APP Podcast Series Part One Save

Hi there. I'm Derek Mueller, PA from Shores Rheumatology in St. Clair Shores, Michigan on behalf of roomnow.com. Today, I'll be talking to you about the creation of advanced practice providers. This includes physician assistants as well as nurse practitioners.

So our story begins in the post World War two era. Around this time, medical sciences exploded. Advances in drug development and surgical therapies are are rapidly evolving around this time. And this really heralds a shift in medicine towards specialization and subspecialization with less emphasis on on the generalist and general internal medicine. Due to rising health care costs, insurance is a, pretty typical benefit offered by employers.

And then the passage of Medicare and Medicaid amendments in 1965 creates an environment where there becomes more patients than physicians. And this is especially true in areas of the country, with poor populations or rural communities. So out of this chasm emerged PAs and NPs. So how did this all pan out? Again, we're in the 1960s at this point in time in the story.

So around this time in the Vietnam War era, we have a plethora of medically trained military servicemen and servicewomen who are, coming out of their service period and looking to transition their health care experience into civilian life. So one pioneer who looked at this situation, seeing the shortage of providers there to pick up the slack, and seeing these servicemen and women fresh out of fresh out of their service and ready to ready to care for people. Doctor. Eugene Stead was an internist. He developed the first PA program at Duke University in 1965.

And this can this group was a mixture of four men, all of which were naval corpsmen. If you're not familiar with that, these are, medics in the navy that provide medical services to the navy and the and the US marines. And and his vision of this PA program was to train a train generalist medical providers who would work in a collaborative collaborative agreement with physicians in order to expand health care across across our country. So this first class of PA school graduates graduated on 08/06/1967, and around this week every year is recognized, as as National PA Week, the the week that October 6, sixth through twelfth lies on every year. So around the same time out West, the nurse practitioner role was being developed.

The first program was created by, Loretta Ford and Doctor. Henry Silver, a pediatrician out West at the University of Colorado. And essentially what their vision was, was in a similar fashion trying to fill these gaps that were being created out of the expansion of medical science and healthcare, and really trying to capitalize on the successes that public health nurses had had in the last fifty to sixty years fighting the scourge of infectious diseases that had ravaged the country for for decades before such as tuberculosis. So so, really, this is where PAs and NPs, had their had their birth. And from the sixties, seventies on, we've seen a a massive explosion of these health care providers working in general medicine as well as specialized fields such as rheumatology, of course.

At this point in time, there's over 300 accredited PA programs in The United States. Most modern PA programs are now a master's level program. They were originally a bachelor's program decades ago. So typically this is a two year track where there is a intense didactic year of medical science training. And then after that, there's a year of clinical work done, akin to the clerkship system in medical school, that involves a variety of medical disciplines that PAs are exposed to.

There are some expanded programs, now that are becoming more common where some PAs may choose to pursue a PhD level of medical science training, and this is typically attracted to, people who go on to work at university centers in a teaching role or, sometimes a requirement for some, corporate level, positions in the pharmaceutical industry. And then looking at the NP side, there are over 500 programs in The United States at this time. Nurse practitioner tracks are either of a master's or a doctorate level track. And there's several specialties or areas of study that each NP program may, have a focus on, and that includes family medicine, gerontology, pediatrics, as well as psych. So we can see over the last, over the last, you know, decades, the way that nurse practitioners and PAs were developed, the thought process is still the same.

We still have plenty of patients who need care that includes rural communities, urban communities, those who have lack of access to specialty care. And there really is no truer situation in the world of rheumatology. So that is it for me. Check out more PA and MP focused content on roomnow.com. Thank you.

Hi there. My name is Rachel Busch Fewer. I am a nurse practitioner practicing out of South Florida in Loxahatchee, Florida in Jupiter. I've been working in rheumatology for nine years, and I will be speaking to you today on apps and the workforce. So let's talk about the workforce shortage.

Really to understand the whole problem, let's start with what happened in 2015. Well, Doctor. Boniferrano in 2015 with a group of others identified there was projected to be a shortage of physicians. Now, one of the ways that we're looking at to combat this is utilizing advanced practice providers to fill in the gap in the meantime. But unfortunately, in this time frame, we're dealing with this increased patient wait time.

