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Podcast
[00:00:12 - 00:00:37] Dr. Vleugels Welcome to the Rheum-Derm Co-Management of The Patient Podcast, brought to you by Bristol Myers Squibb. My name is Ruth Ann Vleugels, I'm a professor and distinguished chair of dermatology at Brigham and Women's Hospital and Harvard Medical School, where I lead the autoimmune skin disease program in the connective tissue disease clinics. And I'm extremely passionate about this area of derm-rheum. I'm the immediate past president of the Rheumatologic Dermatology Society. I'm excited to be here today with Doctor Gordon Lam.
[00:00:37 - 00:01:50] Dr. Lam Thank you. And Ruth Ann let me just start by saying how excited I am to be here and honored to be here with you. I'm Gordon Lam, I'm the medical director of clinical research with the Arthritis & Osteoporosis Consultants of the Carolinas, and a clinical affiliate with Atrium Health, Wake Forest Baptist, part of the Wake Forest University School of Medicine in Charlotte, North Carolina.
Ruth Ann, in recent years, we've seen increasing evidence that rheumatology – dermatology co-management is associated with improved care and decreased time to diagnosis in psoriatic disease. In this podcast, we'll discuss key aspects of the rheum-derm co-management and its implications in clinical practice. Now, as you know, many patients with psoriatic arthritis or PsA are often seen by a dermatologist first because of their skin disease. And as such as a dermatologist, you play a really crucial role in identifying potential psoriatic arthritis by screening for joint pain or other symptoms and then referring to a rheumatologist if necessary. So, tell me, what does that look like to you? How do you do that? What signs are you looking for? Do you use any tools to help assist? And then when do you refer your patient to a rheumatologist?
[00:01:50 - 00:04:42] Dr. Vleugels Gordon, those are all fantastic questions. And I think something that we really want to remind our listeners is that more than 80% of patients who eventually develop psoriatic arthritis develop it after their diagnosis of psoriasis. So, it's super important that in the derm clinic we're on the lookout for these patients. And we really are thinking about screening them early to give them a better chance of less disability from their arthritis.
I think one of the really important studies that I'll often mention is that we know that when we look at well over 1000 psoriasis patients and we think about those that later develop involvement of their joints, we know that there are high risk features that we can actually see on exam in the clinic and the things that I would want all my derm colleagues to realize, and of course, my rheumatology colleagues, as well, is that the scalp involvement, nail involvement, and also sort of intergluteal perianal involvement all have an increased risk of arthritis. And in addition, people with more extensive disease, in particular those with over three sites of involvement, also have an increased risk of arthritis. These are things we're going to be looking for in the clinic. And although we want to screen all patients for involvement of their joints, these are patients in which you're going to be particularly concerned. In order to address your second question, there's screening tools we can use. And these are particularly used in dermatology clinics or primary care clinics.
I'm going to first walk you through the two screening tools that are most often used. The first is the Psoriasis Epidemiology Screening tool, often referred to as PEST. And this is just five simple questions, and if the patient has three out of five positives, then they are likely to have a diagnosis of psoriatic arthritis. And the simple way to think about this is one is actually asking the patient if they have been diagnosed with arthritis, and then we ask them if they've had a swollen digit. Thinking about our dactylitis patients. We ask them about heel pain, if they have had nail pits or holes, and then if they've had joint swelling. So, they are very, very simple questions.
Another one we often use is our Psoriatic Arthritis Screening and Evaluation Questionnaire. And really when we do this, we're trying to think about who we need to get into rheumatology quickly. This was actually developed at my hospital, Brigham and Women's Hospital, by many of our colleagues and our Psoriasis Joint Rheumatology Dermatology clinic. If you don't have time to do these screening tools, I just want you to think about the questions I just mentioned and what you may want to ask your patient in clinic. So common ones would be do you have any morning stiffness? Do you have any back pain? These are really two crucial questions. I think if you can add in the heel pain and look at their nails, ask about swollen digits or inflamed joints. This really gets you to where you need to be and really, you're going to know which of those patients you want to get into your rheumatology colleagues right away. Gordon how do you think we're doing with that?
