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The Neurotransmitters: Clinical Neurology Education
Pediatric Epilepsy with Dr. Shilpa Reddy
Dr. Shilpa Reddy is a child neurologist and epileptologist at Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center.
Join me as she shares:
- The process of training a pediatric epileptologist
- Clinical pearls on dealing with childhood epilepsy
- Tips on evaluating episodes that may or may not be seizures
I was fortunate enough to have Dr. Reddy as one of my own instructors during my fellowship training and I'm so grateful that she stopped by to talk with us in this recording!
You can also find her on Twitter/X via the Vanderbilt Pediatric Epilepsy account.
A bi-monthly podcast where we share the stories of our Caregivers, patients and...
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The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.
Hello and welcome back to the Neurotransmitters. I am your host, dr Michael Kentris, and we are here to be your source for everything related to clinical neurology. I am very happy to introduce, like I always am, one of my former instructors, dr Shilpa Reddy from Vanderbilt University Medical Center. But, oh my gosh, I apologize. What is the name of the children's facility on Vanderbilt University Medical Center? But, oh my gosh, I apologize. What is the name of the children's facility on Vanderbilt's campus?
Dr. Shilpa Reddy:Monroe Carroll Junior Children's Hospital at Vanderbilt University Medical.
Dr. Michael Kentris:Center. Oh my gosh, there is no way I would have remembered that. I'm so sorry. No, that's okay. So I was really happy to hear from you and the joke I always like to make right child neurology it's basically just neurology, but for smaller people, right?
Dr. Shilpa Reddy:Funny that you said that, because we have a lot of and we'll get into this but we have adult neurology residents that train on the pediatric side and pediatric residents that train on the adult side and we're so used to people saying aren't kids just little adults? And I had one of the trainees tell me aren't adults just big kids?
Dr. Michael Kentris:I think that's probably the more accurate one. So what goes so? First off, let's start with broad strokes. For people who may not be familiar with the specialty, how does one go about becoming a child neurologist? And once you are one, what do they generally do?
Dr. Shilpa Reddy:So everyone starts out in medical school.
Dr. Shilpa Reddy:So you do your four years of training in medical school and when you start thinking about what specialty you want to do, I've kind of seen two different types of people that go into neurology. Some people really love the actual brain, anatomy, physiology and they will try to decide between becoming an adult neurologist or a child neurologist. But then I've also seen people come at it with their pediatricians at heart and they really love working with kids and being with kids and so they come to neurology through the pediatrics route. So it doesn't matter, I guess, how you started, but just more where you end up. So when you start applying for residency, if you are on the adult neurology path, you will apply to a four-year program at a ACGMA accredited university and that generally consists of one year of a internal medicine residency program and then you do three years of neurology training. Within that three years of neurology training you'll spend, um, I think somewhere around six months doing child neurology rotations. And then, on the flip side, if you are a pediatric neurology resident, you apply to a five-year child neurology residency program and you will do your first two years being a general pediatrician under their training program and then your last three years, similarly, are neurology. You'll spend kind of depending on the program, anywhere between six to 12 months doing adult neurology rotations and the rest of the time either doing peds rotations or research or elective time and things like that. So those are the kind of two big pathways. And then as a child neurologist, as you're going through your neurology years, there might be different aspects of the field that you're more drawn to.
Dr. Shilpa Reddy:Epilepsy is one of the most common diagnoses, or seizures or epilepsy are the most common diagnosis that we see as child neurologists. I think the data shows somewhere between like 60 to 70% of a child neurologist practice is some sort of seizure disorder or epilepsy. So you'll find that people, if they're drawn towards epilepsy and seizures, they can finish their five years practice as a general neurologist and still have a big chunk of epilepsy in their day-to-day practice. But there are also some people that are super drawn towards epilepsy and see that passion towards more complicated forms of epilepsy and or wanting to learn more about advanced management options, whether that's the ketogenic diet or doing surgical things, and you'll find or, on the flip side, we'll see people really be interested in neurocritical care and it's not that you have to do epilepsy to do neurocritical care. But again, we're noticing that in both adult and pediatric ICUs there's a high incidence of seizures, that we are learning more about detecting and how treatment affects outcomes.
