Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives - Episode 3
Melodie S. Young, MSN, A/GNP-C: I know you also have a big sphere of influence among a lot of other nurse practitioners, NPs, and PAs [physician assistants], and even physicians. They sometimes look to us and say, “You know stuff that we don’t know. You look at things a little differently because you’re trained as a nurse.” How do you encourage people to develop those relationships so that patients will tell you how much this disease is affecting them, and maybe begin to hope? How do you instill hope and trust in people?
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: Mel, you’ve done this for 30-plus years now with psoriasis, and that’s the No. 1 biggest thing. The average psoriasis patient sees anywhere from 4 to 7 providers before they find one that they say listens to them and that they trust. Developing that relationship is absolutely essential because they want someone who will listen to them and take some time. Yes, initially, it may take some time to develop that relationship and spend some time chatting with them.
I can tell you that visits with patients with whom I’ve developed those relationships have control of their disease. It’s a 5- or 10-minute visit, and they are the most rewarding patients to take care of. It’s one of the first things I love to do when I have a new psoriasis patient. I’m thrilled when I see them on my schedule because, to me and Mel, who is the same way, this is an opportunity. I think of it as a gift that we can give our patients to say, “I'm so glad that you are here.” This is absolutely the disease I love taking care of. I say, “You and I are going to become dear friends.” I tell them that I’m going to give their kids graduation cards, and they’re going to give me expensive Christmas gifts. I say, “We're in this for the long haul.”
One of the important things that one of my patients taught me was not to overwhelm patients in that first visit. I want to give them tons of information. As nurse practitioners, physician assistants, nurses, and physicians, we feel obligated to educate our patients, but patients can get overwhelmed. You tell them that they have psoriasis, that we don’t have a cure for it, and that there are all of these comorbidities associated with it. They could get joint disease, heart disease, and diabetes, but we can help them, and we’ve got injections for them. Their mind is going crazy.
I have learned that you give them bits of information. The first visit might be 20 minutes where we talk and say, “This is the disease that you have. You and I are going to be in this for the long haul. You’re going to let me know what your goals are and what your disease is keeping you from doing. I’m going to give you information about the different aspects of this disease in pieces. I’m going to give you all the different treatment options that are available and out there for you, and you and I will come to a mutual decision about what’s going to work for you, your family, and your lifestyle. We’re going to make this. My goal for you is that when you wake up in the morning, psoriasis isn’t the first thing you think about.”
Melodie S. Young, MSN, A/GNP-C: One of the first things I like to do is, I like to touch them because they feel like their skin is unclean, dirty, and ugly. I will often touch them. I don’t hesitate to touch psoriasis. I also tell them right off the bat, “Oh, I’m so excited to meet you. This is my favorite disease. It’s so exciting because we have some awesome therapies. We ought to be able to get this disease controlled for you. Tell me what your life would be like if you didn’t have to think about psoriasis, if I can help get rid of this disease.” A lot of times, that’ll bring tears for both of us, but when you instill hope, then they begin to trust you. Then you say, “We have lots of choices,” and I ask them a few questions. I try to zero in on what I maybe shouldn’t offer or what would be best for them, and then they begin to trust me.
Over time, we will talk about more things, and they’ll sometimes say, “What’s going on in research?” They used to ask that all the time. They’ll say, “I’m seeing new drugs advertised. Tell me about those. Should I stay what I’m on, or should I change?” They’ll ask about infections, immunizations, and other topics that we can delve into. Oftentimes, I make the whole pinky promise thing, or get them to commit. I’ll say, “If I get your skin clear, and I think I can because we’ve got drugs that can do that now, and if I don’t get it with the first agent, hopefully, I’ll figure out shortly thereafter what’s going to be the best drug for you. We’re going to start focusing on your general health.”
They will tell you that they often won’t get a haircut because nobody wants to touch their scalp. They haven’t gone to the doctor because they’re embarrassed to undress in front of an internist. They sometimes do not like to take their clothes off when you see them. You have to do it slowly. If you can do a full-body check, that’s great.
The other thing you said is, look at them as a whole. Get them to trust you. Show that you care. Show that you have therapies that will encourage them. If you’re not comfortable, if you know enough about psoriasis to say, “I can teach you about it, but I'm not the best at treating it. I don’t have enough of these types of patients.” Your expertise may be surgery, cosmetics, or something else. Then say, “I know people who are really good at this” and start working to try to get them to the right person.
What I’ve seen is that then I can also focus on other things. I know you know that as well, but I can’t tell you how many skin cancers we’ve found on patients or how many of them we’ve helped to take better care of themselves. I had a patient this morning, and he was so proud because his skin is the best it’s ever been. The first thing he said was, “I'm down 15 pounds,” because he just feels better about himself overall. I told him, “Look, the skin is no longer going to be your focus. Instead of spending hours a week rubbing on creams and ointments or trying to do phototherapy, if I can look at some of these other treatments, you can spend that time having fun with your family, enjoying your work more, and focusing on your health.”
Transcript Edited for Clarity