Thank you so much for these presentations. We didn't include imaging people, neuropsychologists, EEG technicians. So in the interest of time, I'll conclude and leave the floor open for questions. I have a question. What do you see as the role of telehealth in the multidisciplinary team? I'll just say briefly, telehealth has been a game changer for us in nutrition because we've been able to do a lot of education in between visits, specifically for our pediatric patients when it's a little bit difficult to have that solid time with the families if the kid's bouncing around the room in the exam. So it's much better to be able to do it at home with the family. So that's been really helpful from our standpoint. Yeah, I'll just jump in there and say, I think I mentioned this during my talk, that we've been doing telehealth for many, many years. I think COVID accelerated that and the development of newer and more reliable platforms and technology. But from a medication management point of view, you think if you're starting somebody on, say, one of the newer anesthesia medicines, you're doing a lot of cross titrations and monkeying around with drug interactions, you're not going to bring them in to the office every two weeks. But you can do this via telehealth, whether a visual or just telephonic health. So I think, if anything, it's going to grow even more. Now we just got to get the reimbursement part worked out. I'll echo that. And from the mental health piece, I'll admit that before the pandemic, I was sort of a naysayer when it came to telehealth. I was like, I don't know. Being in the room with the patient that's so instrumental to the alliance and the rapport. And I'm on the complete opposite side of the coin now, where I'm so thankful. Because for our patients coming to C-level IV epilepsy centers, those academic centers can be rare to come by. And they have very large catchment areas. And thank goodness, thank goodness for my patients out and all the way out to El Paso, which is further to drive from Dallas to El Paso than it is from El Paso to San Diego, to give you an impression of that. They really could not get the care they needed without telehealth. And lastly, looking at it, sorry, in a different side of it, when you build a big multidisciplinary team, it's very hard to find space for all those providers. So I think that's a really nice, that you can continue to grow and add more people if you have telehealth. Yeah, I agree with everything. Oh, sorry. No, go ahead. Go ahead. Sorry. I was going to say, I agree with all of that. I think it's still. Go ahead. Do I walk this way? I think it's definitely helped increase access in a lot of ways. I think the families that may live far away or may have transportation challenges, or families that both or if they're single parents, might work full-time jobs, or for our adult patients that maybe can't drive, and just schedule-wise, I think it's been really helpful, especially if you have something going on with a patient that you feel like you need to get them in quickly. I feel like providers also have more flexibility with telehealth. I will say one maybe negative that's not totally a negative is that some families just don't have access to the technology, or they don't understand how to use it, especially for families that maybe don't speak English. Some of the links are not friendly to other languages. So I think that has created some challenges. But I think with the balance of other patients having telehealth, it does free up some in-person options for families that maybe do really need that. So I think there's a balance. My question is, so how do you encourage multidisciplinary involvement when a specialist maybe isn't interested in your topic? So a specific example is I run our psychogenic seizure clinic with a psychologist. I'm an epileptologist. And it's been very hard to get pediatric psychiatry interested. And so maybe Dr. Lin could comment on this or others and other types of epilepsies that you've dealt with. But how do we encourage the psychiatrist or a psychiatrist to want to join our clinic? I mean, is there even a solution to that? I would love to hear your thoughts. Thanks so much. Thanks for being here. Good to see you. It's a great question and a hard question. And I think that the solution to that probably has to come from multiple angles. I think the first angle that I know we're very involved with in our educational division is to teach learners as early as possible and get them excited to care for this patient population. For example, a few months ago, I was in the clinic with a medical student. And I said, hey, just out of curiosity, how much teaching did you get in your pre-clerkship time for FND? And I thought he was going to respond with a whole slide. Boy, was I wrong. It was a bullet point, and it still was called conversion disorder. And so just this fall for the first time, it's 2023, just this fall for the first time, we got to teach an entire hour about FND. And that can take the form in so many different ways for giving grand rounds, going to individual team meetings, and saying, hey, can I get invited to your team meeting for this clinic here or this clinic there? So my colleagues and I, we've gone through many departments. Next on our radar is we're going to primary care, because primary care actually has to be a big player in the multidisciplinary care there as well. It's a lot of, we heard Dr. Laura Hal-Martin speak a bit to this. I had amazing mentors with Kurt LaFrance and Gaston Besley to build the program that we have on the UT Southwestern side. There's one at Parkland and one across the street at UT Southwestern. And it takes a lot of bringing stakeholders together and also convincing them in a way, or making the case of, why does this make sense? We all care about healing, so we realize why it makes sense immediately, very approximately. But sometimes to some of the stakeholders, we have to make the case of, why does this make sense in terms of long-term health care costs? Why does this make