Dr. Mike Smith (Host): This is Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm Dr. Mike, and with me is Dr. Stephen Chorney, a pediatric otolaryngologist at Children's Health and associate professor at UT Southwestern. Today, we're going to be talking about the Multidisciplinary Pediatric Aerodigestive Clinic, or MPAC, and how this program helps navigate complex aerodigestive referrals and care for children with challenging airway, breathing, and feeding issues. Dr. Chorney, welcome to the show today.

Dr. Stephen Chorney: Thank you so much for having me.

Host: So to kick it off, tell us about MPAC. What exactly is it? What kind of services does it provide? What kind of patients does it see?

Dr. Stephen Chorney: This is a multidisciplinary clinic, meaning we work in conjunction with several of our colleagues from both pulmonology, gastroenterology, speech therapy, respiratory therapy, and several other services in the hospital to provide the best care for children who have, as you mentioned, trouble with breathing, swallowing, respiratory infections.

These children, as you can imagine, are in our healthcare system frequently for a variety of challenges. And many times, parents struggle to find answers about what might be bringing their child to these difficulties. And so, our clinic is designed to be able to help work up some of these challenges, identify the cause, and provide treatment plans tailored to each child.

Host: I want to talk a little bit about the aerodigestive tract, okay? 'Cause just to make sure we're clear on this. So, this is an area that spans interconnected respiratory and upper digestive tissues, meaning that pathology in one can drive symptoms in another, correct?

Dr. Stephen Chorney: That's absolutely correct. And probably a great way to think about it is one of the more common indications for presenting to our clinic, which is chronic cough. As you could imagine, chronic cough could have a whole host of interrelated etiologies. And many times these children have gone to see providers elsewhere or in isolation and struggle to really find the root cause of why their cough persists.

And while they may have had a number of interventions or diagnostics and even management strategies, many times they find that if they haven't quite unroofed the true cause of that cough, they're going to continue to struggle with these events despite many months or even years of trying to address it. And so yes, they are quite interrelated, and the presenting symptoms can be vague or nonspecific. But that doesn't mean that we should sort of rest at inconclusive workup and continue to struggle with recurrent admissions or hospitalizations or growth or feeding challenges as well.

Host: Yeah. And of course, the diseases you end up diagnosing and treating, there's many, right? There's a variety here. Everything from esophageal fissures and stuff like that, there's just a whole host of things that you're actually dealing with where these kids are presenting with these kind of symptoms that you have to work through as you try to make your diagnosis. How many kids do you guys see a year?

Dr. Stephen Chorney: We see a lot of kids across our program, MPAC specifically, because as you could imagine, the time that it takes to complete these visits with all of those services I mentioned, we tend to see anywhere between 75 and 100 children a year in that clinic alone. Though to be fair, we see many more children in some of our associated clinics who have similar presenting diagnoses or symptoms, who then get referred to that clinic as well.

Host: Okay. So, what's the difference though? I think another point maybe of confusion for people or for community physicians new to this program, a lot of hospitals, a lot of clinics, they have airway clinics. what's the difference there? what's the difference between MPAC and a single specialty clinic?

Dr. Stephen Chorney: Yeah. And we do have an airway clinic here at Children's as well. Probably the best way to think about it is the children that we see in an aerodigestive clinic tend to have much more involved symptoms and history across a number of different systems. And those systems tend to be focused in pulmonology, gastroenterology, and otolaryngology, as you could imagine. Whereas an airway clinic tends to have children who have perhaps maybe less of an acute or more pressing gastrointestinal challenge, but primarily have an ENT or perhaps often a pulmonology-related challenge.

And many times kids that, let's say, have airway obstruction or a history of a tracheostomy or currently have a tracheostomy, those children are managed a little bit differently or have different needs than perhaps a child who does not have an airway obstruction but continues to struggle with chronic cough, recurrent respiratory infections, or feeding challenges, and many of those things are interrelated. And so, that's where an aerodigestive clinic comes into play because we really need to spend time across several different systems, not just one or two.

Host: So when patients come to you in your clinic, has a diagnosis already been made in many cases and now you're taking over the complex care? Or are you often involved in making that diagnosis?

