LAUSR

When I completed my training as a gastroenterologist—a long path starting with premedical curricular requirements, medical school, residency, and fellowship—I assumed that I was well prepared to take care of patients. I was therefore surprised to find that patients were asking me about conditions that were totally foreign to me: “Do I have a leaky gut?” “Should I be on a Candida diet?” Similarly, I found myself awash in unfamiliar terms when asking patients about their supplement use: Coenzyme Q10, black cohosh, apple cider vinegar, and countless agents I had never heard of. A search on PubMed would yield either no studies or studies suggesting a lack of effectiveness for the agent in question. It became apparent that I would need to develop a strategy, akin to the approach to the patient with abdominal pain or rectal bleeding: I would need to develop an approach to the patient who inquires about, or is heavily invested in, the category of treatments I call “non-evidence-based medicine.” Any physician with patient contact inevitably encounters unproven diagnostic techniques and therapeutic approaches, but gastroenterology is particularly replete with them. At any given moment, there are bestselling books vilifying a particular food group or ingredient or prescribing a diet to promote weight loss, counter inflammation, or cure or prevent diabetes, depression, arthralgias, fatigue, or a host of other maladies. Patients may present to the gastroenterologist with a stack of test results indicating various food intolerances based on unproven methodologies. The proliferation of such tests is a consequence of the current unsatisfactory state of affairs regarding the existing diagnostics and therapeutics for gastrointestinal disorders, particularly those of a functional nature. A patient with newly diagnosed irritable bowel syndrome, after having had a full evaluation for structural pathology, may feel frustrated that “none of the tests showed anything” and seek out testing outside of “mainstream” medicine in order to validate a basis for his/ her symptoms. The fact that the majority of patients with functional gastrointestinal disorders note a link between food and symptoms [1], coupled with the lack of proven diagnostic tools to identify specific triggers, permits the proliferation of unvalidated tests to fill the vacuum.