Tricks of the Trade – Clinic Advice from APPs Save

December 2025 is focused on advanced practice providers, their impact, education and priorities.  In seeking and soliciting the help and advice of leaders in the rheumatology APP world, I have been impressed by APP pride, dedication and passion for what they do.  As such, this month was meant to shine a light on many talented and dedicated APPs working in rheumatology.

To further exemplify APP insights and dedication, I emailed many and asked for them to share their pearls, advice and/or rules in the care of rheumatic patients.  The returns on this request are highly impressive, and are further evidence as to why you should work with as many APPs (nurse practitioners or physician associates) as possible.

Below are a collection of APP pearls, if not tricks of the trade, that we should all consider or live up to.

Declarations

Kayla Carlucci, FNP-BC

• This role is both challenging and incredibly rewarding. My love for rheumatology—and for the APP role—continues to grow every day. I truly enjoy building trusting, longitudinal relationships with patients, staff, and my supervising physician.
• Never stop learning—rheumatology is full of surprises.

Megan Lane, AGPCNP-BC (Rheumatology for the last 12 years and loving it)

• Do more listening than talking
• Do what you say you are going to do
• APPs in rheumatology (need to) come together with groups like RhAPP and RNS to support each other and our clinical practices.

Lisa Carnago, PhD, MSN, BSN, RN, FNP-C

• How rheumatologists (should) think about rheumatology APPs: Rheumatology is a team sport where the rheumatology APP is the bridge between, and to, support access, quality, and timely patient-centered care.
• For leadership and clinicians: Start as you intend to go on: Clarify the care model of care up front, patients and other clinicians in the team thrive when roles and expectations for care are transparent.

Questions to Ask

Emma Bavage NP

• Have you had your annual CV check with your primary health care provider?
• Have you had your annual skin check?
• Question contraception and family planning for all of child bearing age
• Document smoking and alcohol
• If their uric acid levels are not changing, check their dispensing history for urate lowering therapy.
• Create rapport with patients by asking them questions – e.g., about their recent trip or family - grand-daughters ballet class

Pearls

Elizabeth Kirchner, CNP, RN-BC

• Only order labs that are really necessary., and only at intervals that are clinically relevant.

Christine Stamatos, NP, DNP, RN

• You must assess sleep and mood- without this even if you control all inflammation, you will not control pain and fatigue!

Rick Pope MPAS, PA-C (emeritus)

• Tell the staff to treat the PA as you would treat the rheumatologist
• The relationship between PA and MD (should be very tight) will ensure PA retention

Caitlin Hill, FNP

• Patients with rheumatic disease also get common conditions - do not attribute everything to autoimmunity, work up normally as you would for all patients, but keep their condition in mind.
• Listen to your patient.  The history can be the most important part of the consult.
• A normal sed rate and negative CRP do not rule out inflammatory disease. Helpful when they make them, can help to monitor, but not required for diagnosis.

Madison Chastain, CRNP

• Do not order a test if you do not know how to interpret the results whether normal or abnormal.
• Never treat a number. Always treat the patient in front of you.
• Always examine your patient. You cannot adequately assess the joints without laying your hands on the patient.

Emma Bavage, NP

• Point out to every patient with gout that poorly controlled gout will increase their risk of CV events and mortality.
• For fibromyalgia, schedule patients for at least 45minutes and it always takes longer than initially planned for.  I normally spend the first consult listening rather than talking.

Lindsay Tom, PA-C

• When seeing a new patient, never assume that their preconceived or prior diagnosis is the only rheumatology condition that they have.
• Make it a habit to personally review radiology images and not just read the written radiology report.
• Never skip a physical exam. Even if a patient states that they are currently asymptomatic.

Natalie Lane, FNP-C

• Always listen to your patient. Allow them to express their concerns and address any questions they have.
• Patients need to understand their care plan and the ‘why’ behind it is so important. It helps them adhere to their regimen and communicate their … issues
• Get to know your patients and any barriers they have that may impact their healthcare

Chelsea Austen, PA-C

• Always end an appointment with a summary of what the plan is, i.e. “Today we are going to check your labs, increase your methotrexate to 8 tabs weekly, and start PT for your knee pain. Anything else I can do for you?”
• Start an appointment with an open-ended question “(Nurse) told me you are having increased pain in your hands. Can you tell me more about what’s going on with that?”

