Your first patient (prolapse) has chronic constipation, with bowels about as lively as an overstuffed armchair. Your second patient (faecal incontinence) has chronic diarrhoea, and every medical investigation under the sun comes up with a shoulder shrug.
*Everyone knows you should increase fibre in constipation.* (Except when increasing fibre causes worse problems…)
*In chronic diarrhoea, more fibre would logically be the last thing the patient needs.* (Except when fibre is the therapeutic solution…)
Holy motility…how does a clinician make a decision about these things?!
There is a LOT of misinformation about fibre out there.
Like: all fibre is equal; all fibre has a similar effect; all fibre is similarly tolerated; and of course, the worst of the old chestnuts, your patient’s bowel issues are ALL ABOUT FIBRE.
When you’re a bowel-focused clinician who is NOT a dietitian or nutritionist, it can be very confusing. Getting these nutrition-related messages right for our patients – or at least pointing them in the right direction – is critical, especially if they are not also under the care of a clinical nutritionist. How do you know how much to say about diet, fibre, and hot topics like the gut microbiome? More to the point, how do you know WHAT to say?
There are 3 key guiding principles for the non-nutrition clinician when dealing with patients’ bowels:
Let’s talk about EXPERIENCE.
Benefitting from other clinicians’ experience is one of the most reliable ways to help your bowel patient. Whatever you encounter, you can be pretty sure someone’s encountered it before. There’s no point reinventing the wheel. To save time and painful trial and error, first try what other experienced clinicians have found effective. A quick way to do this is to jump on social media and run your case by a group – or an individual clinician – that you trust. But the nature of social media, and everyone’s busy lives, means you’ll be unlikely to get a full picture this way. Suggestions won’t necessarily entail structured thinking; think of them more like leads in a police case. (And you’ll sometimes follow the wrong leads and end up on a wild goose chase.) Courses specific to the problem of interest AND your clinical background are a better bet. For example, for pelvic physios, I developed the online course
Insights Into Insides to delve into aspects of gut function that sometimes get glossed over: transit time, fibre, psyllium, effect of laxatives, gut flora, effect of medications, and how to track your patient’s bowel function via an analytical bowel diary.
Next let’s consider the importance of EVIDENCE.
Using evidence-informed recommendations is usually best for your patient, and it’s certainly best for you as the clinician. There is no shortage of ideas of what COULD be done for any one bowel patient. (If you need way too much inspiration and not enough direction, just jump on social media!) But substance is lacking. Some well-meaning advice is fundamentally just hot air without sound logic behind it and evidence that it works. Research evidence doesn’t answer all our questions. Incorporating it, though, increases the probability we’ll get it right with our patients. Whatever your question, jumping on PubMed and scoping out the availability of a quick, easy answer is a good practice. Of course, things are often not that simple, and it’s helpful to take advantage of when others have explored the question before you (e.g. via a well-done systematic or narrative review, or a clinician who has collated evidence on this before). With my online courses, I aim to provide clinicians with the convenience of well thought-out approaches informed by research, and save them wading through an ocean of information.
For the all-important “how-to”, using SYSTEMS is the key.
Experience and evidence are great to tell you what to try. But without the detail of the how-to, your patient – and you as the clinician – can be left floundering, seeing the shore but not being able to reach it! You need structured systems to apply evidence and experience to help your bowel patient. For example, a framework for understanding the different types of bowel disorders guides you as to the mechanisms involved. Does your patient’s chronic diarrhoea have an osmotic or secretory cause? An inflammatory contribution? Is it structural in nature? The Diarrhoea Wheel, from the online course Insights Into Insides, helps you figure this out, and the Chronic Diarrhoea Checklist makes sure you don’t commit a terrible error of omission in your evaluation. What about fibre? How do you know the patient has tested out a high-fibre diet? The clinical resource A Rough Guide To Roughage, from the Insights course, allows you to eyeball this, even as a non-nutrition clinician. And when your patient is using laxatives, you can maximise its effectiveness and wean off as necessary using a resource like The Senna Slippery Dip, in conjunction with The Constipation Slippery Dip as an alternative bowel agent guide.
Let’s face it – clinical work is not easy, and any timesavers will be appreciated by both you and your patient.
To get started doing bowels better, take a look at my online course Insights Into Insides: Leaving Anorectal Behind