Frank DiPaola, MD, is a pediatric hepatologist with a primary focus on liver transplantation. Referring providers around Virginia consult with him when they see children with early signs of liver disease, like jaundice. Earlier treatment results in better outcomes, so DiPaola works to be as open and available in his communications as possible.
The relationship between patients, primary care providers, and hepatologists is a long-lasting one. Children waiting on a liver transplant need the highest quality of care during that time to ensure a positive transplantation outcome. And post-transplant, they’ll require ongoing follow-up to catch any issues early.
We asked DiPaola how he approaches forming these relationships, and what he wishes referring providers knew about pediatric liver health and working with the UVA Health Children’s Hepatology team.
What made you decide to focus on pediatric liver transplantation, and what’s your favorite thing about practicing in this field?
I decided upon pediatric hepatology and liver transplantation as my specialty during my time as a clinical fellow at Cincinnati Children's.
The liver is a fascinating organ. Also, I really loved the unique and long-lasting connection that gets established between pediatric hepatologists and families.
What I love the most is interacting with children and their families and helping to bring them clarity and effective therapies. I also very much enjoy working with all of my team members and discussing complex cases with referring physicians.
What are some ways you build relationships with pediatricians?
The 1st thing that I would say is that we feel very strongly about making communication with us as easy as possible. Since I joined the faculty here at UVA Health Children’s, we’ve been establishing and strengthening connections with groups across the commonwealth.
I offer my personal cell phone number to every potential referring provider I meet, and I spend a good amount of my time talking and interacting with doctors from across Virginia about cases they're seeing. We also work to make sure that making referrals is simple; it is as simple as reaching out to us. And then, we'll help make sure that kids get into our clinic soon.
Are there early risk factors or early detection methodologies that can help referring providers get patients to you earlier?
I think that keeping in mind certain important principles can help make sure that patients who need a specialized liver center are seen as soon as possible. For example, biliary atresia is the most common disorder leading to pediatric liver transplantation. This disorder presents in early infancy as jaundice.
It is very important for primary care doctors to make sure to fractionate the bilirubin by 2 weeks of life in any jaundiced infant. If the conjugated or direct bilirubin is elevated, then that infant should be assessed by a pediatric hepatologist as soon as possible to make sure the etiology is understood. Biliary atresia treatment is most effective when done earlier rather than later.
Another important principle is to characterize liver function by assessing PT/INR in any child presenting with evidence of liver injury, whether on exam, like jaundice, or by labs, like elevated aminotransferases.
Children with liver failure, or liver injury with coagulopathy not responsive to vitamin K supplementation, are sometimes reasonably well-appearing on first presentation, and liver failure might be missed if the PT/INR is not assessed. These children shouldn’t be sent home; rather, they should be admitted and receive urgent attention, and often need to be transferred to a pediatric liver transplant center. Time is always of the essence when dealing with liver failure.
What’s something about pediatric hepatology you wish every referring provider knew?
That I love practicing as a hepatologist and that I am always happy to talk and help. I also frequently give talks to groups to help with the understanding of the principles of pediatric hepatology for primary care providers and for general pediatric gastroenterologists. I am always happy to meet with groups.
Should pediatric providers talk to their patients more about liver health, and how should these conversations come up?
Yes, of course. We speak with all of our patients about what I call “liver protectiveness,” which involves a number of recommendations. This includes eating in generally healthy ways and regular exercise to mitigate risk for a very common liver condition we call MASLD, or metabolic dysfunction associated steatotic liver disease. This is one of several possible manifestations of metabolic syndrome.
As pediatric providers discuss health maintenance topics such as diet and exercise, they might consider a mention of the benefits to liver health. Another example would be the importance of vaccines, including vaccination against hepatitis A and B. We do see outbreaks occasionally of hepatitis A, and the hepatitis A vaccine is safe and very effective.
Encouraging patients to prudently use medications, including prescriptions, over-the-counter medicines, and herbal and dietary supplements, is something that can be beneficial. All medications can have side effects, and some can cause liver injury. In my practice, this means simply emphasizing that medications should have an appropriate indication or otherwise should not be used.
What’s your approach to working with referring providers?
Referring providers are critical links between children and getting them the care they need. Our job is to:
- Make sure that practices across Virginia know and understand the services we provide to children and families
- Always be available for consultation
- Make it easy for patients to access our services in the form that is best for them, whether virtually or in clinic
- Provide excellent communication back to referring providers
My job is to support the referring provider as they continue to follow the patient or provide more direct care if that best suits the referring provider. Our level of support is always determined within a framework of ongoing communication and collaborative spirit.
How do you handle meeting a newly referred patient?
We reach out personally to the patient and their family through our coordinator team, or for more urgent or emergent transfers, I might personally call the family myself. This gives us an opportunity to orient the family to our team and make sure they understand how to get to our clinic and a number to call for quick assistance if they need help before the visit. We maintain that level of communication throughout our relationship with patients and their families.
We want children and families to know we are absolutely committed to them. Once we meet, my view is we need to communicate our recommendations clearly and provide appropriate, high-quality care at all times. It is equally important that we listen to our patients and families, are always available and responsive to their questions and concerns, and empower them to participate fully with our team in developing their plan of care.
What’s one thing UVA Health Children’s can offer these patients that you think makes their experience better?
Excellent communication and the highest quality care, including cutting-edge liver surgical care.