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Improving Care for Patients with Disorders of Gut Brain Interactions - Presented by Dr. David Rodrigues

By Hailey Schincariol, MSc Candidate, TMED801 Student

 

On October 6, the Department of Medicine had the pleasure of hosting Dr. David Rodrigues, a

Gastroenterologist and Assistant professor in the Division of Gastroenterology at Queen’s

University. Dr. Rodrigues introduced the topic of Disorders of Gut Brain Interaction (DGBI), with

an emphasis on improving patient care through medical education.

 

DGBI, previously known as functional gastrointestinal disorders, are a group of illnesses

characterised by chronic gastrointestinal symptoms (e.g., abdominal pain, dyspepsia, diarrhoea,

constipation, and bloating) in the absence of pathological evidence(3). Symptom presentation is

generally used to diagnose these disorders as lab results, endoscopic findings, and imaging

show no structural changes(2). The global prevalence of DGBI is more than 40% with irritable

bowel syndrome (IBS) and functional dyspepsia (FD) representing 10% of the total cases(1).

 

Dr. Rodrigues emphasized how DGBI are challenging to treat due to perceptions of stigma

associated with the disorder. Stigma is a common phenomenon in healthcare that undermines

the quality of care for patients such as those with DGBI(3). In the clinical setting, stigma is

associated with lower quality of life due to increased depression or anxiety and treatment non-adherence(3).

Without physical findings, patients with DGBI do not fit into the biomedical model,

making the disorder difficult to diagnose and understand for many physicians(3).

 

The societal stigma stemming both from the patients and physicians creates what Dr. Rodrigues

describes as a “vicious cycle” of healthcare seeking behaviours. He went on to explain how

deficiencies in the training of gastroenterologist residents prevents them to accept the

diagnosis of a DGBI. In the process, there may be a lack of communication between the

physician and patient, resulting in an exacerbation of patient distress, restriction in physician

satisfaction and inevitably clinical burnout.

 

It is evident many residents are underprepared to deal with patients of DGBI(4). Therefore, Dr.

Rodrigues promotes the idea of continued medical education throughout a physician’s career

to continually be knowledgeable in treating these disorders. He believes “increasing the

frequency of cases and increasing instruction of care is one of many steps that can help address

potential deficiencies in gastroenterologist training”. Likewise, Dr. Rodrigues mentions

“identifying when and where perceptions of stigma occur could help design interventions to

prevent against them”.

 

Following the excellent presentation, Dr. Rodrigues was gracious to lend his time to the

Translational Medicine Graduate Students for an interactive discussion on DGBI. One point of

interest was the role of the gut microbiome and patients with DGBI. Gut dysbiosis, or the

disruption of the homeostasis of the gut microbiome, has a significant impact on the gut-brain

axis and may manifest physiologically, in the form of IBS or mental illness, such as depression.

We spoke about Equity, Diversity, Inclusion, and Indigeneity (EDII) initiatives that Dr. Rodrigues

practices in his research and clinic. Stigma associated with DGBI disproportionately impacts

those with lower socioeconomic status and Dr. Rodrigues highlighted the importance of

listening to each patient’s story individually to learn more about how DGBI impacts their daily

life. In doing so, Dr. Rodrigues provides treatment plans that are tailored to his patients’ needs.

Speaking on the impact of his education, Dr. Rodrigues is an alumnus of Queen’s University,

undertaking his graduate and gastroenterology residency here, and mentioned of his valuable

time in the Queen’s Motility Clinic with his mentors that provided him with a strong

foundational understanding of DGBI. Notably, he mentioned that not all medical learners may

be privy to such experiences; learners at more remote institutions may not have the

opportunities that he was fortunate to have, and that continuing education for medical learners

should be accessible for all, regardless of location, socioeconomic status, etc. Speaking about

his career at present day, he emphasized the importance of work-life balance. Despite working

in a demanding profession, Dr. Rodrigues makes an emphasis to spend time with his family, as

well as continuing his passion for music. He believes that maintaining this work-life balance

allows him to refresh after a long day’s work and prevent burnout, something that is becoming

more prevalent in the healthcare field.

 

On behalf of the Translational Medicine Graduate Program and its students, I would like to

thank Dr. Rodrigues for his captivating presentation at Grand Rounds and taking the time to sit

down with us for an impactful conversation. His work continues to make a great impact in our

community, and we look forward to seeing him continuing the be a patient advocate and

champion.

