Michele M. Cerra, MSN, FNP-C: Nancy, let's take a minute and talk about the important role… nurse practitioners and physician assistants have in managing patients with psoriatic arthritis.

Nancy Eisenberger, MSN, FNP-C: We play a huge role in taking care of our patients. We do thorough exams just as our physician counterparts do. We do a lot with education, and education is so important. My patients always comment on the fact that I explain things, and I'm sure any of my nurse practitioner colleagues say the same thing. We will sit there and teach our patients. We don't just treat them, we educate them. We teach them their own self-efficacy as well. Again, in my practice I work with 16 physicians, and I'm the only nurse practitioner.

Michele M. Cerra, MSN, FNP-C: Wow, that's wonderful. Tributes to you.

Nancy Eisenberger, MSN, FNP-C: It keeps me busy, but it's good. I see some of my own patients, but I also see all of theirs. I see when they come up with flares. I must help them learn more about their medication, and about how to stop these flares, because with 16 different physicians in the practice, they all have different styles and ways to teach their patients. We can sit there and take that extra step, and we understand their medications as well; [we] understand all the symptomatology of the disease so we can take that time and make sure our patients understand it as well.

Michele M. Cerra, MSN, FNP-C: I know with nurse practitioners and physician assistants, we're at the front line in the clinics. We're in clinic full-time [whereas] some of our rheumatologists are doing more teaching and research, so we're seeing more patients. I see new patients and we see new patients as NPs (nurse practitioners) and PAs (physician assistants) in our practice, so we're making the diagnosis. Making that diagnosis correctly and early will help prevent joint deformities and disabilities and improve their quality of life. How [do] I go about diagnosing psoriatic arthritis? It's looking at the pathophysiology, which we know from years of managing these patients, looking at their genetics, their family history, looking at any preexisting or preceding infections, viral or bacterial. I also ask them about any trauma to any joints or injuries, and looking at imaging whether it's a muscular skeletal ultrasound, an x-ray. We know MRIs are hard to get, but we could get those if we've done ultrasound and x-ray. Earlier you had mentioned CRP [C-reactive protein]. We know in these patients we cannot rely on that because we could see dactylitis, enthesitis, synovitis on exam and that CRP is normal. It’s not only looking at lab markers; it's listening to the patient, taking a detailed, great history which includes their family history, and I always put in my notes for a new patient onset: tell me how long ago this started and describe to me what happened. Did you wake up one morning with a swollen heel or a swollen joint or your back started hurting? We advocate for our patients and part of that advocacy is teaching them about their disease state. Duke has a fellowship for family practice NPs and PAs, so 1 week a month I get a new family practice NP and PA and teach them what they don't get in school. We don't get much in our teaching and education for rheumatology. They spend a week with me and then they have a contact if they need to refer a patient. They could email me with a question. With the shortage of rheumatologists currently—and we know that's going to get worse—training NPs and PAs in rheumatology is important now.

Nancy Eisenberger, MSN, FNP-C: Every physician that I've worked with has told me how much they appreciate all their nurse practitioners or physician assistants that have worked with them because we enhance their practice. Again, like you said, the shortages right now are crazy. It's very difficult to find rheumatology providers.

Michele M. Cerra, MSN, FNP-C: How many times have you heard…a patient [ask], “Do I have to see the rheumatologist once a year, or do I have to see them every other visit? I only want to see you.” I say, if you're comfortable with that, I'm fine with it, but if something turns up out of the ordinary, I might have you go for 1 visit. There's that relationship when they believe in you and they trust you. It means everything with compliance and how they're going to do with their disease.

Nancy Eisenberger, MSN, FNP-C: I don't know about you, but I work in a little bit more time. I mean they're 15-minute follow ups, but I have breaks in between, so if I run a few minutes late, then I can give the patient some time.

Michele M. Cerra, MSN, FNP-C: We're fortunate to have 30 minutes for a follow-up, and that's if the patient is on time, and then 1 hour for a new patient, so I'm thankful for that.

Transcript edited for clarity.