Brian Lacy, M.D., Ph.D.: Dr. Nice Guy
Dr. Brian Lacy's third patient of the afternoon is a boisterous, overweight woman in her fifties who looks as if she'd feel right at home at a Harley-Davidson convention. She couldn't be more different from Lacy, a tall, thin, bespectacled academic who speaks in a soft, velvety voice. Still, they seem to have great rapport. She doesn't hesitate to talk—and laugh—about having "a good poop" and refers to her antidepressants as "my crazy pills," while he uses precise but clear language to explain the course of treatment he's recommending.
Once a year, this patient and her husband drive three hours to consult with Lacy, a Dartmouth gastroenterologist who specializes in functional disorders of the digestive tract. With functional disorders, also called motility disorders, people have symptoms—such as pain, gas, bloating, vomiting, regurgitation, diarrhea, or constipation—but, explains Lacy, there's no obvious cause of the problem. There's no tumor, ulcer, allergy, or obstruction, and all the usual tests come back normal.
A few years ago, the patient's local gastroenterologist referred her to Lacy to get his expert opinion on whether she should receive a gastric pacemaker to treat her diabetic gastropathy—a neuromuscular dysfunction of the stomach caused by nerve damage from diabetes. In the year and a half before she first saw Lacy, she had been hospitalized 33 times for chronic and severe vomiting. After meeting with her, Lacy decided she didn't need a gastric pacemaker, at least not yet. There were several other avenues to try first, like adjusting her diet and altering her medication regimen. He also advised her about where she could purchase her medications at the lowest price.
Jennifer Durgin is the associate editor of Dartmouth Medicine magazine.
To prevent vomiting, he recommended that she try domperidone and Marinol. Both drugs are controversial. Domperidone is not officially approved by the Food and Drug Administration but can be purchased in the U.S. at specialized pharmacies. Marinol contains a synthetic version of the active ingredient in marijuana. Lacy says some doctors are "morally opposed" to prescribing Marinol, but adds that some of those same doctors "give out Percocet like candy."
Although Lacy may occasionally break step with mainstream gastroenterologists, he is the consummate scientist, so it's hard to imagine him prescribing anything without a firm understanding of the scientific evidence behind a particular treatment.
"I was the kid in third grade blowing up things and burning things in my basement," he says. His dad was a physicist, and his mom didn't work outside the home but was college educated. Both of them nurtured his interest in science—though didn't know about his "little experiments," Lacy says, laughing.
After high school, Lacy majored in biology and psychology at the University of Virginia. Then he took a year off from school and worked nights in a warehouse, loading bread onto trucks. He knew he liked science but wasn't sure if he wanted to be a doctor. So he decided to pursue a Ph.D. in anatomy and cell biology at Georgetown University. Then, while in graduate school, he found himself teaching medical students and realized that he really did want to be a doctor. "I wanted to try to bridge the gap between science and medicine," he says.
As a medical student at the University of Maryland, Lacy decided gastroenterology offered "the perfect combination" for him. The field seemed full of research opportunities, because the causes and mechanisms of many gastrointestinal illnesses were relatively unknown. He was also drawn by the fact that the specialty incorporates a lot of procedures. "I like doing something with my hands," he says.
Born: Near Washington, D.C.
Education: University of Virginia '81 (B.A. in biology and psychology); Georgetown University '87 (Ph.D. in anatomy and cellular biology); University of Maryland School of Medicine '91 (M.D.)
Training: DHMC 1991-1997 (residency and chief residency in internal medicine, fellowship in gastroenterology)
Books authored: Healing Heartburn (2002) and Making Sense of IBS (2006), both published by Johns Hopkins Press.
Family: Wife Elaine; son Colin, 20; daughter Hannah Rose, 17
Most unusual extraction: The components of an entire Walkman that an inmate had swallowed to get some time out of prison
Lacy did his residency and a fellowship at DHMC, which has one of only a handful of comprehensive gastrointestinal motility labs in the country. He then spent six years on the faculty at Johns Hopkins, where he became good friends with Dr. Michael Crowell, who also specializes in functional disorders of the gastrointestinal tract. "My impressions [of Brian] have always been the same," says Crowell, who now directs the motility lab at the Mayo Clinic in Scottsdale, Ariz. "He's just a very energetic, sincere, nice guy—to a fault, almost."
