Interview Transcript - General Practitioner #4 Date: October 20, 2025 Interviewee Type: HCP (General Practitioner) Location: Rural Health Network, Wyoming Years in Practice: 28 years Specialty: Family Medicine Psoriasis Patient Volume: ~45 patients with psoriasis Interview Content: Interviewer: Thank you for meeting with us. Can you describe your practice? HCP: I've been practicing family medicine in rural Wyoming for 28 years. I'm part of a small health network that serves four towns across about 150 square miles. It's me, one other physician, three nurse practitioners, and two physician assistants. "We're the primary healthcare for about 8,000 people - ranchers, miners, small business owners, retirees. We see everything from prenatal care to end-of-life care, and everything in between." Interviewer: What's your experience with psoriasis in this population? HCP: I probably have 45 patients with psoriasis on my panel. Most are mild to moderate - I manage them with topical steroids, moisturizers, sometimes coal tar products. "For severe cases, I should refer to dermatology, but the nearest dermatologist is 140 miles away in Billings. That's a 3-hour drive each way. Most of my patients can't or won't make that trip, so I end up managing more psoriasis than I probably should." Interviewer: What systemic therapies do you use? HCP: Methotrexate is my go-to for moderate-to-severe psoriasis that doesn't respond to topicals. I've been using methotrexate for psoriasis and rheumatoid arthritis for years, so I'm comfortable with it. "The efficacy is moderate - maybe 40-50% of patients get significant improvement. The side effects can be rough - nausea, fatigue, hair thinning. But it's affordable, it's familiar, and I can monitor it with basic lab work." Interviewer: Have you prescribed biologics? HCP: I've prescribed one biologic in my entire career - adalimumab for a patient with rheumatoid arthritis. It was a nightmare. The prior authorization took six weeks. The patient had to drive to Billings to see a rheumatologist for the initial prescription. Then we had to coordinate refrigerated delivery to her home. "After that experience, I've been hesitant to prescribe biologics again. It's just too complicated in a rural setting without support infrastructure." Interviewer: Have you heard of Dermovia? HCP: The name is vaguely familiar. Is it a newer biologic for psoriasis? Interviewer: Yes, it's an IL-17 inhibitor that launched about 18 months ago. It's dosed every 12 weeks. HCP: Quarterly dosing is interesting. That would address one of the concerns I have about biologics - frequent administration. "But I still don't think I'd prescribe it. I don't have the training, I don't have prior auth support, and I don't have easy access to dermatology if something goes wrong. In rural practice, you have to stay within your comfort zone." Interviewer: What would make you more comfortable prescribing biologics? HCP: A few things. First, clear protocols and algorithms - 'If patient meets X criteria, prescribe Y drug, monitor Z labs.' Second, telemedicine support from a dermatologist who I could consult with easily. "Third, simplified prior authorization - if insurance companies trusted family physicians to prescribe biologics for appropriate patients without jumping through hoops, that would help. Fourth, patient assistance that works for rural patients - simplified paperwork, flexible delivery options." Interviewer: Do any of your patients end up on biologics through specialist referral? HCP: Very few. I've had maybe three patients over the years who were so desperate that they drove to Billings repeatedly to see dermatology and get on a biologic. "All three had good results - their skin cleared dramatically. But the logistical burden was huge. One patient drove to Billings every month for injection administration because she didn't want to self-inject. Eventually, she stopped going because it was too much." Access is the biggest barrier in rural healthcare, not knowledge or even cost. Interviewer: How do you manage that frustration - knowing treatments exist but patients can't access them? HCP: It's part of rural medicine. You do the best you can with what you have, and you accept that sometimes the best isn't good enough. "I've learned to focus on what I can control - prescribing affordable medications, providing education and support, connecting patients with resources. I can't control that dermatology is 140 miles away or that biologics cost $80,000 a year." You make peace with the limitations. Interviewer: Do you use telemedicine? HCP: We've started using telemedicine more since COVID. We have a teledermatology service where I can send photos and case descriptions, and a dermatologist reviews within 48 hours. "That's helpful for things like rashes, suspicious moles, acne. For psoriasis, they usually recommend topicals