Nick: Hello it's Nick Kemp here with episode four of The Holy Gut podcast. In this episode, we talk with Nicole and Jody about the FMT program.
Hello, it's Nick Kemp here, co-host of The Holy Gut podcast with my cohosts Dr. Nathan Connelly and Nicole Starbuck-Connelly. Nathan is a Gastroenterologist and Nicole is a registered nurse and practice manager of the Moonee Valley Specialist Centre here in Melbourne, Australia.
Moonee Valley Specialist Centre provides a number of services related to gut health, including FMT and bowel cancer screening.
Hi Jody and Nicole, today we're back and we're going to talk about the FMT program in detail and in particular how you look after patients, both local and those who travel from overseas.
So Jody, as you manage the FMT program, do you want to give us a little bit of background about yourself?
Jody: Sure. I joined Moonee Valley Specialist Centre approximately two years ago, two - three years ago. When I joined my role was administration, and since then I've sort of moved in to helping our practice manager, who is Nicole, and Dr. Connelly work on the FMT program. We've seen a very big interest over the last twelve - eighteen months, and I believe that is obviously people researching the internet, there have been a few programs on television regarding the FMT program. When I joined I really didn't know a lot about it and found it quite interesting. The whole concept makes a lot of sense and quite often these patients have exhausted a lot of other avenues, whether it be through medicines, lifestyle, whatever, and they have now come to wanting FMT as a last resort. This is where once the patient makes contact with us, and this is where I get involved.
Nick: I see. So, if we talk about the patient or a prospect when they first contact you, what happens?
Jody: Probably about 80% of our patients make contact via email and the other 20 by phone. Nicole and I have designed a program where that initial contact, we have four attachments that get sent to these patients. We have an initial letter outlining our practice, our fees, what needs to be involved, where they need to come and have the appointment. Then we have an attachment that has the fees. We also have a brochure that just briefly outlines what FMT actually is and how it is done. Then we have an attachment which is an accommodation brochure, that generally will be for patients who are coming from overseas or out of state. So we sort of briefly cover everything, which answers quite a lot of their questions. And then once they review all those, then they will make contact for an appointment, and then I schedule an appointment with Dr. Connelly to answer any medical-based questions that we are not qualified to answer for them.
Nick: Okay. So if they are happy and they understand the procedure, and you're being transparent about the fees and they are ready to make the next step, they come in and they see Nathan and [crosstalk 00:03:59] obviously during that consult he would go through that -
Jody: With that initial appointment, obviously with all new patients they coming to Moonee Valley Specialist Centre and sit with Dr. Connelly and have an appointment. With our overseas patients or out of state patients, obviously it's a teleconference, it's a Skype appointment.
Nick: Mm-hmm (affirmative)
Jody: But if they do go ahead and walk-in for that initial appointment, I try to get them to email all their medical history, any [inaudible 00:18:59] testing or any testing that they've had done. Because quite often a lot of these patients have an extensive medical history, so I try to have all of that information ready to go for Dr. Connelly on that initial appointment.
Nick: I see. I see. So after they've had the consult with Dr. Connelly, then what is the next step?
Jody: So, sometimes with that initial appointment it's very straightforward and Dr. Connelly may decide, yep, they are a candidate for FMT -
Jody: We will then write up a plan, because it is all done on an individual basis, every person is different and we're treating it for different things. If he does that plan, that thing comes to me. Sometimes with these patients he may want a little further testing done on different things.
Nick: Mm-hmm (affirmative)Jody: I might not have gone down that path yet, so he will decide what he needs to do and when he is ready and the patient is ready, it may take another couple of appointments before it even gets to that.
Nick: I see. And then, once everything is clear and ready to go, I think you mentioned you have a pre-FMT appointment?
Jody: Yes. Once he passes over that plan to me, from there, I liaise with the patient, so Dr. Connelly then is out of the picture for a little while. I liaise with the patient, we work out a date that will suit them, because some of these patients may be anywhere from a week to three weeks, the whole process.
