Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!
We explore the often-overlooked world of bowel health with colorectal surgeon Carmen Fong. Carmen shares her journey into this specialty, the stigma surrounding bowel habits, and the critical need to normalize conversations about poop. From patient stories to breaking societal taboos, she sheds light on the importance of open dialogue for better health outcomes. Whether it’s hemorrhoids, constipation, or laughter in the exam room, this conversation promises to inform and inspire.
Carmen Fong is a colorectal surgeon.
She discusses the KevinMD article, “Why your doctor wants you to talk about poop — and it could save your life.”
Our presenting sponsor is DAX Copilot by Microsoft.
Do you spend more time on administrative tasks like clinical documentation than you do with patients? You’re not alone. Clinicians report spending up to two hours on administrative tasks for each hour of patient care. Microsoft is committed to helping clinicians restore the balance with DAX Copilot, an AI-powered, voice-enabled solution that automates clinical documentation and workflows.
70 percent of physicians who use DAX Copilot say it improves their work-life balance while reducing feelings of burnout and fatigue. Patients love it too! 93 percent of patients say their physician is more personable and conversational, and 75 percent of physicians say it improves patient experiences.
Help restore your work-life balance with DAX Copilot, your AI assistant for automated clinical documentation and workflows.
VISIT SPONSOR → https://aka.ms/kevinmd
SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast
RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended
GET CME FOR THIS EPISODE → https://www.kevinmd.com/cme
I’m partnering with Learner+ to offer clinicians access to an AI-powered reflective portfolio that rewards CME/CE credits from meaningful reflections. Find out more: https://www.kevinmd.com/learnerplus
Transcript
Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Carmen Fong. She’s a colorectal surgeon and author of the new book, Constipation Nation: What to Know When You Can’t Go. There’s an excerpt from that book on KevinMD, “Why your doctor wants to talk about poop and it could save your life.”
Carmen, welcome back to the show.
Carmen Fong: Thank you so much for having me, Kevin. Always a pleasure.
Kevin Pho: All right. So let’s talk about this KevinMD article that is based on your new book, “Why your doctor wants you to talk about poop and it could save your life.” Tell me what this article is about.
Carmen Fong: OK. Yeah. So, you know, people ask me all the time, like, why did you go into this business? You know, how come you would want to be a colorectal surgeon? And I always start by saying, you know, I went into this because I wanted to cure cancer. You know, early-stage colorectal cancer is curative with surgery, like stage one and stage two.
But as time went on, you know, I kind of saw more and more rectal disease and found that patients just were very, very satisfied with having their, you know, rectal problems treated. These are frustrating problems that people don’t want to talk about and, you know, their physicians don’t know how to handle.
Eventually I kind of just fell into the space where I mostly do anal rectal stuff and deal with a lot of constipation. Then eventually it became a book, because I was talking about it so much that I started making these little pamphlets where I would hand them out to patients. Then my start requesting them, and then residents and fellows started requesting them, and it kind of evolved into this huge thing, like an actual book.
Because I wanted to, you know, as a surgeon, I want to know everything. So I want to have answers for everything. And I was like, well, I’m just going to look into, you know, what exactly type of fiber we should be eating, like how much water, how much fiber. Because while we were, you know, generally taught, OK, somebody comes into the ER for hemorrhoids—well, tell them sitz bath, you know, fiber, hydrocortisone, but like how much fiber, like how much water, what type of sitz bath. So that’s where this stemmed from.
Kevin Pho: So tell me about removing that stigma about talking about bowel health. What are some of the things that you do to make patients feel more comfortable talking about topics that are, to them, considered taboo? So how do you make patients feel more comfortable and de-stigmatize the topic of bowel health?
Carmen Fong: Yeah, I think that most of the thing is actually just talking about it more, you know, in general, like having it out in the open. I found that patients generally fall into two groups. One is, they’ll be like, “I really want to talk about my bowel health,” and then the other group will be like, “Please don’t ever mention it,” you know, to the point of, “I don’t want you to talk about it. I don’t want you to look at it,” whatever.