Dr. Shilpa Reddy:So I think it is some people will choose to do an epilepsy fellowship along with their neurocritical care fellowship to help kind of round out their um, their training, and so we'll see people come at it from that way. So if you are interested in either epilepsy surgery or neurocritical care, you know EEG people will do an extra year or two of fellowship. If you're not interested in epilepsy or you are more interested in other things, there's a lot of other diagnoses in the pediatric neurology world, such as demyelinating disorders, movement disorders, neuromuscular disorders. We have some people really interested in headaches. Those are kind of the big oh, and then stroke, of course pediatric stroke. So like I said, within child neurology you're probably going to see epilepsy and seizures on a day-to-day. But if you're more interested in a specific aspect it's kind of nice to know you can do fellowships that usually last about a year after the five years of training.
Dr. Michael Kentris:Excellent. Now, obviously I'm biased. So I did my like neurophysiology slash epilepsy training at Vanderbilt and I was very fortunate to spend about a month or so on the child epilepsy service. And I had this one distinct memory in particular. It was like the first. It was one of the first days I was on service and I think it was Dr Patterson perhaps I might be getting the name wrong. I apologize, dr Patterson, perhaps I might be getting the name wrong. I apologize, but it was a child who had a history of Lennox-Gastaut syndrome and I was looking through it and I was like, oh, there's a lot of epileptiform discharges. The EEG is pretty abnormal, but I didn't see any seizures. And she's like, oh, are you sure? And she's like, well, what about this? And there was like the little flattening there, sort of the electro decadental response, if you will, and it's like, oh, each one of these like five per page is a seizure.
Dr. Shilpa Reddy:And yeah, and she, I remember just saying we're still like, don't worry, all of our adult fellows missed that initially I mean it's so funny that just you just said that, because the fellow yesterday reminded me on her for adult fellow on her first month of peds there was two back back to back EGs where there was multiple spasms on the EGs and she's like I didn't see those. But I always say you know, that's why you're here, that's why you're in training.
Dr. Michael Kentris:Right. And now here I am, God, seven years later, and I still have that core memory with me.
Dr. Shilpa Reddy:Yes, I mean this is a little editorial, but I do feel like, by quote unquote, missing things or getting something wrong, you know, in a situation where you have support, is the best way to learn, because as high achieving people as we are, you're going to remember a time that you felt embarrassed or a time where you didn't have that knowledge or you know so, at least for me.
Dr. Michael Kentris:I think that's an interesting way to learn, yes, that kind of emotional tag to the learning experience. Now, as you mentioned, right, you are one of these people who is more engaged with seizures and epilepsy, in fact instructing more junior physicians in becoming better at it. But just like with adult neurologists, we know child neurologists are kind of at a premium across the country. There's definitely not enough people with the expertise kind of scattered, especially uniformly across the country. So it's not unusual, right. People have unusual spells or episodes, and if we were to talk to the family medicine doctors or the pediatricians out there who are providing most of this care, this primary care, what are the things that you would say they should look out for? That might warrant more investigation.
Dr. Shilpa Reddy:Yeah, I love this question because, as you mentioned, neurologists both adult and child neurologists are a limited resource in our country and we know that care is not evenly distributed in different parts of our country. So I think the more that we can empower providers in other areas besides our academic centers that are in bigger cities, then I think we're going to do justice for our patients. So whether that means trying to again educate the primary care providers about how to treat certain conditions, but mostly education about when to refer to like a bigger epilepsy center for care, I don't want patients to miss out on opportunities for surgical management, you know, because other providers are trying five, six, seven medications before thinking about surgery. And both in the adult and pediatric populations we know that early surgery leads to improved outcomes. So more than ever we want to be able to streamline the referrals and the workup and, of course, the treatment that kind of starts in the beginning, so I can speak mostly for pediatric patients and that streamline just because I don't see adult patients.
Dr. Shilpa Reddy:But you know we try to do continuing medical education seminars for general pediatricians in our community and the focus is on, again, seizures being a big part of child neurology. We focus on how to identify seizures and seizure safety, things like that. So for our general pediatricians, I think knowing that seizures can manifest a lot of different ways clinically, that kind of opens the door. So if a patient comes in with weird behavior, weird episodes, we really should be digging deeper into like okay, tell me more about this episode so I can put them in a bucket of this is seizure, this is not seizure. And I start with really asking as many details as possible.
Dr. Shilpa Reddy:So, starting at the beginning, what were you doing when this episode happened? Then, what did you feel? Then what did you feel? And then, if there's a witness or a bystander, kind of asking the family or sibling saying, well, what did they do next? What did they do next?
