Season 3, Episode 17: IBS Healthcare From a GI Provider’s Point of View

Welcome back to The Gut Show! Today's episode is one that I'm really pumped about, because it's a question that I get asked a lot and also a point of tension that we typically see in our community, and that's all about the relationship between GI provider and patient when dealing with digestive disorders like IBS. Our special guest is Jennifer Fijor who is a nurse practitioner in this space and works with patients one to one. She is passionate about breaking down some of these barriers that we see in care so that patients can get quality of care and actually get some sustainable results.

We're going to talk about why there might have been tense relationships in the past with certain providers, some ways that you can advocate for better care yourself and prepare for appointments to get the most out of your time. We've been talked about just kind of a little rabbit trails ourselves about some ways that we can see the health care system changing to support our patients more effectively, just some things for you to think about as you're putting together your health care team and really taking control of your health care as a whole with IBS.

So enjoy the episode and as always, if you want to connect with us after come on over to The Gut Community on Facebook, and let's chat about your thoughts and takeaways from the episode.

What if you could develop skills to help manage IBS symptoms in only 10 minutes per day? Today’s episode is sponsored by Mahana Therapeutics, who has made cognitive behavioral therapy (CBT) more accessible through their app, Mahana IBS. This is a new app that offers evidence-based CBT to reduce the severity of IBS symptoms - until the end of June 2022 this is available at no-cost for eligible patients. Get started now and download the app at mahanatx.com/TheGutShow.

Erin Judge: Hey, Jen, thank you so much for joining us today! I want to jump in with your story, so go ahead and let's get started by you telling me how you actually became a nurse practitioner in gastroenterology and digestive disease?

Jennifer Fijor: Thanks for having me! I know that you've got a lot of guests, so I'm really happy to be here and I can't wait to kind of go out with through everything with you. In terms of me starting out as a nurse practitioner, I had a very weird, winding way to get here. I wasn't sure if I wanted to be a nurse practitioner or a PA when I first started out, all I knew is I wanted to do healthcare in some capacity. As I was trying to figure things out along the way through undergrad, I had done a degree in biology just as a base and somehow got thrusted into the first job that came along after graduation, which happened to be GI tech.

So I started out as like an assistant for procedures and I was like, oh my god, I love gastroenterology, it is so fascinating! It just sucked me in and from there as never let me go. So I've done like a GI tech when I went to nursing school and parlayed my bachelor's into a master's, and then finished my postmasters while I was a GI nurse. So I've been in endoscopy since gosh, 2008 maybe? Wow, it's been a long time!

When I was done with my nurse practitioner schooling, I obviously kind of knew a lot about GI and I was still interested in GI, so it was a very easy transition from a nurse to a nurse practitioner in that role. I started out doing actually GI nutrition. So I had done TPM and CI tubes at University of Chicago, which was an amazing experience, and then kind of parlayed that to general GI and here we are today!

Erin Judge: That's awesome! I think Gi is the best field to be in especially, I mean, as a dietitian, I think we get the most fun, but it's it's such a fun field because of all the new research and because everything that's coming out, it makes our jobs I think a lot harder, but also so much more fun and exciting.

Jennifer Fijor: Absolutely. You're never bored, you always have something new to learn, GI is like an open ended thing to continue to learn and develop and get interested in. There's new fields constantly coming out, so if you're kind of like, I'm just over general GI, there's gut microbiota coming up, there's new biologic medications for IBD that are coming out all the time, so it's really one of the most interesting fields.

I have to say like, it is probably related to nearly everything else that goes on. I feel like everything starts with the gut anyways, so a lot of these diseases, diet, nutrition, can kind of compound other issues. So it is a really interesting field that I don't see myself getting bored with anytime soon!

Erin Judge: Yeah, that’s awesome! And before we get into like healthcare stuff and providers and all of that, I know some other people are going to be asking and wondering what's the difference between a GI nurse practitioner and a gastroenterologist and what does your job entail as a nurse practitioner?

Jennifer Fijor: So a gastroenterologist is a clinically trained doctor, they go through their medical school, then they have their residency and then a fellowship, which is specifically directed at GI, some will kind of divert to hepatology and GI and there can be some other different fellowships, they can take on top of that to further specialize. Afterwards, they do board certification. So essentially, they're learning about a lot of different disease processes, rare and common and they're also learning how to do endoscopy while they go along.

The main difference between a nurse practitioner and a gastroenterologist would number one be schooling and education. So they do have further education, not to say that a nurse practitioner is not educated because they do get a lot of clinical training. So you know, after some time, they can develop a lot of good skills and I don't find them to be you know, inferior in a sense that they don't know what they're doing. They definitely have a lot of experience and learn all of this stuff, but for like those more rare or complicated disease processes, gastroenterologists tend to see that in their clinical training and do board certification to be able to recognize and manage those types of things.

So for me, there's a lot of collaboration with my physicians and the position I'm in and sometimes the patient bounces back and forth between me and the physician depending on the complexity level, or things that need to be done. I don't do any scoping, the physicians do the scoping. There are nurse endoscopists out there, it's a 12 week program for nurse practitioners to learn how to do basic endoscopy, usually it's upper endoscopy at a flexible sigmoidoscopy, and those are tend to be used in more like rural areas.