And I think that maybe the younger generation is more starting to do it and talk more, be more involved with their bodies, like in tune with everything that’s going on, very into wellness and like having overall preventative health. I think my personality has a lot to do with it, honestly, because I feel like people who become colorectal surgeons tend to have a little bit of a sense of self-deprecating humor.
I go in and try to make the patient, like, you know, immediately comfortable. So I’ll be like, “Well, you know, I know you’re here. This sucks, but we’re going to try to make it as good as possible.” The other thing is really, really talking through everything, where I say, “I’m going to tell you everything I’m doing,” you know, in terms of this procedure. “It’s a sensitive area, but I will tell you exactly where my hands are going to go, what’s happening now, so you’re not surprised when something happens.”
Lastly, again, education is such a big part of it. Part of the reason why I do the book and why I do TikToks is that, you know, people don’t know that overwiping causes itching, or people don’t know that there are two types of hemorrhoids. So really taking the time to go through that, I think, makes people comfortable and trust you, and have that feeling that you’re on their side.
Kevin Pho: So tell me some of the most common questions you receive from patients about their bowel health.
Carmen Fong: Oh, OK. So I would say the number one thing is if pain is a problem, you know. So, you know, hemorrhoids bleed and they prolapse, itch, but I would even say that people don’t often come in for hemorrhoids, you know, even though I work at Hemorrhoid Centers of America. They come in for fissures, because by the time it’s painful, they’re like, “OK, something is wrong, I have to go in.”
So the pain is usually not a sign of cancer, right? People are always like, “Well, you know, I want to make sure it’s not cancer.” You know, cancer, while it does hurt, it’s usually not like the first thing. You’re going to have itching; you’re going to have a lump there; you’re going to have bleeding before you have, like, terrible, severe pain. Pain tends to be an external thrombosed hemorrhoid or an anal fissure, so either a cut in the butt or you’re feeling a lump the size of a blueberry.
Differentiating between all anal and rectal diseases is one of the first things. People will be like, “I think it’s a hemorrhoid,” but it could actually be X and X and X. The next most common one is probably itching. I would say what causes itching around the anal area, and, you know, while this can be super multifactorial, the main things I would say are overwiping—wiping with Preparation H or witch hazel wipes, like some sort of medicated wipe, when you don’t need to be doing that on the outside. And then, you know, obviously hemorrhoids in and of themselves can cause kind of this veiny, wormy, itchy feeling when they’re swollen, and that’s when, you know, after an examination, we figure out that you have to treat them.
Kevin Pho: So in your article, you talk about some of the cultural influences and gender dynamics as it relates to people expressing their bowel health. So talk more about each of those factors.
Carmen Fong: Yeah. So I have to say, you know, I think I also talk in the article about where I think my interest in poop maybe stemmed from, or like my no fear of poop, and it’s from my very, very practical Chinese grandmother. It’s like a bodily function; it has to happen, so there’s really no way of going around it.
At one point in my life, when I was a teenager, we went to her house, and I remember going to the bathroom, and I was like, “Oh my gosh, there’s a little poop in the toilet.” And she just actually went in there, came out, and scooped the poop up, and was like, “flush it down the toilet,” and she said in Chinese, which translates to, “it’s just poop,” literally, “nothing to be afraid of.” And so, just basically from that, I’m like, well, it’s true, it’s just poop, and we have to do it, we have to take care of it.
So culturally, I think that there’s definitely going to be differences in how people are raised, like what your attitude toward bowel habits is. There’s also this huge culture in our generation of poop shaming. So, you know, this is why I wrote a book, because I could go on about this forever.
When people are potty trained, they’re taught that, OK, you can only go at certain times, you can only go in certain places, and that, you know, anything related to poop or bodily functions is gross. As soon as you have a baby and you’re like, “Oh, you stinky diaper,” they’re already thinking, wow, this is associated with shame, this is associated with you don’t want to poop. It actually does lead to some childhood constipation where kids will be like, “Hey, I don’t want people to say that I’m stinky,” so they’ll actually hold in their poop.
