A DISCONNECT Among Rheumatologists, Dermatologists and Patients

By M. Elaine Husni, MD, MPH

Patients with psoriatic arthritis commonly have both skin and joint symptoms and, ideally, their treatment should be co-managed by both rheumatologists and dermatologists. Optimal treatment should rely on shared decision-making between patients with chronic inflammatory diseases and their physicians.

To assess how well these ideas occur in practice, a group of researchers including myself recently conducted a study in which we assessed the differing perceptions that patients and physician specialists have about symptoms associated with various organs involved in psoriatic disease.

The DISCONNECT study, recently published in Arthritis Research & Therapy, sought to determine which manifestations of these conditions are the most bothersome to patients as well as which symptoms practitioners felt were most bothersome to patients.

Online questionnaire

We used online surveys for both the patient and the physician cohorts that were designed using a best-worst scaling (BWS) technique, which enabled us to estimate the relative importance to patients, rheumatologists and dermatologists of the various types of joint symptoms and their impacts.

In each BWS question, patients were asked to identify the most and least bothersome symptom from a five-item subset of 20 items if they were to experience all five symptoms.

Physician surveys included eight different BWS questions repeated for two of three possible patient profiles (mild, moderate and severe). They were asked to choose which of a five-item group of the 20 items listed they felt would bother a patient most and least, if that patient had all five symptoms.

Survey results

A total of 200 patients and 300 physicians completed the survey. The most interesting difference between patients and physicians was that physicians assessed bother to patients highly for a few important symptoms, while patients indicated additional items as equally bothersome.

The most notable difference between physicians was that dermatologists ranked embarrassment, difficulty with social or leisure activities, and flaking skin and redness of skin as relatively more bothersome compared with joint pain, soreness or tenderness. In contrast, rheumatologists considered difficulty shopping or doing housework or yard work and swelling of fingers and toes as relatively more bothersome than joint pain, tenderness or soreness.

Ask cross-specialty questions and listen carefully

These disparate findings are important for the management and treatment of patients with psoriatic arthritis. First, both rheumatologists and dermatologists should talk to patients about skin and joint symptoms and impact on daily life, rather than assessing based only on symptoms related to their respective specialty.

Our results also showed that both specialists may differ from patients in what symptoms they believe are most bothersome. This suggests the need for both rheumatologists and dermatologists to listen carefully when asking patients about symptoms that harm their quality of life so they have a complete understanding of their needs and can find the best course of treatment.

Dr. Husni is Director of the Arthritis and Musculoskeletal Center.