by Adelina Detcheva
Question: Well, I would be very curious to have some information regarding your choice of field and the profession of physician and gastroenterologist in particular.
Answer: So, the story begins like this: I was fascinated by our family doctor who lived in via del Governo Vecchio 67. We were then in via Zanardelli. We were a family with 9 children, so this friend of my parents came to visit us regularly. Or we went to his study: there was this famous pediatric bed, with the underlying parquet corroded by the pee of the children he visited and during the visit the children regularly peed on the floor every time. He was a real gentleman, he accompanied towards adolescence. Then there was another very elegant thing: he rode with the driver in a vintage Lancia and I really liked this thing then. He made home visits without any problems. He was a very friendly gentleman with my parents, they were family friends. Then at the end of the year, he made a kind of note for all the visits made to the different children and the
families paid. He worked in “Bambino Gesù” Children’s Hospital in Rome. Those were good times for Rome then. This was for the first question. The reason why I chose gastroenterology is different; I graduated in the 6th year July session and started looking for work. I wanted to be able to get married, I got married early. So I pushed myself to look for a job throughout Italy. In Rome there were only rare pro tempore recruitments in the Ospedali Riuniti. Salaries were paid from month to month for a few semester, then stopped. Instead of doing this process, I thought about moving from Rome. Now, my luck and Providence led me to this Gastroenterology Center coordinated by a brother of a classmate of mine, in Ancona: it was one of the top three gastroenterologies in Italy. I stayed there, 10 years went by, I got married, two of my children were born there and the adventure of gastroenterology began there: fortunately a wonderful adventure. Gastroenterology is part of internal medicine, but it also has an operational part. We began with the exploration of the stomach with the “video camera”: a kind of semi-rigid gastroscope was introduced that took random photographs without the observer being able to see. Then we went on, but very far, with the optical fibers, and the cameras on the tip of the instrument. Then we went further, with the exploration and cannulation of the biliary tract, with the unblocking of the intestine or biliary tract, the insertion of prostheses… but I don’t want to bore you! However, the surgical aspect of the specialty is very interesting. In fact, the anesthetist is always present during the most important procedures, the procedures take place in radiology or in the operating room: a great advantage for the inoperable patient. Some pathologies could be solved only by opening the whole belly, we took a lot of work from the surgeons. And then there is an endocrinological part, very beautiful. There are endocrine tumors of the abdomen: they produce hormones. In short, gastroenterology is a very interesting sub-specialty cocktail and it still interests me a lot. It must be said that it is one of the sectors with the greatest development of technological procedures and drugs. When I started, there were no anti-ulcer drugs. The first anti-ulcer drugs of the 1970s, such as cimetidine or ranitidine, come from researchers who later received the Nobel Prize, they are very precise inhibitors of secretion. The next class of proton pump inhibitors, another class of drugs, also have a 90% potency of antacid secretion inhibition, other Nobel Prize winners, and that was a good experience. Think about the fact that today it is estimated that the advancement of knowledge useful for the patient, I am talking about controlled studies with drugs or new surgical or para-surgical techniques, is approaching a doubling of knowledge in two years. In short, updating is essential. An American teacher of mine used to say: whoever does not keep up to date among doctors risks being a dinosaur in a glass shop. It risks doing damage instead of advancing patient care.
Question: Of course. In short, I was thinking of the clinical part, and also of the operative part, because we are talking about a historical development, a technological development, and a development in taking care of the patient.
Answer: Yes! We are looking, as they say, at the technological aspect. Think about the fact that one of the latest advances, we are talking about 4 years ago, at San Filippo Neri, (long live the National Health System!), was even a vision expansion system during gastroscopy to identify the passage of the single red blood cell within the glands. It is a kind of endoscopic histology, still under study. In short, evolution is very strong!
Question: In fact I feel the passion!
Answer: This is good! Passion is good!
Question: That’s all!
Answer: Yes, it is!
Question: Compared to the gastric ailments you deal with most often, which disorder occurs more frequently in a gastroenterology ward?