 

References

1. Colomier, E., Melchior, C., Algera, J. P., Hreinsson, J. P., Störsrud, S., Törnblom, H., Van

Oudenhove, L., Palsson, O. S., Bangdiwala, S. I., Sperber, A. D., Tack, J., & Simrén, M.

(2022). Global prevalence and burden of meal-related abdominal pain. BMC medicine,

20(1), 71. https://doi.org/10.1186/s12916-022-02259-7

2. Feingold, J. H., & Drossman, D. A. (2021). Deconstructing stigma as a barrier to treating

DGBI: lessons for clinicians. Neurogastroenterology & Motility, 33(2), e14080.

3. Fikree, A., & Byrne, P. (2021). Management of functional gastrointestinal disorders.

Clinical Medicine, 21(1), 44.

4. Simons, J., Shajee, U., Palsson, O., Simren, M., Sperber, A. D., Törnblom, H., Whitehead,

W., & Aziz, I. (2022). Disorders of gut-brain interaction: Highly prevalent and

burdensome yet under-taught within medical education. United European

gastroenterology journal, 10(7), 736–744. https://doi.org/10.1002/ueg2.12271

 

Comments

Name
Abhishek Shastry

Fri, 10/14/2022 - 11:23

Hi Hailey,
You've summarized Dr. Rodrigues' talk and subsequent discussion exceptionally. I was interested in his focus regarding stigmatization in patient diagnosis, and how stigmas can affect patients variably. In their analysis, Earnshaw and Quinn (2012) examined three types of stigmas - anticipated, experienced, and internalized - and their role in physical and psychological wellbeing. Not only did they find that all types of stigma decrease access to care and the efficiency and quality of treatment, but that stigmatization of chronic diseases left patients more dissatisfied with their lives in general. Internalized stigma, which is when patients internalize and believe the negative stereotypes put on them by others, was an especially strong predictor of access to care and quality of life. In terms of DGBI, which is an umbrella of multiple chronic diseases, what do you think is the role of the physician in addressing internalized stigmas primarily and reducing the amount of anticipated stigmas a patient experiences as a consequence (e.g. returning to the clinic expecting their physician to invalidate their symptoms or experiences)? Do you think addressing these issues will reduce amount of illness-related anxiety that patients experience as a result of the physician making the patient feel invalidated?

Thank you!

Abhishek Shastry

Reference List
Earnshaw, V. A., & Quinn, D. M. (2012). The impact of stigma in healthcare on people living with chronic illnesses. Journal of health psychology, 17(2), 157–168. https://doi.org/10.1177/1359105311414952

Name
Abhishek Shastry

Hi Abhishek,
Thank you for the insightful question and comment! The major problem with IBS is the lack of patient education. I think the stigma in DGBI stems from the ambiguousness surrounding what the disorder or symptoms are supposed to be. It seems as many patients feel as their symptoms are not taken seriously or other believes symptoms are self-inflicted. Given this, I think the role of physicians in reducing stigma is to properly communicate with patients about what they are experiencing. This could entail the physician spending a bit more time talking/listening with patients about their symptoms, or even providing educational packages for patients to take home. By having someone a patient can confide in can go a long way to release some of the pressures associated with the disease. I think addressing the stigmatization associated with DGBI by increasing physician-patient communication could definingly reduce the amount of illness-related anxiety. Communication such as attentive listening, empathy and the use of open ended questions have the power to increase patient involvement and influence patient satisfaction, which overall improves their quality of health/care

Kind Regards,
Hailey

Name
Hailey Schincariol

Name
Matti McFarlane

Fri, 10/14/2022 - 13:26

Hi Hailey!

Thank you for your excellent post summarizing Dr. Rodrigues’ lecture and our engaging class discussion. I found the conversation surrounding Disorders of Gut Brain Interaction (DGBI) informative, as it highlighted the need for both a further understanding of the underlying pathophysiology as well as increased education for health care professionals. As I have an interest in guideline implementation and care maps, I was intrigued to hear about the primary care management pathway that the KHSC Department of Gastroenterology provides. This is a clinical tool that aids in decision support for conditions such as Irritable Bowel Syndrome (IBS) in the primary care setting. I feel that these are beneficial tools for physicians and could be instrumental in improving care for these patients. Importantly, these care maps can improve care for DGBI patients by preventing unnecessary specialist referrals and promoting management with their primary care provider. Do you have any thoughts regarding how to improve the dissemination of clinical tools like this, and how to encourage primary care providers to utilize them in their practice?

