Cheryl sits down with Rheumatologist Dr. Percy Balderia to discuss what a rheumatologist is, and how rheumatology patients can get the most out of their provider interactions. This episode is available on Simplecast and all major podcast platforms!
Cheryl (rheumatoid arthritis patient and occupational therapist) and rheumatologist Dr. Percy Balderia discuss:
- 1:00-2:00: –Â What is Rheumatology?
- 2:00Â – Â Why did Dr. Balderia choose to become a Rheumatologist?
- 04:50- Day in the life of a Rheumatologist
- 06:45 – How to build a good relationship with your provider & prepare for appointments
- 11:16- What should patients know about Rheumatology?
- 13:07- Meeting the mental health needs of people with chronic illnesses
- 14:02- How to pick the best treatment plan & utilize supports available to you!
This interview was originally conducted in April 2019.
Dr. Percy Balderia is a rheumatologist who sees patients at The Polyclinic Madison Center and The Polyclinic Downtown in Seattle, Washington. He has a special interest in rheumatoid arthritis. He trained at the University of Washington and was awarded The Arthritis Foundation fellowship.
Thank you to our podcast interns, Sarieni & Laura from The Modern OTs podcast, for your help in editing this episode!
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Full Transcript:
[00:00:00] Cheryl:
[Introductory music]
​Hi there. I’m so excited to welcome you to The Arthritis Life podcast where we share arthritis life stories and tips for thriving with autoimmune arthritis. My name is Cheryl Crow and I am passionate about helping people navigate real life with arthritis beyond joint pain. I’ve been living with rheumatoid arthritis for 20 years and I’m also a mom, occupational therapist, video creator, support group leader, and I created the Rheum to THRIVE self-management program.
I am so excited to help you live a more empowered life with arthritis. We’re going to cover everything from kitchen life hacks, to navigating the healthcare system, to coping with friends who just don’t get it. Seriously, no topic is going to be off limits on this podcast. My interviewees and I share our honest stories of how chronic illness affects our lives. This includes discussions about mental health, sex, shame, pregnancy, body image, advocacy, self-acceptance, and so much more. You’ll hear stories from all ends of the spectrum from a person who’s living in medicated remission from psoriatic arthritis to somebody living with severe mobility restrictions and severe pain from rheumatoid arthritis.
You’ll hear how people manage their conditions in different ways like medications, mindfulness, movement, social support, work accommodations, and so much more. You’ll also hear from rheumatology experts who just get it. We’ll dive deep into the science behind chronic pain and what’s the latest evidence for lifestyle changes that can help you thrive with arthritis, including exercise, sleep, nutrition, stress reduction, and more. This is your chance to sit down and chat with a friend who’s been there. Ready to figure out how to manage your arthritis life? Let’s get started.
Hi everybody, I’m so excited. Today, I’m talking to Dr. Percy Balderia. He is going to tell us what rheumatology is and give us some advice for newly diagnosed patients. All right, let’s get started.
Hi, my name is Cheryl Crow, and I am passionate about helping people navigate real life with arthritis. I’ve lived with rheumatoid arthritis for 17 years, and I’m also a mom, teacher, and occupational therapist. I’m so excited to share my tricks for managing the ups and downs of life with arthritis. Everything from kitchen life hacks to how to respond when people say, “You don’t look sick.” Stress, work, sex, anxiety, fatigue, pregnancy, and parenting with chronic illness. No topic will be off limits here. I’ll also talk to other patients and share their stories and advice. Think of this as your chance to sit down and chat with a friend who’s been there. Ready to figure out how to manage your arthritis life? Let’s get started.
So, what is a rheumatologist?
[00:02:58] Dr. Percy Balderia:
Well, first, thank you for having me here. So, a rheumatologist is an internist who underwent further subspecialty training to diagnose and manage systemic autoimmune conditions and musculoskeletal diseases.
[00:03:14] Cheryl:
And so, what is an internist, if people don’t know?
[00:03:17] Dr. Percy Balderia:
So, an internist is a specialist who deals with adult patients.
[00:03:23] Cheryl:
So, what kinds of patients do you see?
[00:03:26] Dr. Percy Balderia:
So, the typical patients that I see have rheumatoid arthritis, lupus, psoriatic arthritis, osteoarthritis, and gout.