Dr. Shilpa Reddy:And then what happened at the end of that episode and it's also important to interject and say to the patient how much of this did you remember, did you black out? Because that can help kind of put us in one category or the other. And then going beyond that and saying how, how many times did it happen? Um, how long does it last? Um cause, like I said, there are a lot of things that look like seizures that aren't seizures, but then there's also some strange episodes that end up being seizures. So, just kind of getting as much detail as possible so that if you are able to connect with a neurologist at some point, you can give them as much as a story. Nowadays we have cell phones at our disposal, so we often ask family members, or even teachers, if it's a younger kid, to take videos with parents permission, because we always say, like pictures are worth 1000 words, but videos are even better, it's so true.
Dr. Shilpa Reddy:We, as humans, like to say we remember every single detail about things. In the moment of stress or panic and, to your point, getting emotion into it can can alter the way that we describe things or remember things.
Dr. Shilpa Reddy:So videos are great absolutely so I think the big things that a pediatrician can can be looking out for is is there sort of a loss of consciousness or altered awareness during the episode? So we encourage family members to ask them to do commands or have them talk to them during it. We look out for things that are very stereotyped, meaning, does the episode happen the same way every single time? Yeah, and then beyond that, you know, I don't know how much detail we want to hear, but, like I said, different types of seizures can manifest different ways. So one of the most common ones that we think about are absence seizures, and it can really go both ways. So we see a lot, a lot, a lot of referrals for kids that stare off or zone out, and it's really tempting for everyone to say this is an absence seizure because they're staring, and this is the type of seizure we know is associated with staring. So what I would say is it's really important to test responsiveness in these patients.
Dr. Shilpa Reddy:And even though off-sense seizures classically are very, very short, the zoning out or the staring off is unresponsive. So if you were to touch the patient's face or give them a little pinch, tickle them, they shouldn't be able to respond or break out of their episode, whereas kids that zone out or space out, if you startle them in some way they might not respond verbally but they'll at least either shake their head or blink or kind of tend towards you. So that's an important feature. And then for obstinate seizures, I think something to remember is some kids can have some motor manifestations where they flutter their eyelids, might have a little bit of lip smacking, potentially even something with their hand. So that might distinguish that too. So the tricky part is ADHD is a very, very common diagnosis in kids and it usually starts being clear around that school age five, six, seven years old, which also is the age where absence seizures tend to be. You know the onset. So it can be very difficult to tease out the ADHD staring and attention from absence seizures, especially because we know kids with absence epilepsy have, the more commonly have ADHD or higher incidence of ADHD. So if I can take a detour here, so there is an app that's being developed, which I think kind of goes. I'm sure you've talked about AI and things on your podcast, but there's a lot of healthcare technology that we can start incorporating to our practice and I'm like super excited about some of it being able to reach more people or being able to diagnose earlier. I think that's great.
Dr. Shilpa Reddy:So this app is a hyperventilation app. With obstinate seizures they tend to be induced by hyper ventilation, but we often like it's hard for kids to participate in that type of thing, especially if we're not right there coaching them through it. So the app basically coaches the kid to hyperventilate using some fun I don't know techniques, and then there's a little camera that looks at the kid's face and they can, I think uses an algorithm to track if they have like eyelid fluttering or if they have pauses in their breathing, for how long they have like eyelid fluttering or if they have pauses in their breathing for how long, and then it'll be sent to somewhere where the neurologist can review it. Or there's like an algorithm that reviews it and then it spits out a report saying, hey, this kid had three they can't call them seizures, but like three episodes where there was behavioral arrest or eyelid fluttering and then the neurologist can look at it, or even a pediatrician if they have this app in their office, they can look at it and be like, oh well, this looks concerning, let me send them to the neurologist, if that makes sense, and I think it's a nice way you can use it twofold. One is pediatricians can help triage their referrals for staring.
Dr. Shilpa Reddy:If it doesn't show up as anything, maybe they go down the ADHD path or they can see the neurologist in a couple months. But if the report spits out and says, hey, there's three episodes that sound concerning for seizures, they can call the neurologist and say I need this kid seen for an EEG, like in the next couple of weeks, you know. And then neurologists can use it, because if we have a kid that has absence seizures, then we're starting medication and we want to monitor the response to treatment. We can have the family do this at home and say, okay, well, we still had episodes like maybe we need to up the medicine, I don't want to wait the six months before my return appointment. So I think it's exciting and I hope that it starts being incorporated into practice in the future.
Dr. Michael Kentris:No, that's really neat. That's not something I would have thought about because I also get many consults in the adult world for staring spells, slash absence, seizures and I have to say, no, that's for children.
Dr. Shilpa Reddy:Yes, and even so, like I would say, a large portion of our patients in our pediatric epilepsy monitoring unit come in for staring spells that end up not being seizures because kids, like I said, they zone out, they have an attention. It's just a common thing.
