Patient demand is so high for GI psych – Dr. Riehl (Michigan) and Dr. Simons (Cleveland Clinic)
Patient demand is so high for GI psych – Dr. Riehl (Michigan) and Dr. Simons (Cleveland Clinic)
While COVID was on and people sought help through meditation apps, the business world of behavioral health made a big announcement. Headspace (an app started by a former Buddhist monk) merged with Ginger.io to create Headspace Health in a $3 billion merger. You read that right.
It’s only natural that behavioral health showed up in gastroenterology. Curious, I reached out to GI psychologists Dr. Megan Riehl from Michigan Medicine and Dr. Madison Simons from Cleveland Clinic. What were these large institutions up to in this space? Why were they hiring psychogastroenterologists? Was there patient demand for something like this? What role would cognitive behavior therapy play in digital health?
Well, this is an evolving space with high demand – especially for those GI conditions that don’t have straightforward solutions. Mental health and its role in the making and management of GI conditions is a space to watch. Explore if this could be a brand new ancillary for private practice GI. Well, the brain-gut axis has a significant role to play in GI’s future (watch this one)
Praveen Suthrum: Megan Riehl and Madison Simons, warm welcome to the Scope Forward Show. We are getting together a group of innovators, leaders who are doing things differently in Gastroenterology. And I’m really excited to have you. And we are going to be talking about a very important topic. Really looking forward to learning more. Thanks once again for being here.
Dr. Megan Riehl: Thanks for having me.
Dr. Madison Simons: Thanks for having us.
Praveen Suthrum: Before we get started, let me share your background with everybody. Dr. Megan Riehl is a GI psychologist and Clinical Director at the GI Behavioral Health Program at the University of Michigan and Director of Behavioral Health Services for Gastro Girl and GI onDemand. Dr. Riehl’s current interest focus on the application of digital therapeutics in GI. She participates on several national committees dedicated to research and education to enhance the psychosocial functioning of patients with GI problems. And Madison, you’re a GI psychologist in the esophageal and motility GI clinics at the Cleveland Clinic. Her clinical and research interests include understanding the determinants and consequences of dietary modifications in patients with digestive symptoms. Fantastic backgrounds, and I’m really glad to have this conversation. But I want to start with some basic, really basic questions about your field. So what is psychogastroenterology? It sounds very cool, but what is it?
Dr. Megan Riehl: It’s really great to be here and have this conversation with Dr. Simons and you Praveen. So psychogastroenterology is a field that has really evolved over the last couple of decades, but really we’ve seen an emergence of really exciting research around the application of psychological interventions for the treatment of gastrointestinal issues. So we call these interventions brain gut behavioral therapies. And it kind of encompasses the field of psychogastroenterology, where we work as expert GI psychologists, kind of fitting into a multidisciplinary approach with patients with a variety of GI conditions. So the bulk of the research has been done in kind of the functional GI world or disorders of gut brain interaction. But we have really exciting research that has been happening in inflammatory bowel disease, esophageal conditions. And so really, we’re finding that our treatments are pretty effective no matter where it falls in the gastrointestinal tract.
Praveen Suthrum: Does it have to be very specific to the GI tract? Could it not be broader psychology that might also apply to the GI tract?
Dr. Madison Simons: Absolutely. It could be underlying mental health conditions like anxiety and depression that could be exacerbating the GI symptoms. But I’m sure Dr. Riehl can attest to this as well. If the underlying mental health condition is very severe, then our specific GI interventions are not going to be as helpful. So in that case, we would pull on a colleague who is trained to deal with anxiety or depression to address that first and stabilize it so that our GI interventions can be really targeted to the GI tract. I think we’re going to be talking about the patient demand for our services, and it’s so high just in addressing GI symptoms that we’re really better suited to use our expertise for the GI symptoms and allow other colleagues who are specialized in anxiety, depression, trauma to treat those conditions.
Praveen Suthrum: You’re saying there is a lot of patient demand for the services that you offer. Why and what kind of patient demand?