[00:04:42 - 00:06:30] Dr. Lam You bring up really important points and some of the points that I think are very important from a rheumatologist's perspective. So as part of the rheum boards, one of the questions is the percentage of patients who first present with psoriasis and then psoriatic arthritis. And as you mentioned, the majority of patients will develop the arthritic component after the psoriasis component. But the question is which of those patients are at higher risk to develop the arthritic component? So, you mentioned some really good pearls for rheumatology colleagues. For example, the scalp involvement, the nail dystrophy, the intergluteal/perianal lesions and then the three or more affected sites. That's really good for us to know as well. So, we have a lot of learning points from you and dermatology colleagues.
And I think the screening tools that you folks use are fantastic. But I'll tell you, to make it easy for our community dermatologists, we simply tell them, if you have a patient who has psoriasis and if they're complaining of any joint pain, just feel free to refer them over. And the reason is because not only can we rule in psoriatic arthritis, but we can also rule out other conditions. So, for example, let's say they have psoriasis and just osteoarthritis or psoriasis and fibromyalgia. And it's not truly inflammatory psoriatic arthritis. I think that's still a very valid reason for referral. One of my really good friends and colleagues, Phil Mease from the Seattle area did a trial back in 2013, I think he called it The PREPARE Trial and all he did was simply he and his colleagues follow dermatologists in their clinics, and every time they saw a patient with psoriasis, they would then pull them aside and see if they had psoriatic arthritis. And about 30% of patients who had psoriasis had psoriatic arthritis. So, I think that it's very valid and helpful to feel free to just call your local friendly rheumatologist and to have them collaborate and care.
[00:06:30 - 00:07:32] Dr. Vleugels Gordon, I love that. That reminded me of an important point, which is that from our studies, we know that a third of our psoriasis patients actually have a diagnostic delay of over five years to get their arthritis diagnosis, which is really a shame, right? Because we know that there's some guidelines that suggest that the maximum wait time should be six weeks. And so, we're really having this gap in our ability to diagnose patients quickly. And we really want to engage our rheumatology colleagues early to make sure we're not missing this diagnosis.
So, Gordon, we are both well aware that when we can diagnose these patients with arthritis early, that we can prevent or inhibit joint damage. We know that when we look at patients before and after implementation of a specialized psoriasis and psoriatic arthritis center, we know that we have a decreased delay in diagnosis in these patients when we're working collaboratively. I'm sure our audience would love to hear about your experience as a rheumatologist, communicating and collaborating with dermatologists for more integrated treatment approaches.
[00:07:32 - 00:10:06] Dr. Lam Yeah, absolutely. And in fact, I feel very invested in this. When I was at Hopkins in the mid to late 2000s, we created some of the first interdisciplinary clinics across the various rheumatic diseases whether it was myositis, lupus, Sjögren's syndrome, where we integrated rheumatologists, dermatologists, neurologists, pulmonologists, etc. and it not only led to better outcomes, but it was actually just more fun, I'll be honest with you.
So you mentioned that rheumatology-dermatology collaborations are associated with increased numbers of patients who are diagnosed with psoriatic arthritis, and diagnosed appropriately and diagnosed earlier. And the key to any disease state is early diagnosis, implementation of appropriate therapy because that can then lead to improved outcomes. But I also state from sort of a broader perspective, you know, shared decision making is always important.
Shared decision making has been a key topic in all of medicine and for a very valid reason. Shared decision making, as you know, is the collaborative process between the patient and his or her provider. Where decisions are made first and foremost based on evidence, but also taking into account other factors: patients' preferences, past experiences, everything from socioeconomic status, religious beliefs, etc. Only by doing that can we come to the best therapy for the patient.
And I was always trained with the mantra, we should always try to find the right medication for the right patient at the right time. When it comes to rheumatology-dermatology collaboration and across the interdisciplinary clinics, I just have this simple thought that two brains are better than one. And when you include the patient, then it's three brains are better than one.
