HOW TO BECOME THE BELOVED PHYSICIAN
By Dr. Bell
The pursuit of the Good Stool…is universal … But even for those where regularity is the norm occasions do arise where the need for and the desire for the“Perfect Stool”becomes paramount. Yet what can be considered almost a universal “CC” i.e. chief concern …the quest for satisfaction on the stool is hardly emphasized as part of the medical curriculum…except to emphasize the still common aphorism which I first encountered in an early edition of Goodman and Gilman…The prolonged and habitual use of laxatives is deplorable and unhealthy!! …. As best as I can tell this dictum has led to… like so many other medical dictums which do not consider the human condition… in this case the pursuit of the perfect stool.. to a happy bunch of advertisers and laxative purveyors who love the lucre in laxatives!!… but we are do not pursue lucre for itself …instead our first pursuit is to become The Beloved Physician…
So how does a PGY49 pursue becoming a beloved physician???
Here is how it can be done… first ask the patient what they have done in the past in their pursuit of the good…stool!…and if they smile remembering what worked then encourage them to try again…
I should note that for years EX-Lax was at least in the Bronx the laxative of choice…it contained what is referred to in the pharmacological literature as the stimulant laxative phenolphthalein I never was satisfied with the explanation as to how stimulant cathartics work but it is alleged that they work by stimulating the accumulation of water and electrolytes in the colonic lumen…they probably effect the transport of Na and K and also increase the synthesis of the prostaglandins which effect intestinal motility. In any case the favored stimulant laxative of the old Bronx has been removed from the over the counter market by the FDA… I t was removed because it caused cancers in rats and mice… I did not see the article but it would seem a bit strange that for drugs that have been used for a hundred years there would be some evidence of an adverse event on humans. …anyhow it is gone and I will miss it because it was good for roundsmanship!!! It turns out that when it was used ubiquitously phenolphthalein was a much common cause of Red urine than porphyria…. because as you may recall phenolphthalein is an indicator which turns red in an alkaline medium… It is partly excreted by the kidneys and if the urine is alkaline it turns it red… so when people would begin to pontificate on porphyria …I always demonstrated “that the porphyrin in the urine” was in fact from Ex-lax…it was Phenolphthalein . This pH indicator was also excreted in the bile and on occasion when stool hit starched sheets … sheets were starched years ago!! … the alkalinity of the sheets also made for colored stools…and so here was another opportunity for roundsmanship which is now lost!!
There are many other “stimulant laxatives” available… the one, which is similar to phenolphthalein and is in our in our formulary, which is cheap and WORKS and is popular among our patients, is biscodyl…or dulcolax… Patients like it…. the dose as with most drugs like antihypertensives where outcome is the issue here too outcome depends on the response… It is usually somewhere between three and four 5 mgm tablets…. People have to be told how to use them …particularly because there is no set dose… It usually works in six to 12 hours so it should be given during the day although most people will decide when it is best for them … the suppositories also on the formulary work … sometimes they require two rather than one… Dulcolax suppositories will in some people cause a mild proctitis and can be associated with increased mucous and mild proctodynia.… but when that happens as with any drug, which affects the patient in a perceived or actual unfortunate way…,the patient will no take the medications!! Remember it is easy to prescribe things but it is the patient who decides on whether they are going to take the med.
There are two other “stimulant laxatives” that are very popular…they are anthraquinone derivatives… One is cascara and the other is senna as in Sennakot…both but particularly cascara was popular in the Bronx…..These drugs along with aloe and bile salts are sold as OTC in original and many combinations.. They are constantly being changed and there is money to made in the pursuit of the Perfect stool.
When someone tells me in a very depressed voice that… in very old usage they say I feel “lowgie”… or more recent usage “I am stuffed”…. or in most recent lingo… “I’m really constipated”… I will suggest something that is not on any one’s radar screen any longer… some might suggest that it is not the favorite of patients … that is at least until they get themselves cleaned out…the laxative I refer to is castor oil!!!….for the elderly castor oil is remembered as what mothers gave to children to make sure they were clean!!!… ugh is the usual response… People don’t like castor oil initially because it is hard to hide it’s taste and because it does cause terrible cramps.. But I am told it is worth it... It is impossible to give an overdose of castor oil because it is hydrolyzed in the small intestine to ricinoleic acid, which instantly stimulates intestinal peristalsis and reduces the net absorption of fluid and electrolytes in the small bowel.. As soon as it acts… it gets rid of any remaining unhydrolyzed castor oil… it empties the large and the small bowel completely… and is in reality… if anyone bothered to do a RCT (a randomized controlled clinical trial) it is better than anything for emptying the bowels including expensive alleged laxatives such as GoLightly …it works rapidly within one to six hours so that if it is to be used before a colonoscopy it should be given in the early evening or late at night… most of the time people say thank you in spite of the cramps ….You can guarantee stooling for those who want to be cleaned out or for those who sadly have organic causes for constipation such as strokes or extra pyramidal disease… A major problem for people with Parkinson’s is Constipation…and the neurologist frequently ignore it….it is then that you can become the beloved physician… People with strokes also will have a problem as well.