Dr. Megan Riehl: Well, I think we work in tertiary care clinics, and so I have over 100 gastroenterologists and trainees that can refer to our behavioral health program, and I started out as an N of one. And over the last couple of years, there’s now three of us full time, working to kind of meet the demand of our patients. And I think that once I started back in, I think, 2014 at the University of Michigan, once the program is built and established and providers begin to see the value that you bring in terms of helping to reduce healthcare utilization, patients that have been suffering with symptoms for decades that haven’t responded well to medication or even diet therapy, our behavioral interventions tend to be very effective for those refractory patients. And so in a fairly short period of time, anywhere from five to seven sessions, the patients get better. And so that kind of bumps up our referrals, and we form a very collaborative relationship with our referring providers and really work from multidisciplinary perspectives. And patients also find that to be really nice in terms of their gastroenterologist isn’t expected to fit all of the demands of a patient. We oftentimes run wait times, and that’s why, as Dr. Simons said, making sure that the appropriate patients are referred to us is going to help to kind of not not create any bottlenecks in our referral streams.
Praveen Suthrum: What kind of patients are you seeing or what kind of conditions are you seeing Megan?
Dr. Megan Riehl: A lot of patients with irritable bowel syndrome, inflammatory bowel disease, GERD, different esophageal conditions, it’s always fun to use. We have Esophageal hypnosis protocols that are really effective for functional Dysphasia Globus. So some of those really difficult to treat conditions our behavioral interventions can be really effective for, but also some of the gastroparesis, some of those patients are going to be appropriate for us. Some we’re probably going to refer out or really need to work within the context of integrative team. But you name it, we can probably add something to the treatment plan that patients are going to find valuable.
Praveen Suthrum: There are about at least six or seven encounters. What exactly happens in these encounters, and what is the care pathway looks like?
Dr. Madison Simons: Dr. Riehl has been with UOM for the last eight years. And that’s how most of the behavioral medicine programs are run, where all of the gastroenterologists can refer to you, and then it builds up quite a bottleneck of patients. I was brought to Cleveland Clinic to work with two gastroenterologists specifically, though I don’t know how long it will stay with just two. And their ideal model is that I would see every patient that they see, which also is not feasible for an N of one, because our sessions are longer, and we see them for more follow up sessions in a shorter period of time. But I’m working exclusively with patients with gastroparesis and Motility or Esophageal conditions. So both organic and functional conditions that are Motility related and Esophageal related and gastroparesis. So a typical model this is likely similar across centers, would be to see a patient for an intake evaluation about 60 minutes, where we go through not only the GI symptoms, but how those symptoms have impacted a patient’s quality of life, their ability to eat, their sleep, their ability to do the things that are enjoyable and meaningful to them and how their pain has affected them. And from there, we come up with a treatment plan, like Dr. Riehl said, anywhere from four to ten sessions or so. At Northwestern, we were piloting an intervention based on increasing psychological flexibility. We were actually playing cognitive games to get out the thought patterns that were affecting a person’s GI symptoms and how their GI symptoms affected their thinking. So the traditional cognitive behavioral model had patients monitoring their thoughts, monitoring their symptoms, and their emotional reaction to symptoms. And we used this in worksheets that we would get. And this is how cognitive behavioral therapy has been practiced for a long time. But this new intervention we were trialing at Northwestern, where we were playing games with the patients and identifying thought patterns in vivo in the moment proved to be very, very effective. And patients were very agreeable to it. They didn’t feel like they were in a psychotherapy session, and so there wasn’t the same resistance that we might see. But I’m not crazy, and it’s not all in my head. And in that treatment, we were actually working with all organic conditions and a functional Dysphasia group. But mostly this was Achalasia and Eosinophilic, Esophagitis and GERD. And we saw even improvements in symptoms in these organic conditions by identifying thought patterns and helping people challenge them to become just a little bit more flexible with how they view symptoms.
Praveen Suthrum: Are you doing this in a group, or is it always one on one?
Dr. Madison Simons: Its one on one. And we were administering it virtually via zoom, just like this to expand access. It was necessary because of COVID, to do it that way. Helped give us data that virtual treatment does work. But, yeah, it was all one-on-one sessions. We did it in a four-session protocol and saw improvements in symptom severity, quality of life, and symptom anxiety, which we’ve consistently seen as a primary driver in symptom severity across GI conditions.
