Combined Clinics for PsA Save

Much has changed in the management of psoriatic disease since the first prospective trial of etanercept, published in 2000. In retrospect, and in light of all that we’ve learned since, it seems almost funny that the FDA raised concerns at the time that etanercept might be ineffective for skin disease, prompting a study design that allowed for patients taking methotrexate to remain on background methotrexate during the trial. We now have more than a dozen biologic and targeted small molecule therapies for psoriatic disease, and many are even more effective for the skin than for the joints. Finding the right treatment for a patient now means considering all of the skin and musculoskeletal aspects of disease, an approach that has been an important part of each of the iterations of the GRAPPA guidelines for therapy.

Recognizing the importance of addressing all aspects of disease, we started our joint rheum-derm psoriatic disease clinic at Northwestern shortly after I arrived at the institution, and it has been a tremendous success.

Rheumatologists and dermatologists have long worked together in the management of our patients, but the idea of directly collaborating in a single clinic space was novel at the time. Over the years, it has become my favorite clinic session of the week. What I’ve particularly enjoyed, and I believe our patients do as well, is that we’ve been able to truly integrate the concept of shared decision making. Treatment decisions become a three-way discussion between myself, the dermatologist, and the patient, and we’re able to do this in real time. Patients have really appreciated the fact that they don’t have to function as the go between, shuttling messages back and forth between physicians. We’ve been able to have very detailed conversations about which aspects of disease are most important to each patient, and focus our approach in response.

As the concept of Treat to Target has moved into psoriatic arthritis, there’s been an emphasis on including all aspects of disease in the target, but patients frequently have their own opinions about which symptoms have the greatest impact on their lives, and I think it’s important to respect that. These are issues that definitely become clear as the three of us are talking. It’s also been a great opportunity for me to learn more about the relative benefits of each treatment for different aspects of disease, and to apply this in a way that leads to better outcomes.

I realize that the chance to run a truly combined clinic is a luxury that I’m allowed by being in an academic center with a shared infrastructure and EMR. Even with that, there are challenges that we still have to deal with, as rheumatology clinics and dermatology clinics are run very differently. The biggest issue has been the time allotted for each visit. The dermatologist that I work with has had to get used to a reduced volume relative to his other clinics, as we cannot effectively manage complicated patients in a 10 minute visit. I, on the other hand, have had to learn how to evaluate a new patient in just 15 or 20 minutes, which is far less time than I would have thought possible. It’s forced me to become very focused, which I’ve actually found to be a very useful skill in all of my patient visits. I can see that a physically combined clinic might be very challenging in a private practice setting, but I think there could be virtual ways of accomplishing something similar.

As more medical care is being delivered in large, multispecialty settings, I suspect there are ways to structure a clinic similarly to what we’ve done in an academic setting. This shared approach has been incredibly rewarding for both our patients and for us as providers, and I’d strongly encourage anyone involved in the management of psoriatic disease to explore options that could make this possible.