sense in terms of decreasing ER visits and inpatient hospitalizations? And those conversations, knock on wood, can work. Alex from University of Pittsburgh. I just had a quick question about the role of depression screening in epilepsy centers. We collect some data on this, and then we struggle with what to do with it, or even if we should continue to collect it. And I just wondered what your guys' thoughts were on that. So the answer is yes. I actively encourage that. I think it needs to be every visit. You're right. What happens whether, I don't know, whether you're using a PHQ-9 or a NITI or whatever you're using. Yeah, that kind of gets to the previous question, right? You identify there's a significant psychiatric issue. But if you don't have a provider that you can easily get your patient to see, then what do you do? And again, getting back to our setting, number one, we're very lucky to have a very robust psychiatry. But I also have psychiatry-trained PharmDs that are also like epilepsy that are interested in mental health. So we have those pathways. But it takes a lot of work. It took a lot of years for us to build that connection with psychiatry. And I remember one time, one of the who was a medical student at the time, and he now chairs psychiatry, I gave a lecture. And I started with a picture. And I said, I want you, if nothing else, you leave this lecture, that the brain and the mind are, in fact, the same organ. And that actually resonated with this one guy. So he was very supportive of bringing psychiatry in. But yeah, I think you need to continue to do that. But yes, developing, what do you do with that? Now I'll let the real experts talk. No, that was perfectly put. I had very little to add to that other than saying that, again, in 2023, it seems like we're still chipping away at Cartesian dualism from time to time. But I think it is absolutely important to screen. And until you do have that relationship where you can readily get someone admitted, sorry, when someone referred, is to potentially, as we heard from Megan, making a resource handout. And maybe that is psychotherapy resources throughout the community. I refer a lot of patients to psychologytoday.com because it's really hard to get in to see a therapist quickly in most health care systems. But they might be able to find somebody in the community that takes their insurance and is a good match. And then have a conversation with your mental health division, with your psychiatry department. How can we manage referrals? Or is there a consult liaison psychiatrist who's particularly interested in outpatient consultation and epilepsy that can be embedded in our clinic for a day, day and a half, just to start out and see how it goes, and then show the powers that be. Hey, this works. Let's get more. To clarify, I am that consult. No. We just have so many patients that screen positive, I can't even get to them. And then you have to triage. Then you have to triage. Hire an associate. Fair. Ask for more time. Yeah. I have a question for whoever, or maybe all of you, if you can. I was thinking about scope of practice and the confusion as to what people can do, maybe how we started the session. I'm wondering as an example of that confusion, if any of you, if all of you, have a memory of a situation where you were handed something, asked to do something, you thought, I really, that's not what I can do. That happens to me pretty much every day as a ketogenic dietician, because I'll regularly get messages of, well, can I prescribe this medication? Like, it has to be a liquid form. And so I'm like, phone a friend, my person in pharmacy. We can chat about it. So yeah, frequently. And that can be problematic. And I think it's just knowing who you can refer to, but also then the education of, I am not the right person to ask that question to. And there are other more skilled people in that area. But it can be a challenge, for sure. Yeah. That happens to me every day. I think that a lot of people don't have a good understanding of what a social worker does and what we can do and what we have the capacity for. And I think a lot of our time is spent educating our team on what an appropriate referral is. I think we're often really managing provider discomfort. I think it's really uncomfortable when our patients are struggling. And the state of the world is really hard, and the systems are all broken. And so it kind of sucks to be like, I don't know how to help you, but my social worker can. But often, I can't. I can give guidance. I can give advice. I can just help them sit with their discomfort. But sometimes, there's not an answer. Or I'll get a referral that's like, this mom is really angry, and that's it. That's all it is. And I'm like, OK, but I'm not going to like, it's just, yeah. I'll just add to that. When I was a third year medical student on the state hospital, my attending did the orientation. And then she sat me down, and she said, Chad, if you learn anything in the next four weeks, let it be do what the social worker tells you to do. And that advice has never failed me. I was just going to add something that I struggle with sometimes in clinic, because I do get a little more time to spend with patients. I build some really great bonds. And it can sometimes be challenging for me to transition back. Sometimes, right, and you're at the point, I need you to see the staff. They need to talk to you about potential pre-surgical evaluation. I'm not the specialist to do that for you. I know what I know, and I know that you need to see someone. And so I really collaborate. And we set that expectation in the beginning that you're going to see both of us. We are both a team. And I have direct line to the staff and any questions we have. But we need to circle back every so often. And I think that that sometimes is a little challenging for patients when they hang on to someone. But. So, that does actually kind of dovetail into what John asked. So to answer your question, within our setting, no. Outside of pre-surgical, no. We