So the current problem that we're looking at, patients are waiting one to six months to see a rheumatologist, depending on the areas they are in. And this is really extending the length of diagnosis and treatment for them. When you're looking at apps to fill in the gap, one of the things that may be stopping people is training and retaining apps. It's both a lot of work and time. For physicians, which is part of the problem as well, there is limited availability of fellowships, although ACR has been done doing great in trying to increase that number.

And we're also dealing with the fact that rheumatologists are retiring as well. If we're going to talk about urban versus rural areas, there was a study in this year, my desolate, that looked at urban versus rural utilization of osteoarthritis versus rheumatoid that really was showing that urban areas were utilizing tests more than to keep in mind of the population that we're kind of talking about here, only 5% of rheumatologists are in the rural areas. And to kind of expand on that, 93% of all rural counties had zero adult rheumatologists. And this is in contrast to 48 of the urban counties that had no adult rheumatologists. So you can really see that discrepancy between the urban and rural areas.

Now, the average time from referral to receive rheumatologists is approximately seventy four days. But to what I mentioned before, it can go as far as six months. Now, kind of going into what's going on in the milieu of rheumatologists, APPs, and a workforce issue, they have this increase in rheumatologists and APPs that is being seen. We're also dealing with retiring rheumatologists as well. And back in 2015, about 50% stated they were planning on retiring in the next ten years.

So we are in 2025. There is an increasing demand for rheumatology across the patient population as well that is adding into this system. And patients, at least in the rural areas, will travel hundreds of miles just to get to a rheumatologist. So we're really dealing, depending on where the patients are, you have more access if you're in an urban area and you'll have faster access. If you're in a rural area, it can take longer because you have a very small amount of rheumatologists.

With an increasing number of people trying to come in, that wait time is getting longer and longer, along with the retiring rheumatologist as well. So let's talk about how to solve this issue. So now that we've gone past that, let's talk about how to solve some of the workforce and how APPs are going to play a role here. So advanced practitioners with combined can really fill in this gap. So this involves hiring the right person, interviewing people, having working interview, or students who rotate with you for several months.

You really need to make sure someone is a match. This is a marriage, right? So you want to make sure you will fit together in values, personality, and drive. Expectations and buy in must be established upfront for the physician, the APP, and the office managers as well. Expectations for training.

Training can take up to a year, although some are faster, some are slower. You know, what you'll see is an APP will follow with the rheumatologist for three months. And then what they'll do is they'll move into seeing their own patient panels and may start off with seeing more simple cases such as osteoarthritis, low back pain, osteoporosis, gout, you know, and kind of working their way up into those more complex cases. You've really got to understand when we're dealing with this to speed up the process. This is a level up process.

And by that means is every time you're starting with a new APP, it's basically starting with the basic level of information and building up from there in order to give them a solid foundation. And this is where the expectation setting also comes in. Physicians need to review the drugs and disease states with the APPs. APPs will need to take time to review in the evenings as well what they saw during the day. Practice managers should follow-up with the APPs and physicians as well to ensure expectations on all parties are being met.

And the APP is really set up to succeed in the practice. There's a lot of educational opportunities to train here. So there's multiple onboarding processes. You want to use what's out there, but you want to make it work for your office. There's existing ACR, ARP modules, RAP modules training for onboarding.

These are just some examples. Educational opportunities through RNS, RAP, ARP, AWARE, etcetera. APPs, like I had mentioned before, can chat out the physician for three months prior to beginning to see patients on their own. This is the process that's going to help to improve the workforce that we need in order to fill in the gap of the increased patient population, as I said, retiring rheumatologists, and the fellows coming out as well. It's one big process of everybody kind of working together.

But the APPs really have a very large role to help with the demand in rheumatology. When you get the APPs in, we're looking at a decreased patient wait time. That's really what we're looking to do. It'll also increase the number of new patients for physicians, while the APPs will see the follow ups. We're here to work as a team.

And APPs are crucial to the future of rheumatology to continue to see the expanding number of patient populations as we're dealing with an aging population as well. And these are my references. Thank you so much. For more information, please check on RheumNow.