I have never met a nurse endoscopists, it's not impossible to do that, but for the vast majority of the time, that is the doctors doing the scoping. So I may see a patient, have them scoped by a doctor, they may come back to me and then I may share that responsibility with a doctor as well. So there's a little bit of a difference in that the scope is larger for a gastroenterologist than a nurse practitioner. I would say the nuts and bolts are typically the nurse practitioners role with like abdominal pain, diarrhea, constipation, managing irritable bowel syndrome, celiac disease, GERD, things like that. And then when you kind of get to the more complicated or complex arenas, a physician tends to be the more beneficial route to go. But that's not to say you can't specialize in GI as a nurse practitioner, yes, there are sub specialties as well. So you can learn hepatology, IBD and some of those are like the ones that have turned the field around, you know, in terms of care and quality and health maintenance. So there is a huge role for nurse practitioners. And it's not to say you're lesser than, there's just a different role for them.

Erin Judge: Yeah, that makes sense. And it's helpful to understand even from a patient's side or point of view of like, who they're, who they're meeting with, and what that really looks like, but also bringing in your expertise, because what we're going to talk about, we're going to start with looking at things from a patient's point of view.

We know that the other side of health care, of being in gastroenterology is fun, right? For a provider, it’s fun. For a patient, it's not always that fun.

Jennifer Fijor: That's true!

Erin Judge: For a lot of people with IBS, and especially digestive other digestive disorders in this arena of non IBD, more in this functional space. doctor's visits tend to be really tense, and they tend to be filled with more negativity than positivity for patients and their experiences. And, you know, we can look on social media, I mentioned the Rayji memes. And the social media knows all about doctors, and I've kind of done it as well, because it is something that's so relatable, as someone who is providing patient care in this space, why do you think that so many patients have had such a poor experience with their providers and like what's really going on with that relationship?

Jennifer Fijor: I think the most difficult thing is that a lot of providers are taught as they're going through their training to look for structural diseases or organic diseases, or tangible disease processes. There's a bacteria, they treat it with an antibiotic. There celiac disease, they treat it with dietary modifications, and this reduces the inflammation. So it's a tangible source that they're able to treat with a product or a regimen, and they're able to get rid of it. It's a term that they've deemed it's called biomedical reductionism, so it's this idea of treating a disease process.

But what happens when there's like functional disease, or the brain gut disorders, oftentimes, that makes it difficult for both the patient and the physician or provider, because you kind of come to a head where it's, you know, everything comes up normal, or we didn't see anything on endoscopy, and you kind of hit this stride of both of you are frustrated, that there is nothing tangible to blame it on. So I think that the negativity comes not only with the expectations that are set with that, but the delivery of this as well. Oftentimes, when patients hear oh, there's nothing wrong with your labs, it must be in your head or there's absolutely nothing wrong here. The patient themselves is like no, I'm going to the bathroom 15 times a day, I know that's not normal, but they don't always offer an explanation of why that may be.

I think the difficulty comes in with explaining why a disease process may be causing these symptoms without actually, you know, having an organic cause for it. So setting those expectations, describing why stress, anxiety, diet, lifestyle, environment, genetics can play a component. There's multiple facets that can play into this and trying to address those underlying issues may be the better way to go. And oftentimes, doctors or providers have a very full schedule, it is very difficult to take the time to sit there and explain that and so what comes off, in most cases, I presume, would be flippant attitude or ambivalence to what's going on from the patient's perspective, and the doctor, or provider, I'm sure is like, well, there's nothing wrong, you should be happy, there's nothing wrong.

And so they kind of meet this frustration, the patient often then gets more frustrated, because there is no valid answer requesting more tests. And then that's when these like referrals and more tests come into play, when in fact, a lot of this functional disease is defined as the absence of these things. And so if a provider is confident in that, and is able to say, here's what it is, here's how we work with it, here's what else we can do, who else you can see and address it, there may be some more understanding from the patient's perspective of what goes on and the providers perspective of what the patient's expectations are. And that meets a lot less frustration and you can work as a collaboration rather than somebody that you go to a for a service once that service is completed, goodbye.

Erin Judge: Yeah, absolutely. And I love that you brought that up, the need for some empathy, right, and like putting yourself in the patient's shoes and being able to explain things with a softer tone, that matters. And I don't think that a lot of providers are intending to have a poor attitude towards patients.

Jennifer Fijor: Right.

Erin Judge: If that's ever the case, maybe every now and then you know, we have those bad apples that just are not in a good mood that probably should stick to surgery. But you know, that's just a few people, I think what you mentioned with the stress and the load, and sometimes providers may not understand how the recommendations or conversations are coming across, so the empathy is so important and that description and the tools and the resources is also so valuable. I know that's what a lot of patients are seeking and as a dietitian, that's what we're here for too and but you know, not all patients get that referral, or they don't get those answers, and it can be so frustrating. And then the time block, though, I think is probably the biggest barrier, would you say for a provider, the amount of time you have and just how tight that schedule is?

Jennifer Fijor: I think that that is difficult. But I think if you were, I don't want to say smart about it, but like if you're more strategic about it, you know, there is always the opportunity to see a patient again and go over more stuff. So I oftentimes will set up the expectation that this may lead to a FODMAP diet, but a FODMAP diet is way too complicated to start talking about today, we would need another office appointment or a dietitian referral to adequately go through the FODMAP diet, because I know and I've seen this a bazillion times on TikTok, Instagram, the joke of my doctor threw a piece of paper at me and said, do the FODMAP diet.

