Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole, and I invite you to listen as we discuss establishing a multidisciplinary clinic for psoriasis and psoriatic arthritis. Joining me in this panel discussion today is Dr. Eric Ruderman. He's an Associate Chief and Professor of Medicine in the division of Rheumatology at Northwestern Medicine and Dr. Emily Keimig, she's the Chief of Medical Dermatology, and an Assistant Professor of Dermatology at Northwestern Medicine. Doctors, I'm so glad to have you join us today. Dr. Ruderman, I'd like to start with you. Please tell us about the Psoriasis and Psoriatic Arthritis Clinic at Northwestern Medicine. How did it come about? How long has it been in existence? Tell us a little bit about it.

Eric Ruderman, MD (Guest): Well, you know, Melanie, like so many things, it was a great thing that started by happenstance. The clinic has been in existence for about 15 years. We were actually the first combined clinic for psoriasis and psoriatic arthritis in the country. And about 15 years ago, not long after I had joined the faculty at Northwestern, I had an interest in psoriatic arthritis and had been doing some clinical trials in psoriatic arthritis and I ran into a colleague actually in an elevator one day, who was a medical dermatologist who had a real interest in psoriasis, including some of the clinical trials going on in psoriasis at that point. And that was really the first time we were using biologic therapy, major systemic therapy for both psoriasis and psoriatic arthritis. And we got to talking and said, you know, wouldn't it be great if we could do this together. We initially thought it might be a nice opportunity to collaborate on some research work and some research studies. But then saw it as an opportunity for good clinical care. And so we just set it up and it was not something that we sort of planned down to the very last detail. It was something we worked together and said, here's how we think it should work. Let's make it happen. And over a couple of years, we came up with a format that has just worked and has been there ever since. That dermatologist has since moved on, and Dr. Keimig and I have been doing this together for, I guess, three or four years now. Keeping up the same thing. And initially we did it once a month, because we didn't know what kind of demand there would be. We're now doing it every week because there's a huge demand amongst patients for this kind of care. Emily, anything to add to that?

Emily Keimig, MD (Guest): You know, I think it was really designed not only for the physicians, but also the patient in mind. So, as Eric said, it really just kind of happened organically. And our goal has been, and really continues to be, to provide integrated multidisciplinary care for our patients with psoriasis and psoriatic arthritis.

Host: Well, Dr. Keimig then tell us about the value. You mentioned patient care, and obviously that's what this is about. Tell us about the value of a combined clinic for the management of psoriasis and psoriatic arthritis. Why is this so important? And tell us a little bit about some of the advantages of running the clinic this way and how this model might improve the quality of care, does improve the quality of care and treatment selection.

Dr. Keimig: So, psoriatic arthritis screening is really standard of care for patients with psoriasis. But for a lot of patients, you know, there may be a question of is this psoriatic arthritis or is it just run of the mill wear and tear osteoarthritis, or if they do have symptoms, now what? You know, what do we do with these patients? And it's a great clinic for patients who need these, as Eric had mentioned systemic treatments with biologics and other medications for both their skin and joints. So, I think one of the main advantages of our clinic is that they see both rheumatology and dermatology, right there in the same space, in the same room.

They don't even have to move exam rooms. And so, when they leave their visit, they have a coordinated plan from both of us. We will help them to coordinate the labs, any imaging studies that need to be done. We can order the medications and even arrange for something as simple as a prior authorization and we can take care of that all right there in that visit. We don't have to call another doctor or wait for another physician to weigh in. And, a lot of our patients come from far away. And so it's nice to be able to offer them two appointments, on the same day, in the same location. It really decreases the amount of time the patient has to be away from work, pay for parking, or really even arrange childcare.

So, in addition to providing great care for our patients, we're able to take into consideration their day to day activities and make it really as easy as possible.

Dr. Ruderman: That's exactly it. But one of the other highlights for me, has been the interaction between Emily, myself and the patient. So, not only are we in the same room where the patient doesn't leave the room, but we're actually all in there together, having a joint discussion about management of that patient's disease and in an era where shared decision-making is a sort of a key buzzword in the world of rheumatology that you have to value the patient's input, which is, has always been the case, but there's a lot more focus on that.

