Team-Based EPI Care: Why Multidisciplinary Coordination Matters

This episode broadens the lens from individual clinical decisions to the systems and teams required to deliver high-quality EPI care. Dr. Kaul opens by acknowledging that providers do not work in silos—they operate within complex health systems, alongside multiple specialties, and across different care settings.

Sarah Enslin provides a compelling framework: at the most basic level, an EPI patient interacts with primary care, GI, and nutrition—already three providers. In chronic pancreatitis, over 80% of patients experience pain during their disease course, potentially adding pain specialists or palliative care. In pancreatic cancer, the team expands further to include surgical, medical, and radiation oncology. Managing EPI effectively requires all of these stakeholders to be aligned.

Jennifer Geremia highlights the PCP's role in health maintenance: bone density scans, annual fat-soluble vitamin checks, and other monitoring tasks are well within PCP scope and can be proactively embedded in notes and patient instructions to coordinate care efficiently. This minimizes redundant specialist visits while keeping patients appropriately monitored.

Dr. Kaul reflects on the unique reality of specialty clinic schedules—patients may only be seen every 3–6 months at a referral center, making the PCP's more frequent contact invaluable as a touchpoint for day-to-day management continuity. He also notes that combining multiple services results in patients being seen multiple times per year across their care team—especially important during the early stages of a new diagnosis when the path is still unclear and patients need more support.

In the next episode, "Bridging the Gaps: Care Transitions and Breakdowns in EPI," the panel examines where the care continuum most commonly breaks down for EPI patients and how to design better handoffs across care settings.