Making a confident diagnosis, choosing the right neuromodulator, and resisting the urge to order one more test or cut one more food: these were the practical threads running through “How I Explain It: Navigating Difficult Conversations in Clinical Practice,” a session on communicating with patients who have disorders of gut-brain interaction (DGBI) at Digestive Disease Week® (DDW) 2026. Faculty delivered the pitches and metaphors they use in clinic, framed around the premise that rapport is itself therapeutic. The moderators noted that AGA's 2025 quality indicators for irritable bowel syndrome (IBS) now endorse effective patient-clinician communication as a formal quality measure.
Make the diagnosis positive, fast, and in plain language
Darren M. Brenner, MD, of Northwestern University, argued that IBS can be diagnosed quickly and accurately without an exhaustive workup, but that the diagnosis only sticks if it is delivered as a positive finding rather than one of exclusion, and in the patient's own terms.
“An accurate diagnosis can be made in 7 to 10 minutes with minimal diagnostic testing,” Dr. Brenner told the audience. “But you have to realize that while the diagnosis can be made quickly; convincing the patient can take much, much longer. It must be at patient speed. It cannot be in technical terms.”
He described reframing the Rome criteria into a short symptom conversation, then citing accuracy data to counter the patient who dismisses symptom-based diagnosis as subjective — putting the figure at “about 95 to 98%” and challenging the patient to name another diagnosis made with comparable confidence.
Validate the patient, but don't let a bad review push you into unnecessary testing, he said: “Validate symptoms, but do not feel forced into performing unnecessary diagnostic testing. And remember, a bad review is better than doing harm, and you're never going to convince everybody. So, if you work in this world and you get a three-star review, you're probably doing something right.”
Be honest about the limits of microbiome and breath tests
Eamonn M. Quigley, MD, of Houston Methodist, addressing direct-to-consumer microbiome reports, said the science is not yet usable in clinic: “As far as I'm concerned right now, it really is not ready for prime time or anywhere close to it.”
On methane breath testing and the popular rifaximin-plus-neomycin regimen, Andrea S. Shin, MD, of UCLA, cautioned that the combination has not been tested against rifaximin alone in a randomized trial, that neomycin carries boxed warnings for ototoxicity and nephrotoxicity, and that treatment decisions should be individualized.
She said: “The decision to treat elevated methane should be individualized. We should be transparent in our counseling. It's important to acknowledge biological plausibility and clinical experiences, but also recognize that there is a limited evidence base to date.”
Neuromodulators: start low, titrate, and set expectations
Lin Chang, MD, of UCLA, offered concrete prescribing pearls: tricyclics first-line for pain-predominant DGBI starting at 10-25 mg and titrating to the lowest effective dose; amitriptyline when diarrhea or poor sleep coexist; desipramine or nortriptyline when constipation is present; and SNRIs pushed to adequate doses, since low doses will not relieve pain. The framing for patients, she stressed, matters as much as the molecule, saying:
“I’m going to start you at a low dose to make sure you tolerate it,” she said. “That low dose is mainly about side effects; it may not help symptoms yet. Patients need to know that, so they don’t stop early thinking the medication failed.”
Reconsider the reflex to restrict the diet
A live-acted dietitian visit between Kyle Staller, MD, MPH, of Massachusetts General Hospital, and dietitian Lauren Dear, MS, RDN, illustrated a bloating patient whose “clean,” heavily restricted eating and skipped daytime meals were themselves driving symptoms. The takeaway for referring gastroenterologists was that a dietitian's value is assessment, not another handout of foods to avoid. Dr. Staller used the case to introduce abdominal-phrenic dyssynergia as an alternative explanation for postprandial distension, and offered a quick bedside screen — bloating that is absent on waking, appears within minutes of eating disproportionate to volume consumed, worsens through the day, and resets overnight.
DDW is AGA's annual meeting, jointly sponsored by AGA, AASLD, ASGE, and SSAT. Learn more at ddw.org.