Psoriatic arthritis

PsA treatment suboptimal as rheumatologists and dermatologists work in silos


The management of psoriatic arthritis (PsA) may be suboptimal because rheumatologists and dermatologists feel untrained to treat aspects of the conditions beyond their primary speciality scope of practice, an Australian study has found.

While many rheumatologists would like to worked in a shared care model of practice with dermatologists to manage PsA, there are many professional and systemic barriers especially for physicians working in private practice and in regional areas, according to a survey of 15 rheumatologists and 12 dermatologists.

The qualitative study conducted by NSW rheumatologist Dr Daniel Sumpton found that the desire to provide patients with comprehensive care for PsA was hampered by inter-disciplinary uncertainties over management of the skin and joint manifestations of the condition.

Both rheumatologists and dermatologists reported hesitation managing outside of their specialty, with one dermatologist saying : “In terms of actually diagnosing psoriatic arthritis I have to say I’m probably not fantastic at it, because I really just ask them about where they have joint pains, arthritis, any past history of anything like that. I do not really investigate the joints, and I do not have any specific psoriatic arthritic questions per se”

Similarly a rheumatologist expressed uncertainty over treating a PsA patient with potent topical steroids who developed fragile skin.

Dermatologists had a lack of confidence in screening tools to identify psoriatic arthritis, with some believing they were too sensitive and concerned that they would be overburdening rheumatology services by referring patients with mild osteoarthritis.

But when they managed joint pain in patients with PsA, dermatologists said they felt hesitant about working outside their scope of practice, and felt that rheumatologists were more familiar with using biologics.

“I might start them on a biologic thinking they do not have psoriatic arthritis, and then, later on, they do get psoriatic arthritis. Then their arthritis reveals itself, there’s a bit of a lag and then I go, ‘Oh, if I’d had them on a different biologic that’d not have happened’, so I never quite know what the best biologic is to prevent the appearance of psoriatic arthritis,” said one dermatologist.

Several respondents said time constraints meant they were already overburdened and had to default their own disciplinary priorities.

“On the list of things I have to get through in a clinic, if they have not got bad [skin] disease or they do not report it, then perhaps I think it’s lower on the list of priorities and things I have to get through. Therefore, it just falls to the bottom of the pile,” said one rheumatologist.

Some physicians expressed frustration at having to work in silos when dealing with patients who had overlapping comorbid diseases such as PsA, and described a state of “learned helplessness” over fragmented care because they felt health service administrators failed to recognise the merits of multidisciplinary services.

The identified many other barriers to providing shared care such as financial costs for patients, lack of interest or access to other specialists and geographical constraints.

But in their paper Dr Sumpton and co-authors argues that there is a need for innovative strategies to develop and implement efficient and flexible models of shared care, that cover clinicians in different setting such as solo practice and regional areas.

Different models of shared care might include the use of telehealth and “parallel clinics” where patients are seen in separate but nearby clinics with discussion between specialties on the same day of consultation.

Participants who already worked in shared care models in public hospitals said they not only provided more patient-centred care but improved collegiality and enhanced training and education.

“I think we are able to provide the best outcome for our patients by having a clearer picture of their disease and making the right choices with them. And, as I said, managing the patient rather than the disease. So, just because we are a dermatologist, we are not just managing psoriasis, and because they are a rheumatologist, they are just not managing psoriatic arthritis. We’re managing the patient,” said one dermatologist.

The findings are published in Clinical Rheumatology.

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