You and I both know that it's a lot more than just that, and if you Google it, you'll see 1000s of different FODMAP diets out there. So which one are they following? How long do they follow it? Some say two weeks, some say six weeks, some say eight weeks? So you know it's about kind of being able to offer, if you're talking about a diagnosis and treatments, kind of setting that up and if there's a lot more to go through and a patient doesn't feel like they adequately had all their questions answered, saying, hey, looks like you've got a lot more questions to ask, we're out of time today but I really want to work with you and I want to get you to the best place we possibly can. We can always set up another appointment, so we can adequately address it.

I tend to run over because of that stuff, I mean, I'm a talker, and I don't mind educating, because I feel like education is the best tool, like I'm one of those school rock house kids, like knowledge is power, so I tend to be like more of an educator during my office appointments. But I think it just equips patients a little bit better and then they can actually feel more confident in doing their own research so maybe they don't need to come back if you start, you know, kind of getting those things in their mind to address and giving them the right tools at least to look at. And then maybe that next time that they do come in, they're already prepared with more concise questions.

Erin Judge: Yeah, that's awesome. And that's going to be more internal change, right. That's changing the providers perspective, the providers plan, the providers way of providing care, and I do think that's changing, and we're seeing it change, we're seeing improvement, we're seeing more integrated health care happening. We're a team, and there's more referrals, especially within the digestive disorder population, which is awesome.

For those who are patients, while we're trying to change the healthcare system, while we're trying to change the way that us as providers work, what could a patient do to advocate for that care? Even maybe prepare for the appointment to get better care in those situations and avoid some of that disappointment?

Jennifer Fijor: Well, I think you kind of hit the nail on the head, that the relationship of the patient and the provider is changing. It used to be kind of that mentality of I am the doctor, you do what they say, if you know, if you don't do it, that's why it didn't work. But now it's kind of more of a collaboration, then kind of like a patriarchal, I don't want to say patriarchal, that sounds terrible, but you know what I mean, where now it's more of a collaboration where they work on things together. And I think it's not just important for the provider to set expectations, but the patient themselves. Some patients will come in and you know, a provider is just trying to figure out, okay, are they more concerned about rolling out disease processes or are they more concerned about maintaining symptoms? Do they want both?

I think coming in with a clear, concise aim at what you're what you're there for, so if you have abdominal pain, are you just making sure it's not something scary, like cancer and it's something you can live with? And, you know, maybe maintain if it's just an occasional twinge? Or is it something that's really bothering you and impeding in your life and you want it to go away? Or do you want to make sure it's not that and deal with the, you know, the underlying symptoms.

So I think being kind of clear to say, hey, I have a very strong family history and very concerned about XY and Z, this little twinge just came about, I just want to make sure it's nothing. And so you know, it's much more realistic for providers say, okay, well, it may not be nothing, but since you're concerned about this, let's address it. So I think that setting expectations for the patient standpoint is really important, as well.

The other thing that I think is a huge, huge component is understanding your symptoms as a patient, knowing how to describe your symptoms, knowing what medications you're on, knowing what you've tried before. For us providers, we don't want to sit there and waste your time any more than you want to waste our time. So it's like, I don't want to reinvent the wheel and make you try probiotics again, or gas x again, if you've already tried it, and it didn't help in the past. So knowing that stuff and knowing how to describe your pain. “It’s pain” doesn't help me decide, you know, okay, what's the quality? Where's the location? How frequently does it happen? So, you know, that may change my perspective of what tests I need to do, or what I'm looking for as a differential diagnosis. Upper abdominal pain is different than lower abdominal pain, quality of shapes, and smell or consistency of stool is important for us, knowing like, you know, if I point at a Bristol scale, which one of these are your stools is really helpful in determining constipation versus diarrhea. And some people will say, oh, well, I have a, you know, one to two bowel movement every single day, but every fourth or fifth day, I may have a seven out of nowhere. And it may be that it's overflow diarrhea, and not actually alternating constipation and diarrhea from like an underlying IBS. So it may completely change the perspective of what's going on and clue the provider into what may be actually happening underneath.

I just had that happen with a lady the other day, she's been coming in for her diarrhea for years. And then I got an x ray on her finally, I was like, oh, you're constipated? It's all overflow diarrhea, oh, my gosh, how did they miss this? But being able to being able to describe that to a provider really helps paint the picture. And it's not like it's detective work, but in some ways it can be. So you're trying to put together the whole picture rather than little fragments of a picture and say, oh, you have diarrhea, it might be this, oh, you have constipation that might be this. So it's more about treating the whole thing. So being able to convey that to your provider, I think is huge.

And I oftentimes, you know, will tell people write stuff down, write down your symptoms, if you think that there's a food intolerance, start writing it down. If you think that there may be a correlation to your food and symptoms, I'd like to see if there's a pattern forming and then I can sometimes make an assessment based on what I see. Or if you've had a particularly stressful day, lack of sleep, lack of water, that maybe while you're constipated. So I can kind of gauge and see an understanding of what's really going on behind the scenes because I'm not there with you. The patient is my window into their life.

Erin Judge: Yeah, that's awesome. And that's something that we always recommend is writing down your history, like details of symptoms, all the oddball symptoms, like everything that you possibly can and like even just handing that doctor, to the provider, just so that it's simple. And I've prepared so many of those documents for my patients like, these are the characteristics, this is what we see. And I've been on the phone with providers saying, no, you like you're hearing this from my patient. But like actually looking at the log and working with this person, I'm actually seeing the overflow or I'm seeing impaction, I'm seeing more constipation, just the way that the symptoms were described may not actually line up with what's there.

