There is limited written experience regarding combined clinics in other fields that include rheumatology, and although the literature on combined clinics often suggests benefits to education, no actual data on this aspect appear to exist.
Challenges have been documented in the literature regarding combined clinics, and we have had our issues as well, such as scheduling. In my ILD/rheumatology clinic, all my patients are combined, but the three ILD pulmonologists have other patients on their schedules. Occasionally, patients needing a combined visit must wait to see both based on the schedule of the pulmonologist. This issue is easiest to handle at clinics employing the different-specialists, same-time strategy.
Productivity is an issue, too. Dermatologists usually see 12–15 patients in a half day while we academic rheumatologists see about half that. On the flip side, patients referred to a combined clinic are usually more complex and, thus, billing is at a higher level.
Billing can prove challenging as well, with most providers billing via their respective service centers. Thus, patients may see two bills.
We have seen turf wars among support staff. For example, if a patient needs a medication preauthorized, which clinic is responsible? The clinic where we spend the most time in general rheumatology, the clinic with experience doing preauthorizations for immunosuppressive medications or the clinic we attend once a month or once a week as part of the combined clinic? We finally divided and conquered by having the combined-clinic staff handle the oral medications and the rheumatology clinic staff handle the biologics and infusions. Diplomacy skills are definitely needed in such situations.
Finally, institutional buy-in is important to obtain the needed space and support staff to make it all work. Combined clinics can be a local or regional draw to the institution, and I suspect they have a favorable downstream revenue profile even though the institution may remain reluctant to admit it.
Personally and professionally, I find working in combined clinic settings one of the highlights of my career. Thinking about patients using different specialist eyes has broadened my horizons and has helped me look outside my rheumatology box.
I recently spent two weeks in Saipan as a visiting professor, and the lessons I’d learned from my combined clinic colleagues back home helped me be more useful to the patients and clinicians of the island. I saw several patients with complex psoriasis and a patient or two with ILD. No problem; I knew what to do. All I had to do was ask myself, “What would Dr. Kalus (our dermatologist) or Dr. Ho (our pulmonologist) do in this situation?”