Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)

Well, welcome, everybody. Um, it's time for another colorectal quiz podcast, believe it or not. We're thrilled to be here and we're gonna do something quite different today. I'm very excited about that. We have some very special guests with us. We have M Gody, who works in Innovation Ventures at Cincinnati Children's Hospital. And my dear friend for many, many years, Todd Ponsky, who's the Chief Innovation Officer at Cincinnati Children's and of course, the founder of Stay Current, and the reason why any of us are here doing podcasts at all with this kind of media. We did something crazy. I uploaded loaded an article that Jason Fisher and I wrote together about the collaborative model in colorectal care, published in seminars in pediatric surgery and loaded that article using AI into a podcast format. This is one of our podcasts, and it will be what the computer produced of our own work. And to introduce that concept, I've invited these very special guests to tell us about this new technology. Mark, you're always not only good at anal rectum malformations, but you have been interested in All the tech and the media from the very beginning. So, credit to where credit is due, you've seen the power of this. So, M works with me at Children's and is absolutely brilliant doctor who has media and AI experience. What M and I are working on is how we can mass produce content to equilibrate knowledge around the world, and we know that the only way to do that is to use cutting edge technology, automation tools and AI. We work on Audio, video, infographics, whatever it is, and from an audio perspective, there's real power. People that are driving or working out, they wanna listen to something, and the future will be that you will just tell. AI, make me a 10-minute podcast on this, so I can listen on the way to work, and you can actually do that now. And what you stumbled upon, Mark, is something that we've been very impressed with, which is Notebook LM, a free offering of Google, that you can upload anything and it will create an incredibly real sounding podcast between two people. I would love to hear your thoughts, Mark, on your first experience with Notebook LM. It was quite fascinating. I uploaded one of our own articles. And I played the podcast, and I was expecting lots of errors and a very computer sounding experience, and it wasn't that at all. It was a lovely two human sounding voices that were chatting about the article that Jason and I wrote. I found it exceedingly accurate. It foreshadowed things. The computer read, and I put that in quotes, the article fully and then knew what was coming later in the article to get us as the listener excited about it. That part was really, really cool. It made it a much more interesting experience plus, As with many of your offerings on Stay Current, you can double dip, you can multitask. I can walk the dogs and listen to an article. I can get educated while I'm driving to work. I don't have to sit in a chair and pick up a book or an article. Those days are over. This was very, very cool. I wanted to have our listeners to the colorectal quiz experience it. When we first found this, we were blown away. Notebook LM is there to take research notes. Compile them together to create learning from it. So, it could create a podcast, it can it create quiz questions, it can create meeting, whatever it is, the purpose is to create a way to consume it in a learning way. Number one, they have perfected the human sounding conversation. We have been trying to replicate this with different tools. No one has been able to do it as well as Notebook LM. The problem is, it is the same two voices, it's the same man and woman. There's actually an incredible video where they uploaded a document telling these two podcast hosts that they were AI and how they reacted. They freaked out. It is incredible. You literally can upload anything. The way I think it is being used in the most effective way is internal use. So, if you have a complex article, upload it, it takes 3 minutes, and you can download the podcast and listen to it. Do I think this is the future of podcasting? I don't. I think the voices are great, but it's not customizable enough. You're stuck with what it decided. What Notebook LM does now with the beta version is you can join the conversation. You could click join, and it goes, hey, what's up? And you could say, hey, I heard what you just said about the colostomy. I'm not sure I agree, and then it will talk with you. What we've been trying to do is create a podcast platform with whatever voices you want, and you could be interviewed by the podcast host and talk with them. So, for now, it is an incredible tool of summarizing articles, sharing with others. I don't think it's gonna be What everyone's gonna listen to, cause they're gonna get tired of hearing the same two voices in every single podcast. They know it was generated by Notebook LM. But I do think it's an incredible thing, and everyone should go to the website now and try to play with it. I wanted to comment on when Doctor Levitt said it was like 100% accurate. When you upload anything to the Notebook LM, you kind of create your own expert just from the provided document. It's not like any other chatbots or chat GPT go look around what's out there with the anorectal malformations and pulling. Information from that, just takes that as whatever they have, but if you upload more articles or links, you can even have a better conversation. You can have conflicting articles that are published that they don't agree with their results, and that might just create an interesting conversation. One thing I, I really want to highlight in what you said is using this modality, whatever you give it. Is what's in the content that it will review. A friend of mine wrote a review article on an esoteric topic in urology 5 years ago, the old fashioned way, they reviewed 30 articles and they worked 2 weeks on it. They just did the same