Gut Health and The Doctor-Patient Connection w/ Dr. Nathan Merriman

Episode Information

August 31, 2021

Gastroenterologist Dr. Nathan Merriman talks about the difficult events he experienced throughout his life and how he coped with them, how he connects with his patients, the best ways to improve your gut health, the benefits of a stool transplant, and more.

Topics Include:

• Dr. Merriman’s difficult personal experiences and how he came to terms with them
• What inspired him to become a doctor
• His unique personal approach to patient care
• Dietary and lifestyle changes to prevent colon cancer
• Gut bacteria and fecal transplants
• The benefits of probiotics
• His plans for Doctorpedia’s Gut Health channel as CMO
• Up-and-coming innovations in gastroenterology and healthcare in general
• How he stays healthy

Highlights

• “I would also say that [my] patients help me as much as I help them. I think by giving all that I can as a gastroenterologist to each patient, as a teammate, I also connect with them in their care and help them to live their best life possible.”
• “I feel it’s important for us to be vulnerable as human beings in healthcare and to connect with compassion, where we’re empathizing and we’re adding action moving forward with our patient teammates to help them make decisions that are informed and are also helpful for them as people. That’s really been my philosophy, is always thinking about patients as teammates and that what we do we do together.”
• “[In terms of preventing colon cancer], really getting toward eating a healthy diet with a certain amount of fruits and vegetables, avoiding red meats and processed meats definitely is a recommendation. Eating lean meats, also staying hydrated, staying active in terms of exercise, which also helps your gastrointestinal motility.”
• “There’s a lot more that we can do in terms of what we’re eating to help positively influence the bacteria in our intestinal tract.”
• “What I’d like to do and what I’ve done with a lot of patients before too, is curate content from some expert sources and include that content on our Doctorpedia site, as well as some videos specifically around hot topics like irritable bowel, like gastroesophageal reflux diseases you mentioned, like small intestinal bacterial overgrowth.”
• “The impact of stool transplant and what that does in terms of just think about completely repopulating the colon with different bacteria and physically doing that and then looking at the impact afterwards, I find it just fascinating.”
• “Telehealth applications in gastrointestinal care, I think, are fantastic. And whether that’s reaching out to our rural communities and patients, or just figuring out a way to connect in a more patient centered way in the way that patients want to connect, I think is key to what’s next.”
• “I love exercising, specifically hiking with my wife and kids is something really important to me. And the other thing is, I take time to recover and reflect. And I think those are things I think that are important to health, mind / body health, but also just taking time to recover is something I think generally in the US we need to do a better job of.”

Relevant Links

• Doctor Profile
• Doctorpedia Spotlight Interview
• Article: How my forever moments have shaped me as a doctor

Episode Transcript

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

Daniel Lobell: (00:19)
Hello and welcome to the Doctorpedia podcast! I’m your host Daniel Lobell and I’m honored to be joined on the line today by Dr. Nate Merriman. How are you, Dr. Merriman?

Dr. Nathan Merriman: (00:30)
I am doing well. How are you doing now?

Daniel Lobell: (00:32)
I’m good. Thank you for asking. I’m excited to speak with you. I got the chance to chat a little bit with you earlier in the week and read some stuff that you sent me, a personal article that I guess people would say you lived a charmed life. Does that sound about accurate?

Dr. Nathan Merriman: (00:48)
I feel very fortunate to be here, not just on a podcast with you, but also just here generally.

Daniel Lobell: (00:55)
I want to talk a little bit about your story because it’s absolutely fascinating and it’s heartbreaking in some ways, but it’s also inspiring in some ways. So if you’ll allow me, can I start to go into it with you?

Dr. Nathan Merriman: (01:06)
Absolutely.

Daniel Lobell: (01:07)
So when you were just a child, you lost both your parents in a house fire and you and one of your siblings survived. Was it a sister?

Dr. Nathan Merriman: (01:15)
My brother, my brother Zach.

Daniel Lobell: (01:17)
You and your brother survived. How old were you when that happened?

Dr. Nathan Merriman: (01:20)
So I was 13 and Zach was 11.

Daniel Lobell: (01:24)
Wow. I mean, I read that article you wrote, and my heart just broke. I was just like, this story… And that you came through all this adversity and wound up doing the incredible things you do is just amazing. But can we talk a little bit about that journey?

Dr. Nathan Merriman: (01:41)
Absolutely.

Daniel Lobell: (01:41)
Where did you grow up, first of all?

Dr. Nathan Merriman: (01:42)
So grew up in Williamsburg, Virginia and had lived there… I was born in Fredericksburg, Virginia, just up the road from there and then moved to Williamsburg and lived there until age 18, actually.

Daniel Lobell: (01:56)
And once you lost your parents, where did you wind up? Living with a family member, or…?

Dr. Nathan Merriman: (01:59)
Yeah. So that was an interesting experience. As the oldest in the house, I was asked to make a decision about where my brother and I should live.

Daniel Lobell: (02:12)
At age 13.