Dr. Stephen Chorney: I would argue that the majority of the children that present to our clinic have diagnoses in those systems that we talked about, but don't have a really great unifying story to explain the presenting symptoms that brought them there. And so, that might mean they've been diagnosed with asthma or gastroesophageal reflux disease.

But they're there not because of those diagnoses. They're there because their child is not gaining weight and they're having trouble with recurrent respiratory infections. And so, despite there being diagnoses in place for many of them, I would say that the majority of our children come to our clinic looking for answers and a unifying explanation as to why they're still not getting the resolution of the dilemmas that brought them to the healthcare system to begin with.

Host: Now obviously, coordinating a multidisciplinary approach here can be challenging, and can you walk us through an average appointment looks like for one of your patients? You know, they're under one roof, they got a single appointment, yet there's multiple specialties they could see. How does all that work?

Dr. Stephen Chorney: Yeah. And you can imagine a visit like that takes a bit longer than a visit with one of the specialists in isolation. And so, the first thing we just remind our families of is that you're looking at a little bit of a longer duration of time in that room. But they don't actually have to leave the room that they're in. Each of the physicians and providers come to them during the time that their visit is going on. And many times, we're asking similar questions. But as you could imagine, we're also focusing a little bit more on our particular area so that when we sit down and talk about what we found later on that same morning, we can put a nice punctuation on what we each talked about and to devise that plan.

So in other words, we don't have to then go back and say, "Well, we'll speak to somebody later today or next week," or, "We'll send you to them," and their next visit is maybe a month or two away." You're going to get a clear plan delivered to that family as early as later on that same day or by the next day, and that's because we don't go very long before we review all that information.

And so, to that end, they'll get a culmination of the visit sent to them, and very likely that comes with it a plan for either future diagnostics or intervention

Host: How common is a clinic like this for kids? Is this pretty unique in the United States or in Texas?

Dr. Stephen Chorney: Well, you know, over the last 10 to 20 years, the interest in aerodigestive programs have increased tremendously. And so, historically, these were in much more selected locations throughout our country. But what people have realized is that it provides tremendous value to, of course, not only the patient and the child, but to their families as well as to the healthcare system as a whole.

It helps minimize a lot of the bouncing around to different visits, reducing readmissions or rehospitalizations, and really helps streamlines the care for these kids in a way that is strategic and improves the quality of life for these families. And so, it is definitely growing in number. Though it tends to be, even in the state of Texas, pretty unique. And outside of Houston and Austin, there aren't as many of these throughout the state, and even in the region as a whole. I would say what we see are families who look for this care and may be traveling from quite a distance, even a distance outside of our state.

And that's a real advantage for our program because we have been around for a number of years. We're continuing to grow. And as we do, we continue to reach further and further beyond just this area of North Texas.

Host: You've touched on this a little bit, but I want to kind of go over it again. often these patients have profound nutritional and rehabilitative needs, right? So , what about speech-language pathology, specialized nutrition, respiratory therapy? How does all that get integrated into this treatment plan from that one visit?

Dr. Stephen Chorney: I will tell you, I see these children at the same time with our speech therapist who is in the clinic with us in real time. And when we have that meeting at the end of the day, they are there with us to help describe or devise a plan that is very mindful of the need for ongoing therapeutic interventions, whether that's speech or even occupational or physical therapy.

Respiratory therapy and nutrition are also part of this clinic. And depending on the specific need for the child, we incorporate them at the time of that visit and will very likely have them be seen by those individuals before the child leaves that room. And so, that's a huge advantage of this. We don't have to then wait for a visit to open up with, let's say, a nutritionist. We will engage them at that time, depending on the specific needs of that child.

And so to your question, these individuals are a tremendously important asset to the care that we provide, and we can do so in a way that strategizes how quickly we can get the children to be seen by them and not waiting and bouncing around. Because as you can imagine, many of these kids may have seen a nutritionist or a speech therapist in the past, but we're really struggling to connect the dots and communicate across specialties in real time, and that's what this clinic can do.

Host: Now, once you develop a personalized plan for a kid, what happens next? How does your team maintain the care? Or how involved are you in that care once that plan is made?