exercise with Notebook LM and they put the same 30 articles in. And of course, it produced a very elegant outline in minutes. Basically something that took 2 weeks to do only 5 years ago. It noticed the gaps in knowledge, and it said, these are some areas where obviously the researchers had commented, areas of further research, and it noticed the gaps, what was missing from those 25 articles that weren't well covered. And we were discussing this today, and I said, well, let's say a new article had come out. You could add that article to the mix, and then the computer, I predict would figure out that gap is no longer a gap, because that gap has now been filled by additional research. The AI revolution has happened, and each month, it's blowing up and replacing jobs. M now can make you an app on anything you want just by describing the app, and it's created with code. Instantly. So, developers are really in trouble. The key thing is to be like you're doing and everyone else, you have to be looking at AI and using it in your workflow. If you're not, you'll get behind. And I would recommend hospitals have teams like M and others that keep bringing you stuff every week. The other thing that M does is she triangulates. She doesn't rely on one AI platform. She will bring 3 or 4 together and use the intelligence of this one with the audio of this one and the video of this one. To create the best product. You have to have human oversight to make sure they're correct. We have medical writers that make sure that everything we use is correct. Well, I can say that I'm very confident in is you are my help in curating knowledge in the field that I need to become, continue to be knowledgeable about. It's one of the main reasons why you stay current because I trust the information. That's being provided there and I'm thrilled to hear that you are following the technology along and staying right with it. A year from now, we would have a very different conversation about this very subject, and I wanted our listeners to know about it and uh think about it for their own work. Mark, thanks for inviting us to your podcast. I know everyone loves it. It's advancing the way that people are keeping up to date on how to treat the most complex thing we do. Pete Serge, thanks for not only teaching us about colorectal, but keeping us up to date. On, uh, these peripheral things as well, and congrats on releasing this podcast. This will be a podcast that looks like number 49. Awesome. Keep on going. We got 4900 is what we wanna get. Nice to be with all of you. Thanks guys. We want to acknowledge the foundation of this episode, an article titled Creating a collaborative Program for the Care of Children with Colorectal and Pelvic Problems, published in seminars in Pediatric Surgery. The article outlines the benefit of a multidisciplinary approach to treating children with complex colorectal and pelvic conditions. Much of the content and discussion you heard today is inspired by the key insights and lessons shared in that work. Picture this an energetic eight year old just like any other, but, um, their backpack holds not just homework but also diapers and extra changes of clothes because of a medical issue they can't control. It really hits home how profoundly colorectal and pelvic problems can disrupt a child's life, highlighting the critical need for joined up comprehensive care. Absolutely. And that's exactly what we're going to unpack for you today. We're not just looking at individual treatments in isolation, but at the, you know, the bigger picture of how different medical specialists can work together to deliver the best possible outcomes for these children. Exactly. Got a really insightful resource for this, a 2020 publication and seminars in pediatric surgery. Think of it as getting a, uh, backstage pass to see how experts from various leading children's hospitals tackle the complex challenge of building these collaborative centers for kids facing these specific medical hurdles. And for you, our listener, if you're looking to quickly get a solid understanding of a really crucial area within pediatric healthcare. Well, you've tuned into the right place. This deep drive is all about providing those key insights without getting lost in overly technical details. So our goal for this session is pretty straightforward, to understand the essential steps and all the vital considerations when establishing a successful multidisciplinary program for children dealing with colorectal and pelvic conditions. OK, let's get into the core of it. Why is this team-based approach so absolutely necessary in the first place? Well, as the article lays out, colorectal and pelvic disorders in children are often intricate and can have effects that last their entire lives. We're frequently dealing with a network of Connected issues involving not just the digestive system, but also the urinary and reproductive systems and sometimes even the bones and muscles of the spine and hips. It's a, it's a complex picture. That sounds like trying to solve a puzzle where all the pieces are mixed up from different boxes. Precisely. And the article specifically points to conditions where this joined up approach makes a real difference. Think about anorectal malformations, often referred to as ARM, where the anus and rectum haven't developed properly, or Hirschsprung disease, where missing nerve cells in the large intestine cause problems with bowel movements. Then there's severe constipation caused by issues with how the colon moves and neurogenic bladder and bowel dysfunction. Function which we often see in children with conditions like spina bifida where nerve signals to the bladder and bowel are affected. So it's much more than just the physical symptoms, isn't it? The article touches on something else that's clearly very important, absolutely crucial. The emotional and social well-being of these children and the impact on their families is a major consideration. Dealing with these conditions can really affect