How to Achieve Better Care For Irritable Bowel Syndrome

By Margaret Cary, MD, MBA, MPH | Published 1/29/2018 0

Man holding his stomach in pain 1024 x 683

During my medical training, Irritable Bowel Syndrome (IBS) was also known as “spastic colon”.1 It was one of those diseases that the science at the time couldn’t explain and so it was lumped in the category of “it’s-all-in-your-head” diseases.2 In the intervening years, as we have learned more about many of the conditions we relegated to this often disparaged category of illness, we have, thankfully, come to realize that wherever the disease resides—in your head, your heart, or your little finger—the symptoms are real and they must be taken as seriously as symptoms of diseases that we understand in more detail. Further, as science continues to elucidate the physiology of these diseases, we clinicians can help provide effective symptom relief even though we may not yet fully understand the exact causes of these conditions.


What causes IBS? What are the symptoms?

We still don’t know exactly what causes IBS, but here is what we do know:

  • According to Rome Foundation, which creates criteria to help in the diagnosis and treatment of functional gastrointestinal disorders, people with IBS have recurrent abdominal pain on average at least one day per week for the last three months, associated with two or more of the following criteria3
  1. Related to defecation
  2. Associated with a change in frequency of the stool
  3. Associated with a change in form (appearance) of the stool
  • We also know that people with IBS may experience pain differently from those without the disorder.4 Some researchers think that signals between brain and intestine could be shifting into overdrive, causing pain or changes in stool consistency.5
  • Some people with IBS have more immune hypersensitivity in their intestines than in others without the disorder.6
  • IBS can occur after gastroenteritis. 7


The Mind-Gut Connection

Emeran Mayer, MD Ph.D, Executive Director of UCLA’s Center for Neurobiology of Stress and Resilience, has studied brain-body connections for 40 years. His book, The Mind-Gut Connection, explains how what’s going on in our bodies at a cellular level affects our mental and physical health, and even the choices we make. Earlier this year, he published a study showing an association between our gut microbiome and the parts of the brain that process sensory information from the rest of the body in people with irritable bowel syndrome (IBS). Yes, it’s all in our heads. And the pain is real.

How can you encourage the good bacteria to grow in your gut? According to an article in Scientific American, it’s not just eating yogurt, there are many cultured and fermented foods that will help—miso, kimchi, sauerkraut and pickled vegetables. Eat lots of soluble fiber and fresh fruits and vegetables. Avoid sugar, red meat, and undercooked eggs or seafood.


Pharma and IBS-D

Salix Pharmaceuticals, which has a solid reputation in gastrointestinal treatments, invited me to speak at a private dinner they hosted for about 40 gastroenterologists during the 2017 World Congress of Gastroenterology (WCOG). I jumped at the chance to learn more about this disorder and to learn about a treatment for people with IBS-diarrhea. The dinner was part of Salix’s multi-million-dollar consumer awareness and education campaign about IBS-D.

The theme of the dinner was focused on how to improve diagnosis and treatment for patients. I learned that IBS-D is often relatively easy to diagnose based on symptoms alone, as I outlined above. The challenges occur in recognizing the disorder, and then in treating the symptoms.

Mark Pimentel, MD, an associate professor of medicine at UCLA and director of the Gastrointestinal Motility Program and Laboratory at Cedars-Sinai Medical Center, was the opening speaker. He spoke of his research in IBS and how to distinguish and treat IBS-D. In an article in Gastroenterology & Hepatology, he talks about his research. He says stress hasn’t been shown to cause IBS and “it appears that stress is only a factor in the degree of the presenting symptoms of IBS.” He continues, saying the microbiome is at least partly responsible; although, we don’t yet know the extent of its effect.


Coaching to improve communication

After Dr. Pimentel reviewed the latest research, I spoke of using a coaching approach, to enhance conversations between generalist and specialist physicians and other clinicians, and between clinicians and patients. I asked for a volunteer to join me in the front for a coaching demonstration. Then came the dreaded wait when no one raises her hand.

A man at the front table and I locked eyes. I invited him to join me.

I started our coaching presentation by asking him if I had permission to coach him in front of the group.

Yes,” he replied.

What would you like to be coached on?” I asked.

And so we began, with me stepping in and out of my coaching role to explain what I was doing.

This is the magic of coaching when client and coach are operating seamlessly. It’s a dance, think waltz, and it’s easy for me to get lost in the moment.