[00:03:36] Cheryl:
Okay. What inspired you personally to become a rheumatologist?
[00:03:41] Dr. Percy Balderia:
Yeah, that’s a good question. So, I knew early on that I wanted to be in a field where I can see patients long-term, where I can help patients manage their conditions for a long period of time.
[00:03:51] Cheryl:
Okay.
[00:03:53] Dr. Percy Balderia:
So, I started in residency in internal medicine, and then when I was in residency, I gravitated towards rheumatology, because I love the diagnostic dilemmas.
[00:04:03] Cheryl:
Oh, haha, thank you for loving that, because the patients don’t always.
[00:04:08] Dr. Percy Balderia:
Right, and I was excited by the therapeutic advances in the field. And also, I knew then that I could have a tremendous impact on patients.
[00:04:20] Cheryl:
Yeah, I mean, that sounds amazing. And when you say diagnostic dilemmas, can you explain a little bit, maybe to the layperson, what you mean by that?
[00:04:30] Dr. Percy Balderia:
Right. So, in rheumatology, most of the conditions that we see, you know, there’s no single blood test, right? Or exam finding that diagnoses the condition.
[00:04:40] Cheryl:
Right.
[00:04:41] Dr. Percy Balderia:
And a lot of the conditions that we see also are what we call diagnosis of exclusion, right? So, you can have a positive rheumatoid factor or a positive anti-CCP and not have rheumatoid arthritis, for example. Or, on the other end, you can have negative tests for rheumatoid factor or anti-CCP, which are markers for rheumatoid arthritis, but still have the disease.
[00:05:15] Cheryl:
Right, so it’s kind of like if I fell off, you know, a ladder, and it broke my arm. I go to the ER, and they take an X-ray, and they’re like, “Your arm’s broken. I can see it right there,” where rheumatology is kind of, feels like the opposite.
[00:05:18] Dr. Percy Balderia:
Right.
[00:05:19] Cheryl:
You’re like, that could be, kind of like in Dr. House, it could be lupus. It could be lupus. It could always be lupus.
[00:05:25] Dr. Percy Balderia:
And also, I mentioned most of the conditions are also diagnosis of exclusion, right? So, you want to make sure that what the patient is having is not explained by another disease.
[00:05:37] Cheryl:
How do you cope, I’m curious, with all this ambiguity or gray areas? Like, I feel like for me, it would make me kind of anxious or feel overwhelmed.
[00:05:48] Dr. Percy Balderia:
Well, I think a big part of it is being up to date with information, right? Because, the more you know about the different conditions, the more you are better equipped to deal with the uncertainty and the patients are leaning on you to help them make decisions.
[00:06:08] Cheryl:
Right, that makes sense. Yeah, most of the patients, I’m assuming from my own experience, are like a little bit confused by the time they get to you because they’re like, okay, maybe I’ve Googled this a little bit or I have a friend who might have had something similar, but it could be so many different things.
[00:06:22] Dr. Percy Balderia:
That’s right.
[00:06:23] Cheryl:
Having a provider who’s really well-informed and can help patients deal with the ambiguity is like worth its weight in gold. So, I wanted to also see if you could maybe walk the audience through just a typical day as a rheumatologist.
[00:06:37] Dr. Percy Balderia:
Right, so I spend most of my day here at the rheumatology clinic. So, as I mentioned, I see patients with rheumatologic conditions and most of the conditions are diagnosis of exclusion, right? So, I ask them about their medical history. I try to explain their symptoms, thinking about what other potential conditions may cause them, right? And then, when I examined them, I look for evidence of joint tenderness, joint swelling. If there’s a discordance between the history and the physical exam, sometimes I do joint ultrasounds.
[00:07:10] Cheryl:
Oh, okay.
[00:07:11] Dr. Percy Balderia:
And then, we discuss the most likely diagnosis, we talk about the treatment options, and then we make a decision together. Sometimes I also do joint injections.
[00:07:22] Cheryl:
Oh, right, right. How, on a given day, how many patients do you see? On average, maybe that are brand new, that are going through the diagnostic journey versus the ones that are for, you know, the three-month follow ups or the continued care?
[00:07:37] Dr. Percy Balderia:
Right, so I see about maybe five or six new patients.
[00:07:41] Cheryl:
A day?
