Joint Ventures in Complicated Patients: Advent of Derm-rheum Clinics

Among health care professionals, discomfort can be the mother of invention, to coin a phrase. Rheumatologists have long voiced uncertainty about managing the dermatologic manifestations of rheumatoid arthritis, psoriatic arthritis, scleroderma and systemic lupus erythematosus, among other conditions. Conversely, dermatologists presented with a patient who exhibits topical signs of an underlying rheumatic or autoimmune condition have been confounded by treatment and management options. The discomfort runs both ways.

The invention, like many great inventions, is a simple one: A place where patients can be seen and treated by specialists in both fields. Thus, the birth of the joint derm-rheum clinic. The need for multidisciplinary care is familiar territory for dermatologists, who deal with the largest organ in the body and, consequently, intersect with a number of other specialties. However, clearly, some of the most challenging overlaps occur with rheumatology. With an increasing number of rheumatologists on board, both patients and clinicians stand to benefit from this one-stop shopping treatment paradigm.

David F. Fiorentino, MD, PhD, professor in the departments of dermatology and immunology and rheumatology at Stanford University, and former president of the Rheumatologic Dermatology Society, and Lorinda Chung, MD, MS, professor of immunology, rheumatology and dermatology at Stanford University Medical Center, are in a unique position to comment on the utility of a joint clinic, having operated one since 2003.

“Having a dialogue between medical specialists is often critical at so many junctures in a patient’s journey,” Fiorentino told Healio Rheumatology. “This includes establishing a correct diagnosis, performing a proper workup, selecting a treatment plan, and, almost more importantly, deciding when and how to alter a treatment regimen.”

But for as obvious as it may seem to treat patients jointly, opening and operating such a facility presents a unique set of logistical challenges that often fall far outside the expertise of the average clinician in either specialty. There are scheduling and billing issues to manage, and clinicians from different worlds must work together to make diagnoses and treat patients without stepping on one another’s boundaries. Yet, because patients with derm-rheum complications can be so difficult to manage, many feel it is worth the effort.

To that point, the derm-rheum approach may sit well with patients, according to Joseph F. Merola, MD, dermatologist and rheumatologist at Brigham and Women’s Hospital, assistant professor at Harvard Medical School and president of the Psoriasis and Psoriatic Arthritis Clinic Multicenter Advancement Network. “Patients are generally incredibly grateful and have high satisfaction with these models,” he said. “Some of the potential challenges in the academic setting can be the large number of individuals seeing a patient at a given visit and the potential for two copays, to name a few.”

A growing body of data are showing both the necessity and utility of combined derm-rheum ventures. In the meantime, as the connections grow and the need for two-way understanding increases, a thorough investigation of these connections is warranted.

Clinical Whack-A-Mole

Gideon P. Smith, MD, PhD, MPH, vice chair for clinical affairs in the department of dermatology at Massachusetts General Hospital, outlined the disease-specific challenges that gave rise to these clinics in the first place. “While autoimmune connective tissue diseases like scleroderma, lupus and dermatomyositis can affect skin and other organ systems, they do not always affect them to the same extent or at the same time,” he said. “While joints or lungs may be in remission, the patient may be having a cutaneous flare of their disease which is what is currently most impacting their life.”

This raises a clinical conundrum: Increasing medication dosages or switching may be appropriate for the skin, even if muscle or joint manifestations suggest lowering dosages or backing off from therapy, according to Smith. “Equally, skin and muscles or joints may respond differently to different medications,” he said.

This is one of the many areas where communication is critical, according to Chung. “A dialogue between a dermatologist and rheumatologist might allow more rational selection of a therapy that is simultaneously directed at both the skin and the other organs,” she noted. “This is opposed to the less desirable situation, for example, where the rheumatologist decides what systemic therapy to prescribe based on musculoskeletal symptoms while the dermatologist may suggest a different therapy that is more likely to alleviate skin inflammation.”

Smith added that some aspects of cutaneous disease are also not necessarily ameliorated by immunosuppression, such as dry skin or calcinosis cutis. “The dermatologist can make a significant contribution in terms of the overall disease management even if primarily managed by rheumatology,” he said. “From a health care cost and a patient-centric care perspective, it is important to minimize medications and blood draws and to try to coordinate care.”

For some clinicians unfamiliar with medical dermatology, there is the misperception that dermatologists may only look at the skin in isolation, without paying attention to what is happening with the entire patient, according to Fiorentino. “In addition, although much of a dermatologist’s work is based around the use of topical therapy for skin disease, many skin diseases are treated systemically,” he said. “It would be so easy if a dermatologist’s role was only to slap on some anti-inflammatory creams and send the patient back to the rheumatologist. Unfortunately, biology does not obey the boundaries of the specialist.”