Praveen Suthrum: You talked about using games. What kind of tools do you use? Are these developed by third parties? Do you just borrow what’s out there, or do you work on creating your own?
Dr. Madison Simons: The original game, so to speak, came out of what’s called cognitive remediation therapy. This was originally designed to build people’s cognitive flexibility. So we’re doing tasks like showing people an optical illusion, and then we ask them, what do you see in these images? What kind of strategies do you use to find more images? And then the question turns to you pay too much attention to one aspect of those pictures, you might miss out on other parts of it because there’s multiple things there. And so in daily life, are there times when you pay so much attention to one aspect of your symptoms or one aspect of your functioning that you miss out on the other parts of it? So it’s kind of guiding people through, seeing where their thought patterns and attention patterns may be impacting your symptoms.
Praveen Suthrum: Megan, now you’ve worked for several years in the field. What are the insights that you’ve taken away that have been surprising for you personally, having applied the field and seeing so many patients? What have you personally taken away?
Dr. Megan Riehl: Yeah, so as Madison is describing, the intervention that they’re using is really getting at the idea of helping patients to decrease their visceral hypersensitivity and awareness to their symptoms. And over the years, I’ve learned how just explaining some of that to patients is so powerful. So she also mentioned that sometimes there can be reluctance on the side of the patient if the idea of working with us isn’t clearly explained in terms of, okay, my gastroenterologist is referring me to a psychologist. Why? How does that fit in? We have done, and probably Madison and her colleagues at Cleveland Clinic, a lot of education of our referring providers on how do you explain when you’re making the referral to a psychologist, how that person is going to help the treatment plan. It’s not that you’re making up your symptoms. It’s not that you’re psychologically damaged. It’s that that psychologist is really going to help her hone in helping you to manage your symptoms in different ways. And so when the patient gets to us and we’re able to spend a session explaining brain gut dysregulation, and that when you feel your symptoms, it’s not that you’re making them up, it’s that they’re really real. But it’s that the communication between how the brain is picking up those symptoms and focusing in the serial hypersensitivity and hyper vigilance, and then your gut ramps up and sends signals up to the brain, and then we have just this loud, disregulated conversation happening. We’re going to work to decrease the awareness of those uncomfortable sensations using some tools and strategies, and we’re probably going to be able to reduce the frequency, duration, severity of your symptoms in a pretty short period of time. And so being able to watch our evidence-based interventions work over and over and over and even if a patient doesn’t have complete alleviation of their symptoms, their confidence to manage their symptoms get better and so personally rewarding as a clinician to watch people get better and to sometimes have them say, gosh, I wish I would have had this 30 years ago. I’ve been suffering for 30 years with these symptoms. Or and I work on a college campus to teach patients and work together to learn strategies that as they’re graduating from the University of Michigan and going off to do wonderful things in their life, that they’re going to have some really concrete skills that will help them live a healthier lifestyle. So I think that if you would have told me in my graduate training I’d be doing gut directed hypnotherapy and talking about GI issues for my career, I probably would have said you’re nuts. But I got into this field at a very early age in my career and it’s really just been fascinating and rewarding and exciting.
Praveen Suthrum: I’m curious from the gastroenterologist side, I get it from the patient benefits, but do you get now you have a wide stream of referrals, like over 100 GIs. So do you get referrals from the same GIs again and again or the other gastroenterologists? Is everybody open to it?
