Dr. Michael Brown is currently an Associate Professor at Rush University and the Program Director of Rush’s Fellowship Training Program. In addition to his work as a teacher and a care provider, Dr. Brown has held consulting positions within the medical industry and has been invited to serve as a reviewer for a number of medical journals. Rush University Medical Center, where Dr. Brown practices and teaches gastroenterology, is currently one of very few centers in the country offering all three endoluminal procedures currently available for reflux. In this interview, Dr. Brown talks about the promise offered by these procedures, and about the future of his specialty as well.
Reflux1: At what point in your life did you know you wanted to be a gastroenterologist?
Dr. Brown: That was pretty immediate. When I was taking classes in college at the University of Colorado, I thought the gastrointestinal tract was the most interesting. There isn’t another specialty where you take care of as many organ systems as you do in gastroenterology, so there’s a nice variety, which I like. Plus, I’m kind of a hands-on person; I actually came close to going into surgery.
Reflux1: You do a lot of endoscopic procedures at the moment, don’t you?
Dr. Brown: Yes, I do seven half-days of endoscopy a week, and about ten endoscopies each half-day. So that’s at least 50 to 60 endoscopies a week.
Reflux1: What do you feel is your greatest contribution to gastroenterology?
Dr. Brown: I do a lot of teaching; that’s the thing I’m most proud of. I’ve probably taught gastroenterology and endoscopic skills to thirty or forty fellows. It’s nice to know that there are thirty or forty doctors out there using the skills I taught them every day, and that I’m contributing that way. I also run the fellowship program [at Rush], and I get a lot of joy out of that. The fellows keep me young; they keep me on top of things, all the latest and greatest. These days only the best and brightest doctors are going into gastroenterology. It’s become the most competitive, in-demand specialty: even more than cardiology. Teaching is really important to me: it’s important that there are physicians who are patient and willing to train new physicians.
Reflux1: What do you think is your greatest contribution to teaching?
Dr. Brown: We’ve been doing research studies regarding computer simulators that can help train fellows, so they don’t require as many procedures to get the skills they need. That in turn helps patient comfort: [when the fellows start performing procedures after being in a lab], the procedures go more quickly, and the fellows get more out of each patient they do. We’ve been at the forefront of this development, and we actually have an article coming out in the Journal of Gastrointestinal Endoscopy, detailing how these simulators greatly decrease the learning curve. Non-human computer simulators are really becoming the norm these days, which is great. It’s better all the way around: the training is enhanced, the patient care is enhanced. I think it’s great. [Reflux: For more information about this research, go to http://www.hoise.com/vmw/03/articles/vmw/LV-VM-01-03-8.html.]
Reflux1: Can you tell us about your own current research focus?
Dr. Brown: Right now, we’re focusing in two areas: gastroesophageal reflux disease (GERD), and functional bowel disease or irritable bowel syndrome. At Rush we’re able to do all three endoluminal procedures for GERD: EndoCinch, Stretta, and the Enteryx injection procedure. I [personally] do both the Enteryx and the Stretta procedures. Very few places do all three. One complaint has been that there’s no comparative study of those three procedures. We’re getting so many referrals, we thought it would be a good idea to conduct this study. To my knowledge, we’re the only group comparing all three of these interventions for reflux disease and I think the outcome will be very important. In the area of irritable bowel syndrome, we’re opening up a center staffed by a specialist in the management of pain and a nurse who specializes in the area of biofeedback, [among others]. We’ll also be getting involved with effective alternative treatments.
Reflux1: Can you tell us more about the promise you see in these alternative treatments?
Dr. Brown: A lot of patients don’t respond to traditional therapies. Things like traditional Chinese medicine, acupuncture, and particularly hypnosis have roles in controlling the pain in these patients. A lot of physicians close these out as being hocus-pocus. I think one reason these traditional physicians don’t put a lot of the stock in [alternative therapies] is that a lot of the research has been uncontrolled, small studies, typically conducted by someone with a financial interest in the results. But now the National Institute of Health and Rush University are getting involved in placebo-controlled studies.
There’s a role for alternative medicine to play. It needs to be defined, but it’s nice to have something else to tell the patient besides, “You’ve got to live with it.” Patients hate to hear that from a physician, because it essentially means that the physician has given up.