Hello, my name is Betsy Kirchner. I'm a nurse practitioner in the Department of Rheumatic and Immunologic Diseases at the Cleveland Clinic, where I have been working for over twenty five years. And we are going to talk a little bit today about some vaccine pearls, mostly related to pneumococcal vaccine, but just a couple of little tips and tricks that I've picked up in my career. So the ground rules here are that I'm just talking about adults. I'm not going be able to have time to get into the pediatric vaccine schedule or anything like that.

I do practice in The US. That's where I get my guidelines from, although a little bit from the EMA. If you're watching from a different country and you have different guidelines, we'd love to hear about them, but that's not what I will be talking about. And then the last ground rule is that rituximab has its own set of rules. So, patients who are on rituximab, we're not going have time to go into that.

But when I talk about standard vaccines in this talk, I'll be talking about annual flu, COVID boosters, the pneumococcal conjugate vaccine, RSV, recombinant zoster, that series, and Tdap for every ten years. I am not going to go over the ACIP or EMA guidelines. You know where to find those. ACIP, the Advisory Council on Immunization Practices, part of the CDC. EMA is the European Medicine Agency.

They have guidelines for patients with autoimmune or immunosuppressed patients. They're easy to find and they overlap ninety to maybe one hundred percent. Either source is great. The 30,000 foot view for both of them for immunosuppressed patients, use inactivated or recombinant vaccines per the standard schedule for immunocompromised patients. Avoid live attenuated vaccines.

Time vaccination before or after immunosuppressive therapy when possible, not always possible. And expect reduced immunogenicity. Consider re dosing if you're able to, if given during profound immunosuppression. Okay, tips and tricks, pearls, general principles when you're talking about vaccines with patients. If you can, I encourage you to bring it up in a general way as soon as possible?

As soon as you know this is a patient with an autoimmune, auto inflammatory disease who will likely be on immunosuppression, bring it up. You don't need to bombard them with all the recommendations at your very first visit. But in a general way, Hey, your disease, the inflammation, the medicines we use, they're all going to possibly put you at increased risk for infection. We're going to need to start talking vaccines at some point just to sort of get them primed, get them ready for this. Now, that being said, read the room.

If the first second that the word vaccine comes out of your mouth or immunization, the patient sits back, crosses their arms, rolls their eyes, maybe it's not the best time to talk about it. Always be flexible. Keep the door open, Even if you're getting a vibe that the patient doesn't want to talk about it, or the patient specifically says, I don't want to talk about it. It's always legitimate. It's always appropriate to say, If you have any questions, that's what I'm here for.

That way they know that they not slammed the door on you. They can bring it up later. The first little mini topic we're going talk about is that timing. The ACIP and EMA say time vaccination before or after immunosuppressive therapy when possible. If they're about to go on immunosuppressive therapy, it's presumably because their disease is active.

You don't typically want to give vaccines when somebody's disease is active. They're not going to have as good a response. The side effects might cause more flare, symptoms. It's going be hard to tell what's flare, what side effect from vaccines. When the disease is active, not a great time to, to vaccinate.

Also, they're on moderate to high dose prednisone, which we know we often do or sometimes do when we're bridging a patient, when we're first starting them with immunosuppression, we might bridge them with some prednisone for a while. If that's moderate to high dose, not a great time to give a vaccine because the response is going to be blunted. Next question you're going to ask is what is a moderate to high dose? Well, ACR has great guidelines for that as well. They say less than or equal to ten milligrams of prednisone equivalent per day, you can go ahead and and vaccinate.

Still a non live vaccine, still following all those other rules, but less than, or equal to ten milligrams a day, stick to your schedule. Ten to twenty milligrams a day, you know, it's gonna be shared and informed decision making. It's gonna be, you know, what is the risk? What are the benefits? Expect some blunted response, but, some response is better than none.

Greater than equal to twenty milligrams per day, ACR conditionally recommends to defer the vaccines until that steroid dose is lower. One exception to that is if you're in the middle of flu season and you're not expecting to get them on a lower dose before the end of flu season, go ahead and give the flu shot. It's annual. Some response is better than none. Some protection is better than none.

But other than that, wait until you can get that prednisone dose lower. Okay, now, sort of reinforcing that, there was just a systematic review published this year that correlated with what ACR has been recommending for several years. This review said that vaccine responses are maintained in patients receiving prednisone less than seven milligrams per day. Responses are clearly reduced at greater than twenty milligrams per day. And in between there, between seven and twenty milligrams a day, the impact of doses remains inconclusive.