Now there are different models and, Ruth Ann with your academic position I'd really love to hear your thoughts about this, but there are different models as to how to do rheumatology-dermatology clinics. We know that some healthcare centers have dedicated PsA clinics or specialized clinics, where rheumatologists and dermatologists work side by side to manage patients.
There are specific conferences, supported by associations like GRAPPA. And I have to say, GRAPPA is one of my favorite organizations, because not only does it bring together rheumatologists and dermatologists, but it also includes patients and then, of course, the study that you mentioned, which shows that having these combined clinics leads to reduced waiting times to referral to rheumatologists, time to diagnosis, improved outcomes. But the question is, how do we do this? I'd be interested to see how you do it there at Harvard. And then, some of the experiences that I've had outside of it and then other models that I've heard from colleagues in the community.
[00:10:06 - 00:11:08] Dr. Vleugels Yeah. So, we're very spoiled at Brigham and Harvard because we do have joint clinics, and we also have a separate psoriasis and psoriatic arthritis clinics, where we have dermatologists seeing those patients alone. But in our joint clinics, I think the phenomenal addition is we really get dual training, dual teaching between our dermatologists and our rheumatologist. So, I always love it.
Often a patient will come in, referred from a rheumatologist, and maybe their joints are doing well, but they still have substantial scalp disease. And maybe the scalp isn't a typical part of the exam for our traditional rheumatologist. Or I can teach my rheumatology colleagues, what are the nuances of the nail exam? I think that's really helpful. And then on the flip side, I learned from my rheumatology colleagues every day. So, for example, one of my early pearls I learned was, you know, when you have arthritis at the base of the thumb, that's almost always osteoarthritis. Just pearls that really impact our ability to see patients over time, that we can pass on to our trainees and then regardless of their practice location, can improve the care of patients with psoriasis and psoriatic arthritis moving forward.
[00:11:08 - 00:11:37] Dr. Lam But what does that look like to you? So, I've heard of models where the dermatologist would see the patient first, then the rheumatologist see the patient next. And then they'll both come in and discuss the patient together in front of the patient. I've heard of other models where the patient may have a rheumatology appointment in their clinic, then very shortly thereafter, like that same day or the next day, they'll have an appointment with dermatologists in his or her office. And then the dermatologist rheumatologist will then meet afterward or communicate independently. So how does it work there at Brigham?
[00:11:37 - 00:12:37] Dr. Vleugels So, Gordon, great question. And we are sort of an embarrassment of riches because we actually have 14 derm-rheum clinics a week in our department. And so, we actually have both models. We have models where the person sees rheum and derm on the same day, but not in the same exact clinic location. And they make maybe a 15-minute walk between the two, and then we communicate with each other after, which I think is less ideal but still works well. As you highlighted, as long as we're in close communication, our patients still have better outcomes.
And then we have other sessions where we actually have a rheum trainee and a derm trainee go in first, and then they actually come out and they present to both the dermatology and the rheumatology attending. We all go in together, do teaching, come up with the best treatment approach for the patient, and it's all done simultaneously. We have both of those models. And I do think there's advantages and disadvantages to both. But as you highlighted earlier in the podcast, the most important point is just regular, frequent communication between that dermatologist and rheumatologist to get the best outcome for the patients.
[00:12:37 - 00:15:12] Dr. Lam I absolutely agree the consistent communication, as you mentioned, is beneficial to monitor treatment effectiveness, to adjust treatment strategies as needed, to ensure coordinated care, and to lead to improve outcomes. But I think the reason why I'm asking is because from the perspective of our colleagues in the community, they're probably wondering, well, I'm not an academic medical center, so how do we make this work?
And in talking with some of my colleagues across the country, the interest and the demand and the excitement for interdisciplinary clinics is very great. Everyone will agree that that's a great idea. But the question is, how do we make this work in the real world?
