Innovation in a rural gastroenterology practice using a farm [PODCAST]

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“Gastroenterology clinics in rural areas have the unique opportunity to innovate the field by working with local community organizations and farms. Patients and physicians develop a deeper understanding of the root cause for chronic disease, particularly digestive diseases using a food as medicine approach. Cultivating gut microbes in the soil and gut can re-shape the management of chronic diseases rooted in inflammation and metabolic dysfunction. Rural gastroenterology clinics can be at the forefront of shaping the innovative clinic-to-farm-to-table paradigm in health care that can lead to cost savings and improved outcomes. This model ultimately can foster deeper connections between patients, physicians, communities, and nature as well as better health outcomes.”

Savita Srivastava is a gastroenterologist.

She shares her story and discusses the KevinMD article, “Innovation in a rural gastroenterology practice using a farm.”

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Savita Srivastava. She is a gastroenterologist, and she co-wrote the KevinMD article “Innovation in a rural gastroenterology practice using a farm.” Savita, welcome to the show.

Savita Srivastava: Thank you so much for inviting me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Savita Srivastava: So I’m a gastroenterologist. I work for a rural health system in the central Shenandoah Valley called Augusta Health. It’s a very unique health system in that it has a farm on the campus of our health system that really frames and provides a great opportunity to develop programs and also create a positive culture around the concept of food is medicine. I think when you juxtapose a hospital and a campus with a farm right next to it, you really do appreciate the importance of where your food comes from, and just a deeper appreciation of the importance of food for health.

I’m originally from Buffalo, New York. I completed my medical school training at the Albert Einstein College of Medicine in New York City and then went on to do my internal medicine residency at Georgetown in Washington, D.C. So, of course, most of my beginnings in terms of my clinical education and initial medical school education were in urban environments. I then went on to my GI fellowship at Yale University in New Haven, Connecticut, where I’m going to say I came out very well trained in therapeutic endoscopy and clinical research through the NIH training grant.

Yale was an amazing place, I think, to learn acute care medicine. I think being on the wards at Yale New Haven Hospital, you were exposed to some of the sickest patients. On any one day, we were managing a massive GI bleed, or we were managing a patient with acute liver failure that needed an urgent transplant evaluation, or someone with severe pancreatitis that needed an advanced endoscopic procedure. And I think for that day, you always felt like you saved the patient. But in the back of my mind, I was always thinking, “Well, we probably haven’t improved the morbidity and mortality for a lot of the patients that we take care of in the hospital.”

And then I settled into my first job as a gastroenterologist. I had the fortunate opportunity to work at Duke University, where I spearheaded some of the work in their community-based clinical practices. And it was during my time at Duke that I realized that all of gastroenterology wasn’t acute care medicine and research, that we had a tremendous opportunity to actually participate in managing chronic diseases, where we were providing a different type of care, more incremental care, more of a different skill set, with a greater focus on slow care and perhaps not the quick fixes or solutions that we were used to.

I think it was during my time at Duke that I met women from all over the country who would come to see me for, I’m going to say, a wide variety of very vague symptoms. They oftentimes would present to me asking for a diagnosis. They wanted somebody to listen to them, and they wanted us to provide them with solutions that they felt hadn’t been presented to them previously. And many of these patients would present with vague symptoms such as chronic bloating. And I really, at that early point in my career, felt like, “Gosh, I think I’ve uncovered a pandemic of bloating in my practice, and I don’t quite know what to do with this diagnosis.”

And many of these women would have additional symptoms like fatigue, depression, anxiety, and food intolerances, things that I just felt ill-equipped to handle. And it really bothered me for a long time that I couldn’t find a solution for them. A procedure wasn’t necessarily their answer, nor was a pill, and we tried all sorts of things. And it was really my journey to help more challenging populations with different diagnoses that led me to this journey towards a hospital on a farm.

Kevin Pho: So tell me some of the challenges you face practicing gastroenterology in a rural setting.

Savita Srivastava: I think certainly in any environment where you don’t have all the tools and technology that a tertiary care center offers, there are always going to be more challenges. I think particularly during this time in the history of medicine, where we’re dealing with the COVID pandemic, working in a rural health system certainly has a lot more challenges. I think we oftentimes will see challenges in just drug shortages and the availability of basic things like blood for our patients that need resuscitation. There are more challenges in terms of having the tools and technology that you were used to, and there are also challenges in just having that spectrum of all the different members of a hospital community that you were always used to having at your fingertips.