You can use your best clinical judgment there. Now we're going to zero in here on pneumococcal vaccination because that is what I get a lot of questions about from my colleagues, from my patients. The recommendations got a lot easier recently. There used to be this prime boost with PPSV23 and then PCV, it used to be 13, then it was 20. Now it's just PCV20 or PCV21 one and done.

Of course, if they've already gotten one of the other ones, can go back to those guidelines, go back to the website. They actually have very clear instructions on which doses and what the timing is, how many years do you have to wait. Aside from that, it's a one and done PCV20 or PCV21. Strongly recommended regardless of age for patients who are on disease modifying antiremotic drugs, DMARTs. But here we go into sort of the nitty gritty.

Here we go into, well, the guidelines don't cover everything, do they? They can't. They they do a great job, but they can't cover everything. Data on weaning protection after p c v twenty, p c v twenty one are limited. I mean, these vaccines were only licensed in the last two years for PCV twenty one and five years for PCV twenty.

So we don't have twenty years of data to say how long is this protection gonna last? Available evidence suggests durable immune response, But the study follow-up period is still only two to three years. Are we really going to give a 25 year old their one and done PCV20 or PCV21? Maybe. If they have other risk factors, if they're a smoker, if they have asthma, if they've already had pneumonia, something like that, then sure, they're going to be more likely to want to give them that protection.

But we don't really know if that's going to wane. Don't know if a booster is going be available. Again, best clinical judgment based on benefits and risks. One thing we can draw from is some of the data that is out there. A fairly recent study from Japan in RA patients who are on targeted therapies, biologics JAK inhibitors, indomethotrexate, the risk of the disease of pneumonia, the rate of hospitalized infection for 100 patient years, for these RA patients on targeted therapies, was three point two.

So three point two per 100 patient years, if the patients were between 16 and 64 years old. It was five if there were patients between 65 and 74, and it jumped to ten point one in patients who are greater, than 75, 75 or older. So we know that the risk of, serious infection, the risk of hospitalization goes way up the older they get, which might play into our decisions of when to vaccinate. But again, the guidelines say any adult who's on a DMARD is eligible for these vaccines. These vaccines, is it PCV20 or is it PCV21?

Mostly yes. If one is available and the other isn't, great. That's the one you want to give or recommend. There are some caveats, of course. PCV21 does contain eight unique serotypes that are not included in PCV20.

However, that serotype four is not included. Where is serotype four very prevalent? Alaska, California, Colorado, the Navajo Nation, and Oregon. So, PCV20 is recommended by the CDC over PCV21 in those regions. Otherwise, dealer's choice, really.

Tell my patients whichever one you can get, that will be just fine. I practice in Ohio, so I don't have to worry so much about serotype four. Last little bit, co administration. We don't have a ton of data, but patients ask me this all the time. Can I get this and this together?

Can I get that and that together? What I basically tell them is, what we have data on is PCV20, not 21 is too new, but we have PCV20 data given with adjuvanted influenza vaccine. And it's maybe if you have the luxury of not doing those on the same day, that might be a better idea. Because given them together, we have found that it blunts the PCV20 response just a little bit. So, in a perfect world, no, we would not give those two together.

On the flip side, patients sometimes want to go and start their shingles vaccine series, especially if they're about to go on a JAK inhibitor. And if, they want to sort of get their flu shot or their pneumonia shot with their, zoster vaccine, either one of those with zoster, I generally tell them it's okay. We do have data that coadministration of zoster and the old pneumonia vaccine, PPSV23, had non inferior responses to both vaccines. But solicited adverse reactions were more frequent with simultaneous dosing. So, if the patients have some sort of restriction, transportation, getting an appointment, whatever, sure, it will probably be fine.

Their long term response should be good. Just warn them their side effects might go a little bit. Last little bit. Prioritization is sequencing. So, for a patient receiving a biologic DMARD, all six vaccines can be administered not the same day, but how do you prioritize it?

Patients say, I need all six of these. Which should I get? Look at the season. Look at what's circulating right now. What's the biggest risk?

Look at their disease activity. Basically, other than the PCV20 flu thing, co administration of most vaccines is acceptable. But consider separating the adjuvanted vaccines to minimize that side effect reactogenicity. That is all we have time for today. I thank you so much for your attention.

