Understanding your Medical Provider Team, with James Haddad

Episode Transcript

Ariel: Hello, everybody, and welcome back to another episode of the “Colon Health Podcast.” I am here with, can I call you Dr. Haddad, or is it just James at this stage of the game?

Dr. Haddad: Dr. Haddad is the formal title, but you certainly can call me James.

Ariel: Okay. Well, you’ve worked very hard for that title, so, Dr. Haddad, it is lovely to have you here today. Can you start off by just sharing exactly what it is that you do with our audience?

Dr. Haddad: Sure. Well, hi, Ariel. And first of all, thanks for inviting me to speak with you today. I’m currently a gastroenterology fellow in Dallas, Texas. And so, I see a diverse group of patients, actually, at three different hospitals in the area, through a combination of inpatient hospital consults, clinic visits, and, of course, inpatient and outpatient endoscopic procedures, which I think, for most people, they know our specialty best by those. And that includes colonoscopies.

Ariel: That’s amazing. I didn’t even bring up to you that I’m from Dallas originally. So, that’s something that we’ll have to get into later on.

Dr. Haddad: Oh, all right. Yeah. I’ve been here for a couple of years now, and I actually read that you’re in New York currently. I’m actually from New York, so yeah, we might have to chat about hometowns later.

Ariel: Oh, my goodness. We definitely have to. We just did a whole kind of play swap thing. So, definitely need to chat about that more later on. But, since you are from New York, I would love to hear, I always ask guests at the very beginning to share sort of their journey to get to where they are today. So, I’d love to hear about what made you want to pursue medicine, and gastroenterology specifically, how you wound up in Dallas, all that good stuff.

Dr. Haddad: Sure. Well, my journey is in some ways a very traditional path to medicine, in others, non-traditional. There was a period where I wanted to be a veterinarian, and later, actually, a physical therapist. Ultimately, my focus shifted towards medicine, probably in no small part due to a shadowing experience that I had with the surgeon who took out my own appendix.

At the time, for me, a laparoscopic surgery was probably the coolest thing I had seen in my life. Performing operations in a minimally invasive fashion was just fascinating to me. I was back at work, lifting boxes at my job within three days. Of course, you know, in GI, we take that concept actually sort of to the next level, and we perform many procedures without any cuts in the skin, which is pretty incredible, I think. And these capabilities are only going to expand in the years to come, with technology and techniques that are being developed.

In college, I wound up taking a scholarship for medical school through the Navy, and this is where it gets a little non-traditional. So, after graduating from medical school, I completed my residency training in internal medicine, with the Navy. And then I spent several years in practice, to fulfill the terms of my commitment, before returning to training in gastroenterology.

I knew I wanted to specialize in gastroenterology since probably around my second year in medical school, but for a number of reasons, including the fact that it would lengthen my commitment to the Navy, I chose to pursue my fellowship training after a period of practice. Whereas the majority of physicians tend to enter fellowship training just after completion of their residency.

Ariel: Well, a couple of things. First, I think that is really cool. I, when I was…we were just speaking about my previous medical journey, but when I was in my training, I did a, I shadowed lap-band surgery, and I was like, this is one of the coolest things I have ever seen…in Dallas, actually. I’m trying to think of the hospital, and it’s escaping me at the moment where I was at. I’m wondering if it was one that you were working in.

Dr. Haddad: It very well may be. A lot of the names have changed over the years. We don’t do a lot of lap-band surgeries anymore, for a number of reasons, but actually, obesity medicine and obesity surgeries are a big area of my interest.

Ariel: Yeah. It was so, so fascinating. I’m not sure if we have anyone, any young people who are interested in pursuing medicine or anything like that, but if you’re able to have any shadowing opportunities, I cannot recommend it enough. It’s such a useful experience to have at the beginning part of your journey.

Dr. Haddad: Absolutely. I would second that, and, for most people, I think it solidifies, as it did for me, and maybe you, your interest, but also, it can be invaluable if it also just shows you that, “Hey, maybe this is not the thing for me,” because obviously, it’s a huge commitment to start your training, because it is such a, for many people, such a long road.

Ariel: One billion percent. Yes, I feel like that opportunity of watching a surgery really solidifies you in either direction, and both are equally beneficial. You started explaining your journey, and I would love for you to elaborate on what exactly a fellow is, because I think a lot of people generally get confused by the different steps of medical school, and when you are a doctor, when you become what we think of as a doctor, and who is coming to treat me, and all of that stuff. I think if you can explain, that would be so helpful for the listeners.

Dr. Haddad: Right. It can be confusing with various types of professionals patients can meet in a clinic or hospital setting these days. The number of credentials is just exploding, and it’s really sometimes unfair to patients, actually. There are people in my own family, probably, I would bet, who wouldn’t be able to explain to you what it is that I do, and are also probably wondering how many more graduations they have to congratulate me on.