What do you think could be ways to share this information?” I said after a few exchanges.

He took the microphone, faced the audience, and talked about how to speak with generalists, how to approach patients, and how to listen to them.

Listen to your patients. Not just their symptoms. Listen to what they want, how their symptoms are affecting their lives. You may have seen hundreds of cases. Your patients are living the one case they really know about.

I watched, surprised and pleased. I couldn’t have asked for a more engaging coachee or coaching client. He was passionate about what he was doing and cared for patients.

He finished, handed the mic to me and I wrapped up with a review of our presentation stressing the importance of open-ended questions, of asking “What” questions rather than yes/no questions. And the power of just sitting with your patients, of bearing witness to their pain and working with them to alleviate their symptoms and anxiety about the disorder.

Audience members came up to thank me. A few said, “Nice job. You practiced. It shows!

Neither of us had met the other before I invited him to join me.

He was a pro.

I left the dinner with gratitude for the work being done by clinicians to help provide symptom relief for our patients, as the science is being researched. And a reminder for the power of coaching, and for sharing the mic!

And since we’re already in the gastrointestinal tract, here’s a reminder to get your colonoscopy.

1. Spastic colon: What does it mean? Mayo Clinic website. Accessed January 2, 2018.
2. Cambridge Handbook of Psychology, Health and Medicine, pg. 766, Bennett, P. (2007).
3. Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders. Rome Foundation. pg. 896, 2017; 1.
4. Peristalsis. U.S. National Library of Medicine website. Accessed December 14, 2017.
5. Irritable bowel syndrome. Mayo Clinic website. Accessed December 14, 2017.
6. Principle of Ambulatory Medicine. Zieve, P. 1982. 680.
7. Irritable bowel syndrome. Mayo Clinic website. Accessed December 14, 2017.

Margaret Cary, MD, MBA, MPH


Margaret Cary, MD, MBA, MPH AKA Dr. Maggi, graduated from the University of California, Santa Barbara with a degree in zoology and a minor in polo. She exercised up to 23 polo ponies/day to put herself through college. Her MD is from Baylor College of Medicine, her Master’s in Public Health (MPH) from UCLA, and her Master’s in Business Administration from the University of Colorado, Denver. She completed her Family Medicine residency in Santa Rosa, through UCSF.

From an emergency room physician in a ski resort, Dr. Maggi has worked in nearly every aspect of health care, landing at her current post as CEO of The Cary Group Global. The Cary Group Global provides executive and leadership coaching and consulting to executives in health care and film and television production.

Dr. Maggi graduated from Georgetown University’s Leadership Coaching program and holds a Professional Certified Coach (PCC) credential from the International Coach Federation. Her clients include

• Mayo Clinic,

• AMIA (American Medical Informatics Association),

• University of Massachusetts Medical School,

• Bon Secours Health System,

• Yale School of Medicine

• Weill Cornell College of Medicine,

• Georgetown University School of Medicine,

• Dubai Medical College,

• and other academic medical centers and research organizations.

Dr. Maggi is an expert at facilitating others’ learning, from medical students to health system CEOs. Her client base consists of C-suite executives to VPs and department chairs, both new and experienced. She developed and led the Community of Champions, the national physician leadership development initiative at the Veterans Health Administration.

She has held many executive posts and practiced medicine in Santa Rosa and Mammoth Lakes, California; Denver, Colorado; London; and Kendal, UK.

Her research for Telemedicine and Telehealth: Principles, Policies, Performance, and Pitfalls (The Lancet’s review) led her to the realization it’s all about the people, the relationships, and asking questions. Her passion project is A Whole New Doctor, a leadership development and coaching program for medical students, staffed entirely with volunteers. A Whole New Doctor serves medical students from Georgetown University School of Medicine, Penn State College of Medicine, University of Nevada, Las Vegas School of Medicine, University of Virginia School of Medicine, Howard University College of Medicine and Hofstra Northwell School of Medicine.

Dr. Maggi is adjunct faculty at Georgetown University School of Medicine and has taught at the Harvard Macy Institute. She coaches TED Fellows and Global Good Fund Fellows and leads nonfiction writing workshops.

In addition to being a contributing author for The Doctor Weighs In, Dr. Cary also serves on the TDWI Editorial Board, where she medically reviews articles submitted for publication.

She is intellectually curious about nearly everything, a lifelong learner, animal lover, gardener, and always ready for adventure.

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