Clinical trials in a number of diseases bear this out. In their study in Clinical Reviews in Allergy & Immunology, Ferreli and colleagues described the cutaneous manifestations of scleroderma and scleroderma-like disorders. The researchers suggested that a group of scleroderma mimics — which can also be called sclerodermiform diseases, or pseudosclerodermas — “shares the common thread of skin thickening but presents with distinct cutaneous manifestations, skin histology, and systemic implications or disease associations, differentiating each entity from the others and from scleroderma.”

Diagnostic clues to these disorders include a lack of Raynaud’s phenomenon, capillaroscopic abnormalities, or scleroderma-specific autoantibodies, according to the researchers. “As cutaneous involvement is the earliest, most frequent and characteristic manifestation of scleroderma and sclerodermoid disorders, dermatologists are often the first-line doctors who must be able to promptly recognize skin symptoms to provide the affected patient a correct diagnosis and appropriate management,” they wrote.

“Because the manifestations of the rheumatic diseases are so nuanced, it is critical that we have specialists with unique, organ-based expertise, trained to recognize and treat manifestations of the disease,” Fiorentino said. “However, with specialization, we pay a potential price of loss of all around medical expertise. Having two or more physicians with contrasting expertise provides a nice opportunity to minimize this.”

“Greater Than the Sum of Its Parts...”

Another area where communication is critical is simply making an accurate diagnosis. In a recent study in Journal of the American Academy of Dermatology, Griffith and colleagues examined the impact of joint derm-rheum clinics in psoriasis in 111 patients. Diagnoses were altered in about one-third of patients, and most patients underwent a modification of the treatment plan after evaluation in a joint clinic.

“We see time and time again that many diseases require the input of a skilled dermatologist, rheumatologist, and often other specialties, to make the correct diagnosis,” Chung said.

For many of the diseases that fall under the derm-rheum umbrella, a single, simple diagnostic test does not exist. “These diseases are nuanced, often with overlapping features, and require the skill of multiple specialists to arrive at an accurate working diagnosis,” Fiorentino said.

Looking beyond diagnosis, the most important benefit of this collaborative approach, for M. Elaine Husni, MD, MPH, vice chair of the department of rheumatic and immunologic diseases and director of the Arthritis Center at the Cleveland Clinic, is that the two specialties can learn from each other.

“I am not a dermatologist, but I am learning how to describe and diagnose rashes and conduct a topical exam while my dermatology counterparts are learning how to conduct a joint exam and understand the severity of disease in the joints,” she said. “We are each learning how to use DMARDs for different purposes, which is a huge opportunity for any physician.”

Fiorentino noted that not only can the learning process improve care for individual patients, but it can also make participating doctors better at being doctors. “Shrinking the black box that represents the thought processes, skills and therapeutic armamentarium of another specialty truly helps improve one’s own ability to diagnose and manage complicated patients,” he said. “This type of insight is especially critical when you return to your own solo-specialty clinic and you don’t have the luxury of that other specialist with you.”

As more and more joint clinics emerge, the communication can benefit the next generation of experts. “There are tremendous benefits to education where interaction between dermatology residents, rheumatology fellows, medical students and other trainees interact in a unique multidisciplinary setting to cross train in the complex care of these patients,” Merola said. “There is also increased satisfaction among attending providers in the collegial environment.”

In their retrospective review published in Journal of Cutaneous Medicine and Surgery, Samycia and colleagues observed 320 patients seen at a derm-rheum clinic over a 2-year period. The researchers saw a cross-section of SLE, RA, PsA and undifferentiated connective tissue disease patients, along with patients with dermatitis, psoriasis, cutaneous lupus, various types of alopecia and infections. “Skin diagnoses were often unrelated to the underlying rheumatologic diagnosis,” they concluded. “Rheumatologists and dermatologists can both benefit from being aware of the dermatologic conditions that rheumatologic patients are experiencing.”

Within any clinical visit, real-time communication is worth its weight in gold, according to Husni. “In any visit, there is very little time to stop and go talk to another doctor,” she said. “In the joint clinic, it can be done.”

Fiorentino suggested that something “magical” can happen when the two specialists are in the same room together. “The whole often becomes greater than the sum of the two parts,” he said. “Combined specialty clinics allow a real-time dialogue between the providers as they are examining or talking to the patient. This allows each clinician to modify their own history taking or physical examination as it is happening in real time.”

With the input of the rheumatologist, for example, the dermatologist may start to look more closely for a subtle cutaneous finding or be able to better assess contextual relevance of a more obvious skin manifestation, according to Fiorentino. “By being together, each specialist’s encounter becomes appropriately sculpted, which ultimately benefits the patient,” he said.