Claudia Rivera-Salas, NP

• Steroids are not a long-term plan.
• One visit cannot fix everything.
• Toenail fungus and psoriasis look very similar.
• Make sure to differentiate between fibromyalgia trigger points and points of enthesitis.
• Lupus can cause a lot of symptoms, but it doesn't cause everything.
• Many patients like to be able to control something in their disease - teach them to eat an anti- inflammatory diet.
• Normal inflammatory markers do not exclude inflammatory disease.
• Repeat key points often.
• Not all non-adherence is non-compliance.

Advice

April Woodrow, APRN, ANP-BC

• …bear with me and please remember to give all of the meds we try at least 8-12 weeks to work
• Patients on a biologic/specialty meds…are given a biologic handout sheet with all of our meds and the 1-800 numbers
• Bring a friend/loved one (to clinic). 4 ears are better than 2 especially in the beginning
• All of my patients fill out a RAPID 3 prior to being put in a room
• When I’m explaining treatment options, I say “hey you are the captain of this ship, I’m your co-captain. I help to guide you along this journey… (I can help you) avoid that Hurricane.”

Ben Smith, DMSc, PA-C

• Always ask a patient to remove their shoes and socks as part of the physical examination when evaluating joint pain.
• Ensure a patient understands the weekly dosing instructions for methotrexate.  

Lisa Carnago, PhD, MSN, BSN, RN, FNP-C

• My mandatory ROS includes: unexplained weight loss, lymphadenopathy, (recent infections, fevers, cough), chest pain, shortness of breath, rashes, then any diagnosis based ROS (i.e. SLE: Raynaud’s, mouth/nose ulcers, sun-sensitive rashes, hair loss, fatigue, joint pain (if not already covered).
• Addressing a rheumatology patient’s pain may very well be your job, as up to 50% of people with RD have chronic pain.

Miguel Rodriguez, ANP

• Pain, swelling and morning stiffness -- If these 3 things worsen or last over 48 to 72 hours you should probably reach out to our clinic
• Explaining Autoimmune disease - the difference between an overreactive immune system vs. a weakened immune system
• Explaining the positive ANA: I explain it as a check engine light coming on. Needs further work up to ensure everything is working properly and not a lupus diagnosis.
• Explain age-related (OA) arthritis and inflammatory. OA is worse at night and gets better with rest vs inflammatory that is worse in the morning and improves with movement

Jeannette Hart PA-C MCHS MHA

• Do not skimp on the physical exam. Scalp, heart, lungs, feet. A thorough exam not only helps objectify your clinical gestalt, but may uncover a finding that truly saves a patient’s life.
• Learn to read your labs—thoughtfully. When there is a discrepancy between CRP and ESR, turn your eye to albumin and total protein. Consider an SPEP. Patterns matter.
• It’s okay not to “fix” the complaint right away. Validate the patient, then watch and wait when appropriate. The urge to intervene quickly without confidence can be dangerous. See the patient back, keep listening, and continue good history-taking.

Laura Liston, FNP-C, CCD

• Trust your gut – if something goes beyond your knowledge and experience, bring in your attending physician for support. I have learned so much from diagnosis-based my physicians – from evaluation (physical exam, interview questions, labs and imaging) through care planning (medication choices, referrals, etc.)

Shari Fechner, FNP

• I always type out medication titration or tapering instructions and go over it with the patient to make sure they understand. Give them a copy to take home, especially with steroids and methotrexate.

Julia M. Swafford, PA-C, DFAAPA

• Always end the visit with "Any other questions or concerns?"
• Begin with, “What is your goal for today's visit?”
• Always get an accurate height if possible. Patients use their height from when they are a young adult -- we can miss significant height loss.
• BP in both arms in all patients with GCA/PMR.
• If a patient asks a question and you don't know the answer, it is ok to say I don't know …. Patients appreciate honesty and our willingness to research their questions.