Dr. Michael Kentris:Right, yeah, I know, in the adult world, you know, nearly half also end up being non-epileptic. So it's one of those things that when you go into the field you're like, oh, I thought I was coming here to take care of epilepsy and seizures. It's like, well, there's a lot of other things that are in the kind of the orbit of those diagnoses that you end up being the person best equipped to to handle a hundred percent I was just gonna say, sometimes I feel like more, like, like more than an epilepsy specialist.
Dr. Shilpa Reddy:You're kind of like a spell specialist yes, that's a good way of saying that. Well, so in that same vein, there's a lot of things that can look like seizures. Syncope is one of those that's fairly common in kids and not dangerous per se. Psychogenic non-epileptic spells I'm sure you've had like a podcast on that. I think that's super important to talk about. But just understanding the sequence of events and the responsiveness of a patient can help any provider really think about is this in the category of non-epileptic or the category of seizures? So yeah, a lot of different interesting episodes, but videos have been great. I I again with family's permission I've had communications and relationships with pediatricians where if they can just send me a video, I can triage that pretty quickly rather than, oh, putting it in the queue to like, maybe I'll see you in six months when we finally have an opening.
Dr. Michael Kentris:No, absolutely. Yeah, Triageing is so important and, as you said, the video, not always but very often, can provide such good insights to someone who knows what to look for. The semiology is what we in the biz call it, but basically just like the clinical manifestations of the event, and it's one of those things where, you know, I consider in neurology, like the movement disorder specialist, to be kind of like the grandmasters of this, but I feel like we're maybe, you know, second place in terms of like looking at an event, what's happening. You know, it's the story of the spread of an event, or of a non-epileptic event as well, and it's one of those things where I really appreciated my training at Vanderbilt, where I kind of think of it as like the athletes who had run tape after after a game and they're watching. You know it's like like well, did you notice this? No, it's like all right, let's go back again and we'll watch it again.
Dr. Michael Kentris:And you just do it over and over again for hours every week and it really just drills into you. You know, making sure that the mind recognizes what the eyes are seeing, if you will, and it's kind of one of those weird skills that you don't really think about but like becoming a trained observer of a phenomenon.
Dr. Shilpa Reddy:Yes, yeah, we have the. You know, we're fortunate to have a lot of practice, like you said. I mean, there's been studies that show like different levels. So, if you're a patient versus provider, versus family member and like that, are you a neurologist, are you epileptologist? And the accuracy of detecting a non-epileptic spell versus a seizure, um, it gets a little bit better and better as, like, the more training that you have. But we're honestly like, we're good but we're not. We're not perfect by any means.
Dr. Michael Kentris:no, no but it's interesting I have been fooled uh, more times than I care to think about.
Dr. Shilpa Reddy:I think I was fooled today.
Dr. Michael Kentris:Every day is a new opportunity.
Dr. Shilpa Reddy:Yes, for learning yes.
Dr. Michael Kentris:So so you know you are in an instructor role and, as you mentioned earlier, there are certain kinds of people who are maybe attracted to the specialty. But what kind of skills does someone accrue in particular in a child epilepsy training program or just a general more neurophysiology epilepsy training program that might give them a leg up in these kinds of particular patient populations? That?
Dr. Shilpa Reddy:might give them a leg up in these kinds of particular patient populations. I really love this question because I've been asked this a few times as fellows or, excuse me, applicants have been applying to our fellowship program this year and they always ask what are you looking for in a fellow? I was like, okay, let me tell you, michael Kendrick Only half joking, but really honestly, as an epileptologist, I think you hinted at this you really need to be detail oriented. So, although, in order to triage patients to our clinic, we want to get kind of a big picture of what the story is and what the what these episodes look like, the semiology, what we are looking for when we're analyzing seizures is like the nitty gritty of okay, did their face turn this way for one second before their eyes went? Was it their left hand that was doing a dystonic movement versus a rhythmic movement, versus you know so there's so many details that help us pinpoint exactly where the seizures are coming from, which is going to be really important to if we wanted to do surgery and take that area out. That is like the first step. So very, very important to be detail oriented. You know that even drills down to when we're reading the EEG. Let's say it's not epilepsy surgery, it's an ICU patient being able to describe the waveforms in a way that if I sent this report to you, michael, you would be able to draw this out. I think Dr Pagano maybe told you that too. You should be writing a report where I could take it and draw the EEG and it looks exactly like the one that's running. So I think that's a very good skill set to have.
