Albena Halpert’s research while affiliated with University of Massachusetts Boston and other places

Background and Aims Over several decades, changes in health care have negatively impacted meaningful communication between the patient and provider and adversely affected their relationship. Under increasing time pressure, physicians rely more on technology than face-to-face time gathering data to make clinical decisions. As a result, they find it more challenging to understand the illness context and fully address patient needs. Patients experience dissatisfaction and a diminution of their role in the care process. For patients with disorders of gut-brain interaction, stigma leads to greater care dissatisfaction as there is no apparent structural basis to legitimize the symptoms. Recent evidence suggests that practical communication skills can improve the patient-provider relationship (PPR) and clinical outcomes, but these data are limited. Methods The Rome Foundation convened a multidisciplinary working team to review the scientific evidence with the following aims: a) study the effect of communication skills on patient satisfaction and outcomes by performing an evidence-based review, b) characterize the influence of sociocultural factors, health care system constraints, the patient perspective, and telehealth on the PPR, c) review the measurement and impact of communication skills training on these outcomes and d) make recommendations to improve communication skills training and the PPR. Results Evidence supports the fact that interventions targeting patient-provider interactions improve population health, patient and provider experience, and costs. Communication skills training leads to improved patient satisfaction and outcomes. There are several relevant factors to consider in establishing an effective PPR: addressing health care system constraints, incorporating sociocultural factors, and the role of gender, age, and chronic illness, and considering the changing role of telehealth on the PPR. Conclusion We conclude that effective communication skills can improve the PPR and health outcomes. This is an achievable goal through training and system change. More research is needed to confirm these findings.

Method: A literature search of PubMed was conducted using the terms "Irritable Bowel syndrome", "Patient Physician Relationship", "Patient Provider Relationship", and "Patient Physician interaction". Preference was given to articles with a clearly defined methodology and those with control groups if applicable/appropriate. This article provides a review of the literature on Patient-Provider interaction and patient education as it relates to IBS and provides practical recommendations on how to optimize this important relationship.

Irritable bowel syndrome with diarrhea (IBS-D) is a common, chronic functional gastrointestinal disorder with symptoms that can be distressing for patients and often result in substantially impaired quality of life. This review focuses on providing clinicians with information on practical, evidence-based treatment for IBS-D. Current therapies commonly used for the treatment of IBS-D, including pharmacologic and nonpharmacologic interventions, are briefly reviewed, followed by discussion of the emergent pharmacologic treatments (rifaximin and eluxadoline) and medical foods (IBgard® and EnteraGam®). Given the lack of a standard treatment algorithm for IBS-D and the emergence of new pharmacologic therapies, treatment needs to be tailored to the individual patient and take into account the severity of disease. In this context, the latter part of this manuscript examines how treatments for IBS-D can be used in clinical practice by presenting three patient case scenarios with varying degrees of IBS-D severity. For each case, the patient’s medical history and clinical presentation are related to the Rome Foundation multidimensional clinical profile (MDCP) and potential treatment options with current and emergent therapies are reviewed. The interplay of gastrointestinal symptoms and their psychosocial impact, as well as the importance of a patient-centered approach to therapy, are discussed. Consideration is given to the potential need for combination therapies and how emergent treatments could fit into the treatment pathway for mild, moderate, and severe cases of IBS-D in clinical practice.

We provide a general framework for understanding functional gastrointestinal disorders (FGIDs) from a biopsychosocial perspective. More specifically, we provide an overview of the recent research on how the complex interactions of environmental, psychological, and biological factors contribute to the development and maintenance of FGIDs. We emphasize that considering and addressing all these factors is a conditio sine qua non for appropriate treatment of these conditions. First, we provide an overview of what is currently known about how each of these factors - the environment, including the influence of those in an individual's family, the individual's own psychological states and traits, and the individual's (neuro)physiological make-up - interact to ultimately result in the generation of FGID symptoms. Second, we provide an overview of commonly used assessment tools that can assist clinicians in obtaining a more comprehensive assessment of these factors in their patients. Finally, the broader perspective outlined earlier is applied to provide an overview of centrally acting treatment strategies, both psychological and pharmacological, which have been shown to be efficacious to treat FGIDs.

Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, IBS, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extra-intestinal manifestations, are more prevalent in women than men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies suggest sex differences in somatic but not visceral pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been adequately studied. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men.

Quality communication skills and increased multicultural sensitivity are universal goals, yet teaching them have remained a challenge for educators. To document the process and participant responses to Interactive Theater when used as a method to teach physicianpatient communication and cross-cultural competency. Three projects are reported. They were collaborations between Theater Delta, the UNC Center for Functional GI and Motility Disorders, the Rome Foundation, the World Gastroenterology Organization, and the American Gastroenterological Association. 8 forced choice and 6 open ended were collected from each participant using a post-performance evaluation form. Responses to the 8 indicators relating to a positive experience participating in the Interactive Theater. The vast majority either agreed or strongly agreed with the statements on the evaluation form. Written comments explained why. Data indicates that Interactive Theater stimulates constructive dialogue, analysis, solutions, and intended behavior change with regard to communication skills and adapting to patients from multicultural backgrounds. Interactive Theater directly focuses on communication itself (active listening, empathy, recognizing cultural differences, etc.) and shows promise as an effective way to improve awareness and skills around these issues.

