Returning guest Dr. Ara Dikranian, a rheumatologist at Cabrillo Center for Rheumatic Disease, and a member of the global advisory panel on Pfizer’s RA NarRAtive initiative, discusses the new RA NarRAtive Conversation Guide that helps to improve doctor/patient communications. Visit Pfizer.com/RANarRAtive.
Dr. Ara Dikranian recently joined the Cabrillo Center for Rheumatic Disease. Prior, he worked as a Senior Rheumatologist at the San Diego Arthritis Medical Clinic (SDAMC). Dr. Ara Dikranian joined SDAMC in 2004. “Dr. D,” as he is known to his patients, comes from a long family line of health care providers, following in the footsteps of his father, grandfather and two uncles. His enthusiasm, compassion and love for rheumatology are greater today than ever before.
Neal Howard: Welcome to Health Professional Radio, glad that you could join us once again. I’m your host Neal Howard, our guest today is returning guest Dr. Ara Dikranian. He’s a rheumatologist at the Cabrillo Center for Rheumatic Disease in San Diego California and he’s joining us today to talk about Pfizer’s RA NarRAtive Initiative to discuss this new RA NarRAtive conversation guide that aims to help improve doctor/patient communications. Welcome back to the program Ara.
Dr. Ara Dikranian: Thank you Neal, it’s a pleasure to be here.
Neal: Well for our listeners who may not be familiar with you, give us just a bit of your background. I know that I introduced you as a Rheumatologist there at Cabrillo, describe how many people are dealing with RA.
Dr. Dikranian: Yeah, certainly. So as you said, I’m a Rheumatologist. My practice is in San Diego California and I’ve been in practice for about 18 years after training here in Southern California and I think it’s an exciting time to be a rheumatologist given the new advances that we have in managing patients with rheumatic disease in particular rheumatoid arthritis. And the estimates in the U.S. at least are that about 1.6 million people are living with RA.
Neal: Is RA something that is easily diagnosed and managed once it’s properly diagnosed? Or is it something that’s extremely difficult about a person’s life?
Dr. Dikranian: Yeah, it’s a great question Neal. The diagnosis isn’t necessarily easy in their early stages and a lot of people think that aches and pains and fatigue are just part of our normal daily life or due to stress or activities or what-not. But given the sort of the predominant symptoms of just swelling and stiffness of the joints, if it’s a textbook case of rheumatoid arthritis it’s pretty easy to diagnose but sometimes people don’t fit into neat patterns and so in the early stages it might be a diagnostic dilemma. Once it is diagnosed though, we’re very thankful that there are a number of therapies we currently have that were not available even a decade or two ago – so with that, we’re definitely much better able to manage rheumatoid arthritis in many patients but we still fall far short of achieving true remission being that there’s no cure for this disease. Our medications are helpful but we still have a way to go to find better outcomes for most patients.
Neal: Now Pfizer has spearheaded this initiative and you’re on the global advisory panel for Pfizer’s RA NarRative. What is it about RA that we need to have a better communication between physician and patient? I mean once you’ve got RA you think maybe these aches and pains are something more, is there a problem communicating with the physician or is there a problem with the physician explaining things to the patient?
Dr. Dikranian: Yeah, it’s a good question. So very similar to any other chronic disease that sort of ebbs and flows during its course you, with rheumatoid arthritis there can have periods of remission if they’re well controlled on therapy. They might have periods of flares but really what what this RA narRAtive initiative has uncovered is that there’s an opportunity to have better conversations and the reason for that is because many physicians believe that patients are settling for treatments that really only make them feel good enough even though RA affects their daily lives. And so there’s a bit of settling that comes across in many patients and patients may necessarily not feel comfortable bringing up concerns, they might feel that they might negatively affect their relationship with a physician if they ask too many questions or bring up too many problems. So really this one of the findings out of the RA narRAtive was that we just need better communication in terms of physicians understanding a little bit better where patients are coming from and then patients understanding that in the limited time that they have available with a physician is to maximize and make most efficient use of that time.
Neal: So when you say that patients are settling for something that makes them feel good enough, you’re talking good enough to function at work or maybe in participate in a few sports? But there are management techniques and strategies to make them feel extremely well, almost as if in remission with no symptoms and discomfort whatsoever.