a child's quality of life, create significant stress within the family, and sadly can sometimes, you know, contribute to mental health issues. A collaborative program recognizes this interconnectedness and makes sure that crucial psychological and social support is built right in. And it's not just a nice to have, is it? Is there evidence that these programs actually lead to better outcomes? Yes, the evidence is compelling. The article highlights that these collaborative programs lead to better treatment plans that are actually put into practice more effectively. You see improved communication between all the different specialists involved, fewer complications for the patients, and ultimately better overall health outcomes. It's about everyone working together seamlessly. OK, so we understand why these programs are so vital. But how do you actually take that first step and get one started? What are the real foundational elements? The article uses a very relatable starting point, the story of an 8-year-old girl who had a history of ARM and was still struggling with bowel control issues. Seeing the daily impact on her life can be a really Powerful motivator for individuals to say we can do better. It really grounds it in the human experience. It does. And the article emphasizes that the initial driving forces behind these programs are often a strong focus, a genuine passion, and a deep interest from a few key people combined with a solid work ethic. The detailed knowledge of these complex conditions will grow over time, but that initial commitment and enthusiasm are absolutely essential to a Get the ball rolling. It sounds like you need someone who is a real driving force. You do. The article stresses the necessity of a dedicated physician leader, most often a pediatric surgeon, who not only has that genuine interest, but is also deeply committed to the long-term care these patients require and has a clear vision for how to improve the overall quality of colorectal care. This is someone who often sees firsthand through their clinical work that the current system isn't always meeting the complex needs of these children. And recognizes the need for a more integrated approach. So it begins with identifying that unmet need and finding that passionate leader to champion the cause. What happens next? Do you immediately start recruiting doctors? Not exactly. That leader first needs to really understand the local healthcare landscape. Is there a genuine need for a new center in that specific geographic area? Is it actually feasible, given the services that already exist? Are there underserved groups of patients who would particularly benefit? It's about doing your homework and understanding the context before you start building. That makes perfect sense. You wouldn't want to duplicate existing services or create something that isn't truly needed by the community. OK, so let's say you've confirmed the need and you have a passionate leader ready to go. How do you begin to assemble that multidisciplinary team? The article talks about the crucial step of planning those initial multidisciplinary conferences and eventually clinics. And when you're first starting out, a few key medical specialties are. Absolutely vital. You'll need general surgery, urology, gynecology, a specialist in GI motility, which is how the digestive system moves, and critically, a dedicated nursing team. Nursing seems to be highlighted very early on. What makes their role so foundational. According to the article, they are the backbone. You can have the most brilliant surgeons, but without a truly dedicated and passionate nurse who specializes in managing bowel issues, the program won't function effectively. This nurse needs to be someone who is proactive, deeply cares about the specific group of patients, and understands their vital role in achieving positive outcomes and ensuring patient satisfaction. The article even points out that for programs in countries where English isn't the primary language, having a nurse who is fluent in English and can attend international meetings can be a significant advantage for staying up to date on best practices. That's a really interesting point about the international collaboration. So, The nurse is almost like the central coordinator in those early stages. What about the surgeons themselves? From a surgical perspective, building the team requires thinking about how these specialists will collaborate in the operating room. Often these complex cases necessitate the combined expertise of pediatric surgery, urology, and gynecology. The article notes that finding a pediatric gynecologist can be a challenge in some areas, and in those situations, a pediatric surgeon might also manage those aspects for female patients. If the program involves an adult gynecologist, it's crucial to find someone with specific expertise in malarian anomalies, which are congenital abnormalities of the female reproductive tract, exactly, or disorders of sexual development. And importantly, you need to start having conversations early on about how the patient's care will transition as they move into adulthood. That's so important considering the potential long-term impact. On fertility and other gynecological health issues. What about the digestive system specialists, the gastroenterologists? For that, you need a GI colleague who has a real interest in motility, how food moves through the digestive tract, and in performing manometry studies. Manometry involves inserting a thin, flexible tube into the digestive tract to measure muscle contractions. It helps diagnose issues with how the bowels are working. It's also about establishing clear guidelines for managing constipation, knowing when a patient should be referred to the multidisciplinary team, and what criteria defined when standard medical treatments for constipation haven't been successful. Access to assessments like anal and colonic motility studies is also key, along with incorporating pelvic floor physical therapy