Dr. Corinn Cross (Host): Welcome to PedsCast, a podcast brought to you by Children's of Alabama. I'm your host, Dr. Cori Cross. Today, we are joined by Dr. Sajal Patel. Dr. Patel is an endocrinologist who cares for both children and adults at Children's of Alabama and the University of Alabama at Birmingham UAB. And thus, she is in the unique position to understand the needs of both populations.

Dr. Patel uses this expertise to help children transition from pediatric care to adult care through the Staging Transition for Every Patient Clinic, otherwise known as the STEP Clinic, at Children's of Alabama and the University of Alabama at Birmingham. She is here with us today to discuss the care she provides for patients going through this process. Dr. Patel, thank you for being here with us today.

Dr. Sajal Patel: Wonderful to be here.

Host: Dr. Patel, you are trained both as a pediatric and adult care physician. What led you to pursue a career in both Pediatric and Adult Endocrinology?

Dr. Sajal Patel: So, I did residency in Med-Peds, which is kind of our term for Internal Medicine-Pediatric combined training. And so, I knew I always wanted to take care of the entirety of the age spectrum. During the course of my residency, we're exposed to different specialties and primary care settings. And I fell in love with Endocrine because of the cerebral nature of it. So, I know what the problem is, I know what the outcome we want is, and it's figuring out the puzzle about how to get from one end to the other.

And Endocrinology is, I think, very critical for Med-Peds because a lot of our pediatric patients are now growing up into adulthood with these endocrinopathies or endocrine diseases that we used to think of as life-limiting. So as a dual-trained provider, I'm able to not only use my peds knowledge and my adult knowledge to care for these patients, but also better transition them from a pediatric setting to an adult healthcare setting.

Host: That makes a lot of sense to me as a pediatrician myself. I know that as we've gotten more effective at treating a lot of these endocrinopathies, children are really surviving and thriving much, much longer than they used to. And I remember in residency, I often had patients who were well into their 20s because the Adult physicians weren't comfortable taking over the care.

Dr. Sajal Patel: And I do think being Med-Peds, we're in a special position where we can help our adult counterparts be more aware of these pediatric disease processes that are now becoming adult disease processes.

Host: So, tell us a little bit about your role at Children's of Alabama and the University of Alabama Burningham and really how what's going on at the STEP Clinic is really vital to this patient population. What is the purpose of this clinic?

Dr. Sajal Patel: So, I practice General Endocrinology for both peds and adults, meaning I have my own continuity clinics where I see the entire spectrum of endocrine disease. But more specifically with STEP Clinic, I see patients who have chronic diseases that involve multiple organs and they also happen to have an endocrinopathy.

So, the important and the critical thing about STEP Clinic is that it is for all patients who need that extra bit of help navigating from the pediatric healthcare world to the adult healthcare world. So, it's those who have multiple organs being affected by chronic illnesses. They follow with multiple subspecialists that they need help establishing with on the adult side, or they have technology dependence, like their wheelchair-dependent; parents need help obtaining legal guardianship because of some, you know, mental disability, they're ventilator-dependent or whatnot.

And for the Endocrine world, a lot of these disease processes, unfortunately, also manifest as endocrine disease. So, it may be difficulty with sugar management, maybe difficulty with puberty and maintaining puberty or testosterone, estrogen. It could also mean bone health concerns. So, I see these patients in conjunction with primary care within the STEP Clinic.

Host: And so, as you're describing, it's not specific to endocrinology. There's so many processes where children need to transition from the pediatric to the adult healthcare system. What are the biggest challenges that you see with Endocrinology and diabetes, like you mentioned, that patients are facing when they go through this transition of care?

Dr. Sajal Patel: So, I feel like there's a lot of many aspects of it that can be difficult to navigate. The first and foremost being in the pediatric world, we tend to hold patients and family's hands a lot more. So, we talk them through the process step by step. We call them a lot more often to check in on them. There's a lot more oversight and a true, true multidisciplinary approach, whereas then navigating the adult healthcare world, where a lot of this falls just directly on the patients without that additional help. And it's not through any fault of the adult side, but just with volume and resources. They just don't have the ability to help with micromanaging. And so, that's difficult to navigate. And so, through STEP Clinic, we can help them figure out how to do that with the adult care.

But then also, I think insurance is a big thing that we often forget to discuss with our pediatric patients. So, when you go from pediatric insurance types to adult insurance types, a lot of the medications that are covered, particularly in diabetes, the type of technology that is covered, very much so changes seemingly overnight.

So, my role as an endocrinologist, particularly with diabetes, in both adult care and in the STEP Clinic, is to help the patients navigate the insurance and figure out what we can do to help maintain their diabetes control, but within maybe some limitations in terms of what technology is covered or not covered or how we can best use the technology that is available to us.