Dr. Nathan Merriman: (02:13)
Correct.

Daniel Lobell: (02:14)
Wow.

Dr. Nathan Merriman: (02:16)
Unfortunately we lost the will in the fire, so we didn’t have specifics around where we would go live. So my uncle brought me and my brother into the chamber with the judge and he laid out some constraints and requirements and my brother and I had to stay together. It had to be with a family member.

Daniel Lobell: (02:36)
So Disneyland was ruled out immediately.

Dr. Nathan Merriman: (02:38)
That’s right. No Disneyland. So, yeah, so then I had to do my best to make the best decision in the moment.

Daniel Lobell: (02:45)
Wow. You know, as I was reading the story, I was thinking it’s surprising that you didn’t become a firefighter after that happened, but you did wind up going into a situation where you could help people who are grieving.

Dr. Nathan Merriman: (02:59)
Yes, absolutely.

Daniel Lobell: (03:01)
Did it ever occur to you to fight fires? Was that a thought along the way?

Dr. Nathan Merriman: (03:05)
That’s a great question. I think to be honest, I came at the experience with the mindset of initially trying to help other kids who had gone through traumatic experiences. And so my first goal was initially to be a child psychologist or psychiatrist. So I will admit I did not go the firefighter route.

Daniel Lobell: (03:27)
Why did you opt out of that? You didn’t like talking to kids in the end, you found them… [Daniel laughs] I don’t know. What changed your mind there?

Dr. Nathan Merriman: (03:36)
Another great question. I think ultimately I wanted to move upstream from suffering, meaning that I thought that I could potentially have a great impact on helping to prevent suffering rather than helping specifically with a career designed to adapt to human suffering after it occurred. So one of my teammates from college actually asked me, “Why did you choose gastroenterology?” And I still remember this question and I decided, you know what? I think it really ended up being, because we have the ability to identify these precancerous lesions, polyps in the colon, remove them, and then help prevent the entire cascade of suffering with colon cancer. So I do think gastroenterology as a field of medicine is incredible because we do have the ability to work with patients and other care team members to prevent suffering.

Daniel Lobell: (04:27)
You know, I spoke recently with another gastroenterologist on the podcast and I found it really interesting to find out that colonoscopies were not only diagnostic, but also preventative. And I can’t think of anything else in medicine that is like that, though I’m sure there are things, I just don’t know of them. Are there?

Dr. Nathan Merriman: (04:49)
There are. There are other fields of medicine where it is more of a preventive approach and mindset, especially with breast cancer prevention, with early lesion identification and then different approaches to help prevent breast cancer. There are other fields of medicine where it is similar, but I do think gastroenterology is the most ideal in terms of design to identify the pre-cancer, remove them, and prevent the cancer.

Daniel Lobell: (05:19)
After I found out about that, I was calling everybody, telling them to get colonoscopies. I thought it was like the greatest gift I could give my family. I’m like, “Get a colonoscopy!” They were like, “What got into you?” I said, “It’s preventative!” [Both chuckle]

Dr. Nathan Merriman: (05:32)
And that was before you talked to me. So that’s impressive.

Daniel Lobell: (05:36)
I do want to hear a little bit more about this story. Do you mind my asking what set off this fire and what are your memories of the aftermath of the experience?

Dr. Nathan Merriman: (05:46)
Yeah. And that actually ties into, in reflection, something that I’ve done over time is really work with patients around quitting smoking. So both of my parents smoked cigarettes. And the thought was that it was an overturned ashtray that started the fire on the couch in our living room.

Daniel Lobell: (06:04)
Yeah. That’s tragic. That’s horrible. What did they do for a living?

Dr. Nathan Merriman: (06:08)
Oh wow. Great question. So my mom was an entrepreneur. She started up a typing business actually in partnership with the College of William and Mary, which was across the street from where we lived. And she worked with college students on helping them to type much faster than they could on their own. So she had tons of business with that. And my dad was a mental health administrator. He worked in Newport News and helped to work with adults and with kids with mental illness.

Daniel Lobell: (06:39)
So he was also a doctor, in a sense.

Dr. Nathan Merriman: (06:41)
In a sense, yeah. He was actually still working on his PhD when he passed away.

Daniel Lobell: (06:46)
So that makes a lot more sense to your story in my mind, because it’s almost like you fulfilled your father’s legacy.

Dr. Nathan Merriman: (06:55)
That is… Yeah. That is very insightful.

Daniel Lobell: (06:58)
Your story goes on in this piece that you sent me, which was incredibly powerful, talking about a very frightening situation you had when one of your children was born, where they were put on tubes, breathing tubes. I think it was 17 days, you said, before they were able to come home. Is that correct?

Dr. Nathan Merriman: (07:18)
Correct. Our firstborn daughter.

Daniel Lobell: (07:22)
And then you had a brain surgery. Can we talk a little bit about that?