In the old days you would hear the admonition that one should not use castor oil if intestinal obstruction or an acute belly was suspected… this kind of admonition which persists in other forms till this day is indicative that the people who write articles with such admonitions agree that going to medical school knocks common sense out of people… really… who would suggest castor oil to someone with an acute belly or symptoms suggestive of obstruction???
Currently the most popular laxatives are the saline laxatives… they are Epsom salts which is magnesium sulphate.. And milk of magnesia which is an aqueous suspension of magnesium hydroxide… milk of magnesia works but the dose that is recommended is too small… if someone is on it and says it doesn’twork… I suggest they drink a whole bottle …which almost always works. The other popular saline laxative is Fleet’s phospho soda.. Either as an oral solution or most commonly as Fleet’s enema…from either end some people find it effective but many do not…It should be called by what it is …SODIUM PHOSPHO-.SODA. And it is definitely contraindicated in people with CHF. There is a syndrome that I call Fleet’s pulmonary edema which is a sometime cause for acute left ventricular failure in hospitalized and unhospitalized patients!! The saline cathartics and the osmotic cathartics work because they are poorly absorbed and thereby act osmotically drawing fluid into the lumen of the intestine… GO-LYTELY a most expensive and heavily promoted osmotic and saline laxative reminds me of other brilliantly marketed and highly profitable drugs with similar names such as AntiVert… Flo Max.. The use of such names and I can think of many others demonstrates that the pharmaceutical industry thinks that doctors are as willing to buy snake all as are all consumers!!!… in how Go LYTELY is an isosmotic solution of polyethylene glycol sodium and potassium salts… Which are allegedly not absorbed… the sodium salts are sulfate, bicarbonate and chloride it may be that combining them with polyethylene glycol prevents their absorption…. but I think it is a poor idea to prescribe a laxative for someone with CHF which contains lots of Sodium…besides which many people find it does not work and many others find drinking tons of fluid (4 liters!!) difficult…
Lactulose is also an osmotic laxative, which is not one of my favorites…. It too is expensive… It is a synthetic disaccharide plus some galactose and fructose… on the one hand the PDR says it is “poorly absorbed and no enzyme capable of hydrolyzing (the synthetic disaccharide) is present in human GI tissue” …on the other it says it should be used with caution in diabetics”… this is a good example of marketing hype which as you know I resent… I don’t use it… there are better treatments for hepatic encephalopathy!!…
Colace and other alleged stool softeners are popular with doctors and some patients… I consider them to be largely placebos… but since we are into outcomes they certainly satisfy some patients!!. The idea of stool softeners is drug company palaver… they are thought to be analogous to detergents…. the gospel is “they reduce surface film tension of interfacing liquid contents of the bowel promoting permeation of additional liquid into the stool to form a softer mass””.. now what does that mean? irrespective of the palaver for those people who like Colace I say why not….
My mother had as a life long friend Caroid with Bile Salts which is a combination of cascara and dehydrorocholic acid … As I have mentioned cascara is a stimulant laxative… it in addition to its effects on Na K and ATPase may also increase colonic motility by an effect attributed to stimulation of Auerbach’s plexus…. Dehydrocholic acid and other bile salts are similar to both anionic surfacnts and to stimulant laxatives they reduce net absorption of water and electrolytes and cause diarrhea if they escape ileal absorption…. Anyhow she swore by it…it is still available …so why not …
Mineral oil is mostly messy but people use it… I have been brain washed inappropriately of course that if aspirated it is bad news …but as with many of these no-nos I have never seen a case of aspiration of mineral oil!!.. so what do I recommend to become the BELOVED PHYSICIAN… It is PSYLLIUM SEED in the Form of METAMUCIL. Without question educating patients on the wonders of Metamucil will allow you to receive all kinds of encomiums of which the one I have accepted from the first chair of pediatrics at Einstein. The Beloved Physician!!
Metamucil is a form of fiber and is expensive but if you consider the cost of cereal like bran it is in the within the same ballpark as breakfast. Metamucil binds water (you can see this in the glass) to make a gooey chump but in the lumen of the gut this gooey clump gives substance, or, to be scientific, bulk to the stool… the amount of bulk can be adjusted by the dose.. Which can vary widely but makes the stool quality soft.. the right amount produces the “Good Stool”.. as in doctor you have saved me!!!.. . a prominent side effect is that Metamucil and other fibers bind bile salts.. this reduces their absorption in the ileum promotes their excretion and maybe produces a mild cathartic effect. Excreting rather than reabsorbing bile acids enhances the hepatic synthesis of bile acids from cholesterol and reduces plasma cholesterol!! Metamucil is in effect cholestyramine. Metamucil has other salubrious effects besides the patient informing you with a broad smile in their face…” I don’t squeeze anymore..it just plops out!!!”…. It is useful for treating and preventing hemorrhoids and fissure in ano…it is also recommended because bulk-forming agents decrease intraluminal pressure meaning… Metamucil can be used to prevent and treat diverticular disease and whether it does or doesn’t’ it is something that I tell the patients…but its most efficacious indication is for the population that is most dissatisfied with their stools these are the people…. frequently very successful people… who are given the diagnosis by what most call the irritable bowel syndrome and which I think of as the Dissatisfied Stooling Syndrome!!…these are the people who are the quintessential stool gazers and describe their stools in graphic detail.. such as like pellets ..little balls… or diarrhea (meaning not well formed) .. or mushy and on and on.. these are the people who when you teach them how to use Metamucil will certainly think of you as the BELOVED PHYSICIAN.
