In Collaboration With The
Don W. Powell, MD
Professor Emeritus
Internal Medicine/ Gastroenterology
University of Texas Medical Branch at Galveston
Galveston, TEXAS

Foreword by Don W. Powell, MD

Although it may be one of the most rewarding professions, being a healthcare provider can be difficult at times. The Covid 19 pandemic has been especially challenging for providers, as well documented in the media and professional journals. Providing care can be comparatively easier when well-trained caregivers address straightforward problems that can be diagnosed with certainty by radiologic or endoscopic imaging techniques or laboratory tests. Medical care is much more difficult when the provider encounters a patient who has not improved under their care or, heaven forbid, has been harmed by the medicines or procedures prescribed.

An equally challenging area for caregivers is diagnosing and treating with good outcomes those disorders for which there are no useful diagnostic tests or when the results of tests may be misleading. In treating such patients, the physician's communication skills become paramount. Such is the case for the so-called functional gastrointestinal disorders, a term now replaced by Disorders of Gut-Brain Interaction (DGBI). These disorders are made up of diagnoses with older names, such as irritable bowel syndrome, functional diarrhea or constipation, abdominal or pelvic pain disorders that defy diagnosis, functional dyspepsia, and many others. Often these patients present concurrently with psychosocial issues, which have been made worse by physicians who do not want to care for them because their disorders are difficult to define or treat and occur in patients who may be psychologically demanding. So, in the past, these patients often did not receive expert, compassionate, and patient-centered care (sometimes no care at all), although that plight is changing significantly in the past two decades. The emergence of providers such as the authors of this book, Douglas Drossman and Johannah Ruddy, the scientifically systematic categorization of these disorders and outcome studies by expert clinician-scientists, the teaching about diagnosis and care of DGBI by organizations such as The Rome Foundation, and the growing number of outstanding care givers such as those whose stories make up this book are making a striking difference in the care of these patients.

The present book, "Gut Feelings: Providers Achieving Patient-Centered Care" is one of a trilogy addressing DGBI. The first of the "Gut Feeling" volumes addresses DGBI, how these disorders are defined and systematized, and it champions the Patient-Physician Relationship--the order of patient and physician in this term indicates the priority of the patient in what is known as patient-centered care. It also gives practical knowledge about communication skills and "connecting" with patients. The second "Gut Feelings" volume is made up of patients' stories. It demonstrates what it is like to be a patient with DGBI under the care of physicians who don't understand their illness and are ill-equipped, or do not even want, to treat them, and contrasts that with well-trained and properly oriented caregivers. This third "Gut Feelings" volume contains the stories of providers. It gives the narratives of 14 caregivers who are experts in delivering patient-centered, compassionate care for patients with DGBI. Each volume of "Gut Feelings" stands on its own, but reading all three delivers the greatest impact for understanding these disorders and learning how to care for these patients.

"Gut Feelings: Providers Achieving Patient-Centered Care" can be read at different levels. Each story is an entertaining, medically oriented, short autobiography with a section on examples of challenging patients the caregivers have treated with good but sometimes less than satisfactory outcomes. The stories are well written and because each person comes from a unique culture and heritage, they pique your interest. The personalities of the authors shine through their words and syntax. The reader comes away from the chapters with a view in their mind's-eye of them interacting with their patients and an appreciation for how good these providers really are at their profession. Each chapter is followed by a critique by Dr. Drossman and Ms Ruddy, giving context to the narratives, noting similarities in the providers' experiences, and indicating why they are successful in caring for their patients with DGBI. I would like to add a few comments of my own.

Each provider is different: some were excellent athletes or students, and other had to overcome personal disabilities or environmental challenges. Their stories are brutally honest and not always self-complimentary. All are clearly highly intelligent. Charisma defines some, although maybe not in the manner of a dictionary definition of divinely conferred charm that inspires devotion in others. Many, but not all, were inspired to go into medicine by childhood medical experiences or by shadowing physicians as adolescents. For others, the medical career was an intellectual choice or even a "calling". Most have had diverse and extensive training. They are ambitious in the good sense of the word. Each is highly competent in understanding modern medicine and how to apply it. It is no wonder that they have become thought leaders in their area of medicine, and many are administrator-leaders in their institutions. They believe in and practice interdisciplinary care. All comment on the ability to listen and the value of listening as a hallmark method of communication to achieve patient-centered care. All, I repeat all, name one or several mentors they believe were fundamental to their success as a physician or academician. Caring for patients and experiencing success and sometimes failure has been the bedrock of a meaningful life that brings them happiness.

There is one aspect of their narratives that I looked for as a medical educator but did not always find. How did they become such master clinicians so skilled at the so-called "art of medicine"? It seems intuitive for many of them; perhaps they are not completely aware of their own learning processes during the journey to becoming an expert caregiver. I am a disciple of the type of patient care espoused in this book because Doug Drossman introduced me to its power and rewards when he was a junior faculty member in the GI division that I led many years ago. In his narrative, Doug honors me by mentioning me as being one of his mentors, but he was my mentor at the same time. From him, I learned patient communication (listening being the hallmark) and how to assess and care for complex patients with DGBI in a patient-centered model.

What I learned foremost was the power of empathy. To master the use of empathy, the practitioner first must convert in themselves an ancient and conserved form of empathy called social contagion to a form that might be called medical or nurturing empathy. All highly social mammals, but even fish and birds, may feel and display stressed behavior upon observing this same behavior in others of the same species. This oxytocin-mediated basal empathy is preserved evolutionarily and has group survival benefits. A caregiver plays a crucial role in recognizing fear and distress in a patient. However, it is equally important for the caregiver to respond to the patient's distress by acknowledging it as something they understand and may have also experienced. By doing so, the caregiver can establish trust and rapport with the patient, which can help alleviate their distress. The caregiver should convey a message of collaboration and support, assuring the patient that together, they will work towards overcoming the illness and any associated distress. This is nurturing medical empathy.

Secondly, I discovered that achieving even moderate proficiency in all these skills takes work and practice. One of my favorite contemporary authors, Ann Patchett, commented in her essays about good writing that "Art stands on the shoulders of craft, which means that to get to the art, you must master the craft". She became a prize-winning author by practicing writing, or as she termed it, "slugging away with a pick". Leonardo da Vinci spent years perfecting an art technique called sfumato which translates to 'vanished or evaporated'. Da Vinci, a scientist, and an artist, was interested in how light falls on curved surfaces to produce shadows, so he developed this technique to achieve realism. Sfumato is achieved by applying layers of very thin, almost transparent paint, which blends the transition of shadows and colors imperceptibly with brush strokes that are almost invisible.

Consequently, it took him years to finish a masterpiece. The result is that the skin of the Mona Lisa glows with life-like intensity and her eyes seem to follow you across the room. So, if you want to become a master clinician skilled in both the art and science of medicine, resign yourself to years of practice but, most importantly, hoist your pick or paintbrush and begin to slug away or paint.


1) Ross S. DeAngelis and Hans A. Hofmann. The spread of fear in an empathetic fish. Science 379:1186-7, 2023. doi 10.1126/science. adh0769
2) Ann Patchett. This is the Story of a Happy Marriage. Harper/Collins, 2013
3) Walter Isaacson. Leonardo da Vinci. Simon & Schuster, 2017.

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