Jennifer Fijor: Exactly!

Erin Judge: The hard part for a patient and something I've learned because I see it as a provider often and I never think that the patient is wrong, like patients are not miss telling me their symptoms, most of the times, they don't know, like, we don't know how to describe it, because we don't talk about what's normal. We don't talk about what's not normal. If someone is having urgency to go, they might say that that's diarrhea because that's the only word they have to use, without acknowledging that maybe the output actually isn't that intense, or maybe it is urgency, but the stool is perfectly well formed, you know, and that could actually influence different reasons.

If we just go into the doctor and say, especially a provider that maybe doesn't have that scope on or they have been really busy, and they're meeting with lots of people, you know, they may not hear it. And I think it would be amazing if we had some sort of like assessment tool prior to appointments that just walked people through, like, what's the characteristic of this? Like, is it hard? Is it here? Is it there?

Jennifer Fijor: I totally agree with you. That's why I actually made an IBS journal for patients who are having a hard time like trying to figure out how to convey that stuff. For me, I was just kind of bored one day when my partner was out of town, and I was like, you know what, I'm going to make an IBS diary or journal so that my patients can track their stuff. So I put in the Bristol scale, I put in what is constipation, what is considered diarrhea, the Rome criteria for IBS, why people get IBS and then common terms they may hear, and then there's like a 90 day food diary, but you're also tracking your sleep, your hydration, any medications that you've used, so you can go in and be like, here, I've tried this, this, this, this and this, I've eaten this, and I could look through and say, okay, well, I see a lot of avocados and apples on this that seem to be the days you're having diarrhea, we may need to try to do some FODMAP work or, hey, it looks like you're not getting enough sleep and that may be causing some sort of dysbiosis or, you know, maybe leading towards small bowel bacterial overgrowth, etc, etc.

So, you know, there's a lot of stuff that can correlate to the symptoms, and that we may need to look at as a whole, but without kind of knowing their day to day and you getting a broad symptom, like you said, of, I have urge or diarrhea, and it's like, okay, well, is it a type six, type seven? Oh, it's a type four. Okay. Well, now you know that they this is a regular type of bowel movement, but the urgency is different than the norm. So that's kind of the purpose of that. I've used it in my clinic, for some patients, and I've had some good reception from it, I put it on Amazon just as like an option for people if they don't find a good tool like that to use for their doctors, and I've had some other clinics use it as well. And you know, I've had some good feedback with it. It's not perfect, but it's better than nothing for us.

Erin Judge: I think any way to really describe and break things down is so helpful. We actually do that on one of our courses right now that all of our clients start with, and it just starts with, what are symptoms? What what do they mean? How does digestion actually work? Because sometimes I think we think, oh, like, my gut is hyperactive, but then you may actually understand the digestive system and realize, oh, well, actually, my gut might be really slow. Or you may think your gut is slow, but it's not. It's like there's so many different pieces. And even as a provider, it took me a long time going through like schooling and even training as a dietitian to learn these pieces. I think for patients, educating yourself to help you then come prepared, so you can get the most out of that appointment, knowing that the provider on the other side, yes, could do better, but also is a human being that can't read your mind, so we had to have both where we work together a good way to start collaboration.

I think there are still situations though, where maybe a provider is not the right fit, right> And I've heard it I've seen it. I've had doctors tell me, you know, IBS patients are high maintenance or even my clients will get comments about how they're just overreacting, or they have an eating disorder when they're not actually being assessed for one or even then referred out. And it's just, I think there are some negative experiences that are valid to say that that provider is not a good fit. So if that were to happen, just with your experience, as a provider, what could a patient do or someone do to either is not really even received better care, I think at that point, we need to move on, but transition to a new provider, because that's something that can be kind of tricky, so do you have any thoughts or tips?

Jennifer Fijor: Yeah, I mean, obviously, like you mentioned before, I don't think anybody goes into this field trying to be brash or not helpful. I think the idea is really that they join this field to help people. But I've heard the same things and I've had a lot of patients come back and say, my provider just told me to lose weight, or my provider said, it's all in my head and made me feel crazy, I know, I'm not crazy, because I'm experiencing these symptoms. I think that that puts a really bad taste in anyone's mouth, which, of course, makes you hesitant to go to the next doctor and as soon as you hear something that's even remotely, possibly stigmatizing, or even my newly judgmental, your guard is already up, and you lose that trust with that provider, too.

I don't think every interaction should be kind of looked at as the same, I think it's a new opportunity. I think that some of this, and I hate to say it, I know that the providers can be the issue, but some of it's on the patient as well. It's your responsibility to be an active, engaged person, listen to the provider and then if you do find that they're stigmatizing or judging, you can stop them and say, hey, you know, I know you think that this is related to stress, but I still haven't heard an underlying diagnosis or medical diagnosis that may explain why my stress is in part impeding or contributing to these symptoms. What is the underlying issue? What are the differential diagnoses that you're looking for in this? What are we ruling out? It may change the perception of that provider and say, oh my gosh, I didn't realize I was being stigmatizing like, oh, geez, I didn't realize how it was coming off, and I think that reframes the relationship between the patient.