The positives of such collaboration between specialties is clear. However, a potential red flag is that it raises the need for clinicians to respect each other’s boundaries. “Barriers to such clinics are predictable,” Smith said. “Medicine is sharply divided; often times dermatology is not within the department of medicine but its own entity, and so differences in practice styles or operational standards exist.”

Types of Clinics

While the clinical need for these clinics is obvious, getting one up and running presents an entirely different set of challenges. Of the many considerations to account for at the outset of the project, it must be decided, simply, what the parameters of the operation will be.

“Derm-rheum clinics have grown consistently over the years, with ones focused on specific diseases like scleroderma or psoriasis/psoriatic arthritis to ones that are more general and see all kinds of autoimmune connective tissue diseases,” Smith said. “Different models include jointly-boarded physicians, but also ones where physicians work in parallel.”

The former can sometimes be problematic from a physician standpoint because it requires that same physician to take care of both dermatologic and rheumatologic concerns in the space of just one visit, according to Smith. The latter approach requires providers who have similar approaches to diagnosis, workup and therapy.

“The latter also risks quality and safety issues as with more providers it is essential that it is clearly drawn out ahead of time who will be taking responsibility for what, who orders medications, who follows lab monitoring and whose staff takes care of prior authorizations,” Smith said. “However, either model will work well for patients who can then minimize transportation needs, or trips, or blood draws as care is provided at the same site at the same time.”

Workflow is another consideration, according to Husni. “We have seen where it is done with a simultaneous visit, where the two physicians go in together and examine the patient,” she said. “Then there are successive visits, where the patient sees one and then the other. But can also happen where the rheumatologist and the dermatologist have a relationship, and they have weekly meetings to discuss patients together.”

Merola added that technology can play a role, as well. “We are increasingly interested in continuing to also foster local derm-rheum partnerships in the community as virtual combined clinics,” he said. “These have taken a variety of forms from facilitated communications and expedited appointments between providers to actual clinics occurring in the community with both providers present.”

In their review of more than 20 joint derm-rheum clinics specializing in PsA, Soleymani and colleagues noted that the combined clinics, “have been found to improve outcomes and enhance both patient and physician satisfaction and knowledge.” Scheduling is a key challenge, as is gaining institutional support. “As more of these clinics are established, we must further understand their impact on outcomes and care,” the researchers wrote.

Husni offered practical advice for optimizing outcomes. “Perhaps derm-rheum clinics should focus primarily on more severe cases,” she said. “For patients with mild cases, we can keep the same treatment paradigm.”

More clearly defining the severe cases seen by joint derm-rheum clinics would increase the importance of triage, according to Husni. “Of course, this then raises another problem of who is going to triage these patients,” she said. “We also must decide on the qualifications for mild, moderate and severe disease.”

In short, Husni believes that there are simply not enough physicians, particularly in the rheumatology field, to see every rheumatic disease patient with cutaneous manifestations. “If we try to see everybody, there are going to be shortages of care somewhere,” she said.

Building a Practice

Fiorentino acknowledged that, at the onset, they believed starting a joint clinic would be a “logistical nightmare.” For example, doctors must work out where the visit will occur, who will provide the nursing, and which specialty is responsible for purchasing and stocking which equipment. “It turned out that it was relatively easy to do,” he said. “Instead of having two providers at a separate time and place, you have both providers, with identical patient lists, at the same venue.”

Merola zeroed in on time and money as critical focal points for maintaining a functioning practice, particularly in today’s climate of limited resources. “Support across departments within a hospital system can be challenging in an environment of ever-increasing financial pressures,” he said. “Reducing cost of care and increasing patient volume is critical. We believe the combined clinics save patients time away from work, home and other activities and provide a more rapid time to appropriate diagnosis, therapy and productivity.”

Another important step is actually finding a physician in the other specialty who has a desire to provide care in the multidisciplinary setting, according to Fiorentino. “Most academic providers are not very excited about adding on another clinic to their already busy life, and so a multidisciplinary clinic typically would replace of one of the provider’s solo clinics,” he said. “One problem here is that the derm-rheum encounters are typically longer and so each provider is not able to see the volume that they would be able to in the single-provider setting.”

Choosing a location for the clinic that is convenient for participating physicians can also take effort. “Typically, one of the specialties needs to be willing to provide space and resources for the clinic to operate,” Fiorentino said. “Essentially, the department or division is providing resources for another specialist to see patients and generate revenue. Thus, some clinics have a system whereby there is some sort of reimbursement provided by the specialty being housed.”

As strongly as she feels about the necessity and importance of joint clinics, Husni urged clinicians to think deeply before committing to such a position. “Combined clinics may decrease the ability to see patients in your own specialty, thereby decreasing your productivity in your chosen field,” she said.