Host: And is the idea to eventually transition the patients out of the STEP Clinic into a true adult care facility, or adult care physician?

Dr. Sajal Patel: Yeah. So, the STEP Clinic is meant to be a bridge or a transition clinic. So, it's a way for us to figure out what your adult healthcare needs are and then best help find the fit for you within the adult care world. So within the scope of Endocrine, most of us on the adult side, we practice the entire spectrum of endocrine care, but a lot of us have a particular interest within the endocrine world. So, say, someone's primary endocrine concern is bone health, then I will try to help navigate that family and patient to the Adult Endo who does have a particular expertise in bone health. Or, say, somebody's primary concern is diabetes and their interest is maintaining the insulin pump or the continuous glucose monitoring, then I'll help find them the ideal adult provider who can help keep continue that insulin pump and whatnot. Or, say, it's a concern for adrenal gland dysfunction, then I can help plug them in with the Adult Endo whose primary interest is adrenal function. So, it is meant to be a bridge. I do not take care of all of these patients forever. But there are some that I keep for myself on the adult side if it falls within my adult scope. But also, just trying to figure out what the patient's personality is and how to best get them with the provider where the personalities will mesh much better.

Host: And for the ones that are truly using it as a bridge, is it a year program, a two-year program? What's the average time span that patients spend in this transition process?

Dr. Sajal Patel: It can take anywhere from about three to six visits, I would say, and the time between the visits depends on what the patient's needs are. But from an endocrine standpoint, usually three to six visits are enough for me to figure out what your needs are and find a good provider match for you. But the other thing about STEP is that it's not just me, right? It's also the primary care aspect. So, sometimes it takes longer for our Meds-Peds primary care counterparts to find a good long-term match, because it's a matter of navigating what their overall healthcare needs are, so plugging them into the other subspecialists, if there's a wheelchair issue, if there's kind of long-term assisted care living concerns we need to help establish. So, that might take about a year to two years

Host: Right. It can be a much more complicated process, I would assume. And lastly, have you noticed that having this program has really helped with the continuity of care, that you're having fewer patients lost to followup? Do you have any sort of data showing that this is really working both for the patients and for their families?

Dr. Sajal Patel: I don't know of any hard data, because the clinic is overall fairly new. But I will say anecdotally, since I work both the pediatric and the adult side, I know from a Peds Endocrine world, and from my co workers, my peers here, it feels like a night and day difference. So, we have a place that we can send patients who just need that extra little bit of hand holding, without feeling like we're freeing them to flail in the wind and just hoping and praying that things work out like we want them to.

So, I feel like from a patient and family safety and comfort, it's a big help to have the STEP Clinic available, but then also from a provider comfort, because it lets me know that there's a way for me to hand off a patient to a person that I know is going to be taking care of the child versus kind of calling the office in general and hoping to speak to somebody. That's going to be important to this child's care, but then also knowing that there is a person who truly understands pediatric care and adult care. And so, being able to truly, truly bridge these patients with continuity, rather than the providers having to learn this new disease process and the patients having to teach the providers a new disease process.

Host: No, I mean, it makes perfect sense. It's completely logical. And as both a parent or a patient, it is what I would want for myself. So, it's wonderful that you're providing it. As we wrap up, is there anything else you'd like to share in the last few minutes with our listeners?

Dr. Sajal Patel: So, I think the most important thing for patients and families to know is to advocate for yourself. And that's a lot of what we do in STEP Clinic. No one can advocate for you better than you. So, advocate.

Part of what we do in the STEP Clinic is helping expose families to the resources that are available to help them advocate for themselves and their child. But as pediatricians, we also need to be aware that we need to help enable families and patients to advocate for themselves, especially on the adult side where it might be a little bit easier to have your voice be kind of drowned out. And so, just supporting them the best we can, not only medically, but also mentally, and then being aware of what is available in the community, similar to STEP Clinic, if someone is transitioning outside of the UAB system so that, again, we can help ensure the best care for our patients as they navigate one half of the world to the other.

Host: That is wonderful advice. Dr. Patel, thank you for sharing your expertise with us and for really having this great discussion.

Dr. Sajal Patel: I really appreciate you having me here to talk more about what we love to do and the importance of it.

Host: Of course. If you would like more information about the STEP Clinic or to refer patients to Children's of Alabama, please visit www.childrensal.org/step-program. That's www.childrensal.org/step-program.

That concludes this episode of Children's of Alabama PedsCast. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for other topics that might be of interest to you. Please remember to subscribe, rate, and review this podcast. Thank you for listening to this episode of Children's of Alabama PedsCast. I'm your host, Dr. Cori Cross.