A Special Clinic

There is a unique multidisciplinary clinic every Monday afternoon in Redwood City that focuses on the dermatologic and immunologic aspects of systemic sclerosis. Professor of dermatology David Fiorentino, MD, PhD, helped found the clinic close to 20 years ago because, as he says, “I saw a huge gap in the care of some patients if different doctors weren’t communicating in real time regarding patient care.”

Having patients seen simultaneously by both a dermatologist and a rheumatologist solved that, and the clinic is so successful, says Fiorentino, that “access is a big problem. We’re always scheduling a minimum of three to four months in advance. That is literally our biggest challenge, and it has been almost since the beginning of the clinic.”

The process that patients follow when they attend this clinic is unusual in several ways. For one thing, says Fiorentino, “we don’t see anyone in the clinic whose medical information has not been personally reviewed by either Dr. Chung or me or both. Patients carry around misdiagnoses of rheumatic diseases quite commonly, and clinic appointments are so precious that we need to make sure the appropriate patients are seen in our clinic.”

When patients arrive, they are assigned to a room where their vital signs are recorded and their medications are reconciled. They also change into a gown, which is unusual for rheumatology patients but not for dermatology patients because the skin needs to be examined. Then they are seen by a rheumatology fellow and a dermatology resident together, who go over the history, followed by targeted physical exams. The rheumatology fellow does a general medical examination with a focus on the joints and muscles. The dermatology resident assesses the skin to see how tight it is and to look for other specific skin markers of scleroderma.

After the trainees report their findings to Chung and Fiorentino and they come up with a reasonable plan, all four physicians go into the patient’s room, where, Fiorentino says, “we confirm important parts of the history with the patient, briefly examine the skin, and point out to trainees any unusual findings that might be helpful either diagnostically or prognostically. Patients often have a list of questions, as they’ve waited three or four months, and they’ve often traveled very far for the appointment.”

“At the end of the visit,” Fiorentino says, “Dr. Chung and I always bring up that we do research in the disease. We explain why it’s important to study actual patients and that complex rheumatic diseases are poorly modeled in the laboratory. We stress how rare their disease is and that this is an opportunity to turn the pain and suffering of their disease into something profoundly important and positive. When the patients better understand this perspective, 95% of them agree to be part of our research cohort and donate tissue.”