Furthermore, Dr. Rodrigues highlighted the lack of education surrounding DGBI for medical residents. Interestingly, a study in Great Britain found that, despite the increased utilization of healthcare resources by patients with DGBI, there was a severe lack of educational material pertaining to these disorders within the general medical training curricula1. This lack of awareness seems to be a care gap in Canada and abroad. Do you have any thoughts regarding strategies that the Canadian system could utilize to improve awareness and education of DGBI? Do you feel that education efforts should be for all medical residents, and not just GI residents?

Thank you!

Best,
Matti

Reference

1. Simons J, Shajee U, Palsson O, et al. Disorders of gut-brain interaction: Highly prevalent and burdensome yet under-taught within medical education. United European Gastroenterology Journal. 2022;10(7):736-744. doi:10.1002/ueg2.12271

Name
Matti McFarlane

Hi Matti ,
That’s a great thought-provoking question! In routine clinical practice, there are many different levels of care, a wide range of available resources and a variation in the knowledge and experience of healthcare providers. We also know physicians are extremely busy, therefore, to implement an effective clinical tool, such as a care map, the guidelines should be short and include simple organization such as checklist and tables. Likewise, I think the more convenient a tool is, the more inclined a physician may feel to utilize it in their practice. Given this, the best way to improve dissemination of clinical tools and make them more encouraging for physicians to use is by making them extremely accessible, short, and simple. I think this logic could also go for awareness strategies the Canadian government utilizes. With that being said, I think medical education and awareness efforts for DGBI should be taught to both medical and GI residents – people usually have to visit a family doctor before getting a referral to a gastroenterologist so by increasing awareness to all physicians, it may help provide a second option for GI residents who may be unsure.

Cheers,
Hailey

Name
Hailey Schincariol

Name
Jill Greenlaw

Fri, 10/14/2022 - 19:12

Hi Hailey,

I really enjoyed reading your engaging, and thought-provoking post! I found it really fascinating that the gut microbiota appears to be implicated in DGBIs. Several studies have explored the use of probiotics in DGBIs with an aim to improve this dysbiosis. Interestingly, some studies have found that the use of probiotics has been associated with symptom improvement for patients with IBS1,2, a common DGBI, while others did not find any significant improvement3. Similar findings were observed for the use of probiotics for the treatment of functional dyspepsia, another common DGBI with studies supporting the efficacy of probiotics for the improvement of functional dyspepsia 4,5 with variable significance. The inconsistency in these findings highlights the need for further research to conclusively determine the influence of probiotics on DGBIs. Although further research is needed to understand the mechanism behind this and identify which specific bacterial strains are the most effective, these findings render probiotics and other therapeutics that modulate the gastrointestinal microbiota promising therapeutics for the treatment of DGBIs. What are your thoughts on the use of bacterial therapeutics for the treatment of DGBIs? Are there other promising therapeutic candidates for the treatment of these disorders?

References:
1. Ishaque, S. M., Khosruzzaman, S. M., Ahmed, D. S. & Sah, M. P. A randomized placebo-controlled clinical trial of a multi-strain probiotic formulation (Bio-Kult®) in the management of diarrhea-predominant irritable bowel syndrome. BMC Gastroenterol. 18, (2018).
2. Majeed, M. et al. Bacillus coagulans MTCC 5856 supplementation in the management of diarrhea predominant Irritable Bowel Syndrome: a double blind randomized placebo controlled pilot clinical study. Nutr. J. 15, (2016).
3. Hod, K. et al. A double-blind, placebo-controlled study to assess the effect of a probiotic mixture on symptoms and inflammatory markers in women with diarrhea-predominant IBS. Neurogastroenterol. Motil. 29, e13037 (2017).
4. Wauters, L. et al. Efficacy and safety of spore-forming probiotics in the treatment of functional dyspepsia: a pilot randomised, double-blind, placebo-controlled trial. Lancet Gastroenterol. Hepatol. 6, 784–792 (2021).
5. Ohtsu, T. et al. The Ameliorating Effect of Lactobacillus gasseri OLL2716 on Functional Dyspepsia in Helicobacter pylori-Uninfected Individuals: A Randomized Controlled Study. Digestion 96, 92 (2017).