don't have an established conference, if you will. However, we really, many, many, now decades ago, years ago, really, truly believed, you know, I mean, the focus of today, or hopefully what we're going to be talking about, you know, interprofessional care is more than just having a bunch of different specialists who happen to see your patients, you know, I happen to see that, because that's still just very siloed. Maybe we're all in the same office space or hallway, but that's still siloed. So while we don't, you know, like for example, you know, if I'm seeing patients, I see them independently and do what I'm going to do. But nonetheless, we as a kind of a group, almost informally by the end of the clinic day, is we sort of quickly wrap up, you know, what do we see, what do we learn, what do we think needs to come next, you know, and you can, and that's true, I think, true interdisciplinary care. So we have little mini-conferences weekly, you know, they're informal, and it may involve drinking a cup of coffee at the same time. So I don't know if that addresses either one of your questions, but. That does, and I'll answer that question also. We have weekly, we have two conferences weekly, which get toward what you addressed, neither is surgical. One is what we call psych rounds, but it's with psychologists, and it ends up becoming a matter of addressing both the functional disorders, the cognitive disorders, and the affective disorders of the patients coming through the surgical process. And it becomes a head start for the psych team, for the referral, for moving forward with those patients. But I'll go beyond that and say that for the trainees, the fellows, and the residents, and psychiatry residents included, it's a great teaching opportunity, you know, or learning opportunity for them. We also have another, that's an hour a week, we have another one for half an hour a week, which is more outpatient oriented, where it's the nurses in the clinic, and the social worker, where we go through what's happening, and bringing to attention for everyone's benefit problems. You know, there are system problems or individual patients who are needing referral to go through that. And I really encourage, I mean, both of those are really important meetings for our program at UCLA. We have a little bit of both in outpatient, inpatient, right? And inpatient, we, in our rounds, there's a social worker, a psychiatry team member, a nurse that's representing the team, your APPs, your resident, your staff, an EEG reader, you know, there's literally everyone we need there, talking about patients real time. Outpatient setting is a little more difficult, because we're remote now, and we're different places, so we really rely on the electronic medical record. I am CC'ing the people that need to be CC'ed when I see them. I'm getting, you know, neuropsych reports sent back to me. My psychiatry team, after they've established, are getting back, so we're coordinating care that way. Follow-up? We, in our keto clinic, we have a once a week clinic where we bring our new patients, and then certain follow-up patients back in that clinic. We have, right now, a dietician and our clinical psychologist staffing that, and then we have kind of like a virtual pharmacist. He sometimes comes from inpatient when he can. We share him, and then we also have like child life that will come as needed, and then we generally are getting those referrals from the epileptologist, and we're hopefully adding an APP, actually, next year, so that we'll have kind of the medical piece in that clinic as well. But right now, we just kind of do the care coordination with a referring epileptologist outside of that clinic, but we do round on the patients that we see as well. So that we're working on kind of expanding that a little bit more. I can speak from the FND clinic program that we have on Wednesday mornings. A new patient will see the psychiatrist for an hour, and then immediately after that, we'll see a psychotherapist for a consultation. In that in-between space, the psychiatrist usually does a warm handoff to the psychotherapist, and then from there, we go over, and there's a student, usually multiple learners who are part of all of this. We go over to the epilepsy monitoring unit, and we see patients who have recently received a confirmed diagnosis of functional seizures, and we practice a compassionate, confident, clearly communicated way of discussing the diagnosis, talk to them about the program that they're going to be referred to. Then we come back over, and we have a noon case conference where the learner will present the new patient from that morning, and we'll discuss as a team and triage in terms of interventions. Thank you. Yeah, I'll just add, too, being at Boston Children's, it's such a... The institution itself is so big, and our department is big, so I think it would be hard to have many multidisciplinary meetings, but we do have one for keto in addition to surgery conference, and the keto one is once a week post-clinic. It's clinics on Mondays, the meetings on Thursdays, and we have the whole team there, and we actually create an action grid when the patient is reviewed with what's the change that's happening here, if anything, what's the concern, and whose task is it? So we'll assign, is it the family, is it social work, is it the dietician who's doing it? And then the family actually gets that action grid as well after the meeting, so everyone is on the same page about what's happening. And then also, too, just for going off the kind of multidisciplinary rounds on the fly, I think it's very common multiple times in a day for me and a nurse to be consulting on a situation and then reach out to the provider to ask to talk, and we'll have kind of an informal, I guess, round, per se, to come up with a plan. Thank you all for attending. We had a great time, and thank you again to the speakers and the audience. Thank you.

telehealth

multidisciplinary teams

patient access

interdisciplinary care

communication

collaboration