Serotonin (5-hydroxytryptamine or 5-HT) is an important neurotransmitter involved in multiple functions both in the central nervous system and the periphery. Most of the body 5-HT is synthesized in the gastrointestinal (GI), where 5-HT modulates various aspects of the gut physiology. The wide-ranging effects of serotonin can be explained by the presence of multiple subtypes of 5 HT receptors located on various types of cells (smooth muscle, enteric neurons, enterocytes and immune cells). Agonists or antagonists for 5 HT receptors are used for the treatment of a range GI disorders (e.g. irritable bowel syndrome, chronic diarrhea, constipation and functional dyspepsia). In addition to 5 HT serotonin agents, there are several other classes of medications used for the treatment of chronic diarrhea and constipation. This chapter will provide information on the clinical use of 5 HT modulators in GI disorders and other anti diarrheal agents and cathartics.

Knowing what patients with irritable bowel syndrome (IBS) want or expect from their medical care is critical in helping them manage the symptoms of this common, chronic gastrointestinal condition. Failure to identify patient expectations can lead to patient dissatisfaction with care, lack of compliance with prescribed treatments, and the inappropriate use of medical resources. Surprisingly little is known about what patients with IBS really want. Several studies suggest that IBS patients value the relational aspects of medical care as highly as technical skills and knowledge. There seems to be a significant communication gap between health care providers and patients regarding IBS care. This article reviews what is known about IBS patients' expectations and needs.

The objective of this qualitative study was to examine patients' perspectives on their relationships with healthcare providers (HCPs) as communicated in their expressive writings about irritable bowel syndrome (IBS). As part of a large national online study, IBS patients were asked to: (a) write expressively about their IBS illness experience for 30 min/day for four consecutive days and (b) answer the question, "What is the most important thing your HCP can do to maximize his/her relationship with you?" A key word search was used to identify comments that mentioned the words "doctor," "doc," "physician," "MD," "gastroenterologist," "nurse," "nurse practitioner," or "physician assistant" in the 228 expressive writings completed by the first 57 participants (four writings for each subject). Analyses of the comments about the patient-HCP relationship and responses to the above question were performed by the authors who identified themes and their frequencies over several sessions using a quantitative content analysis method. We report the results of the first 57 subjects who participated in the study. Subjects' mean age was 41.1 (± 12.7) years, gender was 82% female, 98% had seen an MD for IBS, 58% had IBS <10 years, with mild/moderate disease severity (IBS severity scale (IBSSS) 190.6 + 45.55), and IBS-quality of life (QOL; 62.7.3 + 21.58). Of the 57 subjects who wrote expressively about their experiences related to IBS, 40 (70%) wrote about their relationships with their HCPs in at least one of their four writings. Of the 197 relationship comments about HCPs made in a total of 84 writings, 106 (54%) were categorized as "negative," 22 (11%) as "positive," and 69 (35%) comments were categorized as "neutral mentions." The top five themes identified were: "I need more empathy and listening from my HCP about how much IBS affects my life" (27%), "Nothing my HCP does helps my IBS" (25%), "My HCP has been helpful and reassuring" (17%), "My HCP thinks I'm crazy" (8%), and "I don't trust my HCP" (5%). Forty-nine (86%) subjects answered the question regarding maximizing the relationship with their HCP, with 53% reporting that listening, empathy, and providing education were the most important factors for maximizing the relationship. Our results demonstrate that the patient-HCP relationship is central to patients' illness experience. The majority of our study subjects viewed their relationships with HCPs negatively, with major concerns relating to being heard and receiving empathy. The study findings highlight the need for improved patient-HCP communication. Further research utilizing novel modalities, such as expressive writing, in eliciting patient information and perspectives, may provide valuable educational tools.

We sought to test the effectiveness of expressive writing about irritable bowel syndrome (IBS) on disease severity, IBS-related cognition (perceived control over the illness or adaptive cognition), and IBS-specific quality of life. This was an exploratory pilot study, during which subjects with IBS were asked to write at an online portal for 30 min on 4 consecutive days about their deepest thoughts, emotions, and beliefs regarding the disease and their perception of its effects (writing group). The IBS severity scale (IBSSS), functional bowel disease-related cognition (CG-FBD), catastrophizing/coping (CT3), and IBS-specific quality of life (IBS-QOL) were measured at baseline and at 1 and 3 months' follow-up. Subjects who did not start writing for 3 weeks were asked to complete questionnaires without writing (non-writers group). Within-group comparisons pre- and post-assessment were compared. In addition, the writing and non-writers groups were compared. Linear mixed-effects models were used to assess the outcome measures over time (1 and 3 months). A total of 103 subjects were enrolled in the study (writing group, n=82; non-writers group, n=21). The mean age of all participants was 43 years (s.d. ±12), and the majority (91%) were female. The mean duration of IBS was 6.8 years (s.d. ±3.5); 102 subjects (99‰) had received physician-directed care for the disease. There were no significant differences between the writing and non-writers groups in baseline measurements. For the writing group at 1 and 3 months, the IBSSS improved significantly (+37.4 (±10.8), P=0.0012 and +53.8 (±13), P=0.0002, respectively) and this was not seen in the non-writers group. Similarly, the CG-FBD improved in the writing group by 0.58 (±0.2, P=0.006) at 3 months, although the changes in IBS-QOL did not reach clinical or statistical significance. In this exploratory study, expressive writing improved IBS disease severity and cognition in subjects with longer-term duration of the disease. A large, controlled study is warranted to evaluate the therapeutic potential of this novel modality for adjunctive management of IBS in the outpatient setting.