And certainly it requires more creativity, more communication perhaps with other health systems in the area, and more partnerships that you build in the community around you. I think we’re fortunate to live in the backyard of an amazing health system, the University of Virginia. And so we’ve learned that it’s wonderful to collaborate with colleagues, but it’s also wonderful to figure out your challenges within your own health system and how that can drive better health outcomes for our patients.

I think what I have learned working in a rural health system is that we have a unique capacity to be able to offer something different that can also help to innovate gastroenterology. I think I was always in environments in academic medical centers, in some of the elite places to practice gastroenterology, where we were focused on devices, advanced endoscopic procedures, and expensive pharmaceuticals. But working in a rural health system, you really appreciate the fact that you can actually deliver high-level, high-quality care by incorporating lifestyle medicine into the patient’s plan of care. We can suddenly deliver something that oftentimes a lot of health systems in urban environments may not necessarily be able to deliver with the same quality and capacity.

I think it’s wonderful to be, like I said, in the backyard of a farm on the campus of a hospital, where we’re able to deliver more lifestyle-oriented care. One of the unique things that we’ve been able to deliver in terms of our digestive wellness programming is integrated care, where we’ve built partnerships with gastroenterologists in addition to dietary nutritionists, health coaches, behavioral health specialists, chefs, and yes, farmers as well. So that collaborative care provides a more fruitful environment, and we think we make a bigger difference from the perspective of providing lifestyle solutions for our patients.

It’s hard to make recommendations and not have a great capacity to be able to present a follow-up plan in terms of how to practically implement or incorporate lifestyle medicine. But I think working in a place like I am, at Augusta Health, we’re able to actually formulate a practical plan for the patient, so that we can take the written recommendations that we’ve made to the patient and actually create an actionable plan for them. I think it makes a big difference in health care.

Kevin Pho: And you talk more about that in the KevinMD article that you co-wrote. It’s titled “Innovation in a rural gastroenterology practice using a farm.” Now, for those who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Savita Srivastava: I think one of the things that had really inspired me to write this article was actually listening to an NPR segment with what was the director of the National Institutes of Health, Francis Collins. He talked about the amazing innovation in science in the United States, how we’ve got answers to the Human Genome Project, we’ve got mapping of neurons in the brain right now, we’ve got the microbiome project, and we’ve got an enormous budget in the United States for health care. And I think that he got asked a lot of questions, and tough questions, about why, despite the high cost of health care in the United States, we still rank last among industrialized societies in terms of health outcomes and health care access. He then went on to talk about lifestyle medicine and how the big failure of the health care system in the United States is that we haven’t been able to deliver adequate lifestyle medicine within our practice model.

So I think that for us gastroenterologists, one of the most incredible, amazing things that’s happened in the past decade is that we’ve learned a lot about an organ in the human body that we didn’t even know existed during our years in medical school in the 1990s and early 2000s, and that’s the gut microbiome. So the gut microbiome is these trillions of organisms that live primarily in our colon, and we’re unraveling so much information about their functional role in health and disease.

One of the key things about the microbiome that we’ve learned is that it is oftentimes altered in different types of diseases, both inside and outside the gut. And I think that there’s just a multitude of diseases that now have an association with an altered microbiome that may be a trigger or a pathophysiological mechanism for disease. And so certainly one of the things that we’ve learned is that the microbiome is very dynamic, and it is very much shaped by lifestyle factors. So when you look at the vast literature on the gut microbiome, we know that its alteration can be triggered by lifestyle factors like diet, stress, and even our sleep patterns, for example, and our exposure to risky substances like alcohol and tobacco. So clearly lifestyle plays a big role in shaping a robust and healthy gut microbiome.

So as we learn more and more about the gut microbiome, I think there’s a lot of hope that we’ll be able to develop therapeutics by understanding the metabolic and enzymatic pathways and the metabolites that get produced by the gut microbiome. But in 2022, I think lifestyle is the key factor that’s going to help modulate and create a healthy gut microbiome and prevent diseases as vast as inflammatory bowel disease, colon cancer, and irritable bowel syndrome. And so with the knowledge that we have about the gut microbiome, I think our interest has always been to help translate that science into clinical applications.