Dr. Shilpa Reddy:I think as an epileptologist, you really need to be curious. I think in every field there's so much more to learn. But I can only speak to epilepsy, and I think there's so much more to dive into. I talked about kind of the health tech part of things, but there's also more to dive into in regard to surgical devices that are being implanted and how we're actually looking to cure epilepsy rather than treat epilepsy. So having that intellectual curiosity is super, super important.
Dr. Shilpa Reddy:And then I think this is generic, but I, I guess I I want people that are interested in learning and I don't know if that's the same as being curious, but I want them to be engaged. I never want to take anything for face value, I guess. So if you're an epileptologist, you're always thinking about what else could this be and what else can I do for my patient. I think we do everybody a disservice if we just say, okay, return patient on your meds, they're happy, let's go bye. I think there's always something to be not actually changed, but something to talk about and discuss and make sure that you're engaging with the patient for more than just their seizures. Are we talking about quality of life and mood, their social situation? Because, again, you can have a whole podcast about living with epilepsy and what that means at different stages of life. So I think that is kind of what I mean by pushing a little bit deeper with learning and curiosity.
Dr. Michael Kentris:Yeah, no, I think I'm sure that you've seen some of these lectures of the year with Dr Ben Bades. I might. I think, um, I sure, I I'm sure that you've seen some of these lectures of the year with uh Dr Ben bodies I might be mispronouncing his name from uh from Florida, but he's, he's always. You know, maybe you get that referral and you know you've got an EEG report that shows, you know, sharp waves in this, that or the other area. And you know, there there is a sometimes a bit of skepticism. Right, you have to trust, but verify if you will.
Dr. Michael Kentris:And so I know we certainly see that same thing on the neuromuscular EMG side of things and I would say at least to the same extent on the epilepsy side of things, where you know it really becomes a question of like, do I know this person and do I trust their clinical judgment as well? And I know that sounds like a bit of a hard nose take. But if you just, as you said, accept it on face value, more often than not you end up getting burned a little bit.
Dr. Shilpa Reddy:Yeah, that is a very good conversation. I had it with one of our fellows multiple times this year. I like to trust but verify. I think that I think that's a great outlook on life and I think it's a very nice way of saying that.
Dr. Michael Kentris:It's probably the nicest way I can say it.
Dr. Shilpa Reddy:Yes, yes, I mean just to be completely transparent. I mean there are patients where I will read the patient in August and I'll say I think this is a arousal pattern from sleep, that's totally normal. And then we read it again six months later, like me, the same me, and I say oh no, this is, this is definitely a frontal lobe seizure. So that's happened a few times in my career and I would be surprised I mean, I'm sure it happens to everybody. So I think it's okay.
Dr. Michael Kentris:It's okay to look at things with a different lens, whether it's you or one of your colleagues or another institution, you know if you'll indulge me, but the phenomenon we call over-reading or under-reading EEGs, that is, say, calling something abnormal when it's normal versus calling something normal when it's abnormal. And I think we all go through phases At least when I've worked with residents in the past, the first couple of months they miss everything. They don't pick up on any abnormalities whatsoever. And then, after they've done a few months of reading EEG, then everything's abnormal, like is this a central spike? No, that's a vertex wave and all these things right.
Dr. Michael Kentris:You kind of go through these waxing and waning phases where you're under-calling, over-calling, you just bounce back and forth through the extremes until hopefully, you wind up somewhere in the middle. But there are still those cases where you're just like ah, I don't know, this one's a little, it's a little funny looking, but I don't have enough data to say like, does this correlate with every episode? The person has Right and to your point, you know, you maybe you get that second study and now you have this and you're comparing it to your past one and it's like well, this changes the entire lens that I was looking at it through. So it's not necessarily that it's now abnormal as much as like putting these two pieces together gives you like a bigger picture of the whole.
Dr. Shilpa Reddy:No, I love that and I think that's I mean, there's so many pearls to be said in this one is. You know, I think I'm known as a master hedger in EEG reports because I don't like committing to something. If I myself have a little bit of doubt, I don't want to put it down there that, like, I'm 100% sure that this is, like you said, abnormal or normal. So I think it's better to talk about it because you need the clinical context and sometimes time Things declare themselves right.
Dr. Michael Kentris:Absolutely.
Dr. Shilpa Reddy:And then the last thing you mentioned about.
Dr. Michael Kentris:you said Getting the pictures in time.