Name
Jill Greenlaw

Thank you for the insightful comment! Given dysbiosis has been related to the pathophysiology of DGBI such as IBS, I think the modulation of the gut microbiome is the strongest treatment option for those with DGBI! Aside from directly administering probiotics as you mentioned, fecal microbiota transplants (FMT) are also well supported in the literature as a great therapeutic option for IBS. As we both know, FMT involves replacing the gut microbiota of a patient with a condition related to dysbiosis, with the microbiota from a healthy donor. A study in the GUT journal recently recognized FMT as an effective treatment for individuals with IBS and specifically recognized the use of frozen faeces makes the procedure easy to perform in clinic1. Given the success of FMT in IBS, maybe the application could be applied to other DGBI such as functional dyspepsia, although there remains little research regarding the topic.

1. Novick, J., Miner, P., Krause, R., Glebas, K., Bliesath, H., Ligozio, G., ... & Lefkowitz, M. (2002). A randomized, double‐blind, placebo‐controlled trial of tegaserod in female patients suffering from irritable bowel syndrome with constipation. Alimentary pharmacology & therapeutics, 16(11), 1877-1888.

Name
Hailey Schincariol

Name
Abbie Davis

Mon, 10/17/2022 - 11:05

Hi Hailey,

Thank you for facilitating the discussion this week! You did a fantastic job summarizing Dr. Rodrigues’ MGRs presentation. I am glad we got to discuss EDII initiatives in our class discussion as I believe these are vital concerns for patient care and especially important to consider when we are discussing diseases with no biological markers. It is important not to let our biases interfere with the treatment and care each person should be given, regardless of their background or history. It is reassuring that physicians like Dr. Rodrigues spend the extra time to get a thorough history and use personalized medicine regimens that best fit the patient’s needs.

You mentioned the communication gap between doctors and their patients in your blog. I found it astonishing in Dr. Rodrigues’ talk when he shared the results from a survey between patients and residents on call. Specifically, I found it interesting that from the perspective of the patient, the majority of calls were of high importance to their health, while residents rated these same calls as low importance.

I am curious to hear your perspective. Firstly, do you think this difference is an issue? Second, what strategies do you think could be implemented to get doctors and their patients on the same page? You mentioned education is important for the physician in your blog- what specifically do you think should be implemented, and is education just as important for the patient as well?

Looking forward to reading your response. Thank you again for your great work!

Abbie

Name
Abbie Davis

Hi Abbie,
Thank you for your response. You raise an important point that Dr. Rodrigues touched upon, which is this apparent dissonance between the perspective of importance of calls on the ward between patients and medical learners (i.e., medical students, residents, etc.). In your question, you ask whether this difference poses as an issue. Personally, I don’t believe that this is an “issue” because I don’t believe there is inherently a “right” or a “wrong” party; the patient is not incorrect in saying their call is a high priority and the medical learner is not incorrect in saying that they do not believe it is a large concern. Instead, I believe that this is miscommunication between both parties and can serve as a teaching moment for all. I propose that open, transparent communication between the patient and medical learner be established on first contact. For example, what are the expectations of the patient for their care? What responsibilities do the medical learners have in the patients’ care? What are the patients’ most pressing concerns when it comes to their health? What difference can medical learners make in the care for the patient, or rather, what is outside of their scope of practice that they may not be able to address? I believe if this open communication is established and rapport is built when these two parties first meet, it may reduce the dissonance that Dr. Rodrigues highlighted during MGR and our conversation and overall, improve quality of care to patients.

Take care,
Hailey

Name
Hailey Schincariol

Name
Isaac Emon

Mon, 10/17/2022 - 16:00

Hi Hailey,

Very well written post! I think you did an excellent job summarizing the talk and expressing the importance of understanding the challenges faced when treating patients with DGBI. You also did a nice job discussing the value of our TMED facilitated discussion and hearing about Dr. Rodrigues' career thus far. I was interested to hear your thoughts on the effects of diet changes with regards to improving DGBI. There has been a variety evidence suggesting the low FODMAP diet is useful for these patients and that it is a non-medicinal change that can be implemented for IBS patients (1). However, dietary changes are not always easy to implement and there is unfortunately also a stigma around the word "diet". How do you think we can help reduce stigma surrounding dietary restrictions and encourage patients to feel comfortable making these decisions? Further, considering increased stress levels and hormonal alterations can also affect DGBI, do you think it is important that healthcare providers discuss the importance of dietary consumption during periods of stress with their patients (2)? I personally believe it's important that physicians and patients work together to incorporate dietary changes into the patients lifestyle, taking into account times of stress and hormonal changes. Again great job with this blog post!