Reflux1: Can you explain the significance of a "controlled trial" for our readers?
Dr. Brown: A controlled trial is where you have a placebo arm. So [in this case] you’d have one group of patients treated traditionally, and one group getting hypnotherapy. That’s extremely important in gastroenterology, because a lot of patients will respond to placebos. A blinded trial is where the physician interpreting the data does not know what treatment the patient has received, and a double-blinded trial is where neither the patient nor the physician knows. A third thing to look for is that the trial is randomized: that is, that patients are randomly assigned, and that there’s no physician saying, as a patient walks in the door, "Oh, that looks like a good one; we’ll put him in the study group." A controlled, randomized, double-blinded study is the Cadillac of medical research. If you hear those words, you know that you’ve got a high-quality trial, and the results can be believed.
Reflux1: What do you see as the most important new trends in gastroenterology?
Dr. Brown: I think that handling things in a minimally invasive fashion is a good thing. I think that more aggressive screening for things like colon cancer is important. There’s a lot of nifty new technology that’s coming out that will allow patients to avoid surgical interventions and get a more detailed analysis [of their complaints].
Reflux1: How do you expect your practice to be different in five years?
Dr. Brown: In five years we will be seeing more patients up-front for endoscopy, and fewer outpatient visits. The trend is towards open access endoscopy. We are becoming more technicians rather than clinicians, unfortunately. I think that’s one trend that’s unfavorable, but it does expedite care, which is important. We are seeing more medications that are helpful in treating gut motility, in the case of irritable bowel syndrome. Endoscopically, I think there will be a shake-out that leaves us with two [of the three] endoluminal procedures, although I don’t know which two. I personally think that endoscopy will become a more common way of treating reflux disease down the line. Right now, it’s a bit of a black-and-white issue: some doctors [are holding out on performing endoscopy] until the long-term results are in. I think that when we get that long-term information, within five years, this response to these complaints will be commonplace. So I think there’s going to be more direct access to endoscopic procedures. I think that’s going to reduce the amount of gastroenterologist-patient contact time.
Reflux1: Let’s return to the endoluminal procedures you mentioned earlier: Stretta, Enteryx, and EndoCinch. Can you compare those procedures for us?
Dr. Brown: EndoCinch is one I’m only involved in because one of my partners is doing it; it involves tightening the low end of the esophagus with sutures. We initially did quite a number of those, but it’s technically quite difficult, and the sutures kept coming apart. I do perform the Stretta procedure; I think it’s an effective treatment, although it has a little bit of a higher learning curve than the injection procedure, Enteryx. But it’s an expensive piece of equipment. Enteryx is a polymer that thickens and strengthens the lower portion of the esophagus. It’s very easy to do. I’ve done ten patients, and all of them have done well, and the majority - seven, I think - are off their medications.
Most of the patients I have are getting Enteryx done. It doesn’t require special equipment, so it can be done at any of the hospitals at which I have privileges, and I’m seeing similar efficacy [as I am with Stretta]. I think they work equally well.
Reflux1: Are there specific advances or changes in your field that you hope to see in the next five or ten years?
Dr. Brown: What I’m hoping to see is better treatments for inflamed bowel disease, Crohn’s disease in particular. To reduce the chances of those patients needing surgery would be great.
One thing I would particularly like to see in the diseased bowel patients is therapies controlling pain. New drugs controlling motility would be great, but if we had a drug class aimed at controlling pain from the gut, that’s something I would really love to see, because that’s really troubling to those people.
Reflux1: Do you think these changes are on the horizon?
Dr. Brown: I think the better treatments for inflamed bowel disease, better immune modulators, are very likely. As far as drugs directly aimed at controlling pain, I think that’s a little more theoretical. It’s an idea that people would like to see come about, but it’s a little pie in the sky at the moment.
Reflux1: For our readers who may be looking for a gastroenterologist, how would you recommend they find a good one?
Dr. Brown: I think the best place to go is the American Gastroenterological Association website. All of the board-certified gastroenterologists in the U.S. are there. I think board certification is very important; it sets a level of expertise and skill and training. That website is www.gastro.org. The website may also give people an idea of what the physician’s [research] interests are. Another organization which certifies gastroenterologists is the American College of Gastroenterology; their website is www.acg.gi.org.