For more information on this and all things Rheumatologic, go to VroomNow. Thanks again.

Hi, everyone. My name is Lindsey Tom. I am a physician assistant at Northern Virginia Center for Arthritis. And today I'm excited to talk to you about something that we all recognize in rheumatology, osteoporosis, specifically about the pitfalls in osteoporosis and about groups who are underserved and undertreated. Most people we think of osteoporosis and we pictured this classic patient, that thin elderly post menopausal woman.

Of course, that person is at high risk for osteoporosis, but if we only focus there, we do miss a large number of patients who are quietly developing bone loss as well. Patients we see with inflammatory diseases, of course, in rheumatology, inflammatory arthritis like rheumatoid and psoriatic, but also these patients with IBD, COPD, especially those who are on the long term glucocorticoids, we of course know that they're at risk for osteoporosis as steroids clearly weaken bone. Patients with neurologic disorders are also at high risk. And of course, we can't forget those patients who are immobile or more wheelchair bound, and they're at higher risk just simply because they don't have the weight bearing activity needed to maintain that bone strength. Another really big underserved group that we need to focus on is also men.

You know, we always think of women as having the disease and women have osteoporosis more frequently, but men can and they do have osteoporosis as well. And unfortunately, a lot of time men are not always diagnosed until after they have that fracture. And I think that can be a couple of things that contribute. I'd say one, we're still a lot of people thinking of osteoporosis inaccurately at this women's disease. And then the screening guidelines for men, they're just really, it's not that great.

The US Preventative Services Task Force still says there's insufficient evidence to recommend for routine screening. Other guidelines, they'll say to screen at 70 or if there's high risk factors, we think about things like steroid use as mentioned or the risk factor of having a prior fracture. But of course that means at that point the disease may have already progressed. So it does bring in a question, should we be screening some of these people earlier to prevent these fractures instead of catching it after the fact? As rheumatology providers, I think that we're pretty good at screening our patients who have inflammatory arthritis, but we also really need to be vigilant about these other patients.

So about the patient you see with a different type of rheumatic condition, but maybe they also have COPD and they're prescribed steroids from their pulmonologist. Or we might have a different person who's that male patient who we see for osteoarthritis of his hands and his knees, but now he's also had a stroke and he's been wheelchair bound for several years because those patients are also at high risk for osteoporosis and we really need to screen for them as well. Unfortunately, even with screening, we have these other pitfalls. So we see these socioeconomic barriers, transportation cost, access to the imaging centers. These can all affect the delay in getting that DEXA screening.

And then even if they do get screened, unfortunately, there's still other things. We sometimes have DEXA results that can be a little bit misleading. Degenerative changes in the spine can make it look falsely elevated. Sometimes there's differences in calibration of machine or interpretation. So there's unfortunately a lot of different things along the way, including that final part of treatment, where all of a sudden we have to deal with cost, sometimes insurance hurdles, side effect concerns that patients may have as well.

And then you also have to worry about the adherence to the medicine because some patients do have that poor adherence or they miss follow ups. And for certain things like injectable therapies like denosumab where it's so important to have it every six months, patients sometimes get lost to follow-up and that does put them at risk for that rapid bone loss. So lots of things, it's not just about identifying that risk, but it's also about keeping patient engaged, keeping them on their therapy. That being said, well, as rheumatology providers, what can we do? Of course, it's not perfect, but we definitely can be vigilant, really broaden who we think of as at risk.

We can act early and try to really improve that treatment initiation and the follow through. And part of that is explaining that fracture risk, addressing the fears with our patients that they may have around these medications and ensuring those follow ups so they don't fall through those cracks. Finally, also advocating for patients in terms of getting that bone density. Sometimes advocating is also fighting with those insurance to get these medications that we know is right for our patients that they don't always want to cover up front. So that being said, just keeping in mind osteoporosis, we all know about it, but we just want to keep in mind it's not just this thin elderly woman's disease.

We still have groups that are underserved and they're undertreated. So hopefully, from this talk and moving forward, we could just remember that there's these vulnerable groups who are needing treatment. And as rheumatologists, APPs, I think we can all work together and try to close the gaps to ensure care for all of those who are at risk for this disease. For more information about osteoporosis and all things rheumatology, go to roomnow.com. Thanks.