Lacy had loved the work environment at Dartmouth so much that he jumped at the chance to return to Dartmouth when he was offered a position in 2003. "This is a friendlier place," says Lacy. "It's a nice group here. . . . [And] it's a nice place to raise kids."
At DHMC's Motility Center, as the lab is called, Lacy and Dr. Richard Rothstein, chief of gastroenterology and hepatology, have the equipment and expertise to diagnose and treat motility disorders, in which the nerves and muscles of the gastrointestinal tract don't function properly.
To have a successful motility lab, you need to have a "willingness to look at things in a different way," says Lacy, "to really accept a patient's symptoms as an indicator that there is some neuromuscular dysfunction."
Lacy's referral base stretches to Maine, Montreal, Upstate New York, and Rhode Island. He is often the fifth or sixth gastroenterologist his patients have seen. But just because he can do a bunch of fancy tests doesn't mean he always does. "To me a test is useful if it makes a new diagnosis [or] changes treatment," he says. "You shouldn't do a test unless it answers a question."
For several years now, Lacy has been systematically evaluating each of the tests offered in the DHMC motility lab and asking "Are these clinically useful?" For example, he recently looked at the effectiveness of esophageal manometry, which measures the pressure and muscle contractions of the lower esophagus. Although the test has been common for decades, there were no published prospective studies documenting its effectiveness.
"It actually took forever to get that esophageal study published," Lacy admits, "because people kept saying, 'Why are you doing this?' " They were simply assuming it was effective. But the paper was eventually accepted by the Journal of Clinical Gastroenterology, and it turns out that esophageal manometry is quite useful. The study showed that the test provides new information in 87% of patients, often leading to a change in diagnosis or medication.
Lacy also published another prospective study in the same journal, about a procedure commonly used to evaluate acid reflux in children. It found that results from the Bravo pH capsule test, as the procedure is known, changed clinical care in 88% of children in the study.
A former colleague calls Lacy a "sincere, nice guy." But he's not afraid to break step with mainstream medicine.
In both cases, the results supported what was already assumed—that the tests were useful. But that isn't always the case in medicine. For example, until the late 1980s, doctors commonly ordered chest x-rays as part of annual physicals, even when there was no suspicion of disease. "That's just bad medicine," says Lacy. "We constantly have to look at what we are doing."
One of the next things Lacy is looking at concerns not what he and his colleagues are doing but rather what his patients are doing. He estimates that 35% of his patients use some form of complementary and alternative medicine, or CAM—such as vitamins, herbal supplements, yoga, acupuncture, chiropractic manipulation, or homeopathic treatments. "Most CAM therapies have never been tested," he points out. To help patients understand what is known and not known about various treatments, Lacy is writing a book on CAM; it's due out in 2012.
"My view, as a scientist," he says, "is 'Keep your blinders off, keep your eyes open and your ears open.' I think a lot of us used to laugh at this [complementary and alternative medicine] stuff about 10 or 15 years ago, saying it's just quack medicine. There's some stuff out there that probably does work." Next year, he plans to launch a study looking at whether capsaicin, a compound found in hot peppers, can alleviate chronic pain in the digestive track.
For all of Lacy's specialized knowledge and scientific acumen, he converses easily with all sorts of people. When talking recently to a patient who works as a commercial pipefitter, he compared pancreatic stones to "pipe ball valves." And when presenting to an audience of middle-schoolers this past spring, he held them rapt by recounting some of the strange items he's had to extract from people's stomachs and the tools he used to perform the extractions.
Being "such a people person," as his friend Crowell puts it, seems to help Lacy tune in to his patients' needs, too, like helping them find drugs at a cheaper price and making sure they understand how their disease is being managed. For example, he always gives patients a handwritten plan at the end of an appointment. It can be reassuring, he says, for patients to have written instructions to walk out with.
For some patients, the reassurance may come less from walking out with instructions and more from knowing that Lacy wrote them. It's only natural to feel well taken care of when a doctor has helped you stay healthier and out of the hospital.
During the appointment with the boisterous woman with diabetic gastropathy, Lacy leaves the room at one point to fetch a stethoscope. "Coming to this doctor has made all the difference," the woman's husband offers up without any prompting.
"He's the best doctor," she says, nodding in agreement.
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