As for billing, Smith suggested that as long as separate services are being provided by separate physicians, the visits should be billable, although it is not reasonable for the physicians to bill on time if the patient was seen simultaneously by both physicians. Husni added that patients are often required to pay two copays, which can add up over time. “Even though it is one visit, with two specialties involved, the notes are separate,” she said. “So, when patients are asked to pay $100 instead of $50 for each visit, it makes a difference.”

“This is sometimes an ongoing conversation with both patients and insurance, but both can usually see the value in the approach when it is clearly explained,” Merola added. “For both insurers and patients, it is always best to have that conversation prior to ensure no one is surprised and everyone is in agreement.”

Looking Ahead

“It is hard to think of many downsides of this clinic paradigm,” Chung said. “One potential issue is that the visits are often long, sometimes with an equally long wait time.”

Because it is difficult to nail down two providers in the same location, these clinics do not operate frequently, according to Chung. “This means there are few, precious spots with long wait times for an appointment,” she said. “The relative infrequency of the clinics — ours is once weekly — and clinic openings means that it is often challenging to find ways to urgently see new patients as well as return patients with urgent issues.”

Much of the work is done over the phone or via electronic medical records, according to Fiorentino. “We consistently struggle with this issue, but, ultimately, we are always able to figure out creative ways to make sure a patient is seen in a timely manner,” he said.

The main negative from a patient point of view is knowing clearly which provider to contact when complications arise, according to Smith. “Also, this can make it difficult for patients to know how to schedule a visit if only one organ system is problematic,” he said. “However, a positive is that it increases the number of providers intimately familiar with their case and who have followed them over time.”

In general, though, patients welcome the approach, according to Smith. “It is comforting to have two physicians agree and to know that there is consensus on their diagnosis, workup and initial therapeutic approach,” he said.

To help move the ball forward, Merola noted that both the American College of Rheumatology, American Academy of Dermatology, and smaller advocacy and research organizations have been supporting derm-rheum clinics. “The Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN) and Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) have really met the needs of the community in bringing together derms and rheums around educational and research efforts,” he said.

In the end, though, it will come down to individual relationships; in this case, the doctor-doctor-patient relationship. “Medicine is sharply divided but human disease is not, and whether in combined clinics or separate ones, physicians often find themselves in the position of having to, or trying to, help a patient with an issue that is not strictly within their realm,” Smith said. “What is important is that the patient is the center of everything we do to get them the best and most appropriate care.” – by Rob Volansky

• References:
• Ferreli C, et al. Clin Rev Allergy Immunol. 2017;doi:10.1007/s12016-017-8625-4.
• Griffith J et al. JAAD. 2018;doi: 10.1016/j.jaad.2018.05.235.
• Samycia M, et al. J Cutan Med Surg. 2016;doi: 10.1177/1203475416649138.
• Soleymani T, et al. Curr Rheumatol Rep. 2017;doi: 10.1007/s11926-017-0706-0.

• For more information:
• Lorinda Chung, MD, MS, can be reached at 450 Broadway, Redwood City, CA 94063; email: shauwei@stanford.edu.
• David F. Fiorentino, MD, PhD, can be reached at 450 Broadway, Redwood City, CA 94063; email: fiorski@stanford.edu.
• M. Elaine Husni, MD, MPH, can be reached at 9500 Euclid Ave. A50, Cleveland, OH 44195; email: husnie@ccf.org.
• Joseph F. Merola, MD, can be reached at 221 Longwood Ave., Boston, MA, 02115; email: jfmerola@bwh.harvard.edu.
• Gideon P. Smith, MD, PhD, MPH, can be reached at 50 Staniford St. 2nd Floor, Boston, MA 02114-2517; email: gpsmith@mgh.harvard.edu.

Disclosures: Chung reports associations with Boehringer-Ingelheim, Bristol-Myers Squibb, Eicos, Horizon Pharma, Mitsubishi Tanabe, and Reata. Fiorentino reports receiving research funding and consulting for Pfizer, consulting for Janssen, and being a paid member of the DSMB of UCB. Merola reports consulting and/or being an investigator for Abbvie, Aclaris, Almirall, Biogen, Celgene, Dermavant, Eli Lilly and Company, GSK, Incyte, Janssen, Leo Pharma, Merck Research Laboratories, Novartis, Pfizer, Samumed, Sanofi Regeneron, Sun Pharma, and UCB. Smith reports participating in clinical trials with Abbvie, Allergan, Centocor, Cynosure, Idera, Pfizer, Novartis, Regeneron, and Unilever; and consulting for Boehringer Ingelheim, Cipher Pharmaceuticals, and XOMA. Husni reports no relevant financial disclosures.