[00:07:42] Dr. Percy Balderia:
Right.
[00:07:43] Cheryl:
Oh, my gosh. Wow, that’s a lot.
[00:07:45] Dr. Percy Balderia:
Right. And then, maybe, you know, eight to ten follow-up patients.
[00:07:53] Cheryl:
In one day? Wow.
[00:07:55] Dr. Percy Balderia:
That’s a busy day.
[00:07:56] Cheryl:
Okay, yeah. Wow. That’s crazy. I’m amazed, because in my field, in occupational therapy, you have an hour with each person, typically. So, you would only see, like, eight total, and that would be, like you said, a busy day. But, and you normally, for a follow up appointment or a chronic long-term patient, you would have 20-minutes, is that right, typically?
[00:08:16] Dr. Percy Balderia:
Yeah, 20- or 30-minutes.
[00:08:17] Cheryl:
20 or 30, okay. And then with the new patient, do they get more time?
[00:08:20] Dr. Percy Balderia:
Right. I usually give them an hour.
[00:08:22] Cheryl:
Okay. In general, since you’re developing these relationships with patients, you know, over a long period of time and they learn to trust you and confide in you. I general, do you have any advice for how patients, maybe a newly diagnosed patient, can develop a good working relationship or therapeutic relationship with their provider?
[00:08:43] Dr. Percy Balderia:
Right, so, first, you mentioned that the conditions that we treat usually require long-term management, right? So, you gotta find that provider whom you feel comfortable with, right. You gotta find someone whom you feel like your personality matches with his or hers, right. Someone whom you can trust. And we know that here at the polyclinic, so we have, you know, a group of very diverse, you know, seven board-certified rheumatologists. Because, you know, you might not like the first rheumatologist you see, and that’s okay.
[00:09:18] Cheryl:
So, you think, yeah, I’ve seen on social media or in person talking to other patients, they’ll talk about maybe, you know, doctor shopping or kind of going — so, you support people maybe making sure that they find a good fit long-term.
[00:09:33] Dr. Percy Balderia:
Right, so you gotta find someone who you trust, right? But trust goes both ways, right.
[00:09:38] Cheryl:
That’s what I was thinking too, yeah.
[00:09:39] Dr. Percy Balderia:
So, you gotta tell your doctor what medications you’re taking. Or what medications you are supposed to take, but you aren’t, right?
[00:09:47] Cheryl:
Yeah, yeah. I remember when I first started being a chronic illness patient, I just wanted to talk forever to the doctor each time. I didn’t really, I knew what they tell you what time the appointment starts, but not when it ends.
[00:09:58] Dr. Percy Balderia:
Right, that’s right.
[00:10:00] Cheryl:
So, you know, and I think as the provider, maybe you have to kind of subtly, you know, end the conversation sometimes.
[00:10:06] Dr. Percy Balderia:
And also, I think you have to balance, you know, hearing the patient, but also trying to find out information so that you can help the patient. Sometimes what the patient wants to say is not necessarily matched with what the doctors want to hear, for the purpose of making a diagnosis.
[00:10:25] Cheryl:
That’s so true. And I think on the other hand as a patient it can be confusing because I’ve had appointments like where I’ve had things going on, not just my rheumatoid arthritis, but kind of unknown mysteries. And I’ll go through the whole history and I’ll say something kind of offhand like I didn’t think was important. And then, the provider might be like, “Oh, wait, no, that’s really important.” So, I think it’s hard as a patient to know that, like, wait, everything I say could be important. I don’t have the medical expertise to know what’s important or not.
[00:10:51] Dr. Percy Balderia:
Right.
[00:10:52] Cheryl:
But maybe the fact that, like, I really want to get a dog, it’s probably not important. But I might really want to talk about the dog.
[00:10:57] Dr. Percy Balderia:
Unless you have allergies, of course.
[00:10:58] Cheryl:
Oh, yeah, that’s true. No, I just remember I saw, I recently saw a provider. And he was asking me, like, “So, what are your goals?” It, you know, it was a psychology provider, and I was like, I want a dog. And so, I’m like, maybe they had some deeper meaning of that. But I was also like, okay, maybe he means, like, goals for actual therapy. Not just fun goals. You know, are there any, like, logistical tips or tricks you have?