Dr. Megan Riehl: I think yes. So when I first started at Michigan and actually Dr. Simons and I both trained at Northwestern University, so it was a very established program. And so I took models of that to the University of Michigan, and they had never had a GI psychologist and a lot of places have never had a GI psychologist. So a lot of us that are doing this are coming in and doing program development and working on a business model and referrals and really is kind of field of dreams. If you build it, they will come because once one patient has some results and they see like, oh, wow, that person’s inbox messages decrease significantly, that works out for me pretty well. That certainly gets buy in. But I will say what’s been really kind of fun and fascinating is that we have a fellowship program and so our fellows are coming in with this very multidisciplinary approach. They can refer their patients to our GI dieticians. They can refer them to our GI behavioral therapist. They can refer them to a physical therapist. And so then when they’re going and they’re potentially looking at different places in the country, they come back and they’re like they’re not a psychologist. So when I’m thinking about my package and the hospital system I’m building in that I want to build a behavioral health program because we need that, especially if you’re a motility specialist. So it’s kind of fun. That the expectation for clinics or private practices that if somebody decides to go into private practice, they’re thinking about how do we either form connections with mental health providers in the community? That could be a referral stream for us until we potentially can get a GI psychologist. But it’s on the mind. It’s very much now kind of this expectation that if you trained with somebody, you’re going to want that in your clinical practice because you can’t fathom that it wouldn’t be somebody that you could collaborate with.
Praveen Suthrum: How many GI psychologists are there in the country?
Dr. Megan Riehl: Just over 400 worldwide. The Rome Foundation has a special subsection of psychogastroenterology. So we do have a provider directory and they vet kind of who goes on the directory based on expertise. And there are just about a little over 400 members around the world. So not enough when we think about there’s 40 million Americans with IBS, and that’s just those with a diagnosis.
Praveen Suthrum: Both of you work at really large institutions that also do a very good job administratively. So my question, Madison, and we can start with you, is it obviously has to make business sense for a Cleveland Clinic or for the University of Michigan, right? So how does this make business sense? As in, do you get reimbursed for these encounters? Does it make up for the other types of reimbursements that the hospital could be getting? So what does that look like?
Dr. Madison Simons: Megan would be able to give more specific numbers to this. But I know at the Cleveland Clinic, they do have one psychologist who preceded me here in inflammatory bowel disease for the billing for that person. It covered salary, office space, all those things, the amount that he was reimbursed for care. But the peripheral effects is that it decreased hospital admissions related to inflammatory bowel disease. It reduced emergency room visits and reduced the amount of outpatient visits for these patients who were involved with the psychologist. And so established value within the medical care isn’t tangible to just directly what’s being reimbursed by the psychologist. At Cleveland Clinic, I’m working with the surgical transplant team for Dysmotility patients. And so we’re hoping we’ll see value in that way and have even been incorporating hypnosis into colonoscopy to reduce the amount of medications needed during conscious sedation for patients, to make this better patient experience and reduce the costs associated with that.
Dr. Megan Riehl: Yeah, I think Madison is highlighting some of the there’s a lot of different places where we can see value. The nuts and bolts that I think a lot of administrators want to know, though, is are we going to run in the red? And they don’t want to carry that for too long. And the reality is, in a lot of the programs, especially if we are purely clinical, most of my colleagues do not do research at Michigan, and so we are seeing a high volume of patients and their insurance covers it. So in most cases, we’re seeing patients that are not paying out of pocket. It’s covered by Medicaid, Medicare, private insurance. And so, you know, we’re covering salary space. Quite frankly, we’ve been virtual for the last two and a half years. So I’m coming to you from my living room office that I’ve been seeing patients in for the last, however, march 2019 or 18, no, 2020. It’s something that we can cover our costs, and patients are also able to get it covered in most cases. Now, granted, state by state insurance coverage can vary, but the majority of the other programs around the country are utilizing a similar model for at least the clinical side of things. And then a lot of GI psychologists also have some carved out time that maybe they’re covered under research. So they’re maybe 60% clinical and 40% research. And so then they’re applying for grants or working under somebody else’s grant to cover the rest of their salary and time, especially in the private practice sector. They probably wouldn’t be doing research, and you’d be seeing a high volume of patience and likely covering your whole salary.
Praveen Suthrum: Talking about business models, it takes us into the realm of digital therapeutics. And there are a lot of digital health startups that are taking advantage of cognitive behavior therapy. And the way I observe it is it’s being packaged into an app, or people are there behind the app or behind the digital model itself. FDA, for its part, has been approving some of these therapeutics as well. And we see some examples of that even in GI Mahana Therapeutics, for example, that’s a company that comes to mind. There are others in the pipeline. What I’ve also found fascinating is a gastroenterologist wrote a book called VRx, and it’s virtual reality therapy. And when you actually dig a little deeper I’ve interviewed him, and when you dig a little bit deeper into VRx and why some of these applications are getting approved by FDA, it’s all, again, cognitive behavior therapy packaged very differently. Again, as a lay person, that’s how I’m reading this. I’m curious to know what you can share about this evolving field of digital health in the realm of GI psychology.
