It takes guts to talk about your bowels. Centuries of schoolyard jokes mean that almost everyone, to varying degrees, cringes at having to discuss their toilet habits. Where symptoms such as faecal incontinence are concerned, 1 in 5 patients fails to disclose the problem even during a bowel-related consultation unless they are specifically asked.
When a patient presents with symptoms of possible IBS, national guidelines recommend – quite appropriately – that we need to exclude underlying causes such as inflammatory bowel disease, cancer or coeliac disease. Once this is done, we can make a diagnosis of IBS based on the Rome IV criteria – recurrent abdominal pain, on average, at least 1 day per week in the last 3 months, associated with 2 or more of relation to defaecation, change in frequency of stool and/or change in stool appearance.
The natural tendency, once these life-limiting conditions are excluded, is to reassure the patient. After all, IBS isn’t curable, but it certainly does not lead to the life-threatening complications of cancer. Sadly, all too often that reassurance is seen by the patient as lack of empathy for the real impact their condition is having on their quality of life.
What are patients’ health beliefs about IBS?
Even once a diagnosis has been made, many patients have misconceptions about causes and risks of IBS. In one study of 664 IBS patients (with a 39% response rate):
- 80.5% believed IBS was caused by anxiety and 63.2% that it was due to depression
- 71.3% did not recognise abdominal pain as the cardinal symptom of IBS
- 40.6% believed that IBS could be diagnosed on colonoscopy
- 14% believed that IBS turns into cancer
Are we meeting our patients’ needs?
There is often a mismatch between the wishes of patients and the care they perceive they receive from healthcare professionals. In a survey of 1,000 patients, key wishes included comprehensive information, sources of additional information, good listening skills and responses to questions and advice about medication.
Only 64% of these patients felt they had been listened to, 47% felt supported and 40% responded that they had received information. This perception is backed up by another qualitative survey of 57 patients in which the top theme was a need for more empathy and listening from the GP about the impact of IBS on their life.
It is important to recognise that these frustrations may relate in part to unrealistic expectations, perhaps of a ‘cure’ or treatment to provide permanent resolution of symptoms. Nonetheless, it is essential that we approach consultations with IBS patients with the recognition that they may be suffering and require support to alleviate symptoms (through lifestyle and dietary changes, probiotics or other therapies).
How do we overcome the barriers to good doctor-patient relationships?
A 2020 JAMA review identified five practices which could promote meaningful interactions within the consultation:
Prepare with intention – taking a moment to pause and focus and preparing personally for that patient’s consultation. With so many demands on our time in primary care, it is all too easy to rush from one consultation to the next, but perhaps mindfulness advice should be directed at ourselves and not just our patients.
Listen intently and completely – including open body language and lack of interruption (on average, physicians interrupt their patients within 11 seconds). With such limited consultation time, open questions and uninterrupted listening may seem at a premium, but they might just improve outcomes and reduce the need for further, often dysfunctional, consultations.
Agree on what matters most – there has been much interest in recent years in the concept of shared decision making (open discussion integrating the medical issues at hand and the patient’s preferences and context to arrive at a course of action, with the final decision made by the patient with clinician collaboration). Again, open questions, active listening and reflecting on the patient’s answers are key.
Connect with the patient’s story – considering the personal circumstances that influence a patient’s health and focussing on the positive, acknowledging a patient’s efforts and celebrating successes.
Explore emotional cues – in addition to responses to open questions, nonverbal cues are key.
Where IBS specifically is concerned, we also need to take into account the possible impact of previous consultations which the patient has found unsatisfactory. By forming a meaningful relationship, in which the patient feels they are being listened to, we are much more likely to be able to help the patient understand that we are recommending lifestyle changes, not because we do not see IBS as a ‘real’ condition, but because those lifestyle changes are so key to the management of IBS.