Psoriatic arthritis (PsA) impacts multiple organ systems, in addition to the joints and skin, requiring collaboration between not only rheumatologists and dermatologists but also other specialists to optimize patient care. Rheumatologists generally see patients with PsA for the first time only after joint symptoms have developed, making the framework for interdisciplinary care critical for optimal patient outcomes.

Rheumatologic diseases such as PsA affect many organs, not just the joints and skin, and that is where multidisciplinary care comes in. Treating PsA is a “team sport”; we have to be agile and adjust based on the patient’s needs. We are always looking to our dermatologists and other subspecialists (eg, cardiologists and mental health providers) whenever we have a patient with multiple organ involvement.

Dermatology is the first specialty that comes to mind; in fact, dermatology-rheumatology clinics are the most common in terms of multispecialty care clinics. Dermatologists typically see patients with PsA first, and rheumatologists see them when joint symptoms develop. Other specialists can also get involved early and pick up clues that are not obvious to the dermatologist. It is a lot to expect one physician to be responsible for not only the biologic treatment of PsA but also the metabolic syndrome–related management, weight management, and mental health care. Interdisciplinary teams that work together offer coordinated decision making, which is really what we want at the end of the day.

Combined dermatology-rheumatology clinics have been shown to improve diagnostic precision and treatment options for PsA. In a big city, there are a number of dermatologists and rheumatologists, but a rheumatologist practicing in a more rural setting may not have a dermatologist nearby or in the same system. This is where it is important to note that multidisciplinary care does not have to look the same in every place. The way that we do it here at Cleveland Clinic may be different from how you do it somewhere else. However, the more important thing is that you have a framework for this. For example, it could be just 2 or 3 physicians who you know have an interest in PsA or 2 or 3 physicians who are interested in psoriasis. I think that our job is to show people the evidence that a combined clinic or more communication does help the patient with PsA and does improve outcomes. There is no single ideal care model.

Technology has facilitated interdisciplinary care, but I prefer more direct communication, such as a phone call. It cannot be assumed, for example, that a note has been read or that an advanced practice provider in dermatology is particularly interested in treating PsA. And if you send a note to the wrong practice, it does not matter how good the note is or how much you communicate with that practice because the staff is not going to want to see these patients. Sometimes just sending notes and messages does not provide the full picture.

In addition, patient and clinician priorities in PsA do not always coincide, which is called “discordance.” Not uncommonly, physicians may believe that the patient is doing well when the patient actually feels differently. Sometimes it is just not possible to obtain all the information during a 15-minute office visit. The discordance can also go the other way, where, for example, the clinician wants to switch medications due to disease progression, but the patient says that they are doing well and does not want to switch.

A lot of what drives this discordance are measures that we do not know how to treat well, such as fatigue. Many patients with PsA experience extreme fatigue, and yet their clinical measures all look great. In these cases, we can look at nonpharmacologic options. Comorbidities can also cause discordance, and oftentimes, if you do not consider those comorbidities, you cannot get the PsA under control.

Overall, I think that shared decision making is critical for understanding how a patient experiences their disease, what part can be taken care of by DMARDs, and what part cannot.