The other thing is, I think that the biggest issue with the patients who doctors think are high maintenance is because they're just curious about a lot of stuff. So I think it, kind of going back to the previous point, coming with questions in mind, is really important, writing them down, but I would be upfront about those questions and save them to the end, nine times out of 10, they will get answered through the office appointment. But I know you want to feel valid and I know you want to have everything answered for you, so if you kind of come in and interrupt the doctor with these questions, it does kind of offset the relationship and it kind of makes it harder for the provider to get the information too. So I think it's very important to advocate for yourself, ask the questions, but most of the time, we go through a lot of those questions and then if there is stuff at the end, we at least have in our minds that timeframe to dedicate towards asking the questions, rather than bringing them up at the end, at the very last minute or, you know, trying to as we're walking out the door, oh, wait, I have more things. So it at least kind of, again, sets expectations for both sides, minimizes any confusion between the patient and provider relationship, and you know, in terms of trying to frame their their workup or mindset, at least we kind of know that we're getting through everything that they consider important and valid, and also addressing these things to make them feel heard and seen. And that is the biggest issue with a lot of these disconnections is, I don't think that patients feel seen or heard, I think they feel dismissed often, and I think they get casted to the side.

I mentioned that weight as an issue. I think it's, you know, there is a another aspect of things where, you know, it is an important thing in health care. Obesity can contribute to certain disease processes, but it's also about the providers delivery and if you feel stigmatized by it, you know, I know that patients know that they're overweight and they know that it'll help. So I would legitimately ask if that is something that does come up, okay, but how does this impact the disease process? So, you know, if they say you need to lose weight, what will it do for this particular disease process if I lose weight? I know I need to lose weight, but what is the potential, you know, expectations that I'll get from this, and I think you know, in terms of like GERD, we all know that GERD is going to contribute with weight gain, because it pushes up and you know, has more intra abdominal pressure. So explaining weight loss will take away some of that intra abdominal pressure with adipose tissue. It may help relieve, you know, the hiatal hernias, worsening hiatal hernias, and then just explaining why you're saying these things that you're saying.

It's an uncomfortable position and I completely understand why people would be hesitant to do that, but they're never going to know that you're affected by it, unless you let them know. Like you said, we're not mind reader's, sometimes doctors don't even know how they're coming off, or I should say, providers don't know how they're coming off and they don't realize that it may be offensive, what they're saying.

The last part is, you know, you're not alone in this, it's a meme for a reason, there are plenty of people out there, make sure you have a really good support system. We we want you to try to achieve the best goals that you can feeling the best you can. And you know, if you're looking for another provider, and you're not feeling like this is adequate, talk to those people who you do know who may be going through this and if there's somebody that they recommend, make sure when you do go into the next provider, that you're not bashing a previous provider, just let them know what you felt was not achieved. Did you not get a diagnosis? Do the treatments not work? Did you feel like an adequate workup was not completed and why. And so that's the best way to kind of move forward from another provider.

If you come in kind of bashing the previous provider, it almost invalidates both experiences there. So you don't want to ever feel like you're stepping on anyone's toes as a provider either, so it can definitely put a sour taste in the providers mouth, if they feel like you just kind of come in and get offended by them as well, if that makes sense. I'm not saying that that is always the case. But you know, you want to provide a good experience on both ends. So if we can kind of come in and say, this is why I feel that my last workup wasn't adequate, or, you know, I feel like things are missing, that way the next provider can kind of take from that and focus on what that expectation is.

Erin Judge: Yeah, those are really helpful tools. And I'm glad that you mentioned like asking why something makes a difference. And I think something else that I hear patients come away with is like they're frustrated with the recommendation they got and didn't really understand that they had the ability to ask for other recommendations. And I think weight is a great example, like weight loss. It's like, yes, you know, that might contribute to symptom reduction but we know weight loss isn’t the only thing.

Jennifer Fijor: And it's not an easy thing to do.

Erin Judge: I don't believe that weight loss is a recommendation, it's like contributors to like the health behaviors that make a difference are better, just because they are tangible. But you know, whenever we're thinking about like, a medication is a great example, if the doctor recommends a medication, and maybe that medication is definitely going to work. And you know, as the provider, that I can tell you exactly how it's gonna work and I can tell you how long they expect it to work, and I know it's gonna work. If a patient doesn't want to be on a medication, and that's their preference, and they say, I don't want to be on medication. So then they leave the doctor's appointment frustrated that they got told to be on medication, when they didn't want to, and, you know, we talked about expectations, but what could a patient do in the moment to talk through maybe more resources that are available? And like, what could that work with a provider relationship?

Jennifer Fijor: Yeah, I mean, I think that's a really feasible thing to do. And you're absolutely right, oftentimes, we will try dietary and lifestyle modifications first, that is usually my approach. Not everybody, but most people will try that first because it's the cheapest and easiest thing to do. I prefer my patients not to be on a medication if they don't have to be, but oftentimes, there are some things that become a barrier and we do have to put you on a medication for a particular reason, aka to get something approved, before we can do the next step of things. And that is a huge part of a lot of the hoops that we jump through and oftentimes I will, you know, explain why insurance companies mandate this particular medication before, proceeding with an upper endoscopy and what it may actually help with.

If they still say no and want to, you know, try natural things or try different alternatives, I do encourage you to ask that question, like I really don't feel comfortable with medication. Okay, well, why are not comfortable with medication? Addressing the underlying issue. Maybe, hey, I don't feel comfortable with medication because I don't know what this medication does, okay, I'll explain to you what this medication does and how it works. And that may change your perspective. But if it's something that is truly not something for me, I don't want to do it, I have a huge, issue of putting things in my body, including supplements, what can I do to adequately address this with dietary and lifestyle modifications? And if I've already tried them, what other ones can I try that I haven't already thought of?