Nick: I see.
Jody: Okay. So we work out a date that works for them, then we generate all of the paperwork, the quotes, all of the future appointments, so there is a little bit of paperwork involved and a little bit of consultation between me and the patient, getting it all in place ready for them to go.
Jody: Once we've done that, then we like them to have an appointment one week before they transplant -
Jody: Just to go over any unanswered questions. It could be anything, a number of reasons. We give them a patient pack, we make up a patient pack which has all their paperwork, their future appointments, it has their bowel preparation. We go over post-transplant what may happen, what they might feel after the procedure, so that appointment the week before just clarifies any unanswered questions and puts the patient at ease so that they are ready to go.
Nick: So you really roadmap the whole process, and it's not just one day we're talking about, it's almost a process of up to a year, which we'll sort of touch on later.
Nick: But after that pre-FMT appointment, obviously the next time you see the patient, it's the day of the procedure, so let's talk about that.
Jody: Yes. That's right. So, the day of the procedure is obviously at a private hospital.
Jody: Generally, by this time the patient fully understands what's involved, what they have to do. They arrive at the hospital. The whole procedure takes three to four hours. It's just a day procedure. It is done under an anesthetic so we do ask they have someone with them for 24 hours. They are generally not allowed to leave the hospital unless they do have someone with them.
Jody: So, we do ask that, and yeah, the procedure itself takes probably about half an hour, but from admissions right through to leaving the hospital the process is about three - four hours for the patient.
Nick: And then, post-procedure, what is the patient likely to experience?
Jody: Post - three - four days, Nicole and I advise the patients, you know they may feel a little uncomfortable, possibly experience a bit of diarrhea, bloating, sometimes they get flu like symptoms. Not everyone experiences this, but we do point it out so they don't freak out and think "Oh my god, what's going on, what's happening?" It's all very normal. We've designed a little rescue pack and a little card that we give the patients. So it just puts them at ease, so if it's a Saturday or Sunday and they are unable to get a hold of us, they know that this is very normal and it's nothing out of the ordinary.
We do give all of our patients Nicole's mobile number, as you're aware she is our practice manager and our nurse so they always got someone to contact if they are very unsure as a last resort. But generally, post-transplant, we schedule that next appointment three - four days after anyway, so we see them very close to having the transplant.
Nick: Okay. So with that next appointment, is that when they start having their scheduled enemas?
Jody: Yes. That's right. So post, three to four days, that will be when Dr. Connelly does the first enema. Not all patients have a lot of enemas, most patients go from anywhere to one enema up to fourteen enemas. That's where it comes back to the plan that he has for each individual patient, and it depends on why he is doing that and what he is treating.
Nick: And then after that first procedure, scheduled enemas treatment, then your after care service sort of starts.
Jody: Yes. Post-that, with all that initial paperwork, we sit down and work out their next twelve month appointment. So we always have one post-op one week, one month, three months, six months and twelve months. That way we keep in touch with the patient even though they may be well and everything is going great, we still want to keep in touch and have some feedback and just see how they are going and that they just don't drop off the face of the earth.
Nick: Okay. So you really do look after the patient and make sure that they are happy, and I guess you do this also for yourself, to learn more about the treatment and to make it a better procedure.
Jody: Absolutely. They're always looking for ways to improve the procedure and anything, we're open to any positive feedback from patients. So far, the feedback's been amazing and wonderful, but we're always open to any new suggestions, but I think we run a fairly, fairly good program at the moment.
Nick: With your program, I think it is important to touch on donors again. So let's talk about your donors.
Jody: Mm-hmm (affirmative). With our donors, we do rely heavily on our donors, because if we don't have donors, we obviously don't have a program. Our donors, we try to source from social media avenues, I think Nichole tried to reach out to the Vegan society, or naturopaths, all those sort of healthy lifestyle areas.
