In October 2023, Megan E.B. Clowse, MD, MPH, an internationally recognized expert in the field of rheumatology and immunology, stepped into her new role in the Duke University Department of Medicine as the division chief of Rheumatology and Immunology.
In her 18 years at Duke, Dr. Clowse has seen the expansion of the division’s clinical footprint with new faculty, the addition of advanced practice providers, and the growth of its educational and research missions, particularly in the area of lupus.
Clowse plans to continue the expansion and forward trajectory of the division. The cornerstone of her vision is knocking down silos and forging new research and clinical connections across the unit, and potentially across the Department of Medicine and the School of Medicine.
Within the division, Clowse said, there are many investigators conducting synergistic research, particularly with a focus on enhancing clinic care and improving the skills of rheumatologists across the country to provide pregnancy care, better lupus management that meets the needs of patients, and enhanced lifestyle-focused approaches to rheumatic diseases.
Clowse and her team are working to build bridges between providers, advanced practice providers (APP) and researchers to expand the work that is being done, and they are beginning to make a concerted effort to set up more team clinical management of patients.
Building Bridges
“I'm really excited to bring them together, to be able to share knowledge and skills and resources to expand everybody's research moving forward,” said Clowse, an associate professor in the division and in the Department of Population Health Sciences. “Our faculty want to be on a collaborative science team in a clinical care model that works seamlessly and productively. They want more collaboration and more teamwork in our clinical and research efforts. I'm really hoping this will facilitate bonds within our division and allow people to build deep, long careers here in rheumatology.”
Dr. Clowse founded the Duke Autoimmunity in Pregnancy Clinic, created two websites, LupusPregnancy.org and ReproRheum.Duke.edu, to help providers care for pregnant women with diseases like lupus. Her recent research has focused on how rheumatologists can help patients build the families they want as safely as possible. She is also the founding director of the Duke Lupus Clinic (DLC), a model of collaboration known for its clinical care, exceptional training, and innovative autoimmunity research where clinical experiences serve as a springboard for new research and training. DLC is staffed by seven rheumatologists, a rotating APP, fellows and residents, all of whom care for lupus patients in addition to a clinical pharmacist and a clinical social worker.
DLC is one of the largest lupus clinics in the southeast serving over 500 patients annually, 90% of whom identify as female and over half as African American. About half of DLC patients come from medically underserved areas in North Carolina, on average traveling 70 miles to visit the clinic’s providers.
Given the challenging clinical presentation of lupus and other autoimmune diseases, DLC rheumatologists have found that working together and sharing patients has improved the care they provide. It allows doctors to brainstorm improved approaches to care, and decreases provider burnout and stress by increasing the mental and emotional support that physicians can give each other while managing this very challenging disease.
Building on Success
Dr. Clowse plans to build on the success of DLC, which has consistently modeled a patient-centric approach to lupus, incubating such important research discoveries as a new lupus classification and management system, which has been transformative for the practice.
Along with colleagues, Dr. Clowse has classified systemic lupus erythematosus (SLE) symptoms into two categories: type 1, which includes autoimmune inflammation of tissues (e.g., arthritis, cutaneous lupus, lupus nephritis) and type 2, which encompasses the features of systemic lupus erythematosus that are nearly ubiquitous but have unknown causes (e.g., brain fog, fatigue).
To standardize the approach to evaluation and assessment of Type 2 SLE, the team developed the Type 2 Physician Global Assessment (PGA), a visual analogue score assessing Type 2 SLE activity. By implementing the Type 2 GPA into clinical practice, the documented management of Type 2 symptoms greatly improved from 53% to 89% for patients with high Type 2 SLE activity.
Expanding Educational Offerings
One of the division’s distinctive strengths is its education mission, which Clowse also plans to expand. Duke has one of the few and first APP rheumatology fellowship programs in the country. The program has helped grow the division’s APP team, but it also ensures that the APP team really has the skills they need.
“APPS are being hired in rheumatology clinics everywhere, both academic practices and a lot of non-academic practices, without official training, so there is a large unmet need,” Clowse said. “This is a great growth opportunity for us to really expand the educational mission and the brand of Duke into that area.”
Additionally, the division is working to recruit more diverse rheumatology providers. In a program, funded in part by a Diversity, Equity and Inclusivity award from the Arthritis Foundation, Dr. Lisa Criscione-Schreiber, vice chair for education in the Department of Medicine, is educating medical students and providers about inclusive practices in rheumatology while recruiting more students from under-represented groups in medicine.