Dr. Nathan Merriman: (07:27)
Yeah. So that was a powerfully disruptive experience for me where I was a second year resident in internal medicine and had just finished my intensive care unit rotation, was rotating in the ER, and had this awful headache that started on one of my emergency department shifts and didn’t feel right, thought maybe it was some viral thing. I did ask my residents who was overseeing me in the emergency department if I could go home, went home, got really sick for a couple of hours and passed out on the floor in the bathroom and with a splitting headache and then crawled into bed and just went to sleep. And when I woke up, I think it was something like two o’clock in the morning, still had this awful headache and definitely the worst headache I’d ever had. And so my wife took me to the hospital down the street and we went to the emergency department and I shared with the emergency department physician that this was the worst headache of my life. He said, well, you know what that means, we definitely need to do a CAT scan. And they did, and found that there was a very small cyst that had blocked the flow of fluid around my brain. And so I had acute hydrocephalus. And then at that point I got admitted to the hospital and required urgent brain surgery to remove the cyst that helped enable the flow of fluid around my brain.

Daniel Lobell: (08:50)
So you’ve had, again, all this adversity going through your story through your life. And it makes me think, first of all, maybe it’s either ironic or appropriate that your last name is Merriman. [Both chuckle]

Dr. Nathan Merriman: (09:08)
Very well said.

Daniel Lobell: (09:10)
I mean, perhaps you’d need to be so merry to get through all that, but also I’m wondering what got you through it. What was it, an incredible amount of faith? What do you think has been able to propel you in a life where so many people, if given these circumstances, might find themselves as a, perhaps a drug addict on the street, you’ve actually done quite the opposite and gone on to help so many people and become this incredible prestigious doctor. What do you think is the difference in the way you’ve approached these experiences?

Dr. Nathan Merriman: (09:43)
Wow. I think it’s the support of others. And this probably ties in with my approach to working with patients always as teammates, that I believe things are so much better done together. And I will be the first to admit, there’s no way I could have made it through life without the support of my brother, my teammates in rowing in college, that I’m still close to now, really are family, to my co-residents during residency, who supported me when I was out for brain surgery and supported me when I came back, to team members I had in fellowship attendings and other physicians at the University of Pennsylvania who were amazing and always very supportive of me. And then again, it just goes on and on… The private practice group, many supporters. And then now my new team that I’m working with in gastroenterology. I think it really has been the support of others. And it’s interesting you ask that because I would also say that patients helped me as much as I help them. And I think by giving all that I can as a gastroenterologist to each patient, as a teammate, I also connect with them in their care and helping them to live their best life possible, at least from the gastrointestinal side of things, which can really have a dramatic impact on everyone’s life, by the way.

Daniel Lobell: (11:11)
So just to sum up what you just said, patients help you as much as you help them in as much as you administer colonoscopies to them and they do so back to you. Is that correct? Did I hit all the notes?

Dr. Nathan Merriman: (11:23)
Yes…

Daniel Lobell: (11:23)
[Daniel chuckles] I’m just being silly.

Dr. Nathan Merriman: (11:26)
Luckily I am not asking my patients do my colonoscopies. [Both chuckle]

Daniel Lobell: (11:33)
I wanted to talk a little more about what you were just saying about your approach to… It seems like just a small switch because it’s just a word, but I think it’s much larger than that. The way that you refer to your patients as team members. And I do want to relate this also to another piece in the article that you sent me where you talked about being a newly married couple with your wife and being a doctor and encountering this other newly married couple where in the wife was terminally ill and you felt this incredible connection, relatability to put yourself basically into the shoes of that other guy. And I think that really touched a nerve with me. It really spoke to me. “Wow, this guy, his heart is really in the right place as a doctor,” and not surprising at all that you would go on to this new approach of referring to patients as team members. But I was hoping you’d elaborate on that a little bit.

Dr. Nathan Merriman: (12:32)
Absolutely. Specifically around that moment in the ICU with one of the patient family members? Or more broadly, my whole philosophy on working with patients as teammates?

Daniel Lobell: (12:42)
I wouldn’t be adversed to hearing both. To be honest, I think they both sound very fascinating.

Dr. Nathan Merriman: (12:47)
Yeah. I think for that moment in the ICU, I still remember it very well. It’s that human connection of a moment where you try to picture what it must be like for someone else, and you realize you can’t fully understand the amount of pain they’re going through. And you do your best. And I definitely had a lot of things in common with this young guy whose wife was diagnosed with an awful stomach cancer, and he was trying to make decisions about what to do. And you just pause in that moment. And then I think I conveyed in the article after that moment of talking to him and telling him how sorry I was with everything that was going on with his wife. As a clinician, whether it’s a nurse teammate or physician or advanced practice provider, any of us, then sometimes I have to take a moment to recover, because it is so overwhelming to empathize in that moment and try to understand at least a little bit of what it feels like.

