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Getting Interested in Functional Gastrointestinal Patients

Junga, Zachary C. MD; Associate Editor, ACG Case Reports Journal1

doi: 10.14309/crj.0000000000000087

1Department of Medicine, Gastroenterology Service, Walter Reed National Military Medical Center, Bethesda, MD

Correspondence: Zachary C. Junga, MD, Department of Medicine, Gastroenterology Service, Walter Reed National Military Medical Center, Building 9, Rm 1440, 4494 North Palmer Rd, Bethesda, MD 20889 (

Online date: May 16, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

We have all been there, seeing the patient with irritable bowel syndrome or functional dyspepsia on our clinic list and the trepidation that follows. The functional patient cometh! The catastrophizing starts with thinking of the time investment the patient will become, frustration with not being able to “fix” him or her, and the possibility that the patient is unwilling to accept a diagnosis of functional disease with the argument that may ensue.

At the beginning of my fellowship, patients with functional disease made me very uneasy. I was busy, they consumed a disproportionate amount of my time, and I found no professional satisfaction in their care and treatment. Early on, cauterizing bleeding vessels and removing large polyps provided the positive reinforcement of why I chose gastroenterology. On the other hand, the patient with functional disease had the potential to make my clinic run late or drain my energy. I dreaded seeing them and showed it by complaining to my co-fellows, grumbling between encounters, and sighing loudly while writing notes.

Fortunately, one of my mentors gave me some guidance that led to a frameshift on functional patients. He sensed my frustration and advised me to get interested in functional patients early in my training. He explained caring for functional patients is a large part of our practice as gastroenterologists and having this portion be exhausting was a quick path to professional dissatisfaction and burnout. He encouraged me to see their treatment as a challenge and to develop my own approach as there are limited algorithmic guidelines on how to manage patients with functional disease.

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Forming my approach began by reviewing all of the treatment options for functional disease. There are many, and while this was overwhelming early on, I now see it as a large arsenal with which to improve the quality of life in my patients. I usually start with the interventions with the best data of efficacy and use other medications only if they are failing the initial options.

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I give my patients plenty of input in their treatment plan which they greatly appreciate. Initially they can choose between a diet-based intervention (low FODMAP, dairy free, gluten free, etc.) vs a medication-based intervention with early follow-up to assess the impact. This ensures their goals and values are heard while also getting buy-in from them.

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When documenting these encounters, I write detailed and exhaustive notes. This is time-consuming on the front end, but saves time in the future. I document previous “rule-out” studies, index symptoms, and symptoms that cause the most distress. This allows me to track their progress (I often update each symptom with a percentage improvement). I also document the next 2–3 interventions planned so that when I see them again or get a phone call, I quickly know what to order or what information to send them.

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Setting expectations and reassuring patients that they will be followed long term (a combination of clinic appointments and electronic messaging) has also made treating my patients with functional disease more rewarding. They appreciate validation of their symptoms and a follow-up plan when often they have felt ignored or abandoned by prior providers. Expectation management puts my patients and me on the same page where they can anticipate to get better control of their symptoms but not eliminate them completely.

Since changing my perspective and overhauling my practice when it comes to functional disease, I have noticed a substantive improvement in my professional satisfaction. What could have been several difficult cases with my prior mindset are now rewarding patients who I look forward to seeing. I still love the large polypectomies and complicated hemostasis cases, but now I get excited about helping patients with functional disease while managing to reduce my own burnout.

© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.