[00:11:21] Dr. Percy Balderia:
Well, I think just being prepared for the appointment, right. I think you have to have, like, a goal. What do you want to get from that particular appointment? Because you’re right, you know, unfortunately time is limited, right. But something needs to be addressed, right. So, you know, just being ready. Maybe bringing a list of your medications before you go to the appointment. Maybe, you know, thinking about your family history before going to an appointment. You know, maybe asking your relatives. Maybe your mom or dad got diagnosed with something that you just didn’t know about.
[00:11:55] Cheryl:
Yeah, I think I’ve noticed a lot of facilities recently will give you the intake paperwork earlier, which is so great. And there, I thought at first, oh, they’re doing this so that saves them time, but it also allows you as the patient to not be so kind of on the spot, like, “Oh, shoot I don’t remember, did my grandpa have basal cell skin cancer or melanoma?” Like you couldn’t have the time. So, and I know a lot of patients — I mean, I’ve tried much a bunch of different approaches, but they might do you know a list on their phone that they keep track of to ask Dr. Gorman, and I just have a running thing that I edit each time I see her. She’s my rheumatologist here at the polycinic. And so, you know, I say, okay, I asked this one last time, so this time, so you kind of triage it yourself to say, okay, if you put it in priority order, so maybe my number one priority is look, my bottom of my foot is super inflamed right now. But my joints are quiet. Like what’s what do I do about that?
[00:12:49] Dr. Percy Balderia:
That’s right. So, I think that’s a good tip.
[00:12:51] Cheryl:
Oh. Oh, thank you. I’m here to provide tips. What are some things maybe you wish patients with arthritis or inflammatory arthritis like conditions, what do you wish that they knew about rheumatologists or rheumatology as a field?
[00:13:07] Dr. Percy Balderia:
All right, so one is that the conditions that we see, they’re diagnosis of exclusion, and usually there’s no single blood test or exam finding to make the diagnosis, right? I think the other important thing is, especially with the advent of all the ads on TV, you know, a lot of the patients are really concerned about side effects of medications, right? When you hear the ads on TV, they go on and on and on, from infections to cancer. But the vast majority of patients actually do tolerate their medications. And while side effects are potential, you know, what’s happening, let’s say you have rheumatoid arthritis, the pain and swelling and the inflammation in the joints, it’s happening, you know, right now. It is very real and it needs to be controlled.
[00:13:53] Cheryl:
That’s so, so true. Actually, I didn’t even know there was, that methotrexate had this reputation for being this really difficult to tolerate medication until I was active on some social media groups. And I kept seeing people talking about the methotrexate hangover, and the methotrexate horribleness, and I kept thinking, what are they talking about? You know, but it had, ‘cause I try not to think about the side effects, I want to be aware of which would be the most potentially serious, of course. But it’s kind of like, yeah, it’s a little bit of a double-edged sword going through the Internet, and it’s wonderful to connect to other patients and not feel so alone, and to get general advice, but it also can — people’s horror stories can scare each other off.
[00:14:34] Dr. Percy Balderia:
Right. And the good thing is we have so many treatment options. For example, for rheumatoid arthritis, that if you actually do not tolerate methotrexate, for example, you can be on other treatments.
[00:14:45] Cheryl:
Right. Right. Your experiences with patients, you know, not maybe the newly diagnosed, but the ones who have been living with chronic illness for a long time, do you ever have to, you know, refer them maybe to mental health support, for just the kind of maybe anxiety or depression that can come along with that?
[00:15:03] Dr. Percy Balderia:
Well, that’s right. So, one, depression rates are higher in patients with chronic diseases, especially autoimmune diseases, right? And sometimes it’s a lot for people to be told that they have a condition that they’ll have to deal with long-term, right? Or that they have to take a medication for the rest of their lives. So, and if they’re having difficulty coping with that, you know, it’s gonna be hard for them to adhere to the treatment options, right. So, we have here at the polyclinic, there’s a, we have a behavioral health specialist and we can, I certainly send my patients there.
[00:15:40] Cheryl:
That’s great. Is there any hot topic or exciting things happening in rheumatology right now that you want people to know more about?