Holding their poop—there are different reasons for it, but that’s one of the reasons. After holding in poop for a period of time, you start to get a little proctitis, like things start to hurt, and then when it starts to hurt to poop, then you really don’t want to poop, and then it becomes a vicious cycle in children. But it stems from our attitudes toward poop and potty training.
There was a New York Times article, which I talk about in the book, that was really, really eye-opening—that women will go to certain extremes to avoid pooping in public, or pooping at work. They’ll go to a different building; they sell, you know, now they sell things like “Poo-Pourri” where you spray so people don’t have to smell it. In Japan, they actually have, amazingly, bidets everywhere, but the bidets now have music or white noise fans so that if someone’s in public and you have to go, nobody’s hearing it next to you. On the one hand, it’s great that they have bidets, but on the other hand, we’re still contributing to, “Well, it’s not normal to poop, so therefore you have to cover up the smells and sounds and sensations of going.”
Lastly, there was another article where they actually talk about normalization of bodily functions, and it’s actually way more common in women and men who have sex with men, or they actually said homosexual men, versus homosexual women, and heterosexual men have less problem pooping in public just because of societal norms—it’s you have to be a certain way, you have to be clean, you have to be smelling good. All of those things.
Kevin Pho: So, of course, your article is based on your book, Constipation Nation: What to Know When You Can’t Go. You obviously wrote a book about this whole topic. So tell me some of the big take-home messages you want readers to come away with after reading your book.
Carmen Fong: Yeah. So absolutely, people always ask me, “OK, so how much fiber do I eat?” So the general rule of thumb is 25 to 35 grams of fiber, a little bit less if you’re a smaller woman, a little bit more if you’re, you know, a bigger guy. And it should be both soluble and insoluble fiber. A good example is an apple. Right now, I’m trying to eat an apple a day, just to see what happens. Apples have a really good source of both soluble and insoluble fiber.
The pectin on the inside, the flesh, is the soluble stuff that turns into a gel, and the skin is insoluble, and so that’s the roughage that will kind of stimulate bowel movements. But that gel is also necessary to kind of bind everything and move it through. That same soluble fiber is found in cereals, but I also kind of caution against using cereal as your sole source of fiber, because that tends to be mostly soluble.
All right. So you need to have some fruits and vegetables and roughage in there. Again, 25 to 35 grams of soluble and insoluble fiber. And then water daily should be about two to three liters. Most people don’t get enough water, like 100 percent; I know I don’t most days unless I carry a big water jug with me because you don’t want to be peeing all day when you’re working. But the water is important because fiber without water just sits like concrete in your colon, and it gets turned into a gel and doesn’t go anywhere. So it has to be washed through.
Again, if you’re more active, if you’re pregnant, if you’re in a hot climate, it should be more, really toward the three liters of water, which is, you know, three liters like this, as opposed to the two liters. There’s a whole chapter in there about pregnancy and constipation, which is a super common thing. Like, I see in postpartum, you know, people had constipation during pregnancy, and they have hemorrhoids afterward. I won’t go into that in depth here because that’s, again, the whole chapter. But, you know, because of the physiologic changes, because of the hormones, and because of the anatomy, you can actually have pretty bad constipation during pregnancy. You treat it the same way, though, with fiber, water, and then laxatives if needed.
I was thinking modern laxative, like Miralax, is best, you know—it’s safe, it’s not addictive. But the other things that are addictive are, you know, like Dulcolax or Senna. Those are stimulant laxatives which, it’s not like six months, it’s over years and years of use. Your colon might become used to it and kind of need it to function.
So we did fiber, we did water. Moderate activity is important. They recommend 30 minutes three times a week. I think that moderate activity is fine. Some people will be like, “Oh, I exercise so much, but I actually, you know, it makes my pooping worse.” There are a couple of reasons for this. When you exercise really hard, you actually can get dehydrated, first of all, and the second thing is that you’re actually stimulating like a cortisol stress response, where you’re doing fight or flight, and your body in fight or flight mode will not digest, right, because the opposite is rest and digest.