Dr. Nathan Merriman: (13:54)
And I think I do try to carry that moment forward in other circumstances. And I will be the first to admit, it’s hard, that when there is an immense amount of suffering with someone in front of you and you’re trying to feel it yourself, you do need to then take that pause afterwards to recover and reflect. And so that’s a pattern I got into over time where I feel it’s important for us to be vulnerable as human beings in healthcare and to connect with compassion, where we’re empathizing and we’re adding action moving forward with our patient teammates to help them make decisions that are informed and are also helpful for them as people. That’s really been my philosophy, is always thinking about patients as teammates and that what we do we do together. And I’ve shared this comment before from a patient perspective: nothing about me without me is really the approach. Where if it’s about my care, my life, my health, I really want to help make the decision as a patient. And I need your help as a physician, as a nurse, as another caregiver to help me make the best decision. So that I believe is a model of healthcare that we need.

Daniel Lobell: (15:13)
I’m with you a hundred percent. And I think that is really what’s missing in a lot of the healthcare that I’ve experienced in my life, is that you do kind of go in there and are sometimes made to feel the inferior when the patient is you. So I think you’re really hitting on something here. And obviously we don’t know as patients what you know. We don’t have the training, we haven’t been to medical school. And I know I talked to many doctors on this podcast about sometimes this frustrations they have with patients who come in having self-diagnosed on WebMD, but there is this desire to want some type of autonomy over your health and to try and exercise whatever intelligence you have using whatever resources are available to you, which is also why I love Doctorpedia so much and love being part of what they’re doing, because they do empower the patient with the platform to go out and make informed decisions and try and understand in a clearer and less, I don’t know, hyperbolic way what’s going on with them. But I think that very slight adjustment is actually a very big adjustment in what you’re saying.

Dr. Nathan Merriman: (16:26)
I agree. I agree.

Daniel Lobell: (16:29)
So let’s shift over to a little bit more of the technical stuff. I know that right now colon cancer is on the rise. What do you attribute that to? And what foods do you recommend that we eat to avoid and prevent colon cancer? Also what lifestyle changes can we make?

Dr. Nathan Merriman: (16:48)
Oh, great question. I think a couple of things. One, really getting toward eating a healthy diet with a certain amount of fruits and vegetables, avoiding red meats and processed meats definitely is a recommendation. Eating lean meats if you are eating meat, also staying hydrated, staying active in terms of exercise, which also helps your gastrointestinal motility, or a translation to that is, helps keep you regular. Keep the bowel movements coming.

Daniel Lobell: (17:19)
You’ll find this hard to believe doctor, but I’m actually running a marathon as I interview you right now.

Dr. Nathan Merriman: (17:27)
[Both chuckle] I love it. It’s amazing that you’re not short of breath at all. That is really impressive.

Daniel Lobell: (17:33)
People tell me that. I’m always surprised to hear that other people are short of breath in doing that, but, you know, I guess it’s just a gift.

Dr. Nathan Merriman: (17:41)
Oh, and one other big addition that relates back to my “why,” I think in terms of working with patients and really focusing on preventative approaches is quitting smoking. Smoking definitely increases the risk of several gastrointestinal cancers. And by quitting smoking, patients are doing such an important thing for themselves and their families. And that’s actually how I talk to patients about the smoking issue. And I learned that from several patients actually, when I’ve talked to them about quitting and it was one of my internal goals of getting as many patients as possible to work on quitting smoking as I could.

Daniel Lobell: (18:20)
Well, it’s very personal for you as well, I would imagine.

Dr. Nathan Merriman: (18:23)
Exactly. And actually I’ve even shared my personal story with other patients too, because they’ve asked me, “Well, why are you so passionate about encouraging me to quit smoking?” And so I shared my history with them and they really responded in a way that was amazing. They listened to me and more of my background and they also, I think, internalized it and thought about, “Wow, so smoking can potentially impact not just me and my health, but those around me and my family members.” And I think that’s where I connect often and most frequently with patients is when we’re talking about the “why” behind colon cancer prevention and really investing in your own health and putting in effort is to spend more quality time with family and friends and enjoy life to its fullest.

Daniel Lobell: (19:14)
I think I’m going to nominate you for Surgeon General after this. I think you can improve the warning. Out of curiosity, I know that people have told me a million times processed meats are bad for you and it’s not something that I’m particularly challenged by, I don’t eat a lot of processed meat, but what is it about processed meat that is so bad for people?

Dr. Nathan Merriman: (19:34)
So I think the chemicals and preservatives are often thought to play a role potentially in increasing the risk of several issues with the digestive tract. And it’s not just colon cancer. What we eat influences the bacteria in our intestinal tract, which really can influence more about us than we realize.

Daniel Lobell: (19:59)
I had this conversation recently with the other gastroenterologist where I told him that I think if there’s some way that we could figure out what the heck is going on with the bacteria inside of us, that might be the key to immortality. But I really think it’s a huge, huge gap in personal healthcare is that we have no idea if we have good or bad bacteria going on down there only in as much as the side effects that we may feel. And most people can’t identify them or won’t identify them as being bacteria-related.

Dr. Nathan Merriman: (20:33)
I agree.

Daniel Lobell: (20:34)
All right, cool. We’re on the same page. [Both chuckle] But I am hoping you’ll kind of expand on that a little bit because I know that I only can scratch the surface on that. Is there anything you can add to that? Or is there anything that we should know about what’s going on with the bacteria inside us or what we could know?