to help strengthen those muscles, precisely, the muscles involved in bowel control, and crucially, the article emphasizes the need to educate local pediatricians on when and how to refer patients to the center. So it's not just about the specialists within the program itself, but also about building those connections and referral pathways within the wider medical community. What other medical areas are important to involve early on? Radiology is another absolutely essential partner. You need radiologists who are truly invested in understanding these conditions, and the article suggests starting with educational sessions. On colorectal diseases to help them understand the specific imaging needs. This includes knowing how to properly perform and interpret contrast enemas, which use a special liquid to highlight the bowel on X-rays, as well as colostograms and cloicograms, which are specific types of imaging used for certain colorectal malformations. The article even stresses the importance of active participation from the surgeons in these imaging studies, especially in the beginning, so everyone is on the same page with what they are seeing. Makes sense. Pathology is also vital. Having a pathologist with expertise in intestinal disorders such as Hersheyrung disease ensures that tissue samples are handled and interpreted correctly, and good communication between the surgeon and the pathologist is crucial for accurate diagnosis and treatment planning. It sounds like building this team. Involves a significant amount of collaboration and mutual education across different medical fields. It really does. The article also briefly mentions the importance of informing other specialties like adult general surgery for when patients transition to adult care. Neurosurgery, orthopedics, and cardiology about the new center, especially given that these patients often have associated medical conditions in those areas, other related issues, exactly. And to make sure everyone is working together effectively. Regular multidisciplinary meetings, ideally once or twice a week, are essential for reviewing individual patient needs and developing coordinated care plans. And what about the actual physical space where patients are seen? Is it best to have everyone located in one clinic? The article points out that a dedicated multidisciplinary outpatient clinic is the ideal scenario. But sometimes practical limitations with hospital infrastructure can make that difficult, especially when starting out. Sure, I can see that. So if a shared clinic space isn't immediately possible, the suggestion is to at least coordinate appointments so that patients can see the different specialists they need on the same day, even if they have to go to different locations within the hospital. The regular multidisciplinary meetings then become even more important for ensuring that everyone is aligned on the patient's overall care plan. OK, so you've assembled the initial team, but expertise in such a specialized area isn't something that appears overnight. How do these programs continue to learn and develop their knowledge? Continuous learning is absolutely critical. The article highlights several really valuable strategies visiting established, leading colorectal centers to see how they operate, staying completely up to date with the latest research and publications, watching surgical videos to learn new techniques. And even visiting other multidisciplinary programs within your own hospital to see how they function. So learn from others. Yes, the key is to learn from those who have more experience while also being realistic about what your own team can realistically implement in the early stages. That makes sense. You want to aim for excellence, but also be practical about what's achievable initially. Exactly. The article encourages proactively asking other centers if they're willing to share materials they use like patient intake forms or follow-up protocols, and then adapting those to your own needs. It also emphasizes the importance of sharing any improvements or innovations your own program develops back with the broader community. It's a continuous cycle of learning and sharing and for clinical skills, for clinical skill development, the article mentions specialized colorectal fellowships for surgeons, visiting other institutions for mentorship, traveling internationally to learn from experts in other countries, and attending professional conferences, and importantly, encouraging all members of the team, not just the surgeons, to participate in these learning opportunities. So it's really about investing in the ongoing education of the entire team. Absolutely. The nurses and other allied health professionals like physical therapists and social workers play such a vital role and need specific training related to these complex conditions. Staying current with research across all the relevant specialties, including motility, urology, and pediatric gynecology, is also essential. How do they recommend doing that? Well, this can be done by setting up alerts for new publications in medical databases and by attending meetings and conferences. While Surgical videos can be a helpful tool for building confidence and understanding techniques. The article wisely points out that they are not a substitute for actual hands-on surgical experience. Good point. And looking to the future, the importance of systematically collecting data on your own patients and potentially joining research networks or consortia is highlighted as a key way to advance the field. And even looking within your own hospital at successful programs in completely different medical areas can provide valuable insights. Precisely. They can offer valuable lessons on how to successfully apply for resources, achieve recognition as a specialized referral center, and effectively work with hospital administration. Every hospital system has its own unique culture and processes. So learning from those within your own institution who have