Dr. Megan Riehl: I think there’s so much promise in the use of digital therapeutics, but it’s very much it feels like we’re kind of building the plane while we’re flying it right now. That it’s happening, it’s out there. But the model of how and who we get patients who is the right person for digital therapeutic, how do they get it? Because you’re right. Mahana IBS is a very different model from a Nerva. Both treat IBS. Nerva uses gut directed hypnosis, and anybody can download it from the app store. Mahana IBS is a prescriptive. So in order for the patient to get that digital therapeutic app, the gastroenterologist has to write a prescription for it, and so insurance will cover it. And again, that’s really cool. It’s a really cool business model and I think it’s really attractive to patients. But we now as GI psychologists and as a field of psychogastroenterology, we have more education to do in terms of a patient that’s not appropriate to see Madison or I in person because they have untreated mental health symptoms or a trauma history or substance abuse. And they really will benefit from establishing with a comprehensive mental health provider to stabilize those symptoms. That patient really should not be prioritized to a digital therapeutic. And so if they can get their hands on it, though, and they’re coming to the gastroenterologist saying, hey, should I use this? Like, what do you think? We have to educate the gastroenterologist on this. So we’ve been educating gastroenterologists on what we do as GI psychologists since the beginning, and we continue to do that. And it’s fun and it’s actually something I enjoy in terms of talking about how can we collaborate together, and especially for patients that have been suffering. So I think this is just another area where we’re going to be a part of these conversations and working together with the digital therapeutic companies to help them understand this space. Because a lot of times they’re not necessarily GI psychologists that are putting this together. They’re consulting with us. But so far, in my experience, these companies are very open to talking with us who are really in the trenches of delivering these interventions and have a very good understanding of the patients that we’re using our brain gut behavioral therapies with. So, you know, long story short, it’s really exciting and innovative and unnecessary thing when it comes to improving access for our patients. But we still have a lot of work to do in terms of getting the right patients into utilizing these therapeutics.
Praveen Suthrum: So where is the field going? What do you anticipate seeing in the future?
Dr. Megan Riehl: I think Madison is the future. I think the work that she’s doing is innovative, it’s exciting, it’s engaging with patients. Tell us where you’re going because that’s where I want to go.
Dr. Madison Simons: I think the biggest challenge from here is that there are so few of us. And so what I’m hoping to do at Cleveland Clinic is starting to develop a triaging model that really cycles. Who is the most important patient that we can see that I’m not the only one having patients referred to me? Are there different ways that we can provide services to people? My interest area is also in the dietary modification patients. Almost every patient that I see has changed their diet in some way, and my interest is in the metabolic consequences of that. So, yes, the behavior, we perceive that as normal. That would be a very normal reaction to vomiting all the time, having a lot of diarrhea. I think you would do the same thing and so normalizing that behavior, but helping patients reestablish what is nutrition that’s going to support me? Can I develop different flexibility around eating? So like right now I’m looking at blood sugar and Glycemic variability and inflammatory bowel disease and how that might be related to symptom severity. So looking at now, okay, the diet has been modified and what are some of the downstream effects of that? Outside of just weight loss or nutritional deficiencies, which may only come out in some people, we know that many more people are changing their diets. That’s the direction that I’m headed. And I hope that we can have a treatment that’s specifically designed for anxiety and fear around eating. A good amount of literature on avoiding restrictive food intake disorder, but I see it as a little bit different than that. A broader group of patients for whom it’s normative to change their diet. Can we still help them with that?
Praveen Suthrum: Megan?