Dr. Nathan Merriman: (20:52)
Yeah, I think to be honest, it’s one of my biggest interest areas in terms of upcoming and the ongoing research is we’ve learned a lot more about how much we don’t know about the gut microbiome and how much of an impact it plays on mental health, on physical health, on longevity. That’s another interesting angle too, that you brought up. It is massive. In terms of, number one, the volume of bacteria and organisms in our intestinal tract. And then number two, trying to understand the interconnection and interrelation of all those bacteria, different organisms, with each other, and then also with our intestinal tracts and other parts of our body. I think that at least what I do with different patients is number one, I talk to them about, keep in mind when you do get exposed to different antibiotics, it has an unintended consequence in your gastrointestinal tract, every time.

Dr. Nathan Merriman: (21:51)
And we don’t know exactly the impact on an individual level. So I just try to share those unknowns openly. I also encourage just my own personal recommendations are eating a good amount of yogurt daily, which is a good natural probiotic. And again, eating more food that is either anti-inflammatory or avoiding food that’s more pro-inflammatory in the body and there are different theories about that and actually quite a bit of books coming out about. There’s a lot more that we can do in terms of what we’re eating to help positively influence the bacteria in our intestinal tract.

Daniel Lobell: (22:28)
Any book recommendations?

Dr. Nathan Merriman: (22:30)
Oh, that’s a great question. I knew you were going to ask that. I do not have a specific one yet, but I will get back to you on that one.

Daniel Lobell: (22:37)
Well I can at least recommend the Tintin series, but that’s not related at all. I don’t know if you know what that is, but it’s comic books.

Dr. Nathan Merriman: (22:46)
No.

Daniel Lobell: (22:46)
[Daniel chuckles] Silly joke again. But what about taking daily probiotic pills? Is that something you’re for or against?

Dr. Nathan Merriman: (22:52)
Honestly, I think it depends on the patient. One thing that has been found is that once you stop taking probiotics or you stop eating yogurt or drinking probiotics every day, you generally are not going to then create bacteria on your own. So there is a commitment that is required to make sure you consistently get those healthy bacteria in your system. I honestly work with individual patient teammates on this topic where we do a little bit of trial and error, to be honest, where we’ll try a couple different series of probiotics or really try some different yogurts if patients do like eating yogurt every day. And then we adapt the plan together. We’ll check in, commit to a trial of something, whether it’s a probiotic pill or potentially a yogurt series, and then we’ll follow up and check in and say, “Okay, how did you feel with that? Is it something that’s sustainable?” But there’s no way I could do that without my patient teammate. I really think of patients as being the expert in how they feel. And then I try to the GI side of the equation to help with recommendations.

Daniel Lobell: (23:59)
Have you found that any yogurts are better than others with regards to creating probiotics? Any brands of yogurt that you recommend?

Dr. Nathan Merriman: (24:07)
Yes. At least been working with different patients over time and also trialing different yogurts myself. Stonyfield yogurt is a great one. Chobani and Oikos are also two good ones. Those are probably the main ones I recommend. The Icelandic yogurts are great, really leaning more toward yogurts that are higher in protein, lower in sugar, I think is a big key.

Daniel Lobell: (24:30)
So for everybody out there who’s thinking, let me get some of those key lime yogurts, that might not be part of the recommendation here.

Dr. Nathan Merriman: (24:37)
That’s right. Avoid the m&m mix-ins too, not ideal for the gut microbiome.

Daniel Lobell: (24:42)
On a personal note, and I brought this up to you briefly when we chatted on the phone before the interview, I had COVID about two months ago and was put on a series of antibiotics and medications for a few weeks because it was not going away. And it was kind of a bad… I guess it’s all relative. Thank God I wasn’t on a ventilator or anything, but for somebody who’s staying out of the hospital, it was kind of a bad run with COVID. And thankfully I got through it, but it left me with what I would self-diagnosis as GERD. You know what GERD is, but it’s manifesting itself in terms of acid coming up and bloating. And what do you think… My personal takeaway is that these antibiotics and drugs that I took for COVID just destroyed all my good bacteria. What would you say if somebody is in a situation like mine, where there might’ve been some type of Chernobyl or something that killed all their good bacteria inside them, what can they do to quickly restock? Is yogurt the only answer or are there other things as well?

Dr. Nathan Merriman: (25:44)
Oh, that’s a great question. And thinking broadly, not specifically recommending things for you as an individual, but thinking broadly about this topic, I think it’s really important, especially with COVID, because COVID has been found to actually impact the gastrointestinal tract, both with the motility and kind of the, essentially the signaling of moving things through our gastrointestinal tracts, as well as directly infecting the gastrointestinal tract and leading to GI symptoms during the infection, but also afterwards. Which is very similar to post-infectious irritable bowel type syndrome we’ve seen with other infections. I think in terms of, yes, the massive attack on your intestinal bacteria, with what you went through, I think really gearing toward tracking bad symptoms associated with certain foods is something that I work with patients on where, when we’re talking about food diaries, and I know some people do advocate for full food diaries. I tend to take the slightly different approach where I’m asking patients to highlight the bad experiences and then write down the foods they had around that time. And then go through that data together to look for patterns. Certain foods that might aggravate individuals more, whether it’s acidic or, again, red meat, definitely picked up that pattern with patients. Bloating, specific bloating set of symptoms that come up more with the FODMAP foods, where those are really pro-bloating effect for some patients.