navigated these successfully can be incredibly beneficial. Once you begin seeing patients, you need to have the right educational materials and physical resources readily available. What are the essential things to consider in this area? The initial focus should really be on ensuring the colorectal nurse has a strong foundation of knowledge. They need a solid understanding of the different types of conditions they'll be seeing, such as the various forms of anorectal malformations, Hirschsprung's disease, and neurogenic bladder and bowel. They also need to be highly skilled in providing preoperative and postoperative care, which includes things like performing bowel irrigations and enemas, managing catheters, and teaching families how to perform. Perform anal dilations at home. So they're teaching the families too. Yes, and as we discussed earlier, because care is so collaborative, they need to thoroughly understand the treatment plans developed by all the different specialists involved so they can effectively communicate with the families. So the nurse really becomes a central point of education and support for the families as well. Absolutely. And it's also critically important to involve and educate the inpatient nursing staff who will be caring for these children when they are hospitalized. Creating specific protocols and providing educational sessions for them ensures a consistent and high level of care. Well-trained inpatient nurses can significantly increase the comfort level and confidence of families during what can be a very stressful experience. And in terms of physical supplies and equipment. What kind of things are essential to have on hand. The article suggests developing a detailed list of the basic materials that will be needed in the outpatient clinics, on the surgical floors, and in the operating rooms. This might include things like Hagar dilators, which are instruments used for gently stretching narrowed passages, various types and sizes of catheters, gravity bags for administering enemas, and specialized surgical retractors like the Lone Star retractor that help provide the surgeon with a clear view during procedures. Having these materials readily available streamlines the care process and ensures the team has the right tools they need at the right time. Now, as these programs mature and grow, How do they effectively demonstrate their value to the hospital administration and make a strong case for needing additional resources and support? This is where data becomes absolutely crucial. The article emphasizes that building a robust data library is essential for demonstrating the efficiency of the clinic, establishing a strong regional reputation. And showcasing the effectiveness of any new treatment techniques that are being implemented, right? You need the numbers. If you can't track and measure your outcomes, it's very difficult to improve, and it's even harder to advocate for increased support and resources. So what specific types of data are we talking about tracking and analyzing? The article provides several key examples the total number of patient referrals the center receives, the total number of patient visits, the number of new patients seen, the number of patients coming from outside the immediate region, the total number of surgical cases performed, both inpatient and outpatient, the average length of stay for hospitalized patients, the overall revenues generated. by the program, the expenses associated with running it, and critically important safety and quality improvement metrics like complication rates. Even carefully documenting the telephone encounters that the nursing team has with patients and families is important to justify the need for adequate nursing staff, as these patients often require a significant amount of ongoing support and And a tinkering with their care plans. That's a really good point. It's not just about the major surgical interventions. It's also about the ongoing, often daily management that these patients require. Exactly. Children with colorectal and pelvic conditions often need long-term chronic care and don't always follow the typical recovery path of a standard surgical patient. For private hospitals, tracking relative value units or RVUs, which are a measure of the value of services provided, is also an important part of the business plan, even though it can be a bit more complex to track in a multidisciplinary model with multiple specialists involved, right, where multiple specialists are involved in a single patient's care. Continuous improvement hinges on this transparent tracking of data, things like how many patients call the center, how many actually come in for appointments or surgery, and perhaps most importantly, understanding why some patients don't follow through after their initial contact. Asking those tough questions can help identify areas where the program can improve its outreach and patient engagement, and this data really serves a dual purpose, doesn't it? It absolutely does. It's not only essential for internal quality improvement and for making a compelling business case to the hospital administration, but it's also vital for conducting research and publishing your program's outcomes in medical literature. Positive research findings and publications can then attract even more referrals to your center. The article advocates for trying to design your electronic medical record system in a way that allows you to easily collect and tag clinical data that can be used for research purposes down the line, and the business case itself might differ slightly depending on the hospital type. Exactly. The specific focus of the business case will differ slightly depending on whether you are in a private or a public hospital system. In private hospitals, the emphasis might be more on attracting patients and the downstream revenue they generate for the hospital, while in public hospitals, the focus might be more on demonstrating cost savings through things like reduced complications, shorter