So, maybe I can help clarify, as you put it, you know, in the various roles in medical education. Most people understand what a medical student is, so that’s pretty straightforward. You know, these are dedicated student doctors, who usually have completed most or all of their didactic or lecture-based education by the time they’re seeing patients, although this does vary by school. In general, there’s been a move to getting students into the hospital earlier, in a lot of places.

I always tell my patients that it’s a good thing to have a medical student on your case. Since they typically carry the fewest patients on the team, they often have time to consider your case more in-depth, and usually with greater curiosity than the more senior doctors. You know, time is a limited resource, and they just have more of it. I actually have a personal story about a case I helped with as a medical student, I could share with you at some point. I dunno if that would be helpful.

But after a medical student graduates, they are a doctor. And so, a minority may choose to use their degree differently, but most choose to practice clinically. And then they would move on to residency training in one of the medical specialties, which has actually been the way that we train doctors in this country for over 130 years, and evolved, really, from the days of medical apprenticeships, which is how things used to be done, really formalize the process.

The term “resident physician” simply referred to the fact that physicians at this level of training literally lived or resided in the hospital where they were getting their training. So they were on call all the time. And it was really just an immersive way to gain experience. At the residency level, a physician is practicing semi-independently, although anyone who works in a teaching hospital can tell you that residents are typically the workhorses of the team, who are typically most intimately involved in a patient’s care from start to finish.

In the first year, resident physicians may be referred to as interns. And this is a term either from medical TV shows, or, you know, people may be familiar with. I think intern is, in my opinion, it’s a useless, term that doesn’t really add value, and actually is most often used in sort of a demeaning way, to highlight their more junior status. So I actually choose not to use it. If it’s necessary, you can refer to them as a first-year resident, because they’re all resident physicians.

A more formal way to describe the level of a physician’s training is their postgraduate year. And this is more applicable in medical education, but it might be helpful to some people. So, after medical school, so, for example, you know, a first-year resident would be a PGY1 one, or postgraduate year one, then PGY2, and so on.

So, the length of residency can vary from typically three years for a specialty like internal medicine, up to seven years in the case of neurosurgery, which is one of the longest, if not the longest residency training. Other terms you might hear are house staff or house officers. We don’t typically use these terms with patients, although they may slip out, or you may read them or hear about them.

And these typically refer…it’s more of a general term, and it refers to residents and fellows collectively, so all of the medical trainees who might be in the hospital, or the “house” here. After they complete their residency, typically, physicians obtain their board certification, and begin independent or unsupervised practice in the field of their training. And where at this point they’re typically referred to as attending physicians. So, I think a lot of people are probably familiar with that terminology too.

Other terms that are used at this level might be faculty physician or staff physician. In the hospital setting, an attending physician typically supervises multiple trainee-level physicians, and that might include residents and fellows. And, of course, they have the final say for important decisions about a patient’s care, because they’re typically the most experienced individual on the team, and kind of the buck stops with them.

For just about all medical or surgical sub-specialties, a formalized additional training period that’s called a fellowship is typically required. And these can be as short as a year, actually, or as long as an additional few years after somebody’s residency training.

So, while the physician is in this training role, they are really acquiring and honing the new skills that they are gonna use in their subspecialty, but can also sometimes function as an attending physician in their core specialty, and that could get a little confusion. For example, I could practice internal medicine right now [inaudible 00:10:04] gastroenterology fellow.

Many of the subspecialties people are familiar with, such as cardiology or gastroenterology, are fellowships that are completed after training in internal medicine as the core specialty. For example, gastroenterology fellowship is three years long, but in my case, I’ll be doing an additional fourth year, to focus on advanced or interventional endoscopy techniques. Others may do an additional year to become more focused experts in inflammatory bowel disease or liver transplants, for example.

Now, the other context in which a patient may encounter the word fellow, which can be confusing, is with respect to status within a college or a professional organization. And this is typically indicated as an additional designation after a physician’s degree, such as FACP for the American College of Physicians or FACS in the case of American College of Surgeons. And there are multiple organizations like this.

You’ll see this typically on their office signs or their business cards, if anybody still uses those, and their white coats, and it’ll appear after their credentials, like MD or DO, for their degree. Physicians are typically elected as fellows in their respective professional societies after several years of independent practice and some demonstration of clinical excellence, but all societies have their own criteria and guidelines for electing physicians to fellowship.

This type of designation is certainly not mandatory to be a great physician, so I don’t think patients need to worry about whether their own physician has such a designation. And I certainly wouldn’t advise them to limit their search for a physician based upon this.

It is something that when they see it, it might let patients know that, hey, you know, this physician is active in their specialty with respect to something such as research, education, activism, or some combination, such that they were recognized for it. And that’s typically a positive.