While I think there’s hope that things like fecal microbiota transplantation and designer probiotics are going to be available to us in the future, certainly in the current environment, lifestyle is a major factor for optimizing the microbiome. And so I think that what we wanted to focus on is an emphasis on the fact that we need to work on lifestyle, and we need to create our medical plan for our patients’ care not just around endoscopy and pharmaceuticals, but actually around lifestyle. So one of the things I always wished I’d known more about during my medical school years was the existence of this new organ in the human body, because it probably would have changed the trajectory of how I thought about treating my patients over the past decade or so.

And so what we wanted to do was really to incorporate within our practice model important key strategies for helping us to develop a microbiome optimization plan. What we have learned is that diet is probably the key factor that influences the health of the microbiome. We know that the standard American diet, for example, also called the Western diet, can change the composition of the microbiome, attenuating favorable microbes while upregulating unfavorable ones that may lead to cellular stress and chronic inflammation. We also know that fiber is a very important substrate for creating additional metabolites, like short-chain fatty acids, that influence inflammation and even have a downstream influence on bidirectional communication between the brain and the gut.

And so what we’re learning more and more is that fiber is a very important factor in the health of the gut microbiome. It feeds the gut microbiome. So as we look at dietary interventions in the United States, we’re very focused on high-protein, low-carbohydrate, or ketogenic diets. We really are leaning towards low-fiber diets that are oftentimes leading to starvation of the gut microbiome. So really a re-emphasis on applications of diet principles is really important for the health of the microbiome.

We’ve also learned that the diversity of the microbiome has been implicated in almost every chronic disease. So the less diverse microbiota we have, the more likely we are to trigger diseases as diverse as heart disease, diabetes, and inflammatory bowel disease. And the way that we improve the diversity of the gut microbiome is really through having more of a plant-based diet, and that’s where, again, lifestyle medicine and the incorporation of healthy dietary principles come into play.

So really our farm then becomes a central hub for helping us to develop key strategies for incorporating a plant-based diet into our patients’ plan of care. Through utilization of the farm, we’ve been able to participate in various programs that the farm offers. The Allegheny Mountain Institute is an important organization that helps to direct our farm on campus, and they have a program that they cater to patients with chronic disease called the Food Pharmacy, where they’re able to provide patients with access to produce right off the farm. They do nutrition education, and then they also do food demonstrations in partnership with dietitians and chefs within our health system. So it’s an amazing collaboration that really leads to the important application of some of the recommendations that we make in our clinical practice, and how we’re able to provide patients with actionable plans based on a collaborative model of care. We call it our clinic-to-farm-to-table paradigm of care. So clearly the farm plays a very important role in that.

Food insecurity is another important issue that we try to address with our clinical practice. Through our clinic, we’re identifying patients with food insecurity through using social determinants of health, and we’re then able to provide them with access to seasonal produce right off the farm and provide them additionally with education about the importance of a plant-based diet. So really just an incredible collaboration, and just so much learning between farmers and gastroenterologists. It’s been an incredible experience.

Kevin Pho: Now, take us through a sample case study or a real-world example where a patient would come with a symptom that may be due to changes in their gut microbiome, and how you utilize lifestyle medicine and the farm to address those issues that this particular patient would come to you with. Walk us through a sample story or a case study.

Savita Srivastava: Oh, sure. I think that one of the most common diagnoses that we see in a GI practice, and it’s probably also one of the most common diagnoses in primary care, is irritable bowel syndrome. So IBS is defined as chronic abdominal pain associated with an altered bowel pattern. More and more, we’re seeing that this diagnosis is associated with chronic bloating, so many patients with IBS will present to us with bloating as their primary symptom.

And with IBS, when we look at a syndrome in medicine, I oftentimes will tell my patients with IBS that it’s just a definition. It’s defining symptoms, but it’s not telling us the root cause. And so what we do is we try to work towards a root cause analysis for why they have irritable bowel syndrome. We know IBS in particular is very much a lifestyle disorder. We know that there are a lot of factors, like stress, for example, early-life trauma, for example, and diet, that play a pivotal role in terms of the initiation and perpetuation of this disorder.