Answer: So, we have to distinguish the outpatient part from the inpatient part. In the outpatient part, in the ambulatory that I put together there were at least 7 different sectors. Some of these are devoted exclusively to functional diseases, because they are the majority of digestive disorders. Functional disorders are by definition those in the absence of organic lesions: among these there are irritable bowel, dyspepsia, evacuation disorders. We also started an outpatient clinic for diverticular disease. The other sectors are instead ambulatories dedicated to organic diseases: hepatitis, inflammatory bowel diseases, achalasia, rare diseases, etc. In general, count that to make a small estimate, among 15,000 visits to all clinics a year, 700 are hospitalizations. Therefore, hospitalizations are only piloted for the most serious organic disease that requires assistance and are only a subset of the diseases that are seen in the ambulatory.
I: And which one do you prefer? The functional part or the organic part? In other words, are you most interested in the outpatient part or the hospitalization situation?
Answer: The scenary that I designed with all the collaborators is that of a transversal interest: everyone must know what is happening in the other ambulatories, everyone must be able to be a gastroenterologist at 360 degrees! However, some techniques require specific patient safety training. Sophisticated endoscopic techniques are limited to a few super-trained operators to reduce the risk of complications. If you tell me what interests me, well, I am interested in a little bit of everything! Think about the fact that the Nobel Prize went this year to the discoverers of the hepatitis C virus. Until the 1990s, we didn’t have drugs for a large part of hepatitis: we called it hepatitis not A not B. I wrote letters and papers to clarify whether steroid therapy could be of benefit then. And it wasn’t! When the first antiviral drugs were identified, an important thing happened: we saw with great difficulty first with interferon and then with the latest drugs, much faster, to clear the viremia, stopping the progression of cirrhosis towards liver cancer. Today, there are far fewer C-virus liver cancers that require transplantation. This is true in Italy and in Western countries.
Question: Sure. Listen, and how does evidence-based medicine and the relationship with the patient come together? That is, how do the protocols apply in clinical practice?
Answer: This is a good question! Now I try to make a summary. I organize courses based on evidence-based medicine. There are two scenarios to converge: the first scenery is the advancement of high-level clinical studies that can influence the quality of care, trials, studies with different treatment groups to understand which is the most effective intervention. This is a very fascinating field because there is a renewal of knowledge every two years. This is the area of evidence-based medicine with its meta-analyzes, i.e. systematic reviews of clinical studies, clinical trials, sectoral: how ulcer is treated, how cholecystitis is treated, how is it treated diverticular disease and comparative studies in order to adjust the knowledge from year to year. On the other hand, there is the relationship with the patient. The relationship with the patient is sometimes a failure. For example, it is estimated that the internist generally only takes 10 minutes for each outpatient visit, this is a study from 5 years ago. For the family doctor it was down to 5 minutes. 10 minutes is not enough, but the pressure to increase the number of visits for the budget exists. The patient requires superior attention. In the activity in the clinic we schedule today at least half an hour the contact for each visit. The very important issue is precisely that of the doctor’s art of connecting evidence-based medicine with a good relationship with the patient, to which the gains and risks of each therapy must be summarized. The art of the doctor today is different from that of the past. Once there was medicine based on the authority of the primary which is called, in joking terms, eminence based medicine. The director speaks and everyone adapts. Today it is not like that, it doesn’t have to be like that and it is a gigantic space where young people can grow.
Question: Sure. And there is also a slightly broader concept of health.
Answer: For example, one of the questions I start with every visit is about illnesses in the past. This leads to an interview about the life that the person in front of you is having. It is forbidden to stop at the symptom that the patient brings and to treat only this one in medicine. The important thing is to reconstruct the environment in which this person lives and take small forays into the social environment, because these are also important. That’s the stress part. You know how many people come with mournings, or with severe family stress. I’m talking about parent-child relationships and spouses, or stressful conditions, such as the burden of elderly parents. These problems gradually emerge at first contact. Stress covers a variety of problems. And so if the overweight patient opens the refrigerator at night, perhaps there are other reasons behind it: it is useless to ask him at what time he opens the refrigerator at night. Better understand why he opens it.
Question: So is a biopsychosocial model open to different variables widespread enough?