So there may be some more things to address outside of just here's a medication, but you do have to speak up as a patient, because there may be a particular algorithm that we may be going in our mind to try to achieve to get to the next place, and without realizing that that was not your angle or your prerogative, we could at least have a conversation about why we're choosing a medication.

Erin Judge: That's really helpful. And I always like to say, you know, ask why, ask for other options, like it never hurts to ask. And the same is true for referrals, right? So we know that, or well I know that dietitians are a perfect referral, because I see our role. We know that therapists are a great referral, we know that pelvic floor physical therapists can be a fantastic referral.

Jennifer Fijor: Check, check, check.

Erin Judge: All my go tos, but not all providers will refer or something that if a patient does ask, sometimes the response can be, oh, that may not be needed. And I think it's the exact same thing where maybe the providers thinking, oh, that might cost you more money, or, oh, you may not absolutely need pelvic floor PT.

Jennifer Fijor: I send everybody to PT!

Erin Judge: I always laugh because I'm like, if a male doctor recommends that to, it's like, I think there's a little bit of misunderstanding from not living in a body that could definitely benefit, but even male for, you know, whatever, everyone needs a pelvic floor PT. But there are some certain cases where you may not have diagnosed pelvic floor dysfunction. And so I think the providers, sometimes they're thinking like, oh, like we're not, you know, doing any wild diet changes, like it's just a low FODMAP diet, like you can follow this piece of paper, you don't have to go through all that time, like I think they're trying to do good, by maybe not recommending referrals, but patients may see it as, oh, that isn't right for me, or like, why can't I have that? Or, you know, there may be some disconnect there. So do you have any recommendations for when to try to ask for referrals and like what that could look like and some things to think about?

Jennifer Fijor: In a perfect world, my ideal GI clinic would be like, that under one roof. You like hit the nail on the head, I would love to have a comprehensive GI care center that had you know, physicians, nurse practitioners, nurses who are able to sit there and educate on things and take the time to show like injections or go through certain management of things, I would love to have that available. And then also, a dietitian within the same place, a psychologist, a surgeon who works exclusively with the GI tract and and then as you had mentioned, pelvic floor therapy.

Truth be told, anytime I'm even suspicious dyssynergic defecation disorder or, you know, incomplete evacuation with some urinary issues, I'm like, well, it's low invasiveness, let's try pelvic floor therapy first before we start doing these diagnoses, especially since you have some issues with XY and Z. And, you know, it's again, it is low invasiveness, it is usually easy, but the biggest issue is the cost. That is the hugest barrier to this. If I had it my way, all of this would be covered by insurance and we wouldn't have to fight to get upper endoscopy or certain medications or dietitian referrals. We know how important dietitian referrals are and it's so crazy that literally everything is like diet related, and yet dietitians are not covered by insurance. So I find that absolutely insane. And I will tell you that my biggest barrier to care is the dietician referral specifically, because I don't have access to GI specific dietitians. And a lot of times the feedback I've gotten is it wasn't covered by insurance and they just wanted to do weight loss or they specialize in diabetes. And I really have been on a personal mission to find dieticians like you to try to kind of give resources to do not necessarily a referral, but hey, check this out and see, these are the ones that I've kind of vetted and found to be valid and educational but also evidence based, so these are the ones that I would recommend looking into.

The hard part is getting that referral. And I think that that's often why we don't automatically go to the referrals because we know that it becomes more work for the patient, and then it comes back to okay, well, that was not covered by my insurance, name another one. And it's like, I don't have another one to name for you and I'm sorry. And I think that that is why they don't get referred a lot and I wish there was a better pool or database that we could actually like, look into, I know that there's, is it eat right, is that the one that you guys use?

Erin Judge: Yeah, eat right is our organization, there is a new one just for GI providers, and it's GI specific dieticians, we have a collaboration now with the AGA or however you say it. And as a Southerner, I cannot say that word. But AGA and AMD, which is our organization have partnered and so there is, it's called dieticians on demand or GI on demand. It's through ADA. And I think they're marketing in that now. And so there are GI dietitians that have been vetted out to have Gi training, have experience in GI. And it's fantastic because there are some phenomenal GI dieticians. But like, I mean, we kind of talked about earlier, like dietitians, not all dietitians get trained in digestion. We don't get trained in our one organ, which I always say it's like, this is our organ, like it's digestion, absorption, you know, metabolism, like it's ours, and we don't get trained well enough, we get to trained in kind of the absorption piece, but that's really it. And so those who specialize in GI have to go through lots of mentorship, typically, we're going to work through a practice and usually it's the the lucky ones who've been able to get mentored by phenomenal practitioners that care about nutrition.

And even research is lacking in terms of diet and GI conditions. With IBS, I think we see more because we know it's such a big role, but even with that, like we have the low FODMAP diet, but we know I mean, I know as a practitioner, there's so much beyond that I can do along with IBS, and some of it is 100% evidence based, some of it's not considered evidence based, because we don't research, it's just things that we know can maybe help with digestion or have different kind of mechanisms of action. And so it is tricky and you're right with insurance, like insurance doesn't cover, I think that would be maybe an expectation to set with patients is like for patients going in knowing that it's great to ask for referrals, it might not be covered, but maybe talking to your main practitioner about what that could look like and the benefits that could come from it, because then you might be able to see what might be available to you or not. And then with insurance, that's the tricky one, because a lot of the providers, we don't take insurance, just because it's not covered and I want my time to be with my patient. And we're usually in small practices, so you're right, it is a big barrier to care.