Daniel Lobell: (27:16)
Interesting. So a lot of it really just boils back down to nutrition as it often does. You mentioned that you don’t eat much meat. Do you eat any meat? Are you vegan or what does your eating look like?

Dr. Nathan Merriman: (27:27)
I try to avoid red meat. Actually my different nurse teammates and endoscopy suites previously would also probably highlight that. I probably ask all patients to not eat hot dogs. I don’t know that anyone really knows what’s in hotdogs. [Daniel chuckles] So that’s something I don’t eat. Things that I try to eat, more salmon. I’m definitely a salmon fan, a lot of chicken. And those are the big meat-based foods I try to eat. And then a lot of yogurt, not surprisingly, as well as fiber-based oatmeal. What else? Apples, fruits and vegetables, huge broccoli fan and good amount of salads with spinach each week.

Daniel Lobell: (28:06)
I think, if I’m not mistaken, that broccoli and spinach are both anti-inflammatory foods. Is that, am I right on that?

Dr. Nathan Merriman: (28:13)
Yes. I believe they are both categorized as that. Oh, and another big one is avocado. Avocado is a great one. I am a big fan of guacamole and avocados.

Daniel Lobell: (28:24)
Oh yeah, me too. I love avocado. Though every now and then people tell me not to eat it because they say it’s fattening, but then people say it’s a good kind of fat. And I don’t know if the good kind of fat creates the bad kind of bacteria, but it’s the good cholesterol and the bad cholesterol… It’s like all these different things that either are or aren’t on your side and you have to decipher them, but it certainly tastes good with chips, that much I know for sure. [Both chuckle] So I’ll congratulate you on being the CMO of the Gut Health channel at Doctorpedia. What can you tell people to look forward to on that channel? What are your hopes and dreams for what that channel will accomplish?

Dr. Nathan Merriman: (29:08)
Oh, I love that. So I think, and I shared with you too, I think the concept of working with Doctorpedia as a teammate from a patient perspective where I’m hoping that’s what we’re building and with gut health, that’ll be the approach, is to share ideas that are validated and / or studied to really help improve the gut and digestive health for patients who reach out to Doctorpedia as one of their teammates.

Daniel Lobell: (29:36)
So in terms of more specifically, are you working on videos? Are you working on… What’s the plan? What can we look for there?

Dr. Nathan Merriman: (29:42)
Oh, gotcha. You know, what I’d like to do and what I’ve done with a lot of patients before too, is curate content from some expert sources and include that content on our Doctorpedia site, as well as some videos specifically around hot topics like irritable bowel, like gastroesophageal reflux diseases you mentioned, like small intestinal bacterial overgrowth. So highlighting some of the actually most common illnesses the patients suffer with in terms of gastrointestinal symptoms. And number one, explain them in a way that makes sense to patients and also is clear, and number two, give some ideas about things that they can bring up with their physicians, but also potentially some things they could try on their own.

Daniel Lobell: (30:32)
I love it. You brought up earlier that you talk to people about quitting smoking. And I think you said that you had some particular insights on how you’ve been able to help people accomplish that. Can you share that a little bit?

Dr. Nathan Merriman: (30:43)
Oh, absolutely. And again, I look at this as a team effort where my goal is to bring up the topic of smoking actually around the time of colonoscopy in particular and directly connect each patient with our primary care teammate, because I tend to have a model of thinking that each of us is a teammate in each patient’s boat is the model I use. So with that, I also recognize there is no way I can do everything on my own. So I’ll connect them with a primary care teammate on thinking through the different options for them in terms of, whether it’s Chantix or, actually there are lots of modalities in terms of alternative approaches to quitting smoking that I’ve heard from my primary care team. And in addition to that though, I’d pause in the moment to say, because the most common question after having a colonoscopy is probably “When can I eat?” But then the second most common question is “How can I prevent cancer from coming up?”

Dr. Nathan Merriman: (31:47)
So I slow down and I connect with patients and their family at the bedside in that moment, because I do think that’s a moment that matters where you can say, if the patient is smoking, “I really need you to quit smoking. Your goal is to prevent colon cancer. And that’s my goal too. And so I need your help with that.” And so quitting smoking is going to make a big difference on that. And by doing that, and then combining it with family at the bedside and then connecting the patient back with their primary care team on the best approach to quitting smoking, right, it’s been very effective.