first-line, which I'm already doing. If systemic therapy is needed, they say 'refer to in-person dermatology,' which brings us back to the access problem." Telemedicine helps, but it doesn't solve everything. Interviewer: Have you done telemedicine consultations for biologic prescribing? HCP: No. I don't think teledermatology in my network does biologic prescribing. Even if they did, there would still be the prior auth, the cost, the monitoring. "And honestly, if I'm going to manage a patient on a biologic, I want the safety net of being able to call a dermatologist with questions. I'm not sure telemedicine provides that level of support." It would need to be a very robust program. Interviewer: What about phototherapy? Is that an option? HCP: Not in rural Wyoming. The nearest phototherapy center is in Billings, same as dermatology. Patients would need to drive there 2-3 times a week for weeks to months. "That's just not realistic for working people or those without reliable transportation. I've never had a patient successfully complete a course of phototherapy." It's another treatment that works in theory but not in practice for my population. Interviewer: How do you screen for psoriasis comorbidities? HCP: Psoriasis is associated with metabolic syndrome - obesity, diabetes, hypertension, high cholesterol. My rural population already has high rates of those conditions, so I'm vigilant. "Every psoriasis patient gets annual blood pressure checks, lipid panels, diabetes screening. I ask about joint pain for psoriatic arthritis." If I find comorbidities, I treat them aggressively because they're likely at higher risk than the general population. Interviewer: Do you see psoriatic arthritis often? HCP: Yes, fairly often. Psoriatic arthritis can be really debilitating - swollen, painful joints, difficulty working. "The challenge is that there's no rheumatologist within 200 miles. So I end up managing it myself with NSAIDs, sometimes methotrexate. The outcomes are okay but not great." These patients would benefit from specialist care and probably biologics, but access is the barrier. Interviewer: How do patients cope with limited treatment options? HCP: They're pragmatic. Rural folks are used to making do with what they have. "I've had patients say, 'Doc, I know there are fancy new treatments out there, but I can't get to Billings every month. Let's just do the best we can with what we've got here.'" Some patients are frustrated, but most understand the constraints. They appreciate that I'm trying. Interviewer: Do you ever feel like you're practicing outdated medicine because of these constraints? HCP: Sometimes, yes. I read medical journals, I go to conferences, and I see what's possible - biologics achieving 90% clearance, JAK inhibitors, personalized medicine. "And then I come back to my rural practice where I'm still using methotrexate and clobetasol because that's what's accessible. It's disheartening." But I also remind myself that I'm providing care to people who wouldn't have any care otherwise. That's meaningful. Interviewer: What role does patient education play in your psoriasis management? HCP: It's huge. I spend a lot of time explaining what psoriasis is, why it happens, what we can and can't do about it. "I'm honest with patients. I say, 'This is a chronic condition. We have treatments that can help, but we're limited by geography and cost. We're going to do the best we can with topicals and maybe methotrexate. If you're willing to travel to Billings, we can explore more advanced options.'" Setting realistic expectations prevents frustration. Interviewer: Do you address the mental health impact of psoriasis? HCP: Absolutely. Psoriasis can be psychologically devastating, especially in a small community where everyone knows everyone. "I've had patients who avoid church, family gatherings, the local diner because they're self-conscious about their skin. I screen for depression and anxiety." If they're struggling, I'll start them on an SSRI or refer to our behavioral health team. Sometimes treating the depression helps them cope better with their psoriasis. Interviewer: Have you had success stories with psoriasis treatment? HCP: Yes, several. I have a 52-year-old rancher who'd had psoriasis for 20 years. We tried various topicals with limited success, then I started him on methotrexate. "Within four months, his skin was 60% improved. Not perfect, but good enough that he felt comfortable going to town without a long-sleeved shirt. He told me, 'Doc, I can shake hands without worrying people will think I'm contagious.' That's a win in my book." Interviewer: What about patients who don't respond to anything you try? HCP: Those cases are hard. I've exhausted my options - multiple topicals, methotrexate, even tried apremilast once though it was expensive - and the patient is still suffering. "At that point, I really