[00:15:47] Dr. Percy Balderia:
I think this is an exciting time for rheumatology. There are several things that are happening. But to me, what’s important and what I find interesting is I think there are more studies looking at whether we can identify subtypes, right. For example, of rheumatoid arthritis. Because we have several treatment options, but unfortunately we’re not yet at that point where we can identify which patient will respond to a particular treatment. And I think that can look forward to in the future, maybe something similar to personalised medicine. You know, whether Drug A will work for Patient A and whether Drug B will work for Patient B. And eliminate some of the, at least initial guesswork, right, in terms of medications.
[00:16:31] Cheryl:
And then, you know, one trend I’ve noticed as a patient and read a little bit about is that, you know, patients Are active members of the team, right? So, we’re actively help making decisions in our own care. But one thing that I’ve had a little bit of challenge with myself as a patient is like figuring out at what point do I say, okay, well, my opinion as a patient and as like, I guess I’m an occupational therapist, I have some medical training, but not to the same degree as a doctor, obviously. You know, if my doctor says, “Okay, what do you think? What do you think about these two options?” At some point, I’m kind of like, I want you to tell me, you know? Sometimes patients who are a little bit confused by that kind of power that has been given to them, or are they more like, “Yes, give me the power, I want it,” you know, do you know what I’m saying?
[00:17:19] Dr. Percy Balderia:
Right. It’s like, you know, you’re going in the grocery and then there’s several different kinds of milk, right? And which one are you going to get? Well, you know, I tell patients you know, do something that, you know, makes sense to you, right?
[00:17:32] Cheryl:
Right, right.
[00:17:33] Dr. Percy Balderia:
And what you choose the first time, if it doesn’t work, you know, it doesn’t have to be the final option, right? So, I tell them, you know, if you choose this drug, these are the benefits and risks. If you choose this drug, these are the benefits and risks. These are the logistical difficulties, you know, with getting this drug over this drug. And then, we try, I try to help my patients, our entire staff tries to help the patients get, you know, to their first choice.
[00:17:59] Cheryl:
Right, right.
[00:18:00] Dr. Percy Balderia:
And if that doesn’t push through, then you go to the second one.
[00:18:03] Cheryl:
So, maybe a message inside of what you’re saying is that to use the support available to you as a patient. Because I used to think I had to do everything myself. You know, I have to be in charge of following up with the insurance company, and in some degrees, some things I do have to do, but yeah, utilizing all the support you have at your local clinic that you go to. Is there anything else maybe you just want the audience of people with arthritis and their loved ones and other providers, is there anything else you’d want to say?
[00:18:32] Dr. Percy Balderia:
I’d say if you have joint pain or swelling, you want to prevent long-term joint damage, so you should talk to your PCP and ask about seeing a rheumatologist.
[00:18:41] Cheryl:
Yeah. Simple. He’s very succinct. He’s very helpful. Thank you so, so much.
[00:18:46] Dr. Percy Balderia:
Oh no, thank you for having me here.
[00:18:48] Cheryl:
Thank you so much for listening to today’s episode. Don’t forget to check out my latest courses and resources on myarthritislife.net. This podcast is brought to you by The Beginner’s Guide to Life with Rheumatoid Arthritis, a four-week online education and support program that I created from scratch to help people with inflammatory arthritis learn everything they need to know to navigate the social, emotional, physical, and logistical challenges of rheumatoid arthritis and related diseases. The next group is gonna start in August 2020. Learn more at myarthritislife.net or bit.ly/arthritiscourse, all in lowercase. You can also connect with me on my social media accounts, on Instagram, Facebook, Twitter, and even TikTok. Check out the links in the show notes.
[Ending note]
Thank you so much for listening to another episode of the Arthritis Life Podcast. This episode is brought to you by Rheum to THRIVE, an educational program I created from scratch to help you go from overwhelmed to confident, supported, and connected in a matter of weeks. You can go through the prerecorded course on your own, or you can take the course along with a support group. Learn more at the link in my show notes, or you can always go to www.myarthritislife.net. And if you like this podcast, I would be so honored if you took the time to rate and review it. I also encourage you to share it with anyone you know who might benefit from it. I also wanted to remind you that you can find full transcripts, videos, and detailed show notes with hyperlinks for each episode on my website, www.myarthritislife.net. If you have any ideas for future episodes or if you want to share your story or wisdom on the podcast. Just shoot me an email at info@myarthritislife.net. I can’t wait to hear from you.