hospital stays, fewer emergency room visits, and overall improved quality of life for the patients. Let's shift gears for a moment and talk about patient referrals. What's the most effective way for a new program to build trust and foster collaboration with referring medical colleagues in the community? The article offers some really practical and insightful advice here. It highlights the importance of always being polite and patient with colleagues who might be initially hesitant to refer their primary surgical cases to a new center. It's understandable, right? Especially if those referring physicians have been managing these types of conditions themselves for many years. Building trust takes time. So it's about demonstrating the value of the multidisciplinary approach, not just expecting referrals from day one, precisely. By consistently and successfully managing the patients who are referred to you for more focused aspects of care, such as bowel management, even those who may have had previous surgeries elsewhere and require ongoing complex care. You gradually demonstrate the real value of your multidisciplinary approach. The article wisely points out that a significant portion of these patients who are initially referred for management issues will likely need further surgical intervention down the line anyway. Offering to collaborate with referring surgeons on those more complex primary repairs is also a very effective strategy. So working together on cases, exactly. It allows you to share your expertise and build strong working relationships. Ultimately, a collaborative approach with your surgical partners benefits everyone involved and most importantly, leads to the best possible care for the patient. So it's a gradual process of building confidence and demonstrating positive outcomes over time. Now thinking about the team that's been assembled, what kind of infrastructure and support resources are essential to keep things running smoothly? We touched on the nursing team earlier. Infrastructure is absolutely key. The article uses a common example a busy nurse who ends up spending a disproportionate amount of their time on tasks like scheduling appointments. It identifies a dedicated care coordinator or scheduler as a top priority for resources. Allocation. Ah, that makes sense. Having someone in this role can significantly streamline the patient visit process and serve as a central point of contact for families, making it much easier for them to navigate the complexities of multidisciplinary care. That makes perfect sense. Having a single reliable point of contact can make a huge difference for families who are already dealing with a lot. Absolutely. The article also discusses a practical concept called building bench strength by initially sharing resources from existing hospital departments. For example, rather than immediately hiring a full-time nurse dedicated solely to the colorectal program, you might be able to allocate a portion of a nurse's time from the general surgery department to your program in the early stages, kind of like borrowing staff time. Exactly. This can be a more cost-effective way to get started. The same principle can often be applied to other important support roles such as social workers, child life specialists who help children cope with illness, nutritionists, and psychologists. The overall goal is to demonstrate the growing needs of the program and make a clear case to the hospital administration for gradually increasing dedicated staffing as the program's activity increases. The article includes a pretty extensive list of all the potential care providers who could be part of a comprehensive multidisciplinary program. It's quite a wide range of specialists. Yes, Table 3 in the article provides a very detailed overview of the many different types of health care professionals who can contribute to such a program, from various surgical and medical specialists to nurses. Advanced practice providers, therapists, social workers, and administrative support staff. It's a long list. It is, and the authors acknowledge that it's unlikely that any single program will be able to assemble this entire ideal team right from the start, and that the specific needs of each program will vary depending on the patient population they serve and the resources available to them. The important message is that building a truly successful and comprehensive program is a gradual journey that evolves over time. So finally, how do you go about making that persuasive business case to the hospital administration to secure the ongoing resources you need to support this growing program? The article points out that most hospitals have staff in their planning and data analysis departments who have specific expertise in helping to develop these kinds of business cases. Engaging these internal resources early on is a really smart move. Use the hospital's own experts. Exactly. You'll likely need to be prepared to answer some key questions for hospital leadership, such as who is the specific patient population that the program will serve? What is the current volume of activity for these types of patients within the hospital? What specific service gaps will the new program address? Will it enhance the services that are already being provided to existing patients? Is it expected to attract new patients from outside the hospital's current service area? Is there a potential to bring back patients who may have previously sought care elsewhere? OK, lots of strategic questions. Yes. What specific resources will be needed to run the program and how will those needs evolve over time? What are the potential barriers or challenges to moving forward with the program? What are the potential consequences of not building this program for the hospital and its patients? And crucially, how does the proposed program align with the hospital's overarching mission, vision, and strategic plan? It sounds like you really need to articulate a clear value proposition