We are delighted to welcome Dr. Iris Navarro Millan into our midst. Iris was a joint recruitment between the Division of General Internal Medicine and Division of Rheumatology, as an Assistant Professor of Medicine. She joins us from University of Alabama in Birmingham. She received her medical degree from Universidad Autónoma de Guadalajara School of Medicine in Guadalajara, Mexico. She then completed both the Internal Medicine Residency and her fellowship in Rheumatology at University of Alabama. Her area of expertise is cardiovascular disease in patients with rheumatoid arthritis.
Dr. Fred Pelzman: We want to welcome you to New York and have you tell us a little about what brought you here and your research, and introduce you to the Weill Cornell Community.
Dr. Iris Navarro Millan: Thank you, I’m delighted to be at Cornell. I’ve been looking forward to it for a long time and I am so thrilled to finally be here. I’m a rheumatologist and my background is in rheumatoid arthritis (RA), with a special focus on cardiovascular disease (CVD) risk reduction in these patients. But, why should we care about CVD risk in RA? Well, CVD is the most common cause of death in patients with rheumatoid arthritis and also causes mortality of about 10 years earlier than in patients who don’t have RA. This is a national health issue, and when I was working in outcomes research I realized I wanted to do something about it. I paired with Dr. Monika Safford at the University of Alabama at Birmingham (UAB) before she moved to Cornell, to develop tools and interventions that can potentially change and decrease this risk. While working on this development, I realized that I also needed more diversity in terms of expertise, patient populations and cultures. I wanted to work with a more diverse population, especially Hispanics and Puerto Ricans, since I’m Hispanic myself. The faculty expertise on intervention development and implementation at Weill Cornell Medicine and HSS, one of the top rheumatology programs in the nation, is very impressive. Transitioning my career to Weill Cornell Medicine and HSS was a natural next step moving forward.
Pelzman: It’s unusual to see a specialist in internal medicine. How does it feel working with primary care folks?
Navarro: It feels great. At the same time, I felt a little lost at the beginning. In the conferences here in GIM they were talking about endocrine issues or aging, cancer, etc., and honestly, all the conferences that I have been attending for the last few years have been really focused on rheumatology. But I realized recently how important it is to keep in touch with your knowledge of general internal medicine. I’m also learning that to advance the care in rheumatology we still need to be very connected with our internal medicine knowledge and our colleagues. Another interesting part is the amount of curbside consults that I got from GIM faculty in our floor. It is fascinating to have this type of conversation with primary care, even off the clinic. It helps you understand each other's thought process and feel connected with what really matters to our colleagues and not only to what matters to us as specialists.
P: Do you see your work being applied more to rheumatologists, or internists? Who do you think needs more?
N: I think it’s both. You want to give focus of the education to rheumatologists about the importance of comorbidities in patients with RA, because they don’t only come with RA. They have hypertension, depression, anxiety, etc. As my main focus is on CVD risk reduction, and CVD is usually assessed my PCPs, currently there is a huge under-recognition from PCPs about the high burden of cardiovascular risk that exists in RA patients, which is indeed equivalent to that of diabetes. This is one of the reasons that I decided to join the GIM Division in addition to the Rheumatology Division. To try to work with both specialties and bringing their needs to the front page at the same time that we do the patient’s needs and priorities.
P: Do you think primary care doctors are too quick to refer to specialists for these conditions?
N: Remember, rheumatologic conditions are very rare and as specialists that is what we see every day. For a PCP this may be a diagnosis that is encountered by them very rarely. So, in a case of a doubt, there is never such thing as too quick to refer. The outcomes of patients with rheumatic diseases improves with early treatment so, early referral, even if there is no clear rheumatic diagnosis in the end, is a reasonable thing to do. On the other hand, we found in one of our studies using a large dataset, that around 18% of patients with RA do not see primary care. We also identified that co-management of primary care and rheumatologists increase the likelihood of screening for hyperlipidemia among RA patients by around 32% compared to care by only rheumatologists. Maybe rheumatologists need to be referring back to PCP, right? I am very interested in the aspects that PCP have to deal with as part of their practice and how the care of rheumatic diseases can be better coordinated between these two types of physicians. I needed to get back to internal medicine to understand that, so here I am.
P: We’ve heard about the inflammatory state increasing the risk of cardiovascular disease in RA patients for years. Why do you think this message hasn’t gotten across to primary care givers to be more aggressive with these patients?
N: Some of the work that we are trying to do, is to develop education about this topic for PCPs and rheumatologists. We have generated data about the role of inflammation in this area and hopefully this will serve as the basis for including RA as a condition with high CVD risk into the cholesterol treatment guidelines. Once it is there I think the message will be more clear across the medical community. More recent recommendations in the European Rheumatology include the screening and management of cardiovascular risk factors among patients with RA. This recommendation is quite recent though.
P: Are rheumatologists starting to address CVD risk in RA patients?
N: That’s an issue of ownership of a problem. Who takes the ownership of the CVD modifiable risk factors, primary care or the rheumatologists? This comes back to the issue of coordinated care. There is a gap there and what is everyone’s role? Rheumatologists sometimes feel that management of CV risk factors, are out of their scope as specialists. As I mentioned earlier, our data suggests that no, rheumatologists are still not taking ownership of the CVD risk in patients with RA. More importantly, should they? Or should this be addressed by improving coordinated care between PCPs and rheumatologists? I think that this will be elucidated with time, more clearly if RA is included into the general CVD treatment guidelines. This will tell us the direction that we should take. In the meantime, we need to take some action, and I think the most immediate approach is in improving coordinated care between doctors. They can decide who will manage what and in which way, but this should still be well coordinated and currently is not.
P: We’re on the 20th floor of the Baker building here. It’s a long ride up. Give me your elevator pitch of what you hope to accomplish here at Cornell.
N: The big hope that I have is that what we do here at Cornell and HSS serves to make the medical community aware of the cardiovascular risk that exist in RA and other rheumatic diseases. I am very interested also in empowering patients with rheumatic diseases to participate in their care, to bring their interests first and to help them overcome any potential barriers that they may have to obtain the care that they deserve.
P: What’s been the biggest shock moving to New York?
N: The cold! Coming from the South, the winter down there was not really winter compare to this!
P: Thank you.