Daniel Lobell: (32:20)
Yeah. That sounds very interesting. And congrats on, I mean, it’s hard to find anything that’s effective when it comes to addiction. I know that from working in rehabs, which I used to do for years, so if you’ve had good results with that, that’s incredible. I wonder if addiction also has a lot to do with what’s going on in our gut. I think there are things happening within our gut that lend us to certain habits. Am I onto something here?

Dr. Nathan Merriman: (32:51)
Now that, I will admit, is an area I don’t know as much about, I have heard some about that, but I’m definitely not well-read in that regard.

Daniel Lobell: (33:01)
You mentioned earlier that one thing that you are very fascinated by is the research going on with regards to bacterias. Is there anything, any studies that you can point to that are particularly fascinating and / or promising that you’ve come across recently?

Dr. Nathan Merriman: (33:18)
Oh, regarding the gut microbiome?

Daniel Lobell: (33:21)
Yes.

Dr. Nathan Merriman: (33:22)
Wow. That’s a great question. I think… I’ll be honest, one of the things that I’ve been very fascinated by is, which is not the most pleasant topic necessarily to talk about, but it is gastroenterology and this is the Gut Health channel. So I think people are in it to hear about it is a fecal transplant. So the impact of stool transplant and what that does in terms of just think about completely repopulating the colon with different bacteria and physically doing that and then looking at the impact afterwards, I find it just fascinating, whether it’s potentially a behavioral impact or weight loss or weight gain. I mean, to me that’s fascinating, where you’re just completely disrupting the gut microbiome and putting new bacteria back in, and then what impact that has on an individual level, I find fascinating.

Daniel Lobell: (34:21)
I’m with you. And to go back again to my conversation with the other gastroenterologist, I spoke to recently, Dr. Tin, he told me about a study where they did a fecal transplant with mice or rats, and they had a fat rat and a skinny rat, and they were able to put the skinny rat’s feces inside the fat rat, which somehow — you probably know the somehow more than I do — transformed that rat also into a leaner rat and a sub point to that is you mentioned that it changes behaviors, and that’s kind of what I was getting at with the last question, with regards to addiction. I think there’s something to do with the behaviors that we are engaged in that have to do with existing bacterias inside of us. But what I thought was particularly frustrating in hearing about this from the other doctor was that he said they don’t actually do this on humans. How close are we? Because if it’s working on rats, see, I’m like, “Yeah, let’s just do it!” But obviously I’m not in medicine and I’m sure that’s highly irresponsible, but where are we at with that? Do you have any more intel on that?

Dr. Nathan Merriman: (35:28)
I love that question. So my understanding in reading quite a few of the studies on this, but just thinking about the recommendations to an expert perspectives is the unintended consequences and the fear of the unknown and how potentially by fixing X you’ve now created Y, Z, A, B and C as side effects that you didn’t intend to create. And so that’s one of the risks that I know people are worried about.

Daniel Lobell: (35:56)
Can we at least do this on terrorists or someone who we don’t care about? Just to see if it could benefit everybody else? Someone who’s already on death row, is that medically unethical, to try it on them?

Dr. Nathan Merriman: (36:08)
That is medically unethical, yes.

Daniel Lobell: (36:12)
What about our enemies? People who are trying to destroy us. Wouldn’t they want to possibly get in shape?

Dr. Nathan Merriman: (36:17)
I didn’t think of a stool transplant or fecal transplant as a biologic weapon approach. I had not thought of it that way.

Daniel Lobell: (36:25)
So what needs to happen between this working on rats and us being able to try it on human beings? What are the benchmarks that need to be hit before this is considered not potentially catastrophic?

Dr. Nathan Merriman: (36:39)
Oh, I think demonstrating safety is number one and doing some small scale trials to really test the theory with the implemented solution, I think would be very logical to start with. But yeah, this is one of those areas where it’s exciting and there’s a lot of unknown. In fact, it’s definitely more that we don’t know and what we do know about the gut microbiome and manipulation and adjustment and what are the unintended consequences. But yeah, I think starting up some small trials and seeing what we can do in a positive way and helping make sure that first do no harm.

Daniel Lobell: (37:14)
Cut to five years from now, I’m walking down Rodeo Drive and I see they’ve got storefronts that are doing genetically modified and engineered gut microbiomes for the rich. I’m sure that’s coming. Yeah. “I want a specific microbiome that I saw in a magazine.” Is that very far fetched or is that potentially plausible?

Dr. Nathan Merriman: (37:34)
I think that is fascinating. I will admit, I hadn’t necessarily thought of that scenario, but I do think in the next 5 to 10 years, we’ll have a much better handle on personalizing gut microbiome adjustments, which I think is what you’re asking about.

Daniel Lobell: (37:49)
Wow. So coming soon?

Dr. Nathan Merriman: (37:52)
Yes. I think so.

Daniel Lobell: (37:54)
Very exciting. What are the things in the field more broadly are you excited about that you would be willing to share with the audience?

Dr. Nathan Merriman: (38:03)
Oh, with gastrointestinal health in general?

Daniel Lobell: (38:07)
Yeah.