Ariel: Thank you so much for going through with such detail, I really appreciate that, all of the different phases. I think it’s helpful for people as patients too, because I feel like there are so many misconceptions in the media about what each stage of doctor does in a particular practice or medical setting, and I feel like a lot of people feel like they need to have only attending physicians, or someone at a certain level, to provide them a certain level of care. But I think your descriptions of each role says that that is not necessarily the case.

Dr. Haddad: Yeah. And certainly, with all the hustle and bustle in the hospital, people coming in, you’ll meet multiple people. If anyone has had the misfortune of being hospitalized, not everybody introduces themselves. Like I said, there’s a lot of different credentials these days, which I think just makes it more difficult for patients.

And so, I mean, as a patient, you should always feel empowered to ask. It should never be interpreted with offense, but yeah, certainly I encounter that. Some people are under the impression that, “Hey, maybe I only want an attending physician to take care of me.” And typically, there’s always going to be one involved, even if you’re at a teaching hospital. And it really is, in my opinion, typically, a plus, not a negative, to have trainees involved in your care because there tends to be a little bit more of a structured approach because there’s learners present. And that also, I think typically results in a little bit more of a thoughtful and beneficial, of course, for the patient care that’s being selected for an individual.

Ariel: I agree. And I hope the listeners feel more confident and empowered to advocate for themselves, ask questions if they need to, but also feel comfortable that these are acceptable situations to be in when you have multiple people in your care team.

The next question I wanted to ask you is, since you shared that perspective of starting in internal medicine and then going into gastroenterology as a subspecialty, at what point would you recommend that someone see a gastroenterologist versus just following up with someone in internal medicine or their primary care physician for something that they may be experiencing?

Dr. Haddad: Yeah, this is actually a much more difficult question than it appears to be on the surface. And the true answer is that it depends on a number of variables, but I could give a bit of guidance. So, as somebody who spent several years as a primary care physician before fellowship training, I had to decide, you know, when to escalate an issue to a specialist, in many instances.

In GI, sometimes the answer can be easy, when an endoscopy is indicated, such as in the case of abnormal imaging or rectal bleeding without a prior colonoscopy. These are pretty clear cases. Then a referral really should not be delayed, since only the specialist can get that next step done for the patient, which is an endoscopy, right?

But in many cases, when gastrointestinal symptoms are mild and without red flags, as we say, as interpreted by the doctor, they can be safely investigated and managed through a primary care physician, at least initially. Also, in many cases, the long-term management of benign conditions, such as irritable bowel syndrome, for example, can, and, in my opinion, should be managed by someone’s primary care doctor, unless there’s some complex element or a medication that needs a specialist’s supervision.

In these cases, outsourcing to a specialist may result in delays and increased costs for patients. And many patients are actually better served making decisions along with the physician who knows them best and sees them most often.

So, in general, I actually have a very heavy lean towards management by a primary care physician, since that’s the model of medicine that I practiced and I believe in. But I’m also acutely aware that, obviously, medicine is growing and has been growing more complex, and that when there are 15 or 20 issues needing attention, patients and PCPs feel best served by a dedicated specialist evaluation.

So, we’re always happy to see any case no matter how complex or simple it is. And obviously, if someone has been working with their primary care physician, and one or both of them feel as if they’re not making progress, it may be time to discuss that concern with a specialist.

One practice that seems to have gained popularity, especially during the COVID pandemic, is the offering of an e-consult, where there’s a relatively specific or straightforward question for the specialist. And we aim to review the case remotely, and answer the PCP, or whoever’s referring the patient within typically, for example, three business days, or something of that nature. And a lot of specialties do this.

As long as there are enough specialists in the practice to support this, and there’s good communication between the primary care physician and the specialist, I think it’s a good tool that can streamline the consult process for patients and cut down on wait times, especially. But obviously, it’s not appropriate for every scenario, especially when something like a physical exam is mandatory, or there’s a very complex case.

Ariel: I appreciate you sticking with me when I gave you this sneakily difficult question. I appreciate too your approach of encouraging people to actually work in a team with their primary care physician, because I feel like in a lot of medical settings, patients feel like it’s, “Okay, this is my doctor. I have to listen to what they’re telling me to do,” and they either feel nervous or scared to speak up about something or ask questions. But the environment that you are encouraging patients to be a part of, I feel, is one that has open communication. You’re working through things as a team. And with this communication, your doctor gets to know you and your condition better, and then you have a better idea if things need to be escalated, or move in a different direction.

Dr. Haddad: Yeah, absolutely. I think that’s really critical, especially…and it’s a skill you need to have if you’re gonna be practicing primary care. And so, if you’re a patient who feels like that’s not the case, it may just be…I mean, we’re human, and so it may just be that you and that individual maybe are not on the same wavelength.

