Working with Gastroenterologists

Gastroenterologists and colorectal surgeons share a common interest in the gastrointestinal tract but approach it from different perspectives. There are essential differences between surgeons and non-surgeons that color attitudes to disease and reflect the personality traits that go into choice of a specialty in the first place. Based on a lifetime of experience the stereotype of a surgeon is a dominant, forceful “captain of the ship”, used to making quick and sometimes critical decisions, and used to being obeyed. Many diseases can be cured by cutting them out and surgeons like these diseases most of all. Surgeons tend to look for surgical solutions to patient symptoms…the old “hammer and nail” philosophy. Gastroenterologists don’t operate. If they perceive that surgery is required, they must consult a surgeon. In general, theirs is a more relaxed, more academic way of looking at disease. The main roles of a Gastroenterologist are to make an accurate diagnosis and to prescribe effective treatment. Therefore, the work-up of the patient is extensive and the choice of treatment is carefully considered. Gastroenterologists are most distinguished from Colorectal Surgeons by their deep knowledge of the pharmacology of intestinal disease treatment. Medications are the Gastroenterologist’s scalpel and so here is their expertise. Ideally Colorectal Surgeons and Gastroenterologists complement each other to provide comprehensive and effective care of diseases involving the lower gastrointestinal tract. Practice has moved towards this ideal, with specialist centers in inflammatory bowel disease seeing surgeons and gastroenterologists intimately associated in evaluation and treatment. Inflammatory bowel disease is one area where the participation of gastroenterologists and surgeons is crucial. The most common indication for surgery in ulcerative colitis and Crohn’s disease is failure of medical management, and the timing of the referral can impact outcomes. If referral is delayed for the sake of trying one more ineffective drug, patients reach the operating room in poor condition and outcomes are affected. The close relationship between specialists possible in IBD centers prevents this from happening.

In my career I have adopted an unusual dual approach, partly surgical and partly Gastroenterological. Even as a medical student I was fascinated by the process of diagnosis, the rarer the disease the better. As a colorectal surgeon I have based my diagnostic algorithms on an understanding of the physiology and pathophysiology of the gastrointestinal tract. A knowledge of how and why an organ works is the foundation for finding why it is not working, and essential to finding the most effective treatment. This is an ideal background for understanding and treating functional bowel disease. My overlap with Gastroenterology was truly potentiated by my predilection for lower GI endoscopy. Despite an inauspicious start to an endoscopic career (I couldn’t get out of the rectum on my first flexible sigmoidoscopy) I seemed to have a talent for intubating the colon, recognizing polyps, and taking them out. In fact, it makes sense that colorectal surgeons, who handle the colon every day in the operating room and know its anatomy intimately, should be able to intubate it. My career emphasis on colonoscopy allowed me to bridge the divide between our department and Gastroenterology. This was important during the earlier days when there were sometimes conflicts between Chairmen, in particular concerning who was going to “own” the new disciplines of endoscopic ultrasound and anorectal physiology. A similar “turf war” often occurs for colonoscopy and flexible sigmoidoscopy, where even today some colorectal practices risk their referrals if they dare to scope. Fortunately, at the Cleveland Clinic there were plenty of patients for all. Colorectal Surgeons and Gastroenterologists come together in the management of many conditions, including colorectal polyps. Here, being both an endoscopist and surgeon offers patients the best of both worlds. The normal process is for polyps to be diagnosed and removed by Gastroenterology. Sometimes the polyps are too large, too awkwardly placed, too flat, or too suspicious for cancer to be within the Gastroenterologist’s comfort zone. These patients are referred to a polypectomy “expert” or to a surgeon for colectomy.