From Active-Duty Medical Officer To Gastroenterologist: A Conversation With Dr. Paredes

We caught up with Dr. Paredes to learn more about his work as a gastroenterologist, the biggest misconceptions around Crohn’s disease, and his hopes for the future of digestive disease treatment. 

When Angelo Paredes was in medical school at Georgetown University, he thought he was going to become an orthopedic surgeon. It was only a few years in, after being introduced to gastroenterology (GI), that he started thinking differently. 

“I realized that I actually like talking, interacting, and having relationships with patients, which is what GI offers,” explains Dr. Paredes, who now practices at Middlesex Gastroenterology Associates in Connecticut. “Plus, I like the diversity that GI offers: the brevity with certain conditions like colonoscopy screenings, for example, along with chronic conditions whether it’s Crohn’s, ulcerative colitis, or hepatitis. So you’re able to do procedures part of the time while also having that patient-physician relationship, which is the kind of doctor I imagined being.”

During his time in medical school, Dr. Paredes joined the military to help defray the costs of education and, upon graduating, moved down to Bethesda, Maryland to Walter Reed Army Medical Center where he completed his Internal Medicine Internship, Residency, and Gastroenterology Fellowship training.

From Walter Reed, Dr. Paredes transitioned to a role in San Antonio as transplant hepatologist for the military. After a 14-year career as an Active-Duty Medical Officer, including a medical mission to Honduras in 2007 and deployment overseas in Iraq from 2009 - 2010, Dr. Paredes was honorably discharged and moved to Connecticut — a welcome return back to the Northeast for this Queens, New York native. 

We caught up with Dr. Paredes to learn more about his work as a gastroenterologist, including the biggest misconceptions around Crohn’s disease, the trends he’s seeing in his practice, what new studies he’s most excited about, and his hopes for the future of digestive disease management and treatment. 

What are the biggest misconceptions around digestive diseases like ulcerative colitis and Crohn’s that you’d like to dispel? 

The most common misconception I get are patients wondering if they did something that brought upon this disease. Did they live a certain way? Did they eat a certain food? Were they exposed to certain things that brought this upon themselves? And they'll say…no one in my family has Crohn's or ulcerative colitis. Why is it me?

The reality is we don’t fully understand the risk factors. Why is it that certain people who don’t have any predispositions develop Crohn’s? And the alternative is true as well; there are patients who have family members with IBD but they don’t develop it. There are also a lot of theories about why people in more developed nations have IBD compared to less developed nations – could it be something having to do with bacteria? Are we just so hypersensitive to cleaning antimicrobials that we’re training our immune system to be even more hypervigilant? These are just some theories. 

What is the average age of diagnosis? 

In my practice, the majority are younger – so mid-late 20s. And that’s challenging because there’s an adjustment period where it’s common to want to find something or someone to blame. And once you get to the treatment aspect, compliance is often a problem. These patients are young, and there’s a tendency to challenge the system, the diagnosis, and the need for medication. So maybe you skip a dose or two, and then of course the disease flares and you need steroids or hospitalization or recurrent endoscopies or colonoscopies.

In general, young people see themselves as invincible. And when you tell them that they have this chronic disease that is unlikely to go away and that they’ll have to deal with for the rest of their life, that really hits home. 

I imagine there’s mental health implications as well, with a degree of anxiety and/or depression that comes with a diagnosis? 

We definitely see that in our practice. Because while everyone else in their peer group doesn’t have to worry about injecting themselves or taking pills every day, they do. They have to deal with things like yearly skin exams with a dermatologist (because their medications predispose them to skin cancers), and that adds up over time. 

And of course, there’s a very powerful mind-gut access, where eventually you start having patients present with irritable bowel symptoms. So now you have a patient with a disease like Crohn’s or ulcerative colitis that is starting to be well-managed on medications, but they’re living with chronic belly pain and changes to their bowel habits. A good percentage of patients with IBD also have irritable bowel, which makes sense because of the underlying anxiety that goes along with the disease. 

The disease requires a multidisciplinary treatment approach, and being open to referrals for mental health support is important. I often talk to patients about mental health and how it’s normal to feel anxious or depressed, and that they’re not alone. At Middlesex Hospital, there’s an integrative medicine team, and they offer a more holistic approach to treatment anxiety that comes with a chronic disease, which is great for us because our IBD patients have access to their services — anything from acupuncture to social workers to reiki therapy.  

You mentioned that having a patient-physician relationship was one of the main reasons you wanted to become a doctor. Tell me more about what that looks like for you now. 

Early on in the disease, I have to do a lot of handholding and see the patients quite frequently to check in on whether they’re taking the medications, whether their stool is okay, what their most recent blood work shows, and also to reassure them that what we’re doing is right. Then, once they start feeling okay, I spread out the office visits. But in the beginning, it’s very important to give the patients access to me, so I tend to give them my office number and direct line. Hearing a physician call them back goes a long way to gaining trust. 

And then during the times when they’re not in my office, I refer them to the educational resources of the Crohn’s & Colitis Foundation — that’s built into my approach to patients, because it’s also a great way for them to connect with other patients and form a community.

With your extensive background in research, I’m curious if there are any ongoing studies or clinical trials that you’re particularly excited about right now? 

From the time I started training in GI and treating IBD patients to today, there are so many new medications because we know so much more about the mechanisms of the disease. And while that’s great, it’s also sometimes challenging when there are so many medication avenues one can take. So when I think about the future of IBD, I’m seeing emerging research around tailoring, and being able to test patients before starting them on treatment to figure out which is the best medication for them. This way, patients don’t have to jump from drug to drug in a trial and error way. Maybe there’s some sort of genetic marker that will give us a profile of each patient to inform whether they’d be better off with one class of medications as opposed to another. 

Another area of interest is the microbiome. In IBD, the gut barrier is affected by the inflammation of Crohn’s and ulcerative colitis. So could it play a role in knowing who is going to go into remission? Can we get people into remission by manipulating the microbiome? Can we even one day discuss a cure? Right now, I never use the word “cure” with my patients — I always say “remission.” But I hope one day that will change.