And if it can’t be corrected over time, then maybe finding somebody that you can have that kind of communication with is important. Because really, primary care physician is and should be sort of the quarterback of the team, and coordinate care for the patient. They have to know them best. They know their medications, interactions, and really can make good things happen or prevent bad things from happening.

Because I have definitely seen the case of people with complex medical issues, and just, there’s too many cooks in the kitchen, and every specialist is gonna, obviously, by their nature, focus on their little corner of the universe, and sometimes that’s good. If you don’t have somebody keeping track of it all, it can actually, in my opinion, result in, you know, lower-value care, and even sometimes dangerous things.

Ariel: Couldn’t agree more. If you are with a provider that you feel like is not a good match, you are not stuck. You can always go and explore different providers for your needs. That’s something that is always an option for you.

One of my last questions is, if you could just give one piece of helpful advice for our listeners to help them maintain good colorectal health, I know there’s a slew of things, but if you could only give one piece, what would that one piece of advice be?

Dr. Haddad: Well, kind of an obvious answer, and a little bit cheating, but the most important blanket recommendation would be to not delay screening for colon cancer when you become eligible. We hate diagnosing colon cancer, because a lot of it is preventable. In fact, the majority of cases can be prevented through a combination of screening, a healthy diet, avoiding tobacco, moderating alcohol, and maintaining a healthy weight. We have some degree of control over just about all these factors.

Now, diet always seems to be the most mysterious, and has the most, kind of, misinformation out there associated with it. So, if I can give one helpful piece of advice for good colorectal health, it would be to aim for a plant-forward or plant-based diet. It does not have to have a name or a book associated with it. It doesn’t have to be strict vegetarianism, nor does it have to be all or nothing, or even immediate. Any incremental changes you can make in that direction, over time, will generate benefits.

Plant-based diets provide fiber. That’s essential for colon health and a lot of symptoms that people come to see me with. And maintaining a healthy weight, prebiotics, that support the gut microbiome, which is a pretty hot topic these days. And you may have or be discussing this with other guests on your show. And are also just better for the environment, which is something that pretty much everyone should be conscious of at this point, what we’re facing with respect to things like global warming and waste and pollution.

I am far from a vegetarian, but have drastically reduced my consumption of processed foods and animal products over the years. And I’m healthier for it. My favorite quote on diet, especially if we don’t have time to get into specific details, is from Michael Pollan, who wrote “The Omnivores Dilemma,” which I would recommend to everybody. He says, “Eat food. Not too much. Mostly plants. That’s it.”

It’s elegantly simple, but also profoundly accurate and broadly applicable. Obviously, the “eat food” part is a little bit tongue-in-cheek, but it means to eat real food, not things which are processed, or what he actually refers to as “food-like substances.” And generally, if you’re shopping at a traditional grocery store, the best advice is to select unpackaged products from the periphery of the store, as the more processed products are typically in the center, thanks to their shelf life. Just realize that can be applied by just about anyone.

Ariel: Thank you so much for that. I think these are some helpful tips that are easy for our listeners to maybe start applying. I loved that you mentioned it doesn’t have to be all at once. We’re very much about meeting people where they’re at here, and understand that it can be a journey, but those steps that you take will add up over time, and have real benefits.

Dr. Haddad: Absolutely.

Ariel: Well, we are actually just about out of time. Are there any other final parting thoughts that you wanted to share that we didn’t get to quite touch on today?

Dr. Haddad: Not really. I got my plug for colorectal cancer screening in, so I’m happy. I would just say, circling back around, be nice to your medical students and trainees when you have the opportunity to be part of their education. And, you know, I look forward to talking to you again on any other topic in the future.

Ariel: Yes. I definitely would love to reconnect with you, maybe have our own episode about New York and Dallas food, but that is for a different time. But thank you so much for being here today. I learned so much, and I think this is going to be really helpful for all of our listeners.

Dr. Haddad: Awesome. Well, I hope it is. If your listeners are interested, they can follow me on Twitter @JamesHaddadMD. And keep an eye out for an upcoming issue of the American College of Gastroenterology’s magazine. I’ll be having a little feature in there, actually, with a recipe. So, for anyone who’s food-minded like us, I think that’s gonna be coming out this summer.

Ariel: Oh, my gosh. That’s so exciting. As always, I will link all these things that he’s mentioning down in the show notes below, so you can just do a little scroll, scroll and click, to make sure that you are following and subscribe, so you don’t miss any of this awesome and exciting news and updates.

And like I always say at the end of every podcast, we all have colons, so ask questions, do your research, and have a conversation. All right. Thank you so much, and we’ll see you next time on the “Colon Health Podcast.” Bye.