That's what we do. And it becomes a three-way conversation between the patient, Emily and myself to say, well, what's happening with your skin? What's happening with your joints and which treatment is going to best address your issues today, not the treatment that you know, go down a list, but what's right for you. And it's made it both more successful at managing patients, but definitely more fun for us to take care of people because it really becomes a collaborative effort and it has really been great way to combine all that we do. Many times in management people treat one aspect of disease and then another specialist treats another aspect of disease and for psoriatic disease, the joints and the skin are two aspects of the same problem. And it just makes much more sense to manage it together.

Host: Thank you and you know, it really is a great approach and certainly one that is in healthcare today. So, Dr. Ruderman, tell us a little bit about any barriers or challenges. You helped to set it up. So, with this combined clinic model, are there any challenges you'd like to let other providers know that you overcame and how to do that?

Dr. Ruderman: I certainly would. The challenges have never been on the patient side. Patients have always loved this. From the beginning, they appreciated the chance to come once, not to have multiple visits, to pay for parking once. We've had a couple patients over the years who said, well, wait a minute, why am I paying two copays?

Because there are two office visits happening at the same time. But that's been rare. The bigger challenges have really been institutional and logistical and not anything hard and fast. But I think the thing we discovered very early on is that rheumatologists function differently than dermatologists. And that's not very surprising. But it became an issue when we decided to work together. Our clinic schedules are different. We often schedule much longer clinic visits for patients. We schedule much longer visits for new patients because our focus is on everything. We try to get a full history, a full exam, everything there is where the dermatologists are, you know, focused on one organ system, the skin and the medical dermatologists obviously care about everything else, but it's, it's a much more sort of focused approach.

And so, their clinic schedules tend to have shorter visit schedules because they're not covering as much. And so one of the challenges we had when we started this whole thing was to sort of walk that line to say, well, can I see patients on a dermatology schedule, on the other hand, can the dermatologists see patients on a rheumatology schedule and see enough patients to satisfy the clinic administration, and that was the challenge. And we eventually came to terms with it and it and it actually has sort of met in the middle. It has required on my part, an effort to sort of rethink how I manage patients and how I address new patients and how I gather data and gather information to make decisions.

It's been a learning experience, but it's been fun. So, I think the challenge, if anybody else is gonna try to do this, to recognize there are differences between how dermatologists function and how rheumatologists function, acknowledge those differences and come up with a plan that allows you to develop a clinic process that works for both sides.

Dr. Keimig: And I might add too that one of the other challenges really is making sure that patients know what to expect. They should expect as Eric said, to have two copays, because they're seeing two physicians. They should expect to have a plan when they leave. And one thing that we've found over the course of the past several months is they need to know the location of the clinic. So, both Dr. Ruderman and I see patients when we're in our own clinics, in different buildings on the same campus. And sometimes the patient may look Dr. Ruderman up online and say, okay, I need to go to this building. Whereas our joint clinic is held in the dermatology space. So, really, it seems like a simple thing. And it is, but just really making sure you know, where the patients need to be.

Host: Dr. Keimig, how has your clinic evolved care since the onset of the COVID-19 pandemic? What's changed? And how does this pandemic change the way your clinic practices? What do you see happening in the future as well?

Dr. Keimig: Oh, my goodness, what hasn't changed? Certainly with COVID-19 we really had to adapt some of the practices that we had. So, in the very early stages, we were able to successfully convert many of our patients to Telehealth visits. And this was by the request of patients as well as from a Northwestern Medicine standpoint. So, we were very quickly able to pivot to that. We use Doximity as our platform and we were able to provide patients with pretty seamless care, you know, but not everything can be done virtually. So, I can look at the skin, but I can't really palpate the skin and see some of the subtle differences. And I think Eric would probably also say that you can't do a full joint exam. You can't feel for swelling and tenderness over the phone. And so for the patients that we do need to see, see in the office, we've taken the standard measures recommended by the CDC as well as Northwestern Medicine.

So, everybody is masked. Everybody has hand sanitizer. We do COVID screening at the time of scheduling the patient as well as check in, to really make sure that it's a safe environment. On the backend, in terms of in the clinic space, you know, the visit really is the same, where everybody's wearing masks and we're certainly still washing our hands, but really the visit can proceed as it, normally would. We do sterilize the rooms after all patients leave. So, we do have that added layer of precaution. But I think the combination of Tele-health or virtual care combined with in-person visits, when appropriate and certainly when necessary, is really how this is going move in the future. And our hope is that with vaccinations as well as more understanding of COVID-19 and potential treatments, these processes may need to be adapted over time. And I think we're well positioned to do that.