So what we do within our clinical practice is obviously make an appropriate diagnosis of irritable bowel syndrome using our traditional GI principles of care. But then what we’re able to do is expand that into a lifestyle medicine model of care, where we’re able to address their problem with a multidisciplinary team. So in the field of irritable bowel syndrome, there’s been a lot of evidence around how an integrated model of care should actually be the standard of care, that perhaps a gastroenterologist partnering with a nutritionist and a behavioral health specialist may be a better way to globally treat the disease or disorder and then also have positive outcomes. So there’s been a lot of literature that shows that this multidisciplinary approach actually leads to better outcomes and global symptom improvement.

So what we’re able to do is approach our patients and teach them that a multidisciplinary, group-oriented, team-based approach is the way that we should manage this diagnosis. We’re able to refer our patients out to our nutritionists and our behavioral health specialists that are part of our digestive wellness center, and then we integrate or incorporate a lot of education on lifestyle medicine. My partner in crime in this project, Dr. Christina Tennyson, who is also one of the authors of this piece, spearheads a lifestyle medicine series for the health system, where she does virtual, or Webex, education on lifestyle pillars and seeks to help patients with IBS address their symptoms using lifestyle medicine.

Then we also do a lot of collaborative education with the farm and teach patients that one of the root factors within their IBS may be a microbiome alteration called dysbiosis. We’re able to bring them to the farm and incorporate a lot of the principles through education and then also through demonstrations. For example, fermented foods have been shown to potentially decrease microscopic inflammation in the gut and help patients with chronic GI disorders like bloating, for example.

So really just creating a framework of care and also validating symptoms, I think, is really important. I think early in my career, I found that to be incredibly important, because many of our patients that we would see within these tertiary systems were frustrated because nobody provided them with a diagnosis or sort of a pathway towards better care and better management. And so I think acknowledging their diagnosis and providing them with a framework for care is really, really important.

Kevin Pho: We’re talking to Savita Srivastava. She is a gastroenterologist, and she co-wrote the KevinMD article “Innovation in a rural gastroenterology practice using a farm.” Savita, not everyone has close collaboration with a farm, especially in the primary care setting. So what are some ways that primary care physicians can utilize some of your tips in a setting where they may not have that collaboration with a farm?

Savita Srivastava: I think that there are a lot of different ways to think about it. Certainly there are some hospitals, for example, that may be in urban environments that could even create gardens within their facilities. So thinking small and creating big ideas, I think, is oftentimes important. We collaborate, like I said, with the Allegheny Mountain Institute, which does a lot of national outreach as well. The Allegheny Mountain Institute has created a framework for creating a national model where hospitals can collaborate with farms, but they do a lot of virtual education too.

So we have a lot of opportunities where Dr. Tennyson, myself, and the farmers through the Allegheny Mountain Institute have done a lot of virtual seminars that are available on YouTube, for example, where we talk about important topics like disruptors of the gut microbiome, and “Did you know that the soil also has its own microbiome that’s equally important to consider for the nutrient density of food?” So we have a lot of different opportunities for education that we often offer virtually as well.

But I think that, certainly for primary care doctors, it’s finding resources in the community, and I think I’ve done that throughout my career as well, just looking for people in your community that are working in nutrition or perhaps have a lot of avenues for addressing nutrition education. For example, some grocery stores that I’ve worked with previously in other places have a very profound interest in nutrition, and they’ll oftentimes do education with the community. So I think that there are a lot of options and opportunities that are out there. The primary care doctor sort of needs to look at their environment and see what options are there. But nutritionists, and I think grocery stores, have lots of educational opportunities. And sometimes just building a garden near where you are and being able to talk through gut health and the importance of plants is a useful endeavor as well.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Savita Srivastava: I think the most important factor that I want everyone to recognize is that we have incredible research on the gut microbiome, and it’s important to start translating that work to clinical care. One of the key features of the gut microbiome is that it’s extremely dynamic, and it’s influenced by the foods that we eat. And our diets are one of the key factors that fuel chronic disease, and we need to figure out ways to develop team-based care with our nutritionists and other resources, such as the farm for us, where we can collaborate and provide more education.

As a gastroenterologist that sometimes can only see a patient for 15 to 20 minutes, it’s hard to provide that integrated lifestyle plan. So creating your team is a really important factor in providing better health. So we think that lifestyle medicine is an important part of the future of gastroenterology, and we’re looking forward to working with our colleagues to help develop new ways of bringing lifestyle medicine into the practice of GI.

Kevin Pho: Savita, thank you so much for sharing your time and insight, and thanks again for being on the show.

Savita Srivastava: Thank you so much for inviting me. I really appreciate it.

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