push for dermatology referral, even if it means driving to Billings. Some patients do it, some don't. For those who don't, all I can do is provide emotional support and keep trying." It's one of the frustrating parts of rural medicine. Interviewer: If biologics became easier to prescribe - simpler prior auth, better support - would you consider using them? HCP: Maybe. "If there were clear protocols, telemedicine backup from a dermatologist, and the administrative burden was manageable, I'd consider it. Quarterly dosing like Dermovia would be more feasible than monthly or weekly injections." But I'd need to feel confident that I could manage side effects and complications. In rural areas, if something goes wrong, there's no specialist down the hall to bail me out. Interviewer: What would you tell pharmaceutical companies about rural healthcare? HCP: Understand that rural healthcare operates differently. We don't have support staff for prior authorizations. We don't have easy access to specialists. Our patients can't drive hours for appointments. "If you want your medications to reach rural populations, make them simple to prescribe, affordable, and deliverable to patients' homes. Provide telemedicine support for prescribers. Offer flexible patient assistance programs that don't require mountains of paperwork." And price them reasonably. $80,000 a year is obscene. Interviewer: What about biosimilars? Do you think those will improve access? HCP: In theory, biosimilars should lower costs and improve access. But I haven't seen that trickle down to rural practice yet. "Biosimilars are still expensive, still require prior auth, still need specialist oversight in most cases. Until biosimilars are priced like generic methotrexate and can be prescribed by family physicians without bureaucracy, they won't solve the rural access problem." Interviewer: How do you stay updated on psoriasis treatments? HCP: I go to regional family medicine conferences when I can - usually once a year. I read journals, though I'll admit psoriasis isn't a focus. "I subscribe to clinical decision support tools like UpToDate, which help me manage conditions I don't see every day. And I learn from my patients - they'll sometimes tell me about treatments they've read about, and I'll research them." But my education is generalist-focused, not dermatology-specific. Interviewer: Do pharmaceutical reps visit your practice? HCP: Rarely. We're too remote and too small. "I might see a rep once or twice a year, usually for something common like diabetes medications or antidepressants. I've never had a rep come to talk about psoriasis biologics." In a way, that's fine - I'm not going to prescribe them anyway, so the marketing would be wasted on me. Interviewer: If you could change one thing about psoriasis care, what would it be? HCP: Access. "If every patient with moderate-to-severe psoriasis could see a dermatologist within a reasonable distance and get effective treatment without financial hardship, that would be transformative. The medications exist. The knowledge exists. The barrier is geography, cost, and healthcare infrastructure." Those are big systemic problems that go beyond psoriasis, but they're solvable if there's political will. Interviewer: What keeps you practicing in rural areas despite these challenges? HCP: I love this community. I've delivered babies, treated three generations of families, been part of people's lives in profound ways. "Rural medicine is hard, but it's also incredibly rewarding. You're not a cog in a machine - you're a trusted partner in your patients' health. The relationships matter." And even with limited resources, I know I'm making a difference. Interviewer: Any advice for younger physicians considering rural practice? HCP: Be prepared to be a generalist in the truest sense. You'll manage things outside your comfort zone because there's no specialist to refer to. "Lean on telemedicine, decision support tools, and your colleagues. Be humble - know your limits and don't be afraid to say 'I don't know, but let me find out.' And be resourceful - you'll need to make the best of limited resources." But if you can handle those challenges, rural medicine is deeply fulfilling. Interviewer: Any final thoughts on psoriasis management in rural primary care? HCP: Just that we're doing the best we can with what we have. "Rural primary care physicians care deeply about our patients, including those with psoriasis. We're frustrated by the barriers - access, cost, complexity - but we keep trying. We need systemic changes to improve rural healthcare, not just for psoriasis but for all conditions." Until then, we'll keep being resourceful, compassionate, and committed to our communities. Interviewer: Thank you so much for your time and candid insights. HCP: You're welcome. I hope this sheds light on the realities of rural practice.