So you actually can’t be working out too hard expecting your bowels to function, but moderate activity is important and is required for your colon to be stimulated, for gravity to move everything through.
Those are the three main things. The things that I think are, you know, sometimes a little bit controversial will be probiotics. But from my research, I found that there are good strains of probiotics—you need a good mix of probiotics, and you need a good number of probiotics. So while a lot of the research shows that probiotics don’t work on their own, or one specific strain doesn’t do a specific thing, I found that certain strains like bifidobacterium or lactobacillus, you know, having that combination, for most people, will affect the frequency of bowel movements. It doesn’t affect the consistency, but it affects the frequency.
Kevin Pho: So let me give you some common primary care scenarios and ask you how you would approach this. I typically see an elderly patient, perhaps in their 70s or 80s, with worsening constipation. Tell me what kind of dietary changes or suggestions you would make, and at what point would you consider laxatives—perhaps in a patient that doesn’t have, say, any other pre-existing medical conditions or medications that may be leading to this.
Carmen Fong: Right. Yeah. And so, you know, the general evaluation is always like a trial of, I would say, fiber first. You know, do a good dietary and stool intake, see exactly how much fiber and water they’re taking a day, how many bowel movements they’re really having a day. And then, you know, the nature of their bowel movements is important.
So, while most people will say, “Oh, you know, they’re constipated,” I think the definition can vary. Are they going every day, you know? Are they going every day but having a hard stool? Are they going every day but feeling incomplete after they go? Because all of those will slightly change the management somewhat.
And then obviously, you know—and we’re not going there yet—but if all of our interventions fail, then, you know, I will have them do testing for pelvic floor dysfunction. I always explain it to patients like, if the door is closed and you’re trying to push against a closed door, it’s not going to work, right? Or if your door is completely open, like in older individuals, but you compensate by trying to keep the door closed, you can’t go. So things like MRI defecography, anal manometry, or a sitz marker study.
But to go back to the elderly patient: trial of fiber and water, add a probiotic. And then this is actually only barely touched upon in my book because a lot of the research came after I wrote it, which is magnesium. So throwing magnesium at them, like even 400 milligrams a day, actually significantly can change your bowel frequency and consistency.
After all of that, I usually do it for a week or two, and most people, about 85 to 89 percent of the time statistically, will have some change in their bowel habits with just behavioral and lifestyle modifications. If that still doesn’t work, then I try a Miralax cycle—either a Miralax cycle or a Miralax trial. So you can try it, you know, every single day, a capful a day for a week or so, or sometimes, depending on if they’re like, “Oh, it’s like an occasional hard stool,” I’ll do a cycle where it’s three days on and three days off.
So that, you know, most people poop between one and three days, right? So people say, “If I take it every day, I end up having diarrhea on the third day.” So you’re actually just tailoring it so that on their third bowel movement, they’re still going consistently rather than having diarrhea three days later. The important thing is the instructions, though, for doing Miralax. For example, it’s “take a capful of Miralax, but then drink a glass of water after it, drink two glasses of water after it.” I usually tell people try not to mix it into your coffee or juice, especially coffee—it’s like negative water intake, you’re putting in caffeine and dehydration with it. So try to mix it with a glass of water and then, you know, two glasses of water afterward to wash it through. And it does work.
Kevin Pho: And when you suggest fiber—you mentioned apples earlier—proverbially, people recommend things like prune juice. And then what’s your thought about things like Metamucil over the counter for fiber?
Carmen Fong: Yeah. Yeah. So Metamucil is great. You know, Metamucil, Benefiber, Citrucel, psyllium husk—like, all of those things are versions of similar things. I think Benefiber is the one that’s wheat dextran, versus Metamucil is actual psyllium husk, so a little bit of difference there. Metamucil is psyllium husk, which is shown to be the best fiber supplementation that you can take. So even just doing ground psyllium husk on your cereal or on your salad or something will work.
