This transcript has been edited for clarity.
Elaine Husni, MD, MPH: Hi. I'm Dr Elaine Husni, and welcome to Medscape InDiscussion. This is podcast episode 3: extending the reach of psoriatic arthritis patient care. One of the things that I enjoy most about doing these podcasts is that I get to ask the important questions to very smart people. And today I'm really excited to spend some time with Dr Christopher Ritchlin and Shadefai Goldsmith. They are the dynamic duo out of University of Rochester, and I hope to find the secrets of a successful nurse practitioner–physician relationship in rheumatology, specifically around the care of psoriatic arthritis. So let me introduce this power team. First, we have Dr Chris Ritchlin, who is a dear friend and mentor. He's professor of medicine and director of the Clinical Immunology Research Unit at the University of Rochester. He directs a team of investigators. He's doing translational research, and in the clinic, conducting both scientific and clinical research. Shadefai Goldsmith is a board-certified family nurse practitioner, and she also practices at the University of Rochester's Rheumatology Clinic, specifically focusing her practice on rheumatoid arthritis and psoriatic arthritis. Welcome.
Shadefai Goldsmith, FNP: Thank you for having me.
Christopher Ritchlin, MD, MPH: Thank you.
Husni: I wanted to start with a case from a couple of weeks ago. I saw a 28-year-old law student with psoriatic arthritis. It started in his teens with pretty severe psoriasis, about 10% body surface area. He was quite a gifted soccer player and he recalled how difficult it was to be in the locker room with his skin condition. As a teenager it was embarrassing, and he used a lot of different treatments.
By the time he got to undergrad, his skin had cleared and he was lost to follow-up. He had seen a dermatologist quite often as a teenager and then during his college years was doing pretty well. He then got into law school and believes that the stress of law school triggered more flares. He had gone back to club soccer because he was stressed out at law school, and he thought his Achilles pains were from getting back into exercise.
So, he did eventually re-present to us here in rheumatology, and unfortunately workup x-rays showed some early erosive changes in his feet and dactylitis on exam. We discussed treatment strategies, but he wasn't quite ready to commit to any medication, so I had him follow up. Unfortunately, in the next 3-6 months, he missed one or two appointments with me. We called to reschedule with one of our nurse practitioners. He missed that appointment as well. He did call us back to try to get in and, unfortunately, I was booked out about 4 or 5 months. At that point, he had missed several appointments, but eventually he did see our nurse practitioner who was able to spend some time with him and get him started on treatment. But this is probably a good 9 months after he re-presented to me.
I'm not really proud of what happened, but I would love for you guys to help me reflect on this case. What could have been done? I'll start with Shadefai.
Goldsmith: First and foremost, one of the reasons why Dr Ritchlin and I work so well together is that I have gone in with him when he has had patients, so I'm automatically introduced. So the patients are aware of my presence and I am their contact person if they are not able to be in contact with him or able to see him. That actually ends up working out well within the practice. The patients feel a sense of security and knowing that we care about their care in general — and their whole well-being. One of the things that I've noticed in some practices is that not all attendings make it known that they have advanced practice providers (APPs) that work with them, or they may have a personal APP that a patient can reach out to. So that would be one of the things that probably would be helpful moving forward in practice: knowing who the team is and who the contact persons are.
Husni: Great. Thank you. That's really interesting that you go in. Chris, can you elaborate on how you do that when you're busy in clinic?
Ritchlin: Shadefai described it well, I think. First of all, this case resonates very much with me — seeing a young man who's had psoriasis for a period of time and being profoundly embarrassed by the skin disease and then suffering from joint pain. It often takes us several times to convince them that this is something we need to treat. And oftentimes they'll miss visits because they're very busy, they're scared, they're worried about what the future will bring.
Having someone like Shadefai on the team really makes a difference, and we do bring them in to see her; that can bridge a lot of problems for these patients. So, she hit the nail on the head: We have a team-based approach. The team consists of myself, a couple of other rheumatology attendings, Shadefai, our administrative secretary, and a clinic nurse.
