Are your bathroom habits normal?

When you’re an expert on the gut, you’re used to conversations others might shy away from. So a book on pooping and what can go wrong in the process is on brand for Trisha Pasricha, a second-generation gastroenterologist whose childhood was marked by matter-of-fact directness.

In her new book, “You’ve Been Pooping All Wrong: How to Make Your Bowel Movements a Joy,” the Harvard Medical School assistant professor of medicine at Beth Israel Deaconess Medical Center shares her sometimes humorous perspective on normal and abnormal bathroom habits. In this edited conversation, Pasricha — who also is the director of research for the Institute for Gut-Brain Research at BIDMC and writes The Washington Post’s “Ask a Doctor” column — discussed emerging knowledge that may illuminate poorly understood conditions like irritable bowel syndrome, the damage a doctor’s doubt can do to patients, and her optimism about her fast-changing field.

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In addition to your clinical and research work, you author The Washington Post’s “Ask a Doctor” column. Did that help in writing this book?

Yes, every time we write about gut health it vastly outperforms any other health topic. Even an embarrassing topic like fecal incontinence or farting would do well. That tension is partly why I wrote the book. I think people want good, accurate information and want it without having to make eye contact with their doctor. And we want people to engage early, especially in this age of early onset colorectal cancer.

It seems like you went through some effort to find the right words. Is it poop? Is it a bowel movement? How did you settle on your language?

A dash of humor helps when you’re talking about something that makes people feel ashamed and vulnerable. Medical school trained me to say “bowel movement,” then I started shadowing a gastroenterologist who would go on to become a mentor for me. A patient came in — a younger guy, college-age — and my mentor’s opening line was, “So, tell me about your poop.” The patient had been awkward and nervous, but as soon as my mentor said that, the whole atmosphere changed. I thought, “This is what I should be doing.” This person immediately opened up. He was relieved, and he told the doctor exactly what was going on.

With our reluctance to talk about it, do people really know what normal is?

I don’t think so. When I was starting out on my own, people would tell me about their specific problem, but if you gave them the chance to step back, what they were really curious about was the basics. How many times a day is normal? What colors are normal? How mushy or soft or hard is stool supposed to be? I worry that when people don’t know what normal is, especially what normal for them is, how will they know when something is abnormal?

You point out that there’s wide variety within the “normal” range. What should people look out for?

It’s not just once a day or bust. The range of normal is going between once every three days and three times a day. You can live a full, healthy life anywhere in that range and be fine. What’s important is when there’s a change. If you are somebody who generally goes two or three times a day and now you’re going every other day, even though that is somebody else’s normal pattern, this is a change for you. And colors are important. It’s not always a healthy shade of brown. When you see red, when you see maroon, when you see something black, tarry, sticky, it’s important that you don’t just brush it off. Let your doctor know about it the day it happened.

What are specific conditions these changes might be signaling?

There are lots of different diseases that start in the gut. And there are a lot of gut conditions that may or may not get a diagnosis or a name but are causing you trouble. Most urgent is cancer, but there are other things that cause bleeding and pain, like inflammatory bowel disease. Diverticuli can bleed, hemorrhoids can bleed. There are also things that probably won’t kill you but are difficult to live with. There’s irritable bowel syndrome and other causes of constipation and chronic diarrhea. And there are people who have GI issues, but no diagnosis: Three out of four people can’t poop in public and one in three can’t go to the bathroom on vacation.

Is this a field that’s advancing rapidly?

Definitely. Neurogastroenterology is the most exciting field in GI, though I’m obviously biased. For the longest time we weren’t getting deep enough into the enteric nervous system, into those deep muscle layers of the gastrointestinal tract. So, for about a century, what we were studying was how the brain influenced the gut and what we could observe with our naked eye about its effects on the gut. But now that we’re more and more able to look at those neurons and cellular changes, the whole field is exploding. Every few years there’s a profound breakthrough that upends everything we’ve learned.

Is the new understanding of the gut-brain connection both cutting-edge and misunderstood, even within the medical profession?

That’s exactly right. One of the most common diseases of our specialty, irritable bowel syndrome, is probably one of the most common disorders in all of medicine. It affects 15 percent of the population and yet is poorly understood by the public and by a lot of doctors because these advances are new enough to have happened after many of them got out of medical school. We haven’t done a fantastic job disseminating that knowledge to people outside neuro GI. That was one of the other reasons I wanted to write this book, to make sure people knew everything that I knew about irritable bowel syndrome and how the gut’s communicating with the brain. Because if you don’t know the data, it can sound really fringe.

Some of the stories you tell, particularly about your interactions with your father — you have to trust the patient — seem like important messages for other doctors to hear.

That was a lesson that stuck with me for life. It’s why I decided to end the book on that note. I recognize that we doctors struggle when we don’t know the answers. It’s hard to be a doctor whose patient is suffering. Not only do you not have a treatment for their suffering, but you don’t even understand where the pain is coming from. So I hope the book shifts our thinking when tests come back normal in a patient with IBS. Instead of simply saying, “You need antidepressants,” we change the way we talk to them. We accept that they have abnormalities even though they’re not being captured by the test. That’s when the conversation changes and trust between doctor and patient is transformed. It’s powerful and may point you toward making the right referral or thinking outside the box for medications that you wouldn’t have thought of before.

Is not believing patients a big problem in medicine? It’s cited by IBS sufferers quite a bit and I’ve heard the same thing about long COVID.

I think about this all the time. It’s not just irritable bowel syndrome, although irritable bowel syndrome is a big part of long COVID. It’s other conditions like migraines. All the brain scans and blood tests are negative and yet they’re living with this difficult condition. They feel dismissed. We are taught in medicine to think algorithmically: Here are the set of abnormalities, here’s the pattern, put that puzzle together. When you feel like there are no pieces to put together because there’s no clue you can latch onto, it’s easier to say this is in the patient’s head rather than it’s something that we might not be capturing yet. But we will start to capture those things in tests in the next 15 years and suddenly we’re going to stop telling people “This is all in your head” simply because we’ll see it.

What are the main takeaways for readers of this book?

I hope people walk away from it feeling reassured, feeling like, “You know what? I’m not weird or abnormal. There are a lot of people dealing with exactly the same thing I’m dealing with.” I hope, too, that they feel reassured by the practical tips I give for the day-to-day problems that more people suffer from than we might know because we don’t ask about it, don’t talk about it. I also hope it’s validating to people who have ever felt dismissed or felt that they haven’t been believed, that there’s a whole world of scientists and doctors who are working on this problem.