GI and psychiatric symptom overlap complicating diagnosis? Experts say this first step is critical in every patient exam
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My advice would be to make sure you show you are listening and to set expectations.
—Eric Molloy, MD
While many GI problems are common and not life-threatening, I am always on guard to not dismiss patients, because complex patients and patients with behavioral health conditions can develop serious GI conditions, too.
—Elisabeth Fowlie Mock, MD
Your patient comes in with GI issues. What is your first step?
MDLinx spoke with two experts about the best strategies for managing patients presenting with GI issues.
“The first thing I do is review their symptoms through a thorough history and physical,” says Elisabeth Fowlie Mock, MD, a family physician and member of the AAFP board of directors. “Knowing my patients, their social situation, and having access to their medical history gives me additional insight as a family physician. Knowing that common things are common helps with my differential.”
Build the patient relationship
“While many GI problems are common and not life-threatening, I am always on guard to not dismiss patients, because complex patients and patients with behavioral health conditions can develop serious GI conditions, too," Dr. Mock says.
Related: What cancer screenings should older adults get?"Many conditions go undiagnosed for a long time because their symptoms are not unique. Having a continuous relationship with a medical home results in less things being overlooked. Family physicians will often take the extra time to confirm the right diagnosis to help patients get on the road to feeling better," she adds.
Listen and observe
The approach is similar by the time a patient reaches the clinic of gastroenterologist Eric Molloy, MD.
“I ask them to tell me what has been bothering them, and then I listen. Some of the most valuable information I can obtain is by allowing the patient to tell me the experience of their illness. During this time, I stay attuned for potentially concerning symptoms and other features of their complaint that may help me create a list of possible diagnoses. I am also observing them for any physical clues that may be of help,” he told MDLinx.
Related: USPSTF vs specialty societies: Where cancer screening guidelines clash in older adultsA huge part of working with a patient with GI issues, Dr. Molloy argues, is managing patient expectations.
“Gastrointestinal diseases can be difficult in that the symptoms may be many and vague.” says Dr. Molloy.
Advice for the clinic:
Make sure to show you're listening and to set expectations.
Let patients know that it may take several visits and tests before a plan for management can form.
Make sure you and the patient are in agreement about the plan going forward.
Understand that even if you may know it's the correct course of action, it may not go anywhere if the patient doesn't agree.
Piece together the whole story
Medical school provides a good foundation for physicians in managing GI issues, although both Dr. Molloy and Dr. Mock note there are many management strategies for physicians that can be learned only through practice.
“One of the most important things I have learned over my years of residency training and practice is to go back in the medical record and piece together the data and story,” Dr. Mock said. “With scattered laboratory and imaging results not reviewed longitudinally over time as a complete package, things can be overlooked."
Dr. Molloy says it is also crucial to keep in mind that the Western diet is not ideal and will often exacerbate GI symptoms. Consideration of psychiatric factors is also important.
“There is a high burden of psychiatric illness associated with GI disease, both as a result of the GI disease and/or as a provocative feature. For example, low mood and anxiety is known to worsen irritable bowel syndrome symptoms. And conversely, patients with difficult-to-control Crohn’s and ulcerative colitis often experience psychiatric consequences,” he said.