Dr. Nathan Merriman: (38:08)
Something that I am very excited about GI and digestive health is in, I realize it’s national and it’s on a much greater scale than GIs, is really connecting with patients where they are. So telehealth applications in gastrointestinal care, I think are fantastic. And whether that’s reaching out to our rural communities and patients, or just figuring out a way to connect in a more patient centered way in the way that patients want to connect, I think is key to what’s next. Because I also believe in, I realize it’s not like a GI-specific topic, but it’s the way I want to be treated as a patient. Yeah, I think telehealth, and also adapting in ways that are patient centered in communication, I think is what I’m most excited about.

Daniel Lobell: (38:58)
And that’s been totally revolutionized by COVID-19, correct?

Dr. Nathan Merriman: (39:03)
Correct.

Daniel Lobell: (39:05)
So maybe that’s the silver lining to this whole thing. But do you lose a lot of the doctor-patient connection in the relationship over telehealth?

Dr. Nathan Merriman: (39:14)
Oh, wow. So I’ll be the first to admit that I was incorrect when I thought that we would, cause I really thought… I said, “Oh, I can see kind of a narrow base of patients and things to connect about. This would work really well for GI.” But when I made a move in my career during COVID and then really realized, “Well, I gotta connect with patients over telehealth, they’ve never met me, I’ve never met them. Let’s do this,” it was amazing. And I really think it’s step number one, is listening and being present in the moment and not being distracted. And I think also the other thing that I was surprised by pleasantly from a patient or two things, one was a couple of patients said “It is so nice to see you without that white coat.” I still remember that the first time I heard it, I’m sure I got wide-eyed emoji on them and just thought, “What? Really?”

Dr. Nathan Merriman: (40:09)
And she said, “Yeah, it’s just great to see you at home because that’s where you are, right?” And I said, “Yeah, that’s right.” And so what I did was I learned, because there were several patients that said the same thing, I said, “Well, I’m going to turn this into action.” And so I stopped wearing my white coat in the office and I just noticed very quickly that patients opened up faster and it was great. So that’s one big thing that I learned from COVID is that we don’t really need the white coat to connect. And then the other thing was a couple patients said, and in fact, by the way, maybe the white coat interferes with us connecting as teammates.

Daniel Lobell: (40:47)
You know, I had a very different reaction when I stopped wearing a shirt on Zoom calls. Go on.

Dr. Nathan Merriman: (40:54)
[Both laugh] The other element was I realized how much we lost when we had to wear masks all the time. And so I really honed in on patients’ eyes and making sure I had good eye contact and trying to read responses when they were upset or when something wasn’t connecting with them. But then on telehealth visits, again, multiple patients said, “It’s so nice to see your whole face.” Like not see you with the mask on, it was much harder to connect in person sometimes because you did have the mask. So that was another benefit of telehealth.

Daniel Lobell: (41:29)
Yeah. I imagine that, especially during the height of the pandemic, seeing a face was incredibly refreshing for people. Let me ask you a series of more general questions. What do you wish your patients knew coming in to see you?

Dr. Nathan Merriman: (41:45)
That I trust them. And I see every patient as my teammate is really, I think, the most important way to start off on the right foot together.

Daniel Lobell: (41:59)
What’s the biggest compliment that a patient could give you?

Dr. Nathan Merriman: (42:03)
I still remember it, it was this incredible daughter who was caring for her mother in the ICU with cholangiocarcinoma, which is a bile duct cancer. And she said, when I was talking to her about everything going on, just how real I was. And that’s what she said, “You are so real.” And that’s what I’m striving for.

Daniel Lobell: (42:27)
I’ll echo that sentiment and I’ve enjoyed your realness in this interview, if you will. I’m going to round off this talk with the same question I round all of these off with, which is what do you, doctor, personally do to stay healthy?

Dr. Nathan Merriman: (42:42)
I love exercising, specifically hiking with my wife and kids is something really important to me. And then also I still try to stay connected with the water rower because I rowed in college and so I try to keep up with that as well. And the other thing is, I take time to recover and reflect. And I think those are things I think that are important to health, mind / body health, but also just taking time to recover is something I think generally in the US we need to do a better job of, where we separate ourselves from our work and really just take time for ourselves, get good sleep, stay hydrated, exercise regularly. Those I think are the keys. Every day. Not trying to catch up at the end of a month or twice a year, but really taking time every day to rest recover and reflect.

Daniel Lobell: (43:41)
Great advice, and can’t thank you enough for all the insights. It’s just been an honor getting to speak with you. I’m very impressed with everything that you’ve gone through and how you’ve handled it and where you are now. And I can’t wait to watch what you’re going to do with your channel on Doctorpedia.

Dr. Nathan Merriman: (43:56)
Thank you, Daniel. Yeah, I’ve really enjoyed talking to you and thank you for helping me to keep smiling.

Daniel Lobell: (44:03)
All right. Thank you. Teammate!

Dr. Nathan Merriman: (44:04)
That’s right. That’s right.

Daniel Lobell: (44:08)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.