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Stanley Cohen, MD: Hello. I'm Dr Stan Cohen and welcome to Medscape's InDiscussion series on psoriatic arthritis. Today we're going to be discussing a new concept. It's been around for several years, the combined rheumatology-dermatology clinics with my friend and colleague, Dr Joseph Merola. Dr Merola is presently associate professor at Harvard Medical School. He's director of the Clinical Unit for Research Innovation and Trials. He's also director for the Center for Skin and Related Musculoskeletal Diseases. Welcome to InDiscussion. Looking forward to an interesting discussion about this concept.
Joseph Merola, MD, MMSc: Thanks for the invitation.
Cohen: We're also very excited here in Texas because Dr Merola has agreed to come down to be chairman of the Department of Dermatology at UT Southwestern. You've been one of the leaders in promoting and pushing these combined rheumatology-dermatology clinics. Can you tell me how that started? What were the forces behind it?
Merola: Lots to unpack there. I'll take a step back to talk about psoriatic disease, because I think we know that it's, in many respects, such a perfect model to highlight the need for combined care. We'll take dermatology and rheumatology to begin with. Not everyone wants to do 9 years of training to do dermatology medicine and rheumatology training. But we know there are gaps. Our training in dermatology, I would argue, doesn't emphasize our ability to feel comfortable with psoriatic arthritis (PsA) diagnosis and treatment. We can get there, but it's not there in the training stages. Similarly on the rheumatology side, we have so many things to think about. It's tough to know about every last piece of information regarding treating to target for skin disease, new topicals, all the different ways that we're going to approach treatment, never mind all of the other comorbidities of disease — cardiovascular and other — that come with the complexity of psoriatic disease.
We know there are multiple challenges. There are many ways to do this, but historically in some centers, we still have these formalized models of combined care delivery, and the multidisciplinary clinics that we've seen are typically our derm-rheum. We'll talk about what those models look like. We've seen [combined clinics] around the country now: GI-rheum, GI-derm, and we have a cardio-rheum clinic here at Brigham, which is a cardiologist embedded in rheumatology.
Chris Ritchlin, MD, historically has had, and I believe he still does, a psychologist embedded in his practice. We know that these combined clinics serve multiple purposes. They certainly have benefits to the patients in terms of education support. They love the one-stop shopping. They love having access to this wide array of therapies and all the things you would imagine would happen in that context. In an academic setting, it's phenomenal from an educational standpoint. You have the dermatology residents together with the rheumatology fellows and other folks coming together. It's a rich environment for research, for clinical trials, you name it. In that model, it's tremendous. We've had one at the Brigham for almost 20 years now. There are many other examples of them around the US and around the world.
We actually started a consortium called Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN). That's a nonprofit that's really focused on getting all these clinics in contact with each other. We are trying to harness that power to both create new clinics and also do some cutting-edge research by leveraging each other's resources to move things along.
To that end, I think we've had a lot of success. I know this is a high academic model, and one of the things I'd love to talk about today is admitting that this can't happen everywhere. I'm under no illusion that this is going to happen in the busy private practice. We have ideas for how we can do best by our patients by tapping into this concept of a combined approach without a lot of heavy lifting from what we're doing already. We can talk about what that looks like because I have a hint of practicality in me after all of these academic years. The last thing I wanted to add is we know that these models do benefit patients because this comes up.
Let me leave you with this, and then we'll chew on all the stuff I just emptied here. There's at least one study that Abrar Qureshi and colleagues did a number of years ago that showed that patients seen in these combined clinics had their diagnoses revised — not in a small number of cases, something like 40% of cases. They were more likely to be treated with a systemic or biologic therapy appropriate to their condition when they were seen in these combined clinics. In the combined clinics, there's more treat to target. There's perhaps a slightly more aggressive approach taken, and it seems to benefit patients. I know that we can recapitulate that in practice all the way through to the ivory tower of academics.
Cohen: It seems to be an offshoot of efforts that started after the biologics came out in the late 1990s. We wanted a dermatologist to be able to recognize or at least think about PsA and refer, and we wanted people to develop questionnaires or some kind of methodology to try to help the dermatologist.
You're taking it a step further, where you're taking patients who may or may not have the diagnosis and getting both set of eyes to take a look at them. Logistically, how does it work?
Merola: The models around the country have all varied widely. I'll tell you about ours, and I'll tell you what exists or could exist out there. Even ours has morphed over the years, depending on what support we had. There was a time where we had a pure rheumatologist embedded with a dermatologist physically in the clinic. A part of that was because the ratio and volume was such that it made the most sense for the derm to be seeing that high volume of patients coming through, have the rheumatologist there, and the clinic and nursing staff. Everyone had to be on board to understand who should be in that clinic.
We were always trying to enrich [the experience] for patients who were new consultations or who had the most active skin and joint disease such that the time was being utilized in the best way. If they were really well controlled, one or the other of their domains of disease was controlled, we tried to push them out, either back to the referring provider ideally or into a routine follow-up. Not in that high academic model, and still the ratio and relative busyness of the derm vs the rheum can be challenging. In fact, over time what would happen is we'd have two or three dermatologists served by one rheumatologist in the clinic, and they would sort of hop in and out. You would pull them in and say, "Hey, I have a patient who's got some joint pain, what do I do with this?"
That was the model predating me for many years. Our current model, because I'm a derm-rheum, is I'm now serving more as a rheumatologist, so the derms are grabbing me, and I'm going in doing the joint exam and saying, "Well, I think joint films," etc. That's worked for us. It is a challenging model, and I'll tell you some of the other models that exist around the country have a combined clinic, but perhaps they only meet monthly or twice monthly.