Dr. Shilpa Reddy:Yeah, I think that is the hard and nice thing about reading EEGs because I will say I've been on both sides where I read my own EEGs for patients that I see on the inpatient, outpatient side. But there's a lot of times where I read studies for my colleagues who are non-epileptologists on the inpatient service and so it's tempting to like want to change my read because of something they said in their notes but without seeing the patient. You know, I think I try to be as quote unquote clean as possible in my EG reads, if that makes sense you want to be as effective as possible, because you want your data that you're adding to your clinical picture.
Dr. Shilpa Reddy:Each data point should be objective, so that when you put it together, then it's your turn to interpret.
Dr. Michael Kentris:Right, and it's funny you mentioned that. So after I graduated fellowship, I was at an academic institution for a few years and I remember one of the chief residents at the time said you need to change the way that you write some of your impressions, because the hospitalists don't know what you mean, so they're consulting us on this basically normal report. And I was like, oh, and so that is right, you have to keep your audience in mind. Who is going to be reading this? I know that's one of the things that they emphasize a lot, and so I actually ended up shifting around so that, like, the most generic aspect was at the top, so that if you wanted to get into all the nitty gritty details you had to scroll past the actual impression, which I think stopped a lot of those consults.
Dr. Michael Kentris:But but it was this thing where it's just like, oh, this is just the way I, I've been doing it and it's not working in this environment. So I had to change. You know a little bit of how I put the pieces together. You know, change the verbiage slightly, right, there's a lot of synonyms that we use, like epileptogenicity versus you know, uh, various other things, or seizure potentials, etc. Etc. And uh, know your audience I guess, is.
Dr. Michael Kentris:The is the main takeaway for people who are writing reports, whether it's eegs or anything else yeah, even when we get mri reports from neuroradiologists, like they all you know.
Dr. Shilpa Reddy:I think the point is you have clinical context is important or clinical correlations recommended.
Dr. Michael Kentris:Absolutely.
Dr. Shilpa Reddy:And I find it interesting with trainees in general. I think the point of doing more training is for you to know what you don't know, and I think, as a trainee, it's just natural for us to say, well, I need to know this, I need to know this, I need to know this. But, as an attending, the further that you step out, it's really easy for me to say, hey, I need to know this, I need to know this, I need to know this.
Dr. Shilpa Reddy:But, as an attending, the further that you step out, it's really easy for me to say, hey, I don't know that and that's okay, whereas, like you don't know that point, when you're a trainee, you know everything but, as you mentioned, like we're humbled a lot of times by, by new information and you know things don't fit in a box always I know it feels like every time I'm asked a question anymore these days I have to start with well, it depends.
Dr. Michael Kentris:I can't just give an answer anymore.
Dr. Shilpa Reddy:I've reached that stage in my career I know I think I got feedback um a couple years ago from the residents and they're like you know, dr, ready doesn't like commit and I'm like it's really hard, like when I don't have data, to say, yeah, 100 right thing to do yeah, but that that really, I mean that's, that's medicine, right, it's just, uh, the the practice of medicine.
Dr. Michael Kentris:It's because, yes, we have all these big highfalutin studies, but when you try and break them down to an individual, sometimes it doesn't always work the best yes, I totally agree so you know we've we've talked a little bit about kind of like eeg training yes, I totally agree is when we have these kids who grow up and they start to age out of the child neurology clinics.
Dr. Michael Kentris:And obviously a lot of kids with epilepsy they do grow up, they reach adulthood and then they have to eventually find an adult neurologist, which, let's just say, I'm aware that there is an ethos difference in terms of the amount of, let's just say, white glove service that can sometimes be found. And what do you find are the most helpful things If you're going to say, talking to a family or even to an adult neurologist who's getting one of these people you know, children with epilepsy who are kind of like hitting the 18, you know plus mark, and they're coming to your clinic. What are the considerations, especially for the more, let's just say, not straightforward, you know, not like juvenile myoclonic epilepsy, people with intellectual disability, etc.
Dr. Shilpa Reddy:And we know that based on you know, studies, papers, literature that's come out that that transition between pediatric and adult for medically complex patients not just epilepsy, but you know, in all realms is super, super important. And when it's not done well, we see a lot of patients lost to follow-up, we see more ER visits, we see more just like healthcare expenses, all that depression, quality of life suffers.