We go over patients once a week, once every other week, find out problems with the flow of the practice or individual patients who are having issues, and we try to help them. And moreover, we have a monthly psoriasis/psoriatic arthritis clinic where we have derm and rheum together. Shadefai is at that clinic, so they recognize her there. We also have a social worker that joins us in that clinic.
During the week, Shadefai will see new psoriatic arthritis patients and then call me in the room. We're able to be more efficient that way. So I do meet the patient and she presents the case. She knows psoriatic arthritis and psoriasis really extensively, so she can present the case concisely and accurately. And then I can interact with her and the patient, letting the patient know — and they know this already — that she's an integral member of the team and that this is going to be a relationship they're going to have moving forward.
Husni: I think those are really important points. Sometimes we find it hard in the middle of clinic to pull people in and out. Dr Ritchlin has his own patients to see, but I think that step is important. So, Chris, as you know, there's a big workforce shortage in rheumatology. Do you have any advice or want to share how you train a nurse practitioner?
Ritchlin: I would say, first of all, that we tried to hire APPs for several years — this is quite a while ago, 10 years ago. We would hire an APP and they'd be with us for a period of time, and then they'd really get overwhelmed because of the complexity of rheumatology and the therapeutic armamentarium, which is pretty large these days. It wasn't until we hired a nurse practitioner from the bone marrow transplant (BMT) unit, who the job resonated with because it was all about modulating immune response, that anyone took to the job. Once the nurse practitioner from the BMT unit came on board, we were able to bring on others. Once you create a culture that the APPs feel comfortable in, where they know they are valued by patients and other team members, it's much easier to recruit more APPs into the practice. That's been our experience.
In terms of the training part, there are programs that are put forth by the ACR that we're turning to. We also have interactions between physicians, nurses, and APPs that are educational conferences; we go over cases. We are going to start a conference in the very near future where we go over a disease and talk about our best practices and quality measures and then look over the patients that we've seen over the past month or past year in terms of numbers of patients and diagnoses. So by interacting with the faculty and the trainees, which Shadefai does, and also with the nurses that are in our division, it all makes for a culture where APPs are very much involved and can provide a great service to our patients.
Husni: So just a follow-up on that note. As you know, when we treat psoriatic arthritis, there are nuances. What happens when both of you have a case where you don't completely agree? Could you talk about how you go through that decision-making process with the patient? Because it's not always clear once you, let's say, don't respond to an anti-TNF inhibitor. How do you make your next decision? Shadefai, do you go by what he says? Do you have a conversation? How does that work?
Goldsmith: Because I am working with a psoriatic arthritis guru, we talk through a patient's history of present illness, their physical examination findings, and medications they have previously tried. Then we formulate a plan, whether it's a TNF or an IL-17 they should try that would probably be more beneficial. A lot of times we have discussed, based on the patient's weight, how a weight-based medication would probably be more appropriate; we have definitely spoken about these. A lot of patients do have fibromyalgia, and their PsA symptoms may be masked. So that's a little difficult too, because you wonder how much of this is PsA and how much of this is fibromyalgia. So following the patient and having great communication about the patient — just collaborating — is what keeps us working together. We focus on how to treat patients in the best possible way.
Ritchlin: The other point to make is that in our combined clinic, we have discussions like this in front of the patient all the time — myself, Shadefai, Dr Tausk (a dermatologist), residents, and the fellows. Patients really like it when you're saying, "Well, you know, I think we ought to try this" and then you say, "Well, but then we have to consider this," and you're discussing it right in front of the patient so they're involved in the conversations. You're coming back to them and asking, "What are your thoughts? Would you prefer to go in this direction? Here's what's involved with choice number 1, and here's what's involved with choice number 2." Then bringing in the other elements of their history and physical exam. That's our culture here.
When I'm in the room with Shadefai, that's how we interact. She says, "Well, this is what I think we should do." I say, "I think it's a great idea." Or "Maybe we should consider this." And then, "Do you have sleep apnea?" or "Have you thought about this?"