Hello, I'm Vanessa Hill. I'm a nurse practitioner at the University of Alabama in Birmingham, and I have been in rheumatology for the last twenty years. The first four of which I served as a clinical research nurse coordinator. The remaining sixteen years I've been in the clinic treating patients with autoimmune diseases. And we are going to talk about health maintenance in the rheumatology clinic.

I know some of you may wonder why we need to talk about health maintenance in the rheumatology clinic, but it is very important in the rheumatology setting because we are dealing with patients who have chronic illness and I believe that in the setting of patients who have chronic illness, health maintenance is even that much more important. One of the first things I want to talk about is vaccinations. When it comes to treating our patients who have autoimmune diseases, vaccinations are very important. Unfortunately, all patients are not going to be willing to have the vaccines that may be required. And in that case, you just need to be prepared to educate them on the risk of not being vaccinated, as well as the benefits of being vaccinated.

And they also need to understand that not being vaccinated may alter the treatment choices that we have to offer them. So the second thing we're going to talk about is cancer screenings. Of course, you know, usual mammogram, pap smears, colonoscopies, chest x rays, PSAs for men. I discuss those things with my patients in the clinic for a couple of reasons. One reason is because we do want to make sure that our patients are caring for all aspects of their health care, but also because some of the diseases that we treat and some of the medications that we use may also increase their risk of malignancy.

And we want our patients to be aware of which cancer screenings that should be completed, not only, for for their age, but for treatment and considering their autoimmune diseases as well. And be sure that you discuss their family history of cancer when you're discussing their cancer screenings. The next thing I want to talk about is dental care. Our patients, it's important for all patients to have routine dental care. A lot of our patients though may have dry mouth associated with their disease process or maybe even medications.

Those patients need to have dental cleanings every three months rather than every six months and they may need to be monitored a little bit more closely for dental caries. The other thing to consider is our patients who have forward intention are at risk for infection. And we know that when we're treating our patients for autoimmune diseases, many times the medications that we use may put them at even higher risk for infection. So it's even that much more important that our patients have good dental health. The next thing I want to talk about and this is a little bit outside of health maintenance, but at the same time it's very important for all of our patients and to consider the comorbid conditions that we may be dealing with.

Sleep apnea is one of the first things that comes to mind as well as obesity and then we have diabetes, depression, and all of these things can go hand in hand and play a role in how these patients feel. So for the most part sleep apnea and even obesity can contribute to their fatigue, of course decrease sleep efficacy, and also contribute overall to how they feel and how much pain that they are experiencing not only in their joints but their muscles as well. Diabetic patients may also feel more fatigued than our general population. And then of course, when you put depression in the mix, that adds a little bit more complications to treating our patients. When you think about our patients who have chronic illness, many of them suffer at least to some degree with depression just because they are dealing with a chronic illness.

And it's important to understand that if our patients are depressed and they're not being properly treated, it may affect how they feel, but it may also affect how they manage their healthcare, not only the disease process that we are treating, but the remainder of their health as well. And then osteoporosis is another condition that we need to consider. And to me, the most complicated part of managing osteoporosis is who's going to manage the osteoporosis. Many times our patients screened or are managed routine. DEXA scans may be performed by their primary care provider.

And then our patients, our female patients may be managed by their gynecologist. And then of course we have our patients in Rheumatology Clinic and many times I try to make sure that it's being managed by one of their other providers. But it can slip through the cracks sometimes. Also, the biggest thing I want to the biggest point I want to make about treating our patients and their comorbid conditions is that it can really affect how we are assessing their response to treatment or maybe how the patient is perceiving their response to treatment. Many times patients will expect for so many of their symptoms to improve when we start them on DMARD or when we change a DMARD.

So it's important to really talk to our patients and understand what their comorbid conditions are and what types of symptoms those comorbid conditions can cause, especially for instance talking about lupus patients, many of our lupus patients do have fatigue, but if they also have sleep apnea that may be not treated at all or undertreated or depression, the obesity, you know, of these things can play a part in their fatigue. So if they're expecting their fatigue to improve greatly when we start them on medication and it doesn't improve, they may actually contribute that to an efficacy of the medication itself. So I do think it's very important to have a long discussion with your patients about their comorbid conditions and how those conditions can actually affect how they feel and how they perceive their autoimmune disease, how well it's responding to the treatment. So a few things I like to do in my office that really seems to help me a lot. I'm just going to give a few helpful hints on trying to help these patients manage their either comorbid conditions or help encourage them to maintain just their health maintenance throughout the year.

