Psoriatic Arthritis Diagnosis and Patient Communication

John Tesser, MD: Jen, I want you to chime in here and join the discussion. In terms of your angle as a nurse practitioner, we have physician assistants [PAs] in our practice, too, and we all work integrally together; give us your view on all of this.

Jennifer Simpson, DNP: It’s definitely very important when we’re dealing with these patients in the office and we’re seeing a patient come in, and they just know they’re in pain. They don’t really fully understand what’s going on, and there are a lot of different things that could be going on. There are so many different types of arthritis. It’s really getting down to the nitty-gritty where advanced practice clinicians prove how we are such an asset to our particular practices. As nurse practitioners and PAs, we are spending time with the patient and asking these deep, in-detail questions. Where’s your pain located, how does it bother you, and what patterns is it following? Is it worse in the morning? Does it get better with activity? These are some questions patients maybe haven’t even thought about before. They just know they’re in pain. They just know they’re not feeling well, so they don’t necessarily think about it in these terms. We’re trying to tease out those details for them so we can really understand what’s going on. There could be more than 1 thing going on.

We’re getting all those details from them and asking them those specific questions. How long is that stiffness lasting in the morning? Are you having sausage-like swelling to the digit? They’re not going to know what dactylitis is. They’re not going to know what enthesitis is. It’s asking them those specific questions and getting those details so that way we can really make that diagnosis and get them on the right treatment, and then explain to them what’s going on. That way we get their buy-in. That way compliance and their outcomes are going to be better, right? If they understand what’s going on, they’re going to be more willing to be on track with us to get the disease under control so that they do have fewer complications and fewer comorbidities.

John Tesser, MD: I totally agree. I will tell you that on my team, I have 1 of each; I have a nurse practitioner and a physician assistant. As we all do, I believe all of the teams work this way, that we have our APCs, we call them advanced practice clinicians. We don’t like to be called providers, and we don’t believe that our advanced practice clinicians like to be called providers either. We’re very unique in using the term APC. But I think we all work similarly in that we have the APC go in and see the new patients first and do that detailed work that you mentioned. They go over all the organ systems, take a look at all the organ systems, palpate all the organ systems and the musculoskeletal system [with the patients] and then come back and present to the rheumatologist. Then we go back in with them and go over the important findings.

Now, this is a very critical asset and advantage we have, working in those teams because, from the patient’s perspective, they have 2 rheumatologists on the case, not just 1. So they have 2 rheumatologists gleaning through the history, going over the details of the physical examination, and then assessing the entire situation as we get laboratory test results and imaging in, and coming to a proper diagnosis and a treatment plan. As far as I’m concerned, our APCs are critical to how we practice, and I think they’re critical in terms of value to the overall patient care. Jen, what about the patient/provider-centered approach? Do you think the patients appreciate this for the most part?

Jennifer Simpson, DNP: Yes, I think our patients are pleasantly surprised when I spend the whole time with them to get down to that history, asking them all these in-depth and detailed questions that, as I said, they haven’t even thought of before. Then I tell them after we’re done with all this, “Now I’m going to talk to the physician I work with, tell them about all this, and then we’re going to come up with a plan of how we’re going to help to diagnose this and figure out what’s going on. And we’re going to come back in, and we’re going to talk to you about that.” Many, many times the look on their faces is like, “Oh wow, I get another person who I’m going to have this conversation with? OK, great.” They feel like they’re in great hands. They feel very well taken care of in that someone is actually listening to them and that we’re going to figure it out and help them feel better. I think it’s a really great start to their care but also a really good, I guess, place for them to end up. They’ve been dealing with these issues for months, maybe years, and we’re hopefully going to have answers for them because I think most of our patients, this is what they want, they want answers, they want explanations for how they’re feeling.

John Tesser, MD: Absolutely. Nehad, is that how your team works too?

Nehad Soloman, MD: Yes, that’s exactly how we work in our team. I wanted to add the 2 heads are better than 1 concept. When we discuss this with the patient, they can see it. There’s banter back and forth. There’s getting input back and forth, and they see it. It also helps with future management as well when they call, if they speak to me or they speak to the advanced practice clinician, then ultimately they know, “Oh, these are the same people I saw initially. It’s not somebody else that I’m speaking to but actually somebody engaged in my care.” I think the other aspect of this dynamic team approach is our ability to get patients in the door a lot faster than most community rheumatologists in the nation. As we know, there’s a workforce shortage. Certainly, more rheumatologists are retiring. God bless you, John, for sticking around. But the reality is there are more retiring than there are graduating. Part of that is an aging rheumatology population.

Jennifer Simpson, DNP: An aging population.

Nehad Soloman, MD: An aging population, so the demand is going on. Part of it is also that fellowship programs aren’t expanding, and the use of advanced practice clinicians I think is critical for our field in particular. But I think also the dynamics in medicine in general, there’s a greater and broader use, at least today, compared to the way it was 20 years ago, even I would say 15 years ago, where advanced practice clinicians weren’t as broadly used, in particular in subspecialties. I’m grateful to have that option for our patients so that we can get them identified, treated, and put on the path toward health.

John Tesser, MD: I know sometimes I walk into the room and do my thing with the APC, and the patient is in there. And the patient says, “Oh, by the way, she’s great.” I just know that our people do a great job. Let’s get into section 2, which we’ve dubbed the management of psoriatic arthritis. Nehad, you had mentioned the CASPAR [classification criteria for psoriatic arthritis] criteria for diagnosis, and I think you eminently pointed out that the criteria for diagnosis, like most classification criteria, have been formulated for the purposes of identifying patients who, from a uniform enough criteria, that we all agree have this disease that we call psoriatic arthritis. And then they would be eligible to be included in a protocol where we’re going to have uniform patients with the same disease state. But that has only certain implications for management.

I do want to make a point about that though, which is very helpful in terms of understanding when someone has the disease. The first point about the CASPAR criteria that must be applied is that the patient has an active inflamed joint, or an active point of dactylitis or sausage digit, or tendonitis, a swollen tendon. You need to have that as a physical finding before you can really apply the rest of the criteria, which have to employ psoriasis, or a history of psoriasis, a negative rheumatoid factor, or bony changes on x-ray.

This transcript has been edited for clarity.