A Conversation with a Clinician – Douglas A. Drossman, M.D.
Douglas A. Drossman, M.D. is a long-time supporter of the International Foundation for Functional Gastrointestinal Disorders (IFFGD). As a member of the IFFGD board of directors, as well as chair of the scientific advisory committee, Dr. Drossman has been an important contributor to IFFGD’s mission to inform, support, and assist people with functional gastrointestinal(GI) disorders. Dr. Drossman spent 40 years as a professor at the University of North Carolina School of Medicine, where he founded and chaired the worldrenowned UNC Center for Functional GI and Motility Disorders. Dr. Drossman is also a founder and president of the Rome Foundation, the organization that sets the criteria for the diagnosis and study of functional GI disorders worldwide.
Q. Dr. Drossman, you have dedicated much of your career to the study and treatment of functional GI disorders. Will you start off by giving us a little history of the field of functional GI?
A. The state of the science of functional GI disorders has evolved throughout my career – when I started in functional GI it didn’t exist. The symptoms were understood as disorders of motility, but that wasn’t sufficient. We began to see these symptoms as fitting into clusters or patterns and then developed the Rome Criteria. This allows a condition to be reproducibly diagnosed around the world based on the presence (or lack thereof) of specific symptoms. As a result we were able to study larger target populations for epidemiological studies and have a consistent study group for research on pathophysiology and really begin to see how these disorders affect people’s quality of life and health.
Organic disease: a disease characterized by a specific structural abnormality, demonstrable on a physical examination, pathology, imaging, or other diagnostic test.
Functional disorder: a disorder or disease where the primary abnormality is an altered physiological function (the way the body works), rather than an identifiable structural or biochemical cause. Altered physiology may occur in terms of motility, sensation, or brain-gut regulation.
There needs to be an understanding that functional GI disorders are real biological entities. These are conditions that are defined not by the absence of organic disease, but by the presence of biologic processes – real things that are happening inside the body – that are not visible to the naked eye.
Also, for me, the field of gastroenterology blends together the technical aspects of medicine with the strong focus on the patient. Gastroenterology looks at both a person and his/her symptoms in the context of that person’s environment. Daily functioning, quality of life, coping style, and levels of stress all make up that context. A gastroenterologist needs to understand the science in relationship to the biological factors – that is the possible disease and dysfunction of organ systems that produce symptoms – and also how those factors may be modified by the individual’s life context.
Q. Much of your work deals with the biopsychosocial model. Will you explain this approach?
The biopsychosocial model depicts how the gut and brain, genetics and life events, stress and psychosocial distress, all play a role in functional GI disorders. All of these can interact differently from person to person to influence the gut on a cellular level, leading to the observed differences in symptoms, severity, and illness experiences found in individuals with the same conditions.
A. I was strongly influenced by a great physician and educator, George Engel, M.D. who coined the term “biopsychosocial model.” This model integrates the way a patient experiences an illness with its biologic foundation. It is a way for accounting for the interaction between biological, psychological, and social factors. And it applies to all conditions, not just functional GI. There are people with Crohn’s Disease or inflammatory bowel disease who totally have no inflammation at all, but they have severe pain. Or, there are people with inflammatory bowel who have severe disease, but have no pain. It is this biopsychosocial understanding of illness and disease that puts the patient’s symptoms relative to their disease activity into a clearer and more integrated perspective and opens the door to more effective treatments. This is the type of practice that I choose to do. I find it rewarding to work with someone who has suffered for many years without understanding why and helping them to find the answers and improve their quality of life.
Q. Your practice, Drossman Gastroenterology, seems to really adopt the concept of patient-centered care. Can you tell us a little bit about that?
A. Patient-centered care is a method of providing care to patients that is respectful and responsive to their preferences and needs, with the patient’s values guiding clinical decisions. Actively listening to the patients and collaborating with them on treatments is essential. I truly believe that this principle is a means to increasing personal patient satisfaction, as well as improving clinical outcomes.