Dr. Shilpa Reddy:So one I'm really glad you're asking that question because we need to have awareness that this is a problem not just here across the world, but there are some clinics and institutions that are doing a really good job with the institution, with transition clinics. And what a transition clinic includes is obviously that support from the adult neurologist or evolutologist as well as the pediatric side, but it also that support from the adult neurologist or optologist as well as the pediatric side, but it also gives support from, like, a social work perspective or case management, somebody that is there to figure out. Okay, how do I make that insurance transition, as some of these kids, most of these kids have conservatorship um, from their parents. They need adult, you know guardians to take care of them. They don don't have decision-making capabilities, and then also a psychologist, because there's a lot of probably emotional stress and trauma from the caregiver side and, if the patient is aware enough, that might be hard for the patient as well. So, having multidisciplinary support when you make that transition, it's also kind of a physical challenge to get all these people in one space. It's also, just to be totally frank, there's going to be billing and financial issues that come from sharing the resources, so to speak. So, as much as I say it's really, really important to do this. It's not that easy to actually execute, but the first step is talking about it. So I'm glad you brought it up.
Dr. Shilpa Reddy:And what I do personally is I start prepping patients when they are 15, 16 years old and start saying like, okay, you know, as you get to that 18, 19, 20 years old, we need to start thinking about one. What does life look like? So? Are they independent? Are they going to go to college? How are you going to learn to take your meds and get follow-up appointments? Are you going to be safe with sleeping, safe with alcohol and drug exposure, sleep deprivation All these things are super important when you're not living under the roof of adults that are telling you what to do.
Dr. Shilpa Reddy:And then, for patients that are not independent in terms of daily activities, what does life look like for the caregivers? You know they're not going to be in school every day, so are they going to be in a group home? Are they going to be in a like a work program? You know things like that. So I start asking those questions around, like, like I said, 16 ish. And then, when they're 17, 18, and they cross that technically being an adult age, I always give one or two visits of okay. At the next visit we're going to try to identify somebody that you want to see in adult neurology, whether that's in the same institution or finding somebody closer to home. So at least it gets them thinking, without dropping the surprise on them and saying okay, you're 18, bye, because that can lead to a lot of emotional stress and like tension and, as you kind of hinted at some of these families, because they've had epilepsy for a very long time, they become attached to that specific provider.
Dr. Shilpa Reddy:And so it's a relation, it's hard to say goodbye on both sides, like for us and for them. So I think just trying to like bring it up slowly and gently at a few different points Good. I always find that if I find, if I can refer to a provider that I can what's the word, um, that I, yeah, vouch for exactly that I know personally then I can say, oh, you should see, dr, so-and-so, they're going to be really great with your daughter or your son because they're kind or they're funny or they're super smart or they're gentle, like whatever it is that I think that patient needs is. While I'll try to, I'll try to like connect them with a provider that's going to be a good fit. Does that make sense?
Dr. Michael Kentris:Yeah, a personal recommendation.
Dr. Shilpa Reddy:Yeah. No, that's excellent, everybody's for everybody, you know we all have different.
Dr. Michael Kentris:This is very true.
Dr. Shilpa Reddy:And then I guess I do want to hint on this because we're kind of tying together education People always ask when they're applying for this fellowship, like I'm a pediatric neurologist or pediatric epileptologist, how do I run the adult and pediatric epilepsy program? Because I kind of live in both worlds and I always say, like epilepsy is a lifelong journey, it's a lifelong story. So if you see a patient that's 35 and they have temporal lobe epilepsy from like a structural cause or maybe even not a structural cause, more than likely they probably started having seizures when they were younger, maybe a teenager or a kid, when they had febrile seizures. So you need to understand their journey of how they got there. On our side, as a pediatrician, I need to understand that when I have a five, six, seven, eight-year-old that has intractable epilepsy, I want to be able to treat that now so that when they are 35, what does their life look like if they continue to have epilepsy, with this frequent of seizures? Or can we do something now?
Dr. Shilpa Reddy:Or let's say you are trying to counsel a 17-year-old about a new diagnosis. Are they going to outgrow this in two years, five years, ten years? If I don't understand the life cycle of a particular diagnosis. I can't tell them like, oh, you can have kids or you're never going to work. I need to understand it right. So when we train both adult and pediatric neurologists, epileptologists, they get exposure in both worlds, both adult and pediatric neurologists, epileptologists. They get exposure in both worlds, not so much that they're going to be seeing these patients every day, but just understanding where they came from or where they're going.
Dr. Michael Kentris:Right, getting the big picture. To be honest, I have found that super helpful in my own practice as well. We don't have as much generalized epilepsy or epileptic encephalopathies in the adult population, but you know it's not unheard of that we get. You know someone in their 40s or 50s who has Lennox-Gastaut. You know went through the whole cycle with West syndrome when they were younger, etc. And so they come in on, you know, a fairly complicated regimen of anti-seizure medications which can be a little intimidating if you're unfamiliar with all the interactions and the levels and all the pharmacology in play.