Answer: I don’t know how widespread the attention is. The transition is underway: I am talking about this model of attentive open colloquium with the patient, knowing well the progress of the literature in the pathology that the patient may have, and in communicating with him adequately. This model of the periodic updating of the literature, I am talking about evidence-based medicine, is not so clear yet. You will have noticed the variety of opinions that arise within this battle against COVID. For example, hydroxychloroquine, this great drug that Tramp proposed to take even by mouth, is completely ineffective; proven from evidence-based medicine shows that it is completely ineffective. The need for updating is quite sophisticated to avoid advertising pressures that can come from companies or politicians. There is an area of personal research that is indispensable. You should subscribe to journals or tools that report on trials and meta-analyzes and devote at least one hour a day to periodic updating through many channels, for example by subscribing to journals. A great help is given by Uptodate, a kind of gigantic manual of internal medicine, of which the different individual sectors are advanced for evidence-based medicine from month to month. We should bring ourselves to have these levels. Unfortunately these sources are not of free distribution to hospitals. Only some regions, such as Lazio, promote them. This is a very serious problem. Most universities have subscriptions to journals, to these tools, but in reality this should be more easily distributed to all the medical community, and not just the medical one: I am talking about nurses, physiotherapists, radiology technicians. I teach an evidence-based medicine course for physiotherapists: they are amazed. There are large studies documenting gains or non-gains from physiotherapy techniques already in use! There are studies that show how dangerous some osteopathic maneuvers are. In short, it is also a question of understanding what damage can be caused by therapeutic maneuvers. In my opinion it would be advisable for all family doctors to have access to subscriptions.
Question: What do you think about the link between stress and functional gastrointestinal outpatient diseases instead? Before you said that very often situations of mournings or conflicting family relationships can occur that can affect the pathology. So, do you use a psychologist in the department?
Answer: Well, the answer is yes. I’ll give you an example in my hospital. In my hospital, when I left a few years ago, there were 10 psychologists available. Today there isn’t even one. It is a very serious problem, because the presence of the psychologist, of the support activity in the ward, as well as in outpatient activities, is very important. There are, for example, organic diseases, such as cancer or chronic diseases, which require a psychological support program at the time of discharge. It is also difficult to get the patient to accept some disastrous organic situations. Psychological support is essential. This support for me, in private activity, is easier because patients can be referred to the psychologist I indicate, and quickly get support. This is serious talk. However, not everyone can afford a private psychologist. The problem should be tackled by strengthening assistance in the area, which is now destined to be enormously overloaded. Think about the fact that many psychiatrists of the social services in the area are resigning because the reduction in the number of doctors and psychology staff and the increase in cases implies an overload of work such that it is not possible to treat every single patient with dignity.
Question: Last question. Compared to a collaboration with the psychologist, I do not know if it happened more often that there was a referral to the psychologist for psychological care, including support to organic pathology, or in short compared to stress, anxiety and whatever it is. Have you ever participated in an integrated treatment, that is, did it happen to you that there was a slightly more joint charge? For example, I am talking about cases discussed with psychological staff or about a subsequent interaction compared to the referral?
Answer: The answer is yes. I have a frustrating but important experience for me. It was a group of alcoholic patients managed by a psychologist and myself in the period of starting work, that is, when I moved to Ancona. There were particular weekly meetings. It was a very interesting problem. These meetings don’t always get the attention they deserve. I know a lady with cirrhosis: she began with the psychologist to face tragic events in life that can happen. I’m talking about a twin suicide. For this she started drinking up to liver damage. We just saved her from liver failure. Now she has started drinking again due to severe pain in her shoulder and needs to be operated on. So we hospitalized her another time. We brought her back to abstention with the psychologist. We wouldn’t have done it alone. There is another field, this more theoretical one, in which we found ourselves, and that is systems medicine. There is the system of the intestinal microbiota; there is the system of psychology; there is the social environment system; there is the system of image techniques; there is the infection system and so on. These systems should all converge for better patient care. The best promoter in this workgroup is the psychologist. They are the strongest ones! Do you know that meta-analysis, the systematic review of sector studies, was invented by psychologists ?! It was born in the field of psychology! It’s interesting! From there it exploded into other areas of medicine! Of course, this discourse is a bit complex. It would be a question of redefining pathologies by “axes” (psychological, organic, image, laboratory, social, etc). Perhaps we are moving towards a new redefinition of diseases. No longer “I have an ulcer”, but “I have an ulcer in the context of social stress due to drug-induced diseases because I always have a headache”. The matter is a bit complex, but it is interesting.
It is the integrated framework that can allow you to take charge of the patient in an integrated way.
Translated from Italian by Adelina Detcheva