for the hospital. Exactly. Given that establishing a true center of excellence in this complex area takes time and sustained effort, you'll need to develop a multi-year plan that outlines clear milestones for when you will need additional resources and what results you expect to achieve. You needed a roadmap, precisely. Developing realistic clinical service projections, including estimates for the number of office visits, diagnostic studies, surgical procedures, and inpatient stays is essential. And it can be helpful to provide a range of scenarios from best case to more conservative estimates and payment. That's always key. Payment considerations are also vital. You need to ensure that all the involved providers are properly credentialed with both government pairs like Medicaid and private insurance companies, both within your state and in neighboring states from which you might draw patients. The clinical and administrative teams will need to work very closely together on the credentialing and pre-authorization processes, making sure to allow for adequate lead times. Understanding the different payment models used by payers, such as diagnosis-related groups for inpatient care and case by case or bundled payments for outpatient services, is also key. What about telehealth? And finally, the article touches on the increasingly important role of telemedicine in reaching patients, particularly for initial introductory visits and for follow-up care. And the associated considerations around physician licensing in different states and how different payers reimburse for these types of virtual encounters. The article even gives us a brief look into what a typical week might look like in a well established high functioning program. It sounds incredibly organized. It does. It typically revolves around regular weekly meetings that are specifically focused on both new patients who are being evaluated and returning. Patients who are coming back for ongoing care or follow-up. For new patients, there are often dedicated new intake meetings where the nursing team plays a central role in proactively gathering all relevant medical records, developing an initial multidisciplinary care plan that considers the patient's history, the reasons for referral, and any potential psychosocial, nutritional, or anesthesia-related concerns. So the nurse preps everything, right? They also work with the family to verify all the information and create a tentative plan that might include additional testing. They also start the process of addressing any pre-certification or billing issues. Then the entire multidisciplinary team, including colorectal surgery, urology, gynecology, GI motility, nursing, and social work, reviews the nurses's proposed plan collaboratively. Team review, exactly. This helps to streamline the diagnostic process, reduce the number of separate visits and tests the patient might need, and fosters a real sense of shared understanding and collaboration among the specialists. For families who have to travel a significant distance, these programs often try to consolidate as many appointments as possible into a single visit, and that's helpful for families. Definitely. Following these intake meetings, there's a clear process for scheduling the necessary follow-up appointments and procedures. Then for returning patients, the weekly collaborative meeting serves as a crucial forum for reviewing the status of patients who have upcoming clinic appointments or surgical procedures. The team discusses any updates since the initial intake, determines if any new testing or surgical interventions are needed. Addresses any pre or postoperative considerations and also reviews patients who are coming to the multidisciplinary outpatient clinic that week. So planning the clinic visits too, right? Discussing the reason for their visit, which specialists they need to see, and how much time should be allocated for their appointments. For older patients who have previously discussed treatment plans, the team also uses this time to review and confirm any planned interventions for their upcoming visits. The overall goal is to ensure that everyone on the team is completely aligned and that a final coordinated plan is in place for all upcoming patient encounters. It really underscores the absolute importance of consistent communication and seamless teamwork in delivering this kind of complex care. Absolutely. It's all about creating a well-oiled machine where every member of the team is well informed and actively contributing to providing the best possible care for each and every patient. Well, this has been a truly fascinating and insightful deep dive into the complexities of building a successful collaborative program for children facing colorectal and pelvic problems. It's so clear that it demands an immense amount of dedication, a truly integrated multidisciplinary team, and a rigorous data-driven approach to make these centers a real success for the kids who need them. Agreed. It really highlights that these specialized centers are about so much more than just treating a specific medical condition. They're about creating a comprehensive and supportive environment that truly addresses the multifaceted needs of these children and their families throughout their journey. So for you, our listener, we sincerely hope this in-depth exploration has provided you with valuable knowledge and a deeper understanding of the intricacies involved in delivering this kind of specialized pediatric care. It's a powerful example of what could be achieved through collaboration and tackling some of the most challenging medical issues that children face. And it. Really makes you think about the broader implications of this model of interdisciplinary care across all fields of medicine. What other complex medical conditions could benefit from the same level of integration and shared expertise to ultimately improve patient outcomes? It's certainly a question worth considering long after our discussion ends.