And think of it unlike Lotronex (alosetron) or Tegaserod it does not kill people!!!
Here are the detailed instructions for people who travel and miss their home stool, people with hemorrhoids, diverticular disease, stool gazers, irritable bowel patients, and those with the dissatisfied Stooling syndrome.
1. Metamucil is not a drug. It is a natural occurring seed.
2. The amount necessary to have the perfect stool varies among all peoples.
3. Start with one heaping teaspoon in a full glass of water repeat for a total of two heaping teaspoon. A third glass of water is helpful
4. If two are insufficient to produce the perfect stool then the amount of Metamucil can be increased. Some people take Metamucil in the morning and the evening. There is no possibility of taking too much!!. The right amount is what gives you the PERECT STOOL!
Enjoy Yourself!!
I recently checked to see how many laxative preparations are sold in our country….Believe it or not the Micromedex lists 210!!
I would now like to say a few words on the Irritable Bowel Syndrome. All of you are at the beginning of a new era in pharmaceutical marketing. As you may have heard in the past… GERD is allegedly new disease promoted by the pharmaceutical industry to market PPI’s. PPI’s were last year the largest group of drugs sold.13 billion dollars. That is a lot of money for heart burn and a lot of money for preventing a disease which affects a very small group of people…that is those with Barrett’s epithelium and those who develop adenocarcinoma of the cardia. ..the point is that GERD is not a disease…it is due to a normal physiologic event..the relaxation of the cardioesophageal sphincter…, which can also be affected by drugs and anatomy such as a hiatus hernia… Suffice it to say that everyone has on occasion heartburn, which is well treated with antacids…such as wow sodium Bicarbonate .. The Medical Letter recommends for those with frequent heartburn.. an H2 Blocker such as Cimeitidine and Mylanta but the reason I bring this up is that the pharmaceutical industry now is getting ready to promote and sell Tegaserd which “targets serotonin receptor subtype in the intestine and has been shown ( in pharmaceutical company advertising to relieve IBS patients bloating, abdominal discomfort and constipation significantly more than placebo!!”.. the drug costs $2.00a pill and must be taken bid…. While it is approved woman with IBS-related constipation it will believe me be used for .bloating ,abdominal discomfort and constipation in all people and maybe dogs and cats.. The second drug is Alosetron..it is another good example of the power of the pharmaceutical industry…The FDA originally approved the drug in Feb of 2000 for woman with diarrhea predominant IBS ..the FDA took the drug off the market after a number of people died from Ischemic colitis…and others were adversely affected… the pharmaceutical industry has been able to get patient’s who claim that this drug is the only thing to control their symptoms of diarrhea ( as part of IBS the drug is being put back on the market with interesting restrictions… Physicians prescribing alosetron must register with the drug’s manufacturer and educate patients about risks and benefits…the patients must also sign a consent form before using the drug!! The dose of the drug has been reduced to ½ of what it was when introduced and it is indicated only for diarrhea… In any case this too will be part of the new IBS pharmaceutical industry bonanza.. I predict at least three billion the first year.. so what about IBS… IBS has been around for a very long time…If you look in the Journal of Clinical investigation in ? 1963 there is an article on compliance of the large bowel by ..me among others.. forty years a go we were trying to find an etiology?ies for IBS and we are still trying.. the best we have come up with are the so-called Rome II Diagnostic criteria for irritable bowel syndrome…”The Rome 11 criteria define the irritable Bowel Syndrome as abdominal discomfort or pain for at least 12 weeks (not necessarily consecutive) in the preceding 12 months, with two of the three following features.
1. The pain is relieved by defection.
2. Onset is associated with a change in the frequency of the stool.
3. Onset is associated with a change in the form(appearance ) of stool. The Rome 11 criteria state that the following symptoms cumulatively support IBS diagnosis:
The Rome 11 criteria state that the following symptoms cumulatively support IBS diagnosis:
1. Abnormal stool frequency( for research purpose, “abnormal” may be defined as greater than three bowel movements/day and less than three bowel movements /week)
2. Abnormal stool form(lumpy)/hard or loose/watery)
3. Abnormal stool passage (straining, urgency or feeling incomplete evacuation):
4. Passage of mucus:
5. Bloating or feeling of abdominal distention.
6. These criteria were published in Gastroenterology in December 2002. They were published in this era of evidence-based medicine. This is a good example of pure stool and the dominance of the pharmaceutical industry.
I do my best with patients who are unhappy stoolers, stool gazers and dissatisfied with life.. I try to deal with acute and chronic anxiety, the awareness syndrome and the various concerns, which bring patients to doctors. I think that there are many people where we don’t know what it is precisely which makes them think that we have the answers . I do know that the answers are not among the many nostrums promoted by the pharmaceutical industry.
