that you have a mental disorder. Neuromodulators work on the pain nerves in the gut to reduce activity and on the brain to regulate the perception of pain.”

Patient message 2: “Each neuromodulator has different effects, and it is important to match the medication to your specific needs.” Tricyclic antidepressants (TCA) are first-line agents for GI symptoms, mood, inflammation, and stress. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are effective for addressing GI pain and can be used as a second-line option if TCAs do not work. Selective serotonin reuptake inhibitors (SSRIs) are not as helpful for GI symptoms, but can help address anxiety and depression caused by GI and peripheral pain and improve motivation for self-management. Tetracyclic antidepressants address pain and mood, with an antihistamine effect that reduces inflammation. Dr. Chang shared the IBD Clinical Decision Support Tool from the AGA to help work through finding the best option for each patient (https://cdstforibd.com/).

Patient message 3: “Each neuromodulator has side effects and so dosing is usually done slowly to make sure you can tolerate it. You may start on such a low dose that you don’t feel any difference in your GI pain, but you also aren’t developing any new negative effects.” 

Jill K. Deutsch, from Yale New Haven Health, and Gregory S Sayuk, MD, MPH, from Washington University in St. Louis provided tips on explaining the rationale for pelvic floor testing and biofeedback/physical therapy for hesitant patients presenting with chronic constipation. Drs. Deutsch and Sayuk first work on helping patients understand the concept of dyssenergic defecation, and how the pelvic floor muscles work with the diaphragm to allow a bowel movement. They use an analogy of a pipe with pressure (adnominal push) and a valve (anal sphincter and pelvic muscles), or a tube of toothpaste. Medications may change the consistency of what it in the pipe or the tube, but they will not coordinate opening the valve and pushing the fluid out. Patients are told that symptoms alone are not enough to tell the difference between constipation and dyssenergic defecation, and knowing that will affect which treatment pathway is needed.

The next discussion focuses on how a digital rectal exam can help determine if the various muscles and valves are working together. Drs. Deutsch and Sayuk explain what is happening and what is being tested at each step of the exam: looking for external reasons it may be hard to push or relax, checking the valve (tone of the sphincter), feeling the muscle that helps push to make sure its working, and then asking the patient to expel the gloved finger while pushing on the abdomen to see whether there is coordination. 

A good digital rectal exam will correlate with anorectal manometry, so the patient may not need more testing right away. If they do need testing, Drs. Deutsch and Sayuk explain that “the digital rectal exam gives subjective results about what is happening, but the balloon test will give objective numbers that we can try to return to normal with treatment.”

With regard to treatment with biofeedback therapy, it is important that patients understand there is work involved and that patients need to commit to it to see results. Biofeedback will let patients see, in real time, exactly the effect of what they are doing so that they can learn how to coordinate better. It is also helpful to share that biofeedback therapy works in up to 80% of patients—even better than medications—and the effect lasts for a long time.

Lauren Dear, MS, RDN, of Dear Nutrition, and Kyle Staller, MD, MPH, from Massachusetts General Hospital, shared what happens after a GI refers a patient to a dietitian, and the need for consistent patient communication about diet and medical treatment. The dietitian will start with questions to gauge the patient’s understanding of the problem, their symptoms, what they are drinking and eating, and what the GI wants the patient to do. It is important to acknowledge how GI symptoms are affecting the patient’s life, and ask for their thoughts about the doctor’s recommendations. If the patient suggests an alternative approach, acknowledge their concerns and table those that do not make sense, but do not dismiss them. It is also important for patients to understand that the dietician has experience with their specific problem and they want to help. It is more important to build a trusting relationship with patients rather than try to dissuade them from often strongly held beliefs. Effective communication respects the patient’s experience while providing alternative, evidence-based reasons why they might be feeling symptoms.

Darren M. Brenner, MD, from Northwestern University Feinberg School of Medicine, finished the session by describing how to handle the often aggressively antagonistic response patients have to a diagnosis of IBS. 

Dr. Brenner’s approach starts by (1) sharing how IBS is a disorder of GI symptoms that get better with a bowel movement, and that (2) a diagnosis of IBS is based on the Rome criteria, which have an accuracy of 98%.

(3) Patients may also ask for proof of what caused IBS before accepting the diagnosis. Dr. Brenner explains that there are many mechanisms, but IBS may have been triggered by some outside exposure or internal stress and anxiety. (4) Some patients are also skeptical of an IBS diagnosis because previous therapies did not work. He explains that all medications do not work for everyone, and that each medication works in a different way. He works with each patient to find the therapy that works best for them. (5) Patients may insist on more testing to confirm the diagnosis. Dr. Brenner explains that diagnosis using the Rome criteria is sufficient, and any additional testing is not going to change the symptoms, which will still need to be treated. An effective approach is describing additional testing as a waste of money for information that will not change treatment, but will delay it. (6) Patients may ask about food allergies or the possibility of small intestinal bacterial overgrowth. He offers food sensitivity testing but tells patients that people who have IBS are not tested for SIBO. (7) Finally, patients might share that stool test results say their microbiome is unhealthy. Dr. Brenner explains that there is not enough known about microbiome to pinpoint what is wrong or how to fix it. 

Convincing the patient about the validity of an IBS diagnosis can take much longer than the actual diagnosis. It is important to speak at the patient’s level and clearly lay out what is known and what is not.