We have a social worker in the room helping us with weight loss clinics and with depression, anxiety, and, obviously, access to care. A lot of our patients are challenged by inadequate coverage for their medications. These are issues that we deal with in an open manner and a discussive format, and it's been very well received.
Husni: Chris, in an ideal world when you're managing a clinic, how do you manage how many patients Shadefai sees and how many patients you're seeing?
Ritchlin: Our clinics are very busy, so for a typical clinic I would see two new patients and probably 10-12 follow-ups in an afternoon or a morning. We often go over 4 hours, and I don't mind being pulled from a room to see a patient with Shadefai. They may have to wait a little bit because I might be in the middle of a procedure, but I see follow-ups and obviously new patients as needed.
And then at the end of the clinic, we'll sit down and go over patients that Shadefai has seen and we even go over the inbox — you know, the famous Epic [electronic medical record] inbox — and we'll talk about how we can get through this together. She helps me by contacting patients, answering their questions, and addressing lab issues. I think the challenge is, and we all know this with Epic, when you finish seeing a patient, you've still got notes to deal with, and then you've got an inbox exploding in front of you, especially during the pandemic. Between the two of us, we usually get through the inbox part, so we can focus on our notes either that night or the next day. And I think that works very well.
Husni: I love that idea: "The Epic Inbox Buddy." I need to do that because that inbox really gets me down. But to know that you guys can work as a team and just check that inbox off, that's really a great idea.
Have there been any pitfalls, anything you guys learned from working together that you could tell our audience?
Goldsmith: I would say that number one is recruiting and encouraging APPs to come in to a rheumatology practice. You can start the recruiting by going to their colleges and introducing yourself in the programs. That's something I did not have in my program: I did not have a rheumatologist come in and explain what rheumatology is. We did learn about it in class, but once you hear it from the actual provider who is practicing, it gives you a different perspective.
I also encourage APPs to shadow when they're doing their clinical rotations. That's another way they can get a little comfortable and see what rheumatology is about. I started recruiting, going to different schools.
Husni: We do this a lot, trying to get medical students and residents interested in rheumatology. But for nurse practitioners and physician assistants, is there a way we can outreach? Chris, anything you would suggest?
Ritchlin: I think Shadefai covered it well, and there is an educational component for the faculty when you start working with APPs. There are some faculty who are slow adopters of APPs, and you have to listen to them and work with them so they feel more comfortable working in a team-based environment. Some of them are independent rangers; they just want to do their own thing and they don't want to interact with anybody. I would say that over time, people come around to this model and really appreciate it.
I think the other question is how the APPs interact with the nurses. We have nurses that do infusions, but we're bringing them in to help us with the practice as well — bringing patients in, taking histories. And so when you get that team working — and we have a marvelous team nurse — that makes a richer environment, with additional people to help take care of not only the patients but all of the documentation we have to do.
Husni: We've talked about the urgent need to plan for a workforce shortage in terms of psoriatic arthritis care, the aging population, as well as just current psoriatic arthritis providers. We've discussed a typical case where early intervention could have changed the trajectory of this young man that I just spoke about. I think these are best practices that I'm hearing from the both of you. In closing, what are the top three ingredients you would suggest for an optimal physician–nurse practitioner relationship?
Goldsmith: Three ingredients: time, patience, and understanding.
Ritchlin: Time is obviously very important. Communication, and being willing to listen — and being good listeners.
Husni: Well, thank you both. It's been wonderful to hear about your best practices and some of the nitty gritty of how you do things. The "Epic Inbox Buddy" — I'm going to take that with me, so thank you for that. And I really, really appreciate your time today.
Goldsmith: Thank you for having me.
Ritchlin: Thank you. It was great.
American Nurses Association: Advanced Practice Registered Nurse (APRN)
Addressing the Rheumatology Workforce Shortage: A Multifaceted Approach
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Cite this: Find Out How Teamwork Can Tip the Scales in Psoriatic Arthritis Care - Medscape - Jan 18, 2022.