Jody: We do get interest, and we do get emails, and they are very heavily screened. They have to fill out a very extensive questionnaire. And the questionnaire is related to lifestyle, eating habits, medical background history. It goes in to everything. They answer that, Nicole, our practice manager and nurse, she reviews the questionnaire, and if it looks like it would be a possible donor, then we send them a pathology request slip, and they are heavily screened, they do a full blood screening and they do a stool screening. If that comes back all clear, then they are candidates to be donors.
Nick: And you actually pay them to, don't you?
Jody: We do, our donors are all paid. And they're paid on the day. Once they donate, at the end of the day, because quite often when we're doing enemas it's all mixed fresh on the day, and they are paid at the end of the day.
Nick: I think that's important to point out is that you pull, well we'll just call it poo, you're pulling this quality poo from six - eight donors, and you mix it and, if we talked about it as a product or a medication, it's, you're trying to find the best quality medication for the procedure.
Jody: You probably have to talk to maybe Nicole about this, she might know a bit more than what I do, if you want to step in and talk about the quality of ...
Nicole: I think that there's not quite enough evidence to suggest whether one donor or ten donors is better, what we do know though is that we think that multiple donors give us more of a varied flora, so what we try to do as a basic minimum is have at least two donors. And as you can appreciate not everyone can donate every day, so we are in a situation where, as Jody said, we rely on the donors, we don't want them to donate when they're sick, and we want to make sure that we run a really good program so as a very bare minimum we make sure that we ask the donors to donate every single week, at least once a week, so they're in to the habit of doing this.
Nicole: It allows us to also have a store of our frozen enemas if we do need to use those for any reason. And, all of our donors are, really, really healthy. And there is some, although limited, there is some evidence to suggest that vegetarian and vegan donors are actually better than meat eating donors. So we have one healthy meat eater, and all of the rest of our donors are actually vegan at the moment. And we have got a lot more interest in the program, so I think the bigger we get, we have to make sure that we have more donors, before we open the program up to more patients. I think that is where we at with running our program at the moment. So currently we're accepting maybe one - two patients a week in to our program -
Nicole: But we have quite a lot of capacity I think in the coming year or so to increase that program quite extensively.
Nick: That was actually a question I was going to ask is are you looking for donors?
Nicole: I think it's important to note that we are always looking for donors because when you have a donor who goes and gets a tattoo or goes overseas to Thailand, Bali, countries like that, we end up with a situation where they can't donate for at least three months when they come back. Plus they need to get screened, and every now and then we have a patient that comes back, gets screened, and they don't pass the screening. So we're left with a situation where, it's our practice policy to treat those patients if they would like to be treated, and we treat them as our own patients, our donors.
Nicole: But, whether we use them again as donors is up to Dr. Connelly, and we do have conversations about this, and often we'll wait up to six or twelve months to reuse that donor if one of their tests has come back questionable.
Nicole: Yeah, so it can be challenging. And that's why I think it's important that we always have a rotating door of donors, and we're always open to new donors, even if we don't particularly need them, and we tried an actual, like Jody was saying before, I'm keeping touch fairly frequently with the Vegan Society, on Facebook in particular and I think there is about twenty or thirty thousand members in that and so I have little conversations on there with them, I put posts up. They are very aware of the fact that I'm not vegan, but that I am looking for very healthy people, and I've had a very positive response. And I think we probably get one - two interested parties each week. And they're not all appropriate, but we probably pick up one every two or three weeks at least. They join the program and it allows other people to have time off if they need to.
Nick: I understand. Okay. I think we have gone in to quite a lot of detail and provided some useful insight into your FMT program and your patient care and the time you take to screen donors. So I think we'll end the podcast here. Jody and Nicole, thank you for your time today.
Jody: Thank you.
Nick: This episode of The Holy Gut podcast was sponsored by the Moonee Valley Specialist Centre. For more information about Nathan and Nicole, please visit mvscentre.com.au. If you have any questions related to gut health that you would like answered on the podcast, please let us know via the contact form at mvscentre.com.au.