But again, same thing with Metamucil and Miralax, you want to take it in water, wash it down with two glasses of water afterward. You know, people will be like, “Hey, I had a glass of Metamucil, I’m still not going. How come?” Having a glass of Metamucil in isolation, you know, if the rest of the day you eat chicken wings and French fries, it’s probably not going to help that much.
So I would say do a fiber supplement. There’s actually just so many forms of fiber now that I think people can get a little bit overwhelmed, and people who don’t like the fiber powder, though, you know, because, like, you mix it and it’s a gel, it’s gross. It comes in capsules, it comes in pills, and most recently I’ve actually been recommending gummies because people will take gummies—like, they’re very compliant with taking a gummy a day.
Kevin Pho: So let me give another typical primary care scenario. Perhaps a younger patient that you suspect with irritable bowel that has constipation symptoms alternating with diarrhea. In those cases, how would you approach something like that?
Carmen Fong: So, again, it’s almost like a similar approach, but, you know, the diarrhea is more important here because it’s like, are you getting constipation and then diarrhea the next day, or are you diarrhea-predominant? A little education here does help, though. Fiber, you know, whereas it helps with constipation, also helps with diarrhea, right? Because it’s a bulk-forming substance—if it’s too hard, it makes it a little softer, and if it’s too soft, it makes it a little harder.
So consistent fiber intake, and for these ones, definitely start with a fiber supplement and a probiotic. And IBS patients, you know, they’ll have come in and said, “I’ve been on benzos, I’ve been on blah blah blah, amitriptyline,” all these things that, you know, do work with the hypersensitivity of the bowels. But I find that, you know, fiber normalizes their bowels, and then the probiotic again affects the regularity of the frequency.
The one other thing that sometimes helps with IBS patients, especially when there is a lot of bloating involved, is a digestive enzyme. So not, you know, Creon or anything like that, but digestive enzymes like Beano or Lactaid, just to see if it’s really these higher-carbohydrate foods that are causing the bloating or dairy products.
Kevin Pho: And in terms of the probiotic, the stuff that you find over the counter like a Culturelle—that has been shown to be effective?
Carmen Fong: Yeah, so Culturelle and Align—those have been clinically proven to be effective. But I find that sometimes people will take a certain probiotic and it doesn’t work for them, and we don’t have research into this yet, but I think that we’re going to see this in the future, that certain strains work better for certain people, you know, because of your previous microbiome.
And so I’ve told people that you don’t need to go with the name brand. You can actually just—I take the Costco brand. You need to take the Costco brand. It has, you know, one billion CFUs. It has a good blend of different bifidobacterium and lactobacillus, including rhamnosus and casei, and that should be it. You can take it, and you can switch and see if there’s a different one that works better for you.
They’ve actually come out with a bunch of new ones these days because part of the problem is that probiotic capsules get digested in the stomach and don’t make it to the colon. So there are a couple of different formulations I’ve seen where they have a special capsule or a special enzyme where it doesn’t get digested before it gets into the stomach. I haven’t seen research that that works better yet, but I think that’s coming.
Kevin Pho: We’re talking to Carmen Fong. She’s a colorectal surgeon. She’s the author of the new book, Constipation Nation: What to Know When You Can’t Go. Carmen, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Carmen Fong: Oh my gosh. You know I could talk about this all day. So, you know, I think that the one major thing is, you know, the one bowel commandment that I talk about in the book is, go when you have to and don’t go when you don’t. And that will actually prevent 99 percent of your problems.
So a lot of people will be like, “Hey, you know, before I rush out for work in the morning, I have to make myself go to the bathroom and do whatever it takes—squeeze, strain, whatever—you’re going to squeeze some hemorrhoids out.” And then, on the other hand, once you’re at work, you’re like, “Ah, I’m not going to go to the bathroom. I’m going to try to hold it in as much as possible.” And you hold it, hold it, hold it, and eventually, over time, it turns into an anal spasm and gives you a fissure.
Pooping is normal, you know. Everybody should go, and I think that, you know, like I said, go when you have to and don’t go when you don’t. That’s it.
Kevin Pho: Carmen, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Carmen Fong: Thanks, Kevin.
