Behind the Scenes | Wednesday, April 27, 2022

SGNA Annual Course Preview: When Your ‘Belly Ache’ Isn't GI — Unusual Lessons from GI Second Opinions

Featuring Patricia Raymond MD, FACG

SGNA is gearing up for the 49^th SGNA Annual Course: Reunite, Recharge, Reflect, taking place May 22-24 in Salt Lake City, Utah! The Inside Tract is speaking with presenters to get insights on what you can expect from their sessions and why you won’t want to miss this year’s event.

We interviewed Patricia Raymond MD, FACG who will present “When Your 'Belly Ache' Isn't GI: Unusual Lessons from GI Second Opinions.” Here, Raymond shares more about her experience in GI second opinions.

When are patients generally sent to GI professionals for second opinions?

Patients are either sent or decide to go for a second opinion. When they are sent, you know they have something; they’ve done every test and are simply not getting better. That second opinion needs to go up a level of care to a tertiary referral center such as a university. If that doesn’t work, you need to send your patient to who I call “the man.” There is a person that is considered to be an expert in every disease.

Quite often, when a patient self-refers for a second opinion, it is simply a matter that their local physician has done a poor job of explaining things. They may have done an excellent evaluation, but then they fail in explaining to the patient what is going on and what they can do to help the symptoms, and how they can participate in managing the symptoms. GI is nothing but participatory: you are choosing what goes in your mouth.

Oftentimes, a second opinion from a patient happens when the conversation — what I call the dismount — didn’t go well or didn’t go at all. The second opinion is simply to fulfil their educational needs.

And about a third of a time, I find that the patient has a different diagnosis all together. From a patient’s point of view, if you’re not completely satisfied with your care, a second opinion is always worthwhile, and physicians should not get offended by it.

Can you share an example of an unusual case in the arena of GI second opinion?

Doing second opinions is like a puzzle — reviewing all the records, x-rays, data points, what’s been ruled out. The question is, can you come up with a different answer?

My favorite example of an unusual case was a really nice guy who was a truck driver for a major company. He was unable to drive for about six months by the time I saw him because he was so debilitated. He had severe, excruciating abdominal pain and headaches. He had seen a neurologist; they did CAT scans, lumbar punctures and everything they could do for the brain. He had seen a gastroenterologist and had done blood test and stool tests, and nobody could figure out the head pain and the belly pain — separately or together.

They sent me a huge pile of records. Out of that pile of negative tests for neurology, I saw two blood tests where his blood count was too high, so I thought of a hematology condition called polycythemia. This is where you make too many red blood cells, to the point that your blood stream becomes almost like molasses. This was causing the headaches and abdominal pain.

So I told him to see a hematologist and wrote it out to show his gastroenterologist who didn’t believe it. He was able to self-refer to a hematologist with his insurance and found out that, in fact, he had in fact polycythemia.

The way you treat polycythemia is by scheduling times for the person to donate blood and get rid of red blood cells. Within a month, the headaches and the abdominal pain went away and he was able to go back to work.

It was a team effort, because I could have just gotten the GI records and never seen anything wrong with what they were doing. But my team, my nurses and my medical records people got me the labs, and it was due to only two numbers out of this huge pile.

How can GI professionals collaborate with colleagues in other departments to reduce instances of second opinions that aren’t meant for GI?

It helps to have colleagues locally that you can say, “Hey, this person is in my office and I really don’t think it’s GI.” Locally, I work with specific gynecologists because, often in a woman, belly pain is a GYN problem not a GI problem. Or belly pain could be a urology or kidney problem instead of a GI problem. This even includes having a general surgeon who would be willing to listen to the symptoms and try to figure out what body part we’re talking about. There is a lot of stuff in the belly that does not belong in GI. It helps to have a good team locally, so you can bounce ideas around.

You also need to have your own team in your office. When procuring medical records from someone else, we want every piece of paper. You need to have to staff help in the office by making it clear that it’s absolutely okay to have second option, which the doctor should be saying. I think that unfortunately patients feel like second opinions are the exception to the rule. If we had more second opinions, we would have a lower cost of medical care.

What will attendees take away from the session?

There are several different facets to this session. Facet number one is for the patient, their family or for their friends, which is to not be afraid for a second opinion. If things are not improving the way you presume they would improve with medication management, physical therapy or surgery, you need to ask for a second opinion because it’s not uncommon. About 30% of the time we come up with the diagnosis.

The other aspect I focus on in the presentation is diagnoses that do get missed. I speak on five different cases I’ve done over the past 10 years, where they are uncommon enough that there would never be a one hour lecture on the subject. On subject we will touch on is malrotation of the gut. More generally, we are all striving for better communication with patients; the educational aspect of medicine does unfortunately fall through the cracks, leading to second opinions.