I need to tell you some things that gastroenterologists don't want you to know.
Not because they're bad people. Richard is a wonderful man. He genuinely cares about his patients.
He got into this work because he believes in what it can do.
But I've been married to this man for 34 years. I've been at the dinner table after every difficult case.
I've heard the patients he worries about. I've seen the ones who come back year after year, still suffering, still dependent, still no better than when they started. And there are things you learn, sitting across from a gastroenterologist every night for nearly three decades, that no office visit will ever tell you.
Thing #1: Most chronic diarrhea patients never get better. They just get managed.
The treatment protocol for chronic diarrhea hasn't meaningfully changed in decades. Imodium to slow things down. Bile binders if bile acid malabsorption is suspected. Prescription antispasmodics if cramping is severe. Low-FODMAP diet counseling that eliminates half the foods you love.
These are not cures. They are management tools. The goal of treatment, as Richard has explained it to me a hundred times, is not resolution. It's acceptable symptom control.
For most patients, "acceptable" means still planning every outing around bathroom locations. Still carrying Imodium everywhere. Still wearing dark pants just in case. Still declining invitations because the unpredictability never fully goes away.
Thing #2: The prescriptions are worse than they tell you.
Cholestyramine. Colesevelam. Rifaximin. Dicyclomine. The prescription route for IBS-D involves medications with side effects that often create new problems while managing old ones. Constipation. Brain fog. Nausea. Dependency.
Richard tells his patients the honest version at home. Most improve on paper — fewer urgent episodes logged in a symptom diary — while still living a smaller, more restricted life than they did before the symptoms started. The diary looks better. The life doesn't feel better.
Thing #3: It doesn't address why it's happening.
A chronic diarrhea diagnosis is essentially a diagnosis of exclusion. It means: we've ruled out everything structural, everything inflammatory, everything we can see on a scope — and what's left we're calling IBS. Here are some tools to manage it. Good luck.
What Richard won't tell you in the office — but told me at the kitchen table — is that the majority of chronic diarrhea patients have never had their digestive enzyme production evaluated. Not once. Because there's no standard protocol for it. Because the treatment is cheap and unpatentable. Because there's no revenue in fixing it.
Most patients never ask the right questions. They're too desperate, too exhausted, too relieved to finally have a label to question whether that label is actually helping them.
I know. Because I was one of them.