Host: It really has encouraged healthcare systems to be so creative and innovative in their patient care. And so, Dr. Ruderman, what advice do you have for rheumatologists and other healthcare professionals that are looking to establish a successful clinic like yours for this type of combined care? Tell us what you want them to know about setting one up.

Dr. Ruderman: Well, I think that it can be a challenge if you're not in the same system. So, the advantage that we have is that we're within the same health system, we're within the same medical center. We're both, full-time, employed physicians by Northwestern. That makes it a little bit easier logistically because we're working off the same practice. I think in many cases, the dermatologist and the rheumatologist who might want to do something like this, may be separate practices, and that may be a challenge. And I think that's something people have to work on to sort out how that could work. But if you're in the same practice, I think it makes a ton of sense. It's a great way to meet the patient in the middle, to meet the patient's needs and coordinate what you do and to do it in an efficient and effective way. And as we move into more and more Telemedicine, and I think that's clearly here to stay, we don't yet know how that's going to shape up as we get out of the whole pandemic piece and we get back to some more sense of normality.

I think that there's going to still be Tele-health and Tele-health offers the opportunity to see people or to manage people who are doing well, who are just checking in. They are on medications, they need to check in. We need to check their labs, see how they're doing. It offers the opportunity to see if somebody is not doing well. It's not a great system if somebody isn't doing well because as Emily said, it's really hard to evaluate somebody's skin and certainly somebody's joints remotely. So, it isn't a nice way to treat somebody who has issues or needs changes in therapy, particularly significant changes in therapy. But it's a great way to decide if somebody is well-controlled or not.

And if they're not, we arrange for them to come in. So, I think when you set this up, I would strongly encourage people to include a Telemedicine approach as part of the process, because it allows you to expand your reach just as the advantage for us is patients don't have to make two trips to the hospital. We have patients who come from an hour, an hour and a half away or more. To come in just to get a medication refill seems relatively inefficient. And so, if we can do some of that remotely and still see the patient, as we need to, to make sure that we keep tabs on them, I think that's the right way to set this up.

The other thing I would advise people who do this or want to do this, is to be flexible, to recognize that it may not always go smoothly. Things do not always happen as we would like them to happen. And above all, find a colleague that you enjoy working with. I mean, that, to me as a physician, I mean, I do what I do cause I like rheumatology. I like taking care of patients. I like the whole process. And I really look forward to this clinic every week because I really enjoy working with Emily. We enjoy doing this together and I think that's really critical is you have to find colleague in dermatology, or if you're a dermatologist, a colleague in rheumatology, who you really enjoy working with and spending the time with, because it becomes a really rewarding session each week for us.

Host: Dr. Keimig, I'd like to give you the last word. What else would you like providers to know? When do you feel it's important that they refer to the specialists at Northwestern Medicine and to your clinic? What would you like them to know?

Dr. Keimig: Well, I think this clinic is great for patients who have perhaps moderate to severe skin disease and either confirmed psoriatic arthritis, or really even suspected psoriatic arthritis. Those are the patients that I think are most appropriate for this clinic. You know, not every patient needs to be on a biologic or one of these systemic medications. And to Eric's point earlier, that's part of the benefit of this clinic is that we can really tailor it and individualize the care for the patient depending on what their disease status is, as well as what their needs are. It's also important for dermatologists in particular, to really know that again, that screening for psoriatic arthritis is considered standard of care. And it's really important to diagnose this and treat it early. And there are many therapies that we have now that will treat both the skin and the joints. So, I think for any patient that a dermatologist or a rheumatologist is considering using a systemic agent and you want to try to treat both their skin and the joints at the same time, this is a great option for those patients.

The other thing that I would also like to mention is that, we don't see psoriasis and psoriatic arthritis on their own, right? Many of our patients have other medical conditions, sometimes complex medical conditions, such as cancers or inflammatory bowel disease and selecting the correct systemic therapy in these patients can be challenging. And so those are patients that I would really encourage dermatologists and rheumatologists to refer to this Psoriatic Arthritis and Psoriasis Clinic for evaluation because those are patients where the decision may not be so clear cut and you need to take into consideration multiple factors.

Host: Thank you doctors so much for joining us today and sharing your expertise and telling other providers about the multidisciplinary clinic for Psoriasis and Psoriatic Arthritis at Northwestern Medicine. To refer your patient, please visit our website@nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.