When I was in the hospital, it was easy because we had a set-up very similar to yours. When they moved our office in a building that was outside of the hospital, we arranged that so that my office was right next door to dermatologist office, so patients could literally shuttle back and forth, but I realized that that may not be realistic or practical. What people have mentioned is, they may coordinate a half day a week where the dermatologist comes to the rheumatologist office and they see patients scheduled specifically for the question of psoriatic arthritis, or vice versa. The rheumatologist goes to the dermatology office for half a day, and then they could do it sort of remotely. We learn how to do virtual medicine very proficiently and fluently, where the patient can see the dermatologist, rheumatologist, asynchronously and then the two can then meet virtually or by phone, or discussion. Now the communication can take place in many different formats. It could be something as simple as sharing notes. It could be something as simple as portal messages. But what I really recommend, I'm kind of old school, just to show my age, but I think nothing can beat a phone call.Just pick up the phone, and you can even schedule a specific time of the week. And then just to talk about patients. And that way if you're doing it asynchronously, you can go through the chart of patients. Each can take notes and then you can still have the same benefit.
However, I will mention the benefits of being there in person. You can see different clinical features. You can communicate them. You can point them out. More importantly, we can learn from each other. I can't tell you how much I've learned from my dermatology colleagues, but you can also get real time input from the patient. But at the end of the day, it just makes it that much more gratifying and satisfying for these patients.
So, Ruth Ann, I think we both agree that it's very exciting for the future and potential of improved communication and co-management of these psoriatic arthritis patients by dermatologists and rheumatologists. But give me some of your thoughts about the impact it will have on some of your patients' quality of life.
[00:15:12 - 00:15:52] Dr. Vleugels Yeah, I think that's a fantastic question because that's really what we're striving for, right? We want our patients to leave the office and feel heard, and that we have solved what they came to us to give them help with. So, I think with comprehensive evaluations from both dermatology and rheumatology, we know that we not only have earlier detection of psoriatic arthritis, but we also have a coordinated approach to improve the quality of life of our patients, to ensure we're helping them with both their skin and joint disease.
And I'd love to hear your thoughts about that as well. But clearly, I'm a huge advocate for thinking about patients from a joint dermatology and rheumatology perspective. I really do think it impacts our patients' quality of life for the better.
[00:15:52 - 00:16:56] Dr. Lam Yeah, I agree, and psoriatic arthritis is one of the more complex and heterogeneous diseases in rheumatology. And the manifestations can extend well beyond the joints and the skin. I'll be honest with you, I'm guilty of sometimes just being so hyper focused on the joint that I miss that psoriatic lesion that would be staring a dermatologist like yourself in the face.
But there are other manifestations and comorbidities that may be at play as well. And it always helps to have an extra set of eyes, an extra set of ears, an extra set of hands to evaluate the patient so that we don't miss them. And by better addressing the skin and joint issues and having a more coordinated approach, we can then better address the patient.
And I think by having better disease control, adherence is also really important. We know that patients can only get better if they follow a plan and take a medication, but I also think going back to shared decision making, it helps just to have, someone else who can provide further evidence from which to base therapy and then to have further input as well.
Ruth Ann, any other last thoughts before we close?
[00:16:56 - 00:17:03] Dr. Vleugels I really appreciated all of those recent comments, and I really appreciate this podcast working with you, Gordon. I really enjoyed it a lot.
[00:17:03 - 00:17:59] Dr. Lam Oh, me too. I can't tell you what an honor and pleasure it is to work with you as well. And I also want to take a quick second to thank all of our listeners for taking some time out of your busy schedules to listen as well. I really hope that you found this discussion to be useful, engaging, thought provoking, and informative.
And I really want to emphasize that having specialized dermatologic and rheumatologic patient management may help to more accurately diagnose patients with psoriatic arthritis, to do so in a more timely manner. The hope is that this will then lead to earlier treatments for the patients and better outcomes, and by having a more holistic understanding of patients' individual needs and disease presentation when treatment selections are being made, this may ultimately lead to a better outcome for our patients.
And I always think that in general in life, if you're going to do something, you might as well have fun doing it. So, with that, thank you so much for your time and your attention.
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