Dr. Megan Riehl: I think that the innovation of digital therapeutics is certainly something that is happening. It’s unfolding right now, how that all shakes out. I’m still really interested and I think we’ve got a lot of work to do in terms of really helping to educate both patients and providers around. How to utilize these? And certainly I don’t think that those of us seeing patients in person or virtually, we’re not going to not have work to do. So I think that there’s a lot of marrying of different things that will help. For example, we typically see patients for that few sessions and having additional resources to help them over the long span of their life and helping to build lifestyle changes that are helpful for the management of their IBS or their IBD or gastroparesis. We want to teach them things that are sustainable. Also, I think with different insurance billing models that are changing fee for service and outcomes, I think that having tangible resources that patients have learned that they apply, that they see a value. I think that a GI psychologist fits very well into helping to deliver those deliverables. So I think that the role of the GI psychologist in terms of on the ground work, research, leadership, it’s really kind of endless how the psychology of a patient can be assessed and worked around in GI.
Praveen Suthrum: Any thoughts on how does one scale these efforts? Clearly the problem case is large. There are millions of people who need this and there are just a few of you, as you said, 400 worldwide. How does one scale something like this?
Dr. Megan Riehl: In my opinion, it’s digitizing some of the therapies and creating other resources, whether it be one of the programs I’m a part of is GI onDemand and we’ve put together different webinars to help patients understand their conditions. So it kind of takes concepts that you would get from a GI psychologist but can be disseminated to anybody that has access to the GI on demand platform. And from there also, we’ve created algorithms and pathways to help patients understand. Do they need general mental health? Do they need a GI psychologist? Do they need more comprehensive services? So not only can patients use those resources, but providers can. So our GI on demand platform is really something that’s trying to take ideas from a tertiary care program and bring them to any gastroenterology program in the country. So things like that, I think, are ways that we can scale some of the valuable information and the way we deliver it as GI psychologists. So examples of helping a patient understand their pain and why brain gut dysregulation impacts that and why a dietary modification or a relaxation based intervention is going to be helpful for them. Lots of different ways to kind of educate the masses, I think is one of the scalable solutions.
Praveen Suthrum: I wanted to ask you, what is the latest research surrounding the brain gut access? You keep seeing articles every now and then about it. What is the latest which is out there?
Dr. Megan Riehl: Well, what I’m paying attention to is microbiome. So looking at microbiome, looking at how it’s individualized and how do we work with that in terms of maybe developing more individualized treatment plans. So I think that there’s a ton of emerging literature and exciting research in the space of how the microbiome affects the brain gut access.
Praveen Suthrum: Any final words, Madison, from you and Megan?
Dr. Madison Simons: As it’s even come out in this conversation, but just like being on the ground, working with gastroenterologist, having come from Northwestern, now just starting at Cleveland Clinic, I hear every day what a value I contribute to the team as a GI psychologist. And so for private practice gastroenterologist, I just think there’s not even a question of what value could be provided if hiring a GI psychologist is something that you’re wanting to do from a financial side, from a patient treatment burden and just helping clinicians understand their patients more, develop empathy for those symptoms. It’s really rewarding for myself, but also the team that I work with. So just for any providers, I think you would not go wrong to include a GI psychologist.
Dr. Megan Riehl: Madison and I both, we went the training route, right? So we have a lot of training as GI psychologists, and that may not be necessary for every mental health provider that might be interested in working with patients with Irritable syndrome or inflammatory bowel disease. And so I think that even whether you’re a gastroenterologist or a primary care physician, there’s opportunities with general mental health providers where they could receive some training, some additional training through the Rome Foundation. They have excellent educational opportunities for continuing education. So I think that we also have to think a little bit creatively in terms of our collaborative relationships between gastroenterology practices and mental health. And so just because you might not find a GI psychologist like Madison or I, you certainly could bring value by forming really strong relationships with mental health providers in your area. And if they find, hey, I really like working with these IBS patients or I really like this. Knowing that the resources through the Rome Foundation are available can really be a win win for your practice, for the provider, especially for the mental health provider, because a pretty strong stream of referrals that if you connect with a gastroenterology practice. So it’s just another way to consider that there are additional options out there when it comes to collaborating.
Praveen Suthrum: So Dr. Megan Riehl and Dr. Madison Simons, thank you, both of you, for participating, sharing your insights today and throwing light on this very, very, very important topic.
Dr. Madison Simons: Thank you.
Dr. Megan Riehl: Thank you.
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