Dr. Dikranian: Right, so that very small group of patients whose disease really goes into remission on treatments where they have no functional impairments and have no symptoms of RA are a relatively lucky group but it is, it is a small group. For the majority of patients, we’re talking about a relative improvement compared to how they were before treatment. So patients are very often very symptomatic, in many cases are not able to go to work, are not able to take care of their daily needs and their personal and family requirements. So for those patients, a relative improvement with a therapy is wonderful, they feel better. But our goal is really to bring them closer to remission, is really to treat them to these targets – the target being remission. So it’s really important to set goals for a patient because goals are going to be individually different from patient to patient depending on their age, their station in life, what their activity levels are and really it’s our job to tailor those treatments to meet those goals. But when we say settling or settling for good enough, one is taking a short term view on how patients feel today but also taking a longer view because when we leave patients with some disease activity, we always run the potential of irreversible joint damage – the joint damage that we see particularly on x-rays and that can lead to poorer functional outcomes in the future.
Neal: You did mention a limited amount of time that a patient has with the physician. Is there a difference when you’re scheduling your appointment? How do you let your physician know that, “I need more than 12 minutes with you?” Are we talking about scheduling a normal appointment or actually setting up some type of meeting and meaningful dialogue?
Dr. Dikranian: Yes, it’s a great question as well. So one of the one of the outcomes from this RA narRAtive is the power your inner RA voice conversation guide and one of the hallmarks of this conversation guide is to remind patients that we’re really not having visits with our physician, we should be having more conversations. And if we frame it in that point, one of the recommendations from this conversation guide is to ask patients to write down specific items that they’d like to share at their next appointment because we all have busy lives and other things to worry about and we might forget to bring up things that we might consider important today if our appointment is a month from now. So a lot of what what we recommend patients write down ‘focus on four main things.’ One is to focus on the wins that they’ve made since the the last appointment so ability to do things they weren’t able to do easily before; to write down the problems that they continue to have; to evaluate the goals that we set, have we met those goals? Do we have new goals that we need to achieve? And then finally questions that that they’d like to ask their physician so it’s really making an efficient use of that limited time and preparing for that visit and trying to have a conversation more than just showing up because they have to.
Neal: Having been a patient myself, not necessarily of RA but a patient in general, we tend to second-guess ourselves once we sit down with our physician and maybe tell them a little bit and let them show their expertise and tell us what we need. Don’t we know ourselves well enough to convey that information to the physician in a meaningful successful way?
Dr. Dikranian: Absolutely and that’s really the crux of this conversation guide is that patients know themselves the best and if we leave it really just to the physician to guide our management and treatment, we might be falling short in terms of meeting the goals that are important to us. So sometimes from a patient’s perspective, it’s difficult to bring up areas where we have either unmet needs or trying to bridge the divide between a physician who especially in rheumatoid arthritis may be focusing on the more objective parts of the disease. The swollen joints and the functional outcomes, some of the lab abnormalities maybe but then sort of forgetting to also incorporate areas where the patient might could use some improvement. Comorbidities such as depression, anxiety, issues with function future employability. “Am I going to be able to keep on taking care of my kids?” All of these things that may not necessarily come up which are critically important especially to a patient unless the patient feels comfortable bringing it up.
Neal: In wrapping up Doctor, when it comes to RA, sometimes the person who’s suffering with RA isn’t able to communicate on their own. They’ve got a caregiver or someone, a relative that’s taking care of them basically. Does this Pfizer RA narRAtive conversation guide address how a caregiver can get the conversation started on behalf of the patient?
Dr. Dikranian: It sure does and that was one of the findings in the re narrative initially that’s been addressed in this conversation guide. Is that it really takes a village to help manage a patient. I as a physician am not able to do it on my own nor is my office staff, so it really takes patient advocacy groups, patient advocates, family or friends or someone really to be a spokesperson for the patient such that when she or he forgets to mention a problem that they were having or maybe tries to minimize something because the doctor seems to be in a rush, that advocate or friend brings up and helps the patient, motivates the patient to bring up these issues that otherwise may not necessarily get addressed. So absolutely, that’s a very critical
element of the RA narRAtive conversation guide.
Neal: Where can we go it’s more information about this narrative guide?
Dr. Dikranian: Yeah, so the resources that are available to both patients and physicians are found at www.pfizer.com/news/press_kits/RA_Narrative/About-Changing-the-RA-Narrative
Neal: As always, it’s been a pleasure Doctor. I’m hoping you’ll come back and give us some more information really soon.
Dr. Dikranian: Well we appreciate being back Neal and it’s really gratifying to shed light on this topic so thank you for having us.
Neal: You’ve been listening to Health Professional Radio, I’m your host Neal Howard. Transcripts and audio of this show are available at hpr.fm and at healthprofessionalradio.com.au