I keep vaccine. I print vaccine recommendations and have them on hand for quick reference. I also print off cancer screening guidelines. Sometimes patients may want to have those in hand and I also try to make sure I do that fairly often so that everything is up to date as far as the recommendations are concerned. As far as dental care goes, again encourage regular cleanings and then of course sometimes our patients may not have access to dental care.

We may have to refer them to social services. I have even gone online before while my patient was in the clinic and and Googled dental services and just trying to do anything I can do to to help the patient. As far as obesity is concerned, I try to keep pamphlets on hand for quick references for things such as intermittent fasting or low carbohydrate diet. Just whatever you prefer and what suits the patient but many times I have patients ask me about weight loss and so it's very handy to have something just sitting there in in the clinic exam room itself and I can just reach over and and grab it and hand it to the patient and then have a discussion about that as well. Of course exercise as well and I don't know if this is true everywhere but in Alabama there's YMCA.

It's a large facility where patients are where anybody can go you know they join the gym and they can work out. Sometimes they have an indoor pool but a lot of times places like this will give a discount to patients to join give a discount on their membership for these patients to join if they have a prescription that says exercise is medicine. So that has been helpful for some patients as well. Then we have the sleep apnea. I have facilitated the diagnosis of sleep apnea in a lot of my patients and unfortunately patients will suffer for years with sleep apnea and not sure if they're not having a conversation with their primary care provider or what or if they're just ignoring their symptoms but I will spend an adequate amount of time with patients if I suspect they may have sleep apnea and get them referred over and then of course you have to explain to them why it's important to treat the sleep apnea, all the symptoms, signs and symptoms that can be caused from untreated sleep apnea and how it can affect their overall health.

And then as far as diabetes is concerned, I do quite frequently will check an A1c on patients. It kind of depends on the situation, depends on if they have a good primary care provider that they're seeing on a regular basis, but many times I'm finding these days that most of our patients don't have a regular primary care provider. A lot of patients end up going to an urgent care walk in clinic just for their basic needs or when they get sick and I have found several occasions where patients have diabetes and and no one was aware at the time. And of course it's very important for us to know if our patients have diabetes or not because unfortunately we do still have to use steroids to treat our patients and we definitely need to know if they have diabetes or not. Smoking and vaping.

This is one of my biggest pet peeves our patients who smoke Unfortunately, they're spending, you know, resources, their money on cigarettes and many times they can't afford their medication. So, I really discuss smoking with every patient at every visit. I'm pretty sure some of my patients have quit smoking because they got tired of listening to me but that's okay. Another point I want to make about that is vaping. We all know that smoking can increase disease activity, vaping can as well but just to make a point of that, I had a patient come in and she's been a long time smoker, very active RA, I begged her to quit smoking.

She came back to the next appointment. She had quit smoking. I was excited about that but her joints, the disease activity was probably double what it had been and I was very confused about that. I didn't understand. Know, she'd quit smoking.

I would have expected for things to at least gradually have gotten a little bit better, come to find out she was vaping instead and so it seems that that may have even made her situation even worse. There's a good resource for your patients who use tobacco products. It's one-eight hundred QUIT NOW. It's a program through the CDC so the one-eight hundred QUIT NOW is the actual phone number that you can give the patients and they can call and speak to someone. You can also go to cdc.gov/tobacco, I believe, and you can find information there as well.

They offer counseling referrals for local programs as well as provide free medications to people who are wanting to quit using tobacco products. So in closing, I just want to say that we all understand that health maintenance is very important. I think the problem sometimes is that we aren't sure if the patient is established with a primary care provider who is making sure that their health maintenance is done appropriately. So many times in rheumatology clinic, we may need to do the things that we feel are really primary care related such as ordering mammogram, order the PSA, order the A1C, whatever it is that we need to do to make sure that our patients are really being cared for appropriately. So thank you very much for joining us and I hope that you enjoyed the presentation.

Thank you.