Dr. Stephen Chorney: Well, it certainly depends on the specific diagnosis or the specific underlying reason that brought the child to see us. And to that end, I mean, some of the children don't necessitate all three specialists involved in an active mode at any given time. Perhaps that means, for example, let's say this becomes a bit more of a ENT-related diagnosis, or perhaps more of a GI-related diagnosis, or some combination thereof.

And so, what we do is we work very closely with all of the departments who interface this clinic to ensure that follow-up in their respective clinics, and even in the MPAC clinic, is very strategic. Look, our goal is not to have these families spend more time than is necessary with a healthcare system that many of them interact with on a regular basis. We want to be very mindful of the time and commitment, and be respectful of their resources as well.

And so, what we do is we make sure that we follow these children longitudinally, but that doesn't mean that we follow them in a clinic every several months or even every few weeks. We devise a plan that is mindful of incorporating the providers who need to see them in a more acute or urgent basis, and then have others go perhaps to the background for a period of time until certain aspects of their care are more tidied up.

So, we are following them, and we have opportunities for the families to be able to connect with us very easily, but we are also much more strategic on resource utilization and making sure that we're not overburdening these families with too much time spent in visits that may be unnecessary.

Host: You had mentioned obviously, you know, that first time you see a patient, you're getting all the specialties together. You're making sure everybody sees the patient. I mean, this , a long day, right? I'm just kind of curious. I'm an adult and I don't know if I could make it that long. So, how do you keep the kids engaged and interested in this so you can do your job?

Dr. Stephen Chorney: To be fair, the time from start to finish for the families, it's probably about an hour. So, we're not asking them to be there all day, but that may be longer than you'd be used to for, let's say, an individual ENT visit.

And so, you're right. There are certainly strategies that need to be adopted to keep them interested, and I will say we have a world-class team of medical assistants and nurses and office administrators who are very sensitive to that and to make sure that we're not keeping those children in a room longer than we need to. Because, at the end of the day, you could imagine adults and children alike will get a little bit fatigued as the day goes on.

But the final point to that is if you were to consider the time it would take to go and see three or four different specialists, even in one day, that time would be much, much longer than it would be to have each of them come into the room you're at in sequence.

Host: No, I totally agree with you. And I think the idea from a patient perspective of even as an adult, being able to go to one appointment and see everyone you need to see, coordinate that care, that just sounds so much more efficient.

Dr. Stephen Chorney: And as we mentioned, we sit down later on that same morning and review each of the aspects of our visit amongst one another. And so as I said, that real time punctuation on the visit comes much quicker than it would be to have, let's say, a follow-up with another specialist or to wait for a referral to come through to another specialist. That doesn't have to happen. And I will tell you, a number of the families have come to us and continue to come to us having had that experience where they may have already seen a pulmonologist or an ENT or gastroenterologist, but the ability for them to interface, communicate, and really understand why their child is still struggling is able to be overcome from the meeting we have that same day

Host: So, what's the best way for providers to refer to the MPAC Clinic?

Dr. Stephen Chorney: Well, there's a couple of ways to do it. We have a phone number, an email, that can be shared here for them to connect with our coordinators and our staff to be able to get into that clinic. In the electronic medical record, there are modalities for physicians who have access to our system to place an electronic order. And those are the two big ways. There's information on our website, which we can also share here as well.

You know, I would say that a lot of the times that families will come to us because they've been disappointed with the lack of movement on an understanding of where their child is at. And that doesn't mean that the physicians or therapists in our community aren't doing a great job.

They have the disadvantage of not having the interconnectedness that we can offer at that same time. And so, our goal is not to replace community pulmonologists or gastroenterologists. It really is a complement to what they have been able to offer and can continue to offer for their patients.

So, I think there's a huge satisfaction benefit that can be gained from parents knowing that they don't have to drive to three or four different locations, and wait several months to get an answer

Host: Dr. Chorney, this has been fantastic, really full of great information. Thank you so much for coming on today. And I want to thank you for listening to Pediatric Insights: Advances and Innovations with Children's Health. You can find more information at childrens.com and specifically about today's topic at childrens.com/mpac.

If you found this podcast helpful, please rate, review, and share the episode and follow Children's Health on your social channels. Again, this is Pediatric Insights: Advances and Innovations with Children's Health. I'm Dr. Mike. Thanks for listening.