It's my dream to have a clinic as well, that just has all of the specialties and fitness classes that are specific to digestive disorders and just kind of classes and connection points and all of that. And the downside is that there's no way that could be covered by insurance, because the stuff that really helps, like community, connection, and even therapy like isn't always covered, which is just unfortunate, especially for the majority of the population, which is the healthcare problem.

Jennifer Fijor: Yep, again, you hit the nail on the head with all of this, like you're legitimately echoing everything that I feel about this, I would love to be able to confidently refer patients out with, you know, knowledge that, hey, it's going to be worthwhile, because again, $150 for a session in a week on average is a lot for somebody to spend. But if you feel comfortable knowing this provider, knowing that this is going to be something that might change their symptoms, they may be on board as well as you and like you don't want to be the person that sends somebody to a dietitian who doesn't do any work that's valid or, I shouldn’t say not valid, but anything that is helpful. And then they come back and say, well, I spent $150 on it, it was not helpful. And I'm like, oh, that hurts.

But I'm glad you gave me that resource. That's something I'll have to look up, and if you have any more information on that, I would love to know everything about that because I'm always looking for different things to just, different ideas or different ways to address the problems or barriers that I have with my patient care.

Erin Judge: Absolutely. And I can definitely share that. I think that's a big collaboration that hopefully will improve this across the board, knowing that we do want people to work together and we want there to be access to the right providers. And with telehealth, I think that's opened the door to a lot, even, you know, like you mentioned with without coverage, if you know you're going to spend money, like being able to access someone that is going to give you the value that you're looking for is so important. It's a lot of responsibility, I know you probably feel this too on the providers, getting the time, giving me money, giving me anything, you know, it's like, there's so much pressure to make sure that every like, I answer every question and provide it all well, but that's a good sign if someone feels that way that you're meeting with and like takes on that conviction of, okay, like I care, I want to be here with you. And it's not always as easy as we want it to be, but getting people to work together, like whenever I've been able to work with providers that are able to do testing that we're looking into based on what I might see that they haven't been able to see, or maybe able to talk to my patient about their medication options that I just, it's not in my scope, like I can't fully talk through that. But they will talk through that or be able to refer to a you know, gut psychologist that might be able to talk through those interactions or provide those tools or PT always, to me, it's like a win win, you learn your body better, you learn how to poop better, you learn how to workout, but like it's all better. But you know, being able to refer someone and work with that person and say, like, hey, like, based on my assessment like this is going to give you more results then what I can do alone. And I think when we work separately, it just doesn't happen like we want it to.

Jennifer Fijor: Oh, you're stealing the words out of my mouth, as I think it's become, like we've gotten really good at specializing in a lot of different things. But the problem is, it's become so specialized, that it's so fragmented. And oftentimes I will get a referral for somebody, but then, you know, I'll send them out, they come back, I'm like, hey, what happened? How did it go? What did you do? Where did things leave? What did they say? And so I would love to have that true collaborative care where you're able to focus on each component put together and make it more comprehensive for the patients. I think that just provides a lot better care. Yes, you can poop better because you physically know how to adjust your muscles, but you're still having issues with excreting things because you have slow motility. Okay, now, this is my turn to work on the motility components.

I think it's really important that everybody does work together, I know that, you know, this day and age, things are so crazy busy, and it feels like in a flash everything's passing by, but you stole the words out of my mouth. Like I would love to be able to work with a dietitian who says, hey, I saw this and you said, Ooh, hey, I didn't even think about that because they didn't mention this in our 25 minutes that we had together. But you've been working with them for like several weeks, and they consistently say something and you're like, I didn't even think to look for pancreatic insufficiency, yes, they do have diabetes since they were five, maybe I should do a stool study to look for pancreatic insufficiency. They mentioned diarrhea, but they didn't say anything about bloating and you know, some of the greasy stools or oily stools and there goes my little, you know, light bulb. Okay, now let's get this done.

Erin Judge: Yeah, yeah, absolutely. And I think that's something that the patient can do, too, I think it's not fair that the patient has to carry that load, I think I've talked to there's another episode where I'm talking with another patient, more on IBD and we talked about the strain on patients of managing their own health care and how that in and of itself is like a part time job. But something that a patient can do is request that providers be connected. And some providers won't connect out. I mean, I've tried working with like Kaiser, but like, you know, these groups are meant to work together and they won't talk to me, they won't talk to anyone outside of their group, but what I can do is communicate through my patient. The patient can be the advocate between, they can share, you know, health records with me, I can share information with them, I can send a lab request through them, you know, to their doctor. And so as the patient, what you can do is make sure that like your providers are talking to each other. And so if you do go see a dietitian on your own, and then you're working with your nurse practitioner, but then you don't tell your nurse practitioner that you worked with the dietician, and you did something or maybe you started with an acupuncturist to put you on some herbs and like you didn't mention that and seeing that often we're you know, that's interacting with medication. So it's like you have to make sure that we are communicating to all of our providers who we're working with. And because we have health portals and those communication systems, it's pretty simple to just go in and say, hey, I'm working with this provider, can you connect with them? What would it look like? Can you share information or how do I best make sure that things are coordinated, and that can help a ton.