Dr. Michael Kentris:So I would say there's the whole spectrum the diagnostic aspects, with reading the EEGs and being familiar with what all the squiggly lines mean, and then knowing the existence of the syndromes and then knowing the pharmacology for the treatments and then the surgical treatments that we, you know we didn't hit on a lot. Just that's an entire conversation too. But what are the options? Right? And I think this is just the tip of the iceberg. We're talking just about pediatric epilepsy, but this applies to all the subspecialties within neurology. There are all of these things beyond even what we know, that all of these, our subspecialty colleagues in each of these fields are experts within, and it is one of those things where medicine at large and neurology and then each subspecialty of neurology is expanding at such a rapid rate it's nigh impossible to keep up on the latest advances in every field. It's a very Herculean task.
Dr. Shilpa Reddy:Absolutely. It kind of takes me back to one of my first rotations as a medical student. I was on a rotation and the clerkship director said the biggest mistake you can make as a doctor is not asking for help when you need it. And I think that kind of touches on what you're saying is if I don't know these subspecialties exist, if I don't know this treatment exists, I don't have to be able to do it. I just need to know that I need to call somebody else.
Dr. Michael Kentris:Right, yeah, and I think that's that's one of the things I love the most about about the neurology community is that everyone is so welcoming. And you know, it's so great to be able to reach out to people who helped me become the neurologist I am and, uh, other people who I've interacted with over the years or who I've even helped train early in the residency and then they went on and did different specialty. I can call up my former residents and ask them like, hey, you're a neuromuscular guy now. Uh, what do you think about this? Does this sound like something? And I get advice myself. Yes, so it's very good to have this network, this community of people that you can, like I said, you can trust who's a clinical acumen that you helped form, you've seen in action. You know these people are reliable. It's such an invaluable resource. It's just being able to reach out to people and ask their opinions.
Dr. Shilpa Reddy:I couldn't agree more.
Dr. Michael Kentris:Any final thoughts that you would have for people who might be maybe considering child neurology or even pediatric epilepsy as a future specialty?
Dr. Shilpa Reddy:I would say for child neurology, just know that there's a lot of different options and spaces that you can be in, even after doing residency training, and the same goes for being a pediatric epileptologist. We train two different types of epileptologists. One is they want to do surgical epilepsy stereo EEG device, implants, all that kind of stuff and then we also train equally as many people that go into a practice where they are not doing surgery and they're not at a level four epilepsy center but they are providing really good care for their patients because they know, of course you know, like, how to read their EGs and interpret them, but they know when to refer for surgical management. And I think we need just more child neurologists, more epilogue psychologists, we need more of everybody so that we can reach as many patients as possible.
Dr. Michael Kentris:Absolutely. If people want to find out more about your work or your work at Vanderbilt, where should they look? Should they track you down online? How would you recommend getting in touch?
Dr. Shilpa Reddy:Don't come to my house. Should they track you down online, how would you recommend getting in touch? Don't come to my house.
Dr. Michael Kentris:But so we have. We have a ex, the old Twitter account, yes, formerly known as Twitter yes, Formerly known as Twitter.
Dr. Shilpa Reddy:It's at V-U-M-C, p-e-d, e-p-i-l-e-p-s-y, at V-U-M-C. Peedepilepsy is our handle. I'm the one that runs the account, so feel free to reach out to me or DM me. That way, you know our our. We have a website for the fellowship pages at Vanderbilt on the neurology website yeah, that sounds great.
Dr. Shilpa Reddy:I was like I don't know the link or anything, but I think if you are, if you're specifically interested in, you know, coming to vanderbilt, just like learning about what I do, then I think dming me on x uh would probably be the I know it just doesn't sound right in the mouth, does it?
Dr. Shilpa Reddy:yeah, it doesn't, it doesn't roll off the tongue, but, um, yeah, I think I've connected with a few people that way and I think it's nice to kind of start the dialogue and then we can email or chat on the phone, whatever people are interested in.
Dr. Michael Kentris:Awesome. Thank you so much. You can also find me on X I'm at Dr Kentris D-R-K-E-N-T-R-I-S, or you can follow the Neurotransmitters at neuro underscore podcast and check out our stuff on the website at the neurotransmitterscom. Dr Reddy, thank you again. I really appreciate you taking the time to talk with us today.
Dr. Shilpa Reddy:Thank you, Michael.