Isaac

References:

1. Schindler, V., Giezendanner, S., Van Oudenhove, L., Murray, F. R., Buehler, J., Bordier, V., ... & Pohl, D. (2021). Better response to low FODMAP diet in DGBI patients with pronounced hydrogen response to a nutrient challenge test. Journal of Gastroenterology and Hepatology.
2. Accarie, A., Toth, J., Wauters, L., Farré, R., Tack, J., & Vanuytsel, T. (2022). Estrogens Play a Critical Role in Stress-Related Gastrointestinal Dysfunction in a Spontaneous Model of Disorders of Gut–Brain Interaction. Cells, 11(7), 1214.

Name
Isaac Emon

Name
Martha Ortega Santos

Mon, 10/17/2022 - 21:04

Hi Hailey,
Great facilitating! You did a tremendous job in our zoom discussion. I thought there was a lot of fruitful and inquisitive dialogue thanks to your guidance. Likewise, your report summarizing Dr. Rodrigues' MGR presentation has taken our discussion even further!
Similar to Abhishek's and Abbie's point, I too enjoyed having brought up the relevance and value of EDII initiatives in the context of the effects of stigma in DGBI patients as I feel strongly about tailored patient care that takes into account the unique perspectives and experiences of different statuses, identities, and cultures.
I found it quite interesting that lower socioeconomic status has an effect on the impacts of stigma felt by DGBI patients. This is a reality I never quite considered and am grateful for having it brought to my attention now. With my interest sparked I stumbled across a study involving 574 low-income adults where in-person surveys and follow-up interviews were conducted to analyze the perceptions of Medicaid or uninsured patients in the healthcare system (Allen, et al., 2014). The findings of this study were that although other sociodemographic characteristics could not be associated with stigma, the interviews suggest that stigma was often a result of provider-patient interaction, consistent with what Dr. Rodrigues shared with us. And associated with this stigma was unmet health needs, worse health (self-reported measures), and poor quality of care perception.
In the context of DGBI, in addition to the methods and approaches Dr. Rodrigues implements as EDII initiatives what would you suggest for physicians to adopt in their patient treatment to avoid/remedy the current effects of stigma?
Allen H, Wright BJ, Harding K, Broffman L. The role of stigma in access to health care for the poor. Milbank Q. 2014 Jun;92(2):289-318. doi: 10.1111/1468-0009.12059. PMID: 24890249; PMCID: PMC4089373.

Name
Martha Ortega Santos

Name
Hailey Schincariol

Mon, 10/24/2022 - 14:14

In reply to by Martha Ortega … (not verified)

Hi Martha,
Thank you for the kind and insightful feedback! I was very happy with where our conversation led in regards to EDII with Dr. Rodrigues! Please see my response to Abby for my perspective on initiatives that could be adopted by physicians to reduce stigma in the clinical settings!

Best,
Hailey

Name
Hailey Schincariol

Name
Tarrah Ethier

Wed, 10/19/2022 - 11:40

Hi Hailey,

Thank you for providing a great summary of Dr. Rodrigues' MGR lecture. His discussion of the gut - brain interaction and it's associated disorders was something I had only briefly heard about before, so it was great to get a more in-depth review about it. It is really interesting to see the interactions and the unique manifestations of symptoms in DGBI. I was curious whether this was also apparent in other areas of human health. I found that the heart-brain interaction is something that has recently gained popularity in cardiovascular literature. Specifically, if you were to be diagnosed with coronary artery disease (CAD), it was very likely that you would develop depression [1]. Depression has also been shown to be a risk factor for the development of CAD [1]. More related to DGBI, there is also evidence that the gut-brain interaction, and specifically dysbiosis associated with this, has been linked to the development of hypertension [2]. The specific mechanisms for how this occurs are still being investigated. Have you come across other areas where there is either a similar brain interaction (hepatic-brain axis, for example) or where DGBI has influence over morbidities in another system? I'm excited to hear your thoughts!

Tarrah

[1] Nasser, F. J., Almeida, M. D., Silva, L. D., Barbirato, G. B., Mendlowicz, M. V., & Mesquita, C. T. (2016). Psychiatric disorders and cardiovascular system: heart-brain interaction. International Journal of Cardiovascular Sciences, 29(1), 65-75.

[2] Yang, T., & Zubcevic, J. (2017). Gut-brain axis in regulation of blood pressure. Frontiers in physiology, 8, 845.

Name
Tarrah Ethier

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