Jennifer Fijor: I think that that's also a barrier in and of itself though because people think since we are on portals that we're all able to communicate with each other in you know, independently. There is no one solidifying communication system for providers. There is Epic, which is a really large one that a lot of providers are on, but not all providers are on. So oftentimes they'll say, oh, well, you should be able to see all my stuff that's in my chart. Unfortunately, that's not how that works all the time. My medical records department probably hates me because I'm constantly trying to get records from different systems and I'm like, they had an upper endoscopy, they had this test, they had that test, I want this test, I want those labs, I want this, and it’s maybe a little overzealous on my part, but I think it just provides a better picture and better understanding. And again, I don't want to reinvent the wheel, I don't want to get another celiac panel if they just had one done and it was negative a month ago. I don't want to do an H Pylori test if they just had an H Pylori test, unless, for example, I can ask them, I see that you have the H Pylori test, where you on Omeprazole at that time? And they say, oh, yeah, I was, then I can say, oh, well, that may not have been a valid test and you may actually still have H. Pylori, and that was a false negative test. Knowing that information may completely change my perspective on things. Being able to communicate that with a provider, but also, you know, if there are records, knowing where those records can be obtained from is also important for us as well.

Erin Judge: Yeah. And as a patient, I think keeping things, I think that’s a value to like get a Dropbox folder, get a Google Drive folder, I like Dropbox a little bit more, but get a secure folder and put all of your records in it. If you get a test, ask for the results, put them there. I think legally, like every patient, like we have the right to our test results, correct?

Jennifer Fijor: Yeah. And now there is a Cares Act, which it, basically if you have a result, it is mandated that it's released within, I want to say like five days, normal results for us are automatically released, but we have, I think five days for abnormal results if I’m not mistaken, there's a time frame. But basically, you have access to your chart now and your results. Whereas before, I don't think you were able to access that. So all of her my providers, all of our stuff is automatically released when we sign our note. So they have access to their note, they also have access to the labs as soon as their resulted. And then I have the ability to you know, comment on those, especially if they're abnormal within like a few days. So you should now be able to have access to that, but you can always request medical records from a medical record department and you do have the right to look at your medical records. So if something you know, is questionable, if you've had it done before, you can always call and request those records.

Erin Judge: Yeah, and you can get them faxed, we get faxes quite often from our patients, like we request that with our portal that we use, just because it is better and more secure in that way. But that's really helpful for me even though through test results and see notes that doctors have written or communication, because sometimes I think even you know, test results may not be well communicated, especially if they are normal. And so it's hard to know, like, did we already look at this? Or what is your nutrition status? Or were you on the lower end or the upper end that I need to be aware of or, you know, your colonoscopy, did they mentioned that there were hemorrhoids that maybe they didn't tell you about, you know, things like that, that are really helpful to know, just in case, you know, it's like all of those things that are just helpful. And so I think as a patient, sometimes we forget that those health records and all of those results, like they're so valuable. And so making sure to like, take them and put them somewhere, save them so that whenever you see a new provider you have that, you can write it down and share it so that your provider can provide the best care possible for you and not like you mentioned, just kind of spin in circles. And so I know that we're running a little bit low on time, so anything else that you want to share just for those who are struggling with symptoms or they're trying to figure out their gut?

Jennifer Fijor: I would say be truthful, be upfront. I know it's, like you said before, it may have had stigmatized, you know, experiences in the past, but don't be embarrassed to tell us anything, we will only know if you tell us these things, so it is important that you're upfront and honest. If you're not happy with the way that things are going, speak up, otherwise we won't ever really know, so, advocating for yourself. The other thing of course is you may not always have a nice neat wrapped up answer in a tight little bow. But you know, our goal is to try to you know, keep things as easy and try to get you to the best self that you can be so you may not always have a beautiful linear course, it might kind of zigzag here and there. And, you know, as long as we keep working together and we keep trying on things, I think that's the biggest key and finding somebody that you do relate to and you do find trust with is really important. If things aren't working in that aspect, keep at it, keep telling them that these treatments aren't working, because we will look to the next thing to try to find something.

As you mentioned before, let them know if a medication is not working or you don't want to medication, there are sometimes other items like non medical items or therapies that I will refer to. So you know, acupuncture, as you mentioned, cognitive behavioral therapy, hypnotherapy, these are other things that we will try. So there are options that we can really try to do and exhaust before we, I don't want to say give up, but you know, that is something that we can explore and try to do before we say that we've exhausted as much as we can.

The other thing is, there are going to be times where you're doing well and there are going to be times where you're doing not well. Sometimes these are, flares eb and flow, there will be stressful situations that put you off course and it's okay to talk to your provider about those times where you get knocked off course, you may need some reinforcements and say reeducation on things or just maybe need support through it. And I think that if you have a good relationship with a provider, touching base with them, letting them know and sometimes it's just about having somebody on your side saying hey, try this for a little bit, try this for a little bit and getting through that.

Erin Judge: Awesome, great tips, great takeaways, and if anyone wants to continue learning from Jen, connect with her, I've got all the social media handles in our show notes and Jen is very active on social media so TikTok and Instagram you know, learn have fun connect. And thank you so much for being with us and cheering all of us on!

Jennifer Fijor: Thanks for having me. Oh my gosh, you are so great to talk to you!