There are some that meet in tandem but the same day. This means I tee up a bunch of patients I think need to see you, you have some slots open in your clinic, and I throw them over the fence for later that day or something like that. Some people are just doing virtual or monthly meetings, almost like psoriatic disease grand rounds.
Bring your bad skin patient to our rheumatology meeting, or whatever it may be.
Cohen: So, like, a tumor conference?
Merola: Like a tumor board. That's a perfect analogy, I'm going to start using that. Thank you, Stan. That's a better way to say it. It's like a tumor board for the psoriatic patient. Then, there are other models we're hearing about. There was one model, and I don't know how well they're doing presently, but for years, there was a model in the DC area run by Evan Siegel and Ben Lockshin. They were driving to each other's office and doing this in a private practice twice a month or something like that. They were literally booking a clinic where they said, "I'm going to send this complex person to that clinic." A person shows up in their office, and they do it.
Now, again, I'm under no illusion that that's going to happen in most places. The one thing that we're finding that is really the key ingredient is two words: facilitated communication. I'm of the mindset now that one of the best models is just to find the person or people in your community who are the psoriatic disease go-tos. The people who are really dedicated to the PsA, ankylosing spondylitis (AS), and the spondyloarthritis (SpA) world. Also, vice versa in the derm world where — no offense to my colleagues there, but not a cosmetic derm — someone who really is a medical dermatologist and uses appropriate systemic agents and is treating to target psoriasis. Then, make some arrangement where you text or phone a buddy, maybe you're sharing notes in a facilitated way. I can talk about that more later. Maybe it's that you agree, "Hey, I'm going to leave one or two slots open every week out of my entire schedule. It'll revert to a new patient. If I don't hear from you, I have that one slot available for this partnership, and I'm going to stick this complex patient in or this PsA patient in there."
We've seen that work in a number of places. Just having that go-to, the psoriatic guru in Fort Worth, for example, and you pick up the phone and communicate. We've seen that work really beautifully. Our PPACMAN group, if anyone's interested, developed these electronic medical record (EMR) templates, and they're free to use. You can go on the website and download them. They're made by derms and rheums for the other provider. For example, it's a rheumatologist who has said, "Hey, I want my derm colleague in the course of their visit to document X, Y, and Z. Put this in your derm template for your psoriatic patients. I want you to do a Psoriasis Epidemiology Screening Tool (PEST) screening. I want you to document the pain Visual Analog Scale (VAS)." Whatever it may be. We have those available on the website and vice versa [for dermatologists], "I want the rheumatologist to document in the note the body surface area (BSA) of this patient. How severe is it?" By the way, reminder in the note, the National Psoriasis Foundation (NPF) [recommends] treat to target is less than 1% body surface area, which is less than one palm's worth.
If they're not at that, consider a referral or changing therapy to jog us in rheum about saying, "Hey, I've had them parked on a tumor necrosis factor (TNF) inhibitor with a 30% BSA. Maybe it's time to think about switching to another class of medications?
Cohen: You're talking about enhanced communication. It can be done in a formal setting like you've been able to do at the Brigham, and we'll probably be doing here at UT Southwestern during your reign here. We have good relationships with our dermatologist. We have the other diseases like lupus that we share a great deal, certainly subacute cutaneous lupus erythematosus (SCLE), discoid lupus, and so forth. For pre-screening when a patient's referred to your clinic, does your nurse say, "That patient isn't really a candidate here," or, "Yes, that'd be a perfect person to be seen?"
Merola: Look, nothing's perfect. A lot of what we see and do is by referral, so it's a little bit pre-screened in so far as the rheumatologist over at the Brigham says to me, "Listen, I'm managing their systemic lupus erythematosus (SLE), leave their belimumab alone, but I can't get their discoid under control. What would you recommend?" And send them over.
Those are ideal, right? Because it's a targeted focus consultation. The idea is to get the referral, help them with the targeted question, and send them back. Most people want to retain their relationship with their patients. It's a consultation. I think a lot of these high academic models work best that way. And it also doesn't gum up the system, because patients do better and get better, and then you're just seeing these patients to say, "You're doing well, see you in 6 months." That's not a good use of resources.
To your question about the connective tissue disease, I think for the derms, one of the things we found helpful is trying to send visuals, whether it's through the patient gateway or from the referring provider. I can often tell you quickly, "Boy, you know what? That's rosacea. I really don't need to see that." Or, "Boy, this is osteoarthritis and eczema." I can assure you, I don't need to see them for that psoriasis optimization. That's one trick. A lot of our EMRs now have really facilitated that. In Epic, for example, it's easy enough for my nurse to just shoot me a quick photo. That's helpful. On the rheumatology side, it's trickier for a lot of those patients who just aren't getting better after their fifth biologic, and I don't know how to control their PsA. I then need to be prepared for some fibromyalgia visits, and that's okay. I don't have an easy way around that one yet.
Cohen: Well, that's what we signed up for.
Merola: That's right.
Cohen: We have a very close relationship with our dermatologist. There aren't many people like you who have done both rheum and derm. We are fortunate to have some dermatologists with special interest in our diseases. It's going to be great to have you here to help us as well. As we close, give me the website again with the organization so people can go to that if they would like to.
Merola: I appreciate that. The nonprofit is called PPACMAN. It's www.ppacman.org. They have lots of resources on that website. And then, of course, there's lots of other groups that are interested in this, like Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and so many others.
But PPACMAN is focused on these combined clinic models. How we can get teams together and do the best by our patients.
Cohen: It's been a pleasure to have you today, Joe. Thank you so much. And I hope that everyone learned quite a bit about these combined clinics. Thanks so much for joining us. This is Dr Stan Cohen for InDiscussion.
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Cite this: Combined Clinics for PsA: Can It Work in Private Practice? - Medscape - Jul 25, 2023.