Building Mutual Trust with Dermatology

It’s extremely important to have a good relationship with our dermatology colleagues, especially when dealing with patients with possible psoriatic arthritis (PsA). As most of you know, patients diagnosed by their dermatologist with psoriasis can sometimes suffer with joint pain for years before a referral is made to rheumatology. By the time those patients reach us, there is often irreversible joint damage and disability, even with the variety of current treatment options in our arsenal.

Part of the issue is that our dermatology colleagues typically do not ask their patients with psoriasis about possible joint pain and/or do not examine their joints appropriately. Compounding the issue is the fact that psoriasis patients often do not understand that there is a link between psoriasis and arthritis, so they never bring up their joint pain to their dermatologist.

I recently met a patient, JL, who epitomizes this disconnect.

A 36-year-old male, JL was diagnosed with psoriasis in his early 20s. He had seen a dermatologist several times a year during the previous decade due to frequent psoriatic flares. His previous treatments consisted mainly of light therapy and topical therapies; he has no history of oral medications or biologic therapies.

At our initial meeting, JL told me that his joint pain began approximately 3 years ago, progressing to the point where he was unable to play with his two small children. He also complained of chronic heel pain, low back pain that woke him up several times a night, and severe morning stiffness. He said he took the maximum allowable dosage of ibuprofen to get him through each day.
Physical exam showed dactylitis (sausage digits) in two toes on his right foot and a finger on his right hand. Based on his history and physical exam, there was little doubt in my mind that JL had PsA.

As I wrapped up the initial exam, I asked JL if his dermatologist had ever talked to him about the link between psoriasis and joint pain. JL explained to me that he goes to a large dermatology practice where he sees a variety of providers depending on who is available when he needs an urgent appointment. That said, he did not recall ever being asked about joint pain or undergoing any sort of physical assessment to assess possible dactylitis (a classic finding in patients with PsA).1 He just assumed his chronic pain was something he would need to deal with. It wasn’t until JL mentioned his issues to a friend of his, who was also a patient of mine, that he even thought of asking for an additional referral.

“…being open-minded and willing to accept advice from external specialists can be extremely helpful in cluing us into key symptoms of comorbid conditions we may not often come across.”

After our initial appointment, JL was tremendously relieved, breaking down in tears when I told him that there were a variety of options we could try to relieve his chronic pain and allow him to play with his kids again. After a battery of lab tests and X-rays, I started him on methotrexate monotherapy. We’ll keep an eye on his progress and make adjustments to his treatment regimen, if needed, in 3 months.

Once JL left my office, I sought out his primary dermatologist to try to provide her with some education. Fortunately, I had a previous positive relationship with JL’s dermatologist, and we have collaborated on the care of a number of patients over the years. These provider-to-provider conversations can be tricky, requiring us to strike a balance between active listening and pointed education. I relayed to her my initial meeting with JL and how I determined that he likely had PsA. Without placing any blame on any parties—as I noted, JL met with a number of dermatologists over the years—I provided some general guidance on the kinds of questions that she could ask her psoriasis patients as well as a few tips on what sorts of physical symptoms she could look out for. She promised me that she would keep a closer eye on possible joint pain in her psoriasis patients and send any additional referrals my way.

Even though it can be even more difficult to call providers I do not know, I try to have a similar conversation with them to make sure important issues are on their radar screens. It is vital that they know I respect and appreciate what they do, and I try to offer additional education to help them moving forward. The same holds true when an external specialist calls me. I sincerely value their input and find that I learn a lot from what they share with me, knowing this will help me with future patients.

As healthcare providers, there is a lot of information we need to store in our heads about dozens of different diseases. None of us can be experts in everything. Serving as a resource to external specialists regarding the diseases we are most familiar with is key. By the same token, being open-minded and willing to accept advice from external specialists can be extremely helpful in cluing us into key symptoms of comorbid conditions we may not often come across.

Developing mutually beneficial relationships outside of our practices takes time and patience, and there certainly have been times that I have run into challenges. Nonetheless, I try to always remember that everything I do is in the best interest of my patients, which makes it critical that I build these bridges between providers as best I can.

 

AUTHOR PROFILE:
Amanda Mixon, PA-C, is a physician assistant at Arthritis and Rheumatology Clinic of Northern Colorado in Denver, Colorado and a Board Liason for the Rheumatology Nurses Society.

 

References
1. Brockbank JE, Stein M, Schentag CT, Gladman DD. Dactylitis in psoriatic arthritis: a marker for disease severity? Ann Rheum Dis. 2005;64(2):188-90.