Patient satisfaction is extremely important. Data shows that increased patient satisfaction really relates to very simple things. The patient has to see the doctor as humane. The doctor has to have an interest in the patient’s medical problem. The doctor has to be seen as technically competent and must also have an interest in their psychological and social environments. The doctor must also work to not give too much biomedical information, as that has a negative response.
There is also evidence that when the doctor and patient work together, improvements in various health outcomes can occur, such as symptom reduction, reduction in blood pressure, in blood glucose, and so on. Physicians can help develop this partner-like relationship by the way they interact with the patient. These skills are not learned through technology or textbooks. Rather it requires that gastroenterologists be mentored from knowledgeable teachers, learn from their own experience with patients, and also possess a genuine desire to help the patient.
This is at the core of what we are trying to do at my practice, and also at the Drossman Center. My vision has been to “translate” the teachings of patient-centered biopsychosocial care to other physicians. It has been a mission of mine to improve health care by creating a Center that teaches communication skills and ways to improve the patient-doctor relationship. And when you reach that level of connection with the patient that is achieved through this concept of patient-centered care, this leads to better clinical results – patients feel better.
Q. What about the patient? What can they do to increase their chances of a better health outcome?
A. Find a doctor who will listen and make sure you’re talking to them. The doctor needs to work with you and ask the right questions, but you (the patient) have the right to say when you don’t understand something. You should also establish your own set of priorities – but don’t overwhelm the communication by stating them all at once. Start with the most important. Also, sometimes patients are most anxious about the thing that is the most important to them or the thing that is the scariest to them, so they don’t bring it up initially; rather they wait until they are leaving. By that point many times the doctor doesn’t have time.
You should begin with the thing that is really concerning you. You want to start with your best move.
It also helps to be self-educated. Reputable sites, like IFFGD.org, drossmangastroenterology.com, or MayoClinic.com, are tremendous educational resources on these disorders. Some of the literature, like that on psychological methods, might seem a little technical and more difficult to understand but it can be helpful. It’s a matter of feeling that you can be in control and can speak to your doctor with confidence.
Q. Why is patient education so important?
A. Because functional GI disorders do not have specific findings with laboratory studies, x-ray, or endoscopy, the patients often feel that they don’t understand what is going on with their body: that something is being missed or their symptoms are “all in their head.” Sometimes patients will go to see a doctor feeling like nobody understands them and nobody can help them. One of two things generally happens at that point. They either feel that a diagnosis has not been made and they take the course of more and more testing, or they feel resigned that no one can help them and they stop trying to look for help and take unneeded treatments, like narcotics. However, knowledge is power; it is important for patients to understand their condition in order to help themselves for a number of reasons. First, the more a patient knows about their condition the more self-assured they will be in speaking with their physician, but there is another reason why it’s important. A patient has the capability to downregulate symptoms. When patients learn about why they are having pain for example, as a result of visceral or central sensitization and the relationship between the brain and the gut, they can accept their symptoms as real and be open to treatment options. By gaining this knowledge they can, in essence, begin treating themselves by reducing anxiety, increasing a sense of understanding and hope, and begin to approach logical and effective treatments, ideally with their doctor.
Q. What do you see as you look to the future of functional GI disorder treatment?
A. I am hopeful. I see that younger doctors are becoming more knowledgeable about patient-centered care, about communication with their patients, and about the newer pathophysiological understanding of functional GI and new treatments. Over the last decade there is an unprecedented amount of knowledge accumulating on brain-gut interactions, GI mucosal immune dysfunction, and alterations in bacterial flora, and this is opening the doors to more novel and effective treatments. In addition, people are starting to think about these disorders from a biopsychosocial context and that will influence how the doctors are treating patients and how patients can increase their role in their own care. I also think it’s important for both physicians and their patients, through more education, to truly understand the power of the brain and their ability to modify it.