We live in an era of specialization in the medical profession, so patients with psoriasis, psoriatic arthritis, and co-occurring conditions will require a number of different doctors.
I live in an urban area in California, so I have had the good fortune to have a choice of talented dermatologists (“derms”) over the years. Early on, my treatments were medicated shampoos, topical treatments, and phototherapy, which were limited to what was available and considered effective at the time. Occasionally, a treatment seemed bizarre but turned out to work. At one time, I was referred to a derm who would inject small doses of cortisone directly into my psoriatic lesions. I felt like a pin cushion, but it worked.
My most unusual experience involved a derm that I liked personally, but his knowledge of psoriasis was limited. On many visits, he would assemble his derm colleagues in the examination room and I would share with them the latest treatments available for psoriasis (based on what I learned at National Foundation board meetings). I have found that derms who are affiliated with an academic medical center are the most knowledgeable and up to date on medications.
I was fortunate to have found a very capable rheumatologist who guided me through my arthritis for over 35 years and served as my primary care doctor. When I was diagnosed with PsA, there were no treatments specifically prescribed for PsA, so I took medications that had been developed for rheumatoid arthritis, mostly nonsteroidal anti-inflammatory drugs. Later, I took disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate. In the early ‘90s, I took gold injections and then oral gold medicine, but their use has been discontinued due to side effects.
In 1999, I started with biologics. After I had six major joints replaced, one rheumatologist has told me that he would only advise me regarding non-replaced joints (neck, elbows, wrists, hands, ankles, toes), and he would leave the replaced joints to the orthopedic surgeon.
Orthopedic Surgeon (Joint Replacements)
I first saw an orthopedic surgeon in 1996, when my left knee locked at a 90-degree ankle. He corrected an issue with my meniscus and removed excess synovial lining of the knee. In a follow-up visit, he took X-rays of both knees and both hips, and told me I was a candidate for total replacements of both sets of joints. This was extremely disappointing news, but I was resigned to whatever would come next. In 1999, I had double knee replacement surgery, and in 2006 and 2015, I had my right hip and then my left hip replaced. Finally, I had both shoulders replaced in separate surgeries. At present, I do follow-up surveys with the hip and shoulder surgeon, and I am now seeing another local surgeon for IT band issues.
In 2015, I was having pain in my legs, so several orthopedic and spine surgeons recommended an infusion of cortisone into my spinal column at L4-L5, the attachment point for nerves to the legs. I was not willing to undergo such a procedure without a second and third opinion.
After two of three planned infusions, I had a regularly scheduled blood test. The next day my doctor tracked me down to inform me that my blood glucose had skyrocketed to 590, and that I must see an endocrinologist immediately.
Needless to say, I did not take the third spinal infusion, and the endocrinologist diagnosed me with type 2 diabetes. This was not a total surprise, since my father and both brothers had diabetes. I thought that I had “dodged that bullet,” but no such luck. The evening of the diagnosis, I had a minor breakdown when I went to bed, sort of a “Why me?” episode. I had seen the impact of diabetes on my family. My survivor instinct kicked in, and ever since, I have been aggressively treating the diabetes with weight loss, careful diet, insulin injections, and supplemental injections. Fortunately, the diabetes is under control, with a normal A1c score.
I first saw a nephrologist after I took Bactrim short term to treat cellulitis (when I was also taking methotrexate), because of an elevated creatinine score. I discontinued the methotrexate and have started taking a blood pressure medication that has begun to normalize my creatinine score.
Recently, I had sharp pain in my left shoulder and left abdomen. After an ER visit, I was diagnosed with pneumonia and pleural effusion and was treated with two rounds of antibiotics. I will be having follow-up visits with a well-regarded UCLA-affiliated pulmonologist who is a fellow board member of a local hospital.
Sad but true that when you have this many doctors, it is important that you serve as your own quarterback for your course of treatment. It is most important to keep each of the doctors and your pharmacy apprised as to your current medications and any changes therein, to avoid any adverse interactions among the drugs. Although my first rheumatologist also served as my primary care doctor, I have learned that rheumatologists today no longer serve in that role.
Fortunately, the adoption of electronic health records has enabled each of these doctors to have ready access to